FRAUD AND AUDIT

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FRAUD CORRUPTION QOF THE INVESTIGATOR
DAVID KENEALY HEAD OF COUNTER FRAUD SOUTH COAST
AUDIT
Website - www.scaudit.nhs.uk
Email- david.kenealy_at_scaudit.org
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What is fraud?

• No legal definition of fraud within the UK
• Fraud is a term used to describe a criminal
  deception and that deception could take place in
  any number of different ways
• Generally offences are dealt with by way of the
  Theft Act 1968 and 1978

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Fraud a Definition

• Fraud
• The intentional distortion of financial
  statements or other records by persons internal
  or external to the organisation, carried out to
  conceal the misappropriation of assets or
  otherwise for gain
• (Audit Commission)

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The Impact of Fraud

• Fraud within the Health Service deprives the
  public of the care they rightly expect
• It places the NHS in a publicly embarrassing
  situation resulting in a loss of confidence
• The total of monies recovered by the Counter
  Fraud service since Jan 1999 is 675,000,000

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The Cost

• QOF is potentially high cost and leaves scope for
  fraud and error to occur
• Two ongoing cases within our client base
  estimated cost of the fraud in excess 100,000
• Investigation costs to date for one case is
  10,000

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Countering Fraud The Process

• Firstly we operate to a sound Counter Fraud
  Strategy Countering Fraud in the NHS
• Primary Care provider must involve Counter Fraud
  at an early stage
• Senior Management must be prepared to be involved
• Get professional help and advice at an early
  stage
• Forward planning What might happen if the Doctor
  is unable to continue practicing?

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Problems

• COST
• As can be seen investigating fraud is not cheap
• SYSTEM
• Using the current QOF system it is difficult to
  establish a direct cost per patient
• The system does not breakdown the value of each
  point

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Problems (cont)

• THE LAW
• Difficult to use traditional Deception offences
• Much easier to use the offence of False
  Accounting
• Evidence ( mainly computer based sometimes
  difficult to obtain)
• Courts

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Outcomes

• Criminal
• Prosecution or Police caution
• Disciplinary (internal professional)
• Disciplinary action to include Professional
  bodies
• Civil
• Consider civil recovery of losses to include
  investigation costs

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Prevention/Deterrence

• Work with professional bodies to ensure GPs are
  aware of possible consequences
• Publicise successful outcomes internally/externall
  y
• Use the lessons learnt as best practice
• Get the LCFS involved in spreading the message

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