Detection of medical fraud has greatly increased in recent years and offenders are dealt with severely, says Dr Gerard Panting of the Medical Protection Society
The essence of fraud is obtaining financial or other advantage on the basis of false statements or misrepresentation.
Medical fraud can take many forms, for example submitting a curriculum vitae with false claims to qualifications necessary for a particular appointment, submitting data on fictitious patients in a drug trial to obtain payment, submitting item of service claims for services not requested or undertaken, submitting claims to the Prescription Pricing Authority for the cost of vaccines never used and later returned to the manufacturers for refund, or obtaining additional capitation fees by registering false patients. The list of examples goes on and on.
In some cases, the sums involved are trivial - leaving one to wonder why anyone would contemplate taking the risk involved - but in others they are enormous. One dispensing GP issued bogus prescriptions to the value of £700 000 over a period of several years.
But no matter how much money is involved, the Department of Health, the criminal courts and the General Medical Council (GMC) will always come down heavily on doctors who abuse their position of trust to feather their own nests illicitly.
Concern about the level of fraud in the NHS resulted in the establishment of the NHS Counter Fraud Service (CFS) in September 1998. According to the CFS 1999-2001 performance statistics,1 nearly 400 professionally trained and accredited fraud specialists now work in the NHS with the support of 700 directors of finance.
The main areas of activity of the CFS are prescription/pharmaceutical fraud, dental services fraud, optical services fraud, medical services fraud, procurement fraud, payroll fraud, telecommunications fraud, and fraud in hospitals and trusts.
Since its inception, the CFS has been extremely successful. Before it became operational in the year 1998-99 just five cases of potential fraud were detected and investigated. The following year 188 cases involving approximately £2.6 million were identified.
The next year 418 cases worth more than £4 million were investigated and the projected number for 2001-2002 is 407 potential frauds costing the NHS more than £7 million. By January 2002, CFS investigations had resulted in 91 criminal prosecutions with just one acquittal. In addition, the CFS seeks recovery of money lost to fraud through the civil courts.
In addition to criminal prosecution and the recovery of fraudulently obtained gains, two further sanctions almost inevitably follow the unmasking of a GP guilty of defrauding the NHS. The first is removal from the medical or supplementary list and the second is a finding of serious professional misconduct by the GMC.
New regulations came into force on 1 April 2002 allowing the removal of a doctorÍs name from the medical list on grounds of unsuitability, fraud or inefficiency. Fraud cases for these purposes are not confined to those where there has been a criminal conviction.
The Medical Law Reports record a number of cases where GPs had appeared before the GMC, been found guilty of serious professional misconduct and then appealed to the Judicial Committee of the Privy Council.
Erasure from the medical register
In one case, a GP was found guilty on 10 counts of fraud and sentenced to 15 months imprisonment suspended for 2 years.
The case involved broadly three types of offence: claims against insurance companies for sickness and accident benefit payable under income protection policies; claims against the Department of Health and Social Security for sickness benefit and invalidity benefit; and claims against the Family Health Services Authority for the cost of locums.
Following the conviction, the matter was referred to the GMC where the GP was found guilty of serious professional misconduct and his name suspended from the medical register for 12 months. An appeal against that direction was subsequently dismissed by the Privy Council.
During the course of all these proceedings, the GP was consulted by two journalists posing as patients who covertly recorded the consultations. The first was given, for a fee, a disabled parking permit and the second, who was posing as an asylum seeker, was given a sick note stating that he was unfit to travel for an interview with the immigration authorities. Both journalists were in fact fit and well. Neither was questioned and neither was examined.
The story was subsequently published in a national newspaper which gave rise to a second referral to the GMC. When the doctor reappeared before the Professional Conduct Committee (PCC), the factual circumstances were admitted and on this occasion, the direction was that the doctorÍs name should be erased from the medical register. The chairman of the committee stated that ñsuch unprofessional behaviour is no less serious than the matters which led to your conviction in October 1996 on ten counts of fraud relating to your practice, and the subsequent suspension of your registration.î
The Privy Council dismissed the appeal, finding that the doctorÍs conduct was deliberately dishonest and corrupt less than a year after the suspended sentence imposed upon him and just months before his first appearance before the PCC.
In another case, again involving the work of undercover journalists, a GP provided two journalists with medical reports for submission to insurers detailing injuries which neither had suffered. Following the expos³, the doctor pleaded guilty to two charges involving production of false medical records for the purposes of making fraudulent accident claims against insurance companies.
The case was referred to the GMC with the PCC finding the doctor guilty of serious professional misconduct and directing that his name should be erased from the medical register.
The doctor appealed on the grounds that the PCC had failed to attach significant weight to the fact that he had not knowingly participated in the fraud and stood to make no financial gain other than a modest fee for a report, and to his long unblemished record of service to patients. His appeal was dismissed.
In a third case, a GP submitted to the local health authority more than 1000 requests for payments for health screening tests, each attracting a fee of £7.10. A subsequent police investigation resulted in the doctor being charged with 41 counts of false accounting and two counts of obtaining money by deception.
The doctor pleaded guilty, and was fined £100 on each of 14 counts and ordered to pay £5000 costs. (The total value of the claim forms resulting in conviction amounted to £99.40.) The matter was referred to the GMC, and the PCC found the doctor guilty of serious professional misconduct and directed that his name be erased from the medical register.
On appeal, the Privy Council held that the object of disciplinary proceedings against a doctor who had been convicted of criminal offences was two-fold: first, to protect members of the public who may come to him as patients and, second, to maintain the high standards of the profession. However, the object was not to punish the doctor for a second time for the same offence.
Nevertheless, the Privy Council dismissed the appeal on the grounds that the doctorÍs conduct had placed patients at risk, as other practitioners must be able to rely on the accuracy of patientsÍ records and the integrity of the practitioner who made them. Consequently, they found that the committee had not exceeded its remit and that the sentence of erasure was appropriate in the circumstances.
Suspension from the medical register
In a fourth case, a doctor providing ophthalmic services was found to have altered the dates on claim forms to make it appear that he had carried out fewer tests on particular days, enabling him to charge more substantial fees.
He pleaded guilty to five charges, asking for another five similar offences to be taken into consideration. The conviction was reported to the GMC, resulting in the doctor being arraigned before the PCC who found him guilty of serious professional misconduct and ordered that his name be erased from the medical register.
When this case came before the Privy Council, the board found that the PCC had not explored the other sanctions available to them and in the circumstances of the case, found that the direction to erase the doctorÍs name from the register was unduly harsh and disproportionate and was not in the public interest. Instead, they said, his name should be suspended from the register for 3 months.
- The NHS Counter Fraud Service. Countering Fraud in the NHS: Protecting Resources for Patients. London: Department of Health, January 2002. Available online at www.doh.gov.uk/dcfs/