A strategy document setting out NHS England's approach to tackling fraud, bribery and corruption cites an NHS Counter Fraud Agency estimate that '£1.29bn could be lost to economic crime from the NHS in England on an annual basis'.
In general practice alone, the report says that '£88m could be lost annually' because of 'list inflation, claiming for services not provided, quality payments manipulation, conflicts of interest, self-prescribing'. The report suggests that audit teams could be brought in to carry out 'forensic' checks on primary care payments - with a view to clawing back money from providers.
GP leaders said that any cases of fraud were to be condemned, but that these were exceptional - and warned that extrapolating figures about 'economic crime' without clear evidence was unacceptable.
Almost £750m of the potential losses identified in the report relate to 'losses in primary care'. Of the primary care figure, nearly half is linked to patient fraud, while the rest of the estimated figure is put down to potential fraud by dental, optical, pharmacy and general practice contractors.
Much of the 'patient fraud' is tied to possible false claims for free prescriptions, while £126.1m is linked to dental contractor fraud, £79m to optical contractor fraud and £111m to fraud by pharmaceutical contractors.
The report also highlights concern about a potential £35m lost each year by overseas patients obtaining 'fraudulent access to NHS care' after registering with a GP - leading to referral or prescribing costs.
It says that because primary care services 'are provided on the whole by independent contractors', they are 'high trust environments [that] present considerable scope for manipulation and sharp practice'.
Primary care intelligence
NHS England has 'considerable gaps in intelligence' around fraud risks in primary care, the report admits - and contractual issues, confidentiality and data protection present 'barriers which need to be overcome to effectively apply proactive analytics within primary care'.
The report raises the possibility of introducing 'post payment verification' checks in primary care, with potential clawback of funding if inappropriate payments are found. It says that in some areas, regional NHS teams have 'commissioned third-party assurance providers to conduct PPV and forensic reviews of claims within primary care'.
BMA GP committee chair Dr Richard Vautrey told GPonline: 'You question how they have worked out the figures in the first place in these types of reports.
'Where there are exceptional cases, which often impact on GPs and partners in the practices as much as anyone else, they need to be dealt with appropriately – we would never defend fraud where it is clearly demonstrated. But to extrapolate to create figures that don’t have a firm basis should not be done.'
Primary care support
Dr Vautrey pointed out that NHS England had 'singularly failed' to resolve problems with primary care support and payments to general practices following the decision to outsource Primary Care Support England (PCSE) to private provider Capita.
'Before they start criticising general practice, they should get their own house in order,' he warned.
The GPC chair added that the government had sent 'mixed messages' to GP practices about patient registration, with guidance now making clear that practices should not ask for proof of ID or address before registering patients - but practices then facing criticism over allowing patients to register 'fraudulently'.
Dr Vautrey said fraud in general practice was not common. 'The vast majority of people in the NHS go to work to do a good job for patients. In a complex, large industry, errors will be made – but it is often that, rather than deliberate fraud. We will never defend those who defraud the NHS, but we need to focus on the vast majority working hard to deliver as good a service as possible.'
GPonline reported earlier this year on two cases in which practice managers were jailed for defrauding their practices out of six-figure sums.
The NHS England report also highlights a potential £266m loss around procurement of services, because of potential for 'conflicts of interest, bribery offences, contract splitting, bid rigging and tender manipulation'.
The report says NHS England 'will always aim to fraud proof and design out weakness from new or existing policies'.