• Legislative and structural changes to NHS have “blurred the lines of accountability” for counter fraud operations
  • Moves towards primary care co-commissioning has risked “dilution of management controls and increased fraud risk”
  • Report says mitigations being put in place 

Structural changes to NHS organisations and GPs’ involvement in primary care commissioning may have increased the risk of financial fraud, an NHS England report has warned.

In its economic crime strategy, published for the first time on Monday, the national commissioner said legislative and structural changes to the NHS had “blurred the lines of accountability” for counter fraud operations.

NHS organisations are required to have various counter fraud measures in place, but the report suggested these have changed in recent years, with foundation trusts now subject to new directions.

It added: “This is likely to require further clarification with the introduction of new models of care, devolved arrangements and cocommissioning, where the relationships between primary and secondary care, as well as providers and commissioners, become more intertwined…

“It is also recognised that as the level of proactive anti-fraud work undertaken increases, this may potentially identify the need to revise the applicable regulations, contracts, the drug tariff and other frameworks to embed and incorporate anti-fraud arrangements throughout areas where NHS England could have an influence.

“This will not be without challenges but NHS England is committed to working collaboratively with all its key stakeholders to minimise the risk of exposure to fraud.”

The document is dated 2018-2021 and has previously been circulated in the service. It is due to be reviewed in November 2019.

The estimated loss to the NHS from fraudulent activity was around £1.3bn in 2016-17, the report said. Patient fraud was thought to be the largest contributor (£342m), followed by procurement and commissioning (£266m).

In a section about primary care co-commissioning, where local clinical commissioning groups and their GP members are involved in commissioning decisions, the report warned: “In an evolving landscape there is a risk that responsibilities and accountabilities may become less clear, leading to the dilution of management controls and increased fraud risk.

“The publication of revised conflicts of interest guidance for CCGs intends to mitigate some of these risks.

“There is an opportunity to proactively assess, clarify and contribute to the design of cocommissioning governance arrangements to ensure anti-fraud measures are embedded as the arrangements develop.”

The report said the majority of NHSE’s allegations of fraud relate to GP services, with an estimated loss of around £88m per year.

It added: “[GPs] are commissioned by NHS England and CCGs via a variety of contractual arrangements. These high trust environments present considerable scope for manipulation and sharp practice. There is the potential for differing interpretations in relation to clinical opinion and some areas operate historic paper-based claims systems…

“Due to the nature of primary care information and the way it is held, there are a number of barriers which need to be overcome to effectively apply proactive analytics within primary care… this is compounded by contractual as well as data protection and confidentiality issues.”

The report set out various measures being taken to mitigate the risks.