Tackling NHS Fraud: a 10-point Plan

13th May 2023

by Louisa Macintosh

With estimated NHS fraud figures topping £1.2bn a year (est. by NHS Counter Fraud Authority (NHSCFA)), the risk of inadequate fraud detection is concerning. As newly-formed Integrated Care Boards (ICBs) take the place of Clinical Commissioning Groups (CCGs), health leaders are under the cosh to proactively tackle fraud risk during the transition. But there’s also a potential risk blind spot — as criminals look to profit from immature control measures and governance processes.

Pave the way with best practice

ICBs are only obliged to undergo National Fraud Initiative Portal checks once every two years. In the past, many NHS bodies relied on reporting of suspected fraud with some controls in place. Whether it’s unintended, mandated or even internal procurement fraud, it’s the reason why the NHSCFA is keen to prevent and detect NHS fraud early.

Knowing it will take time for each ICB to standardise their digital systems and procurement processes, the Financial Sector offers a best practice blueprint for success. Working with many clients in the industry, GoBeyond Partners, a consulting firm, points to their inbuilt detection systems that continually scan for potential fraud.

• Review processes, identify pain and potential failure points. Understand issues with your current processes and how to design solutions.
• Review processes through a fraud lens. Think how criminals may defraud your processes to pinpoint weaknesses and vulnerabilities.
• Simplify processes. Ensure processes are simple, making it easier for staff and managers to understand, remember and manage.
• Eliminate duplicate processes. As organisations are joined together, keep best practice processes and remove those you don’t need.
• Redesign. Understand current processes before starting to redesign and involve fraud detection experts.
• Design a fraud assurance regime. Prevention controls identify fraudulent activity across processes. Sharpen effectiveness with exception analysis and regular audits.
• Ensure ownership. Assign an Information Asset Owner to every process and digital platform, training them on responsibility for regular fit-for-purpose reviews.
• Automate where possible. Once manual processes are simplified and redesigned, use automation to increase efficiency and accuracy.
• Fraud education. Most employees will want to counter fraudulent activity. Empower them with the knowledge and skills to help in the fight against fraud.
• Test and refine. Plan appropriate testing of processes to pick up and report undesirable activity, helping to prioritise potential issues.

A future for AI

Government plans for reform include new opportunities for Artificial Intelligence (AI) — to pinpoint and guard against identity fraud. AI can be used to identify changing trends, which is particularly useful for new ICBs. And as they seek to monitor spend and procurement patterns, predictive modelling will help close the net on fraudsters.

Our specialist healthcare team has worked with over 50 NHS and other health and care organisations. We believe preventing and detecting fraud should be seen as part of a holistic drive to ensure an organisation’s processes are clean and efficient. And together, we drive sustainable improvements to healthcare services across systems that enhance patient experience, access and outcomes.