Some of our efforts in combating fraud should go into attempting to shift the moral baseline of the majority

The NHS Counter Fraud authority (CFA) estimates that fraud and other economic crime costs the NHS about £1.29 billion a year. “Fraud affecting the NHS”, says the CFA, “is a blight, taking public funds away from patient care and into the pockets of criminals.” Much of this fraud occurs at a corporate level, but some of it is down to individuals like us. When we hear reports of such incidents, our instinctive reaction is probably a mix of shock, disgust, and perhaps anger that a colleague could have deviated so far from the ideals which surely brought them into healthcare in the first place.

The truth about dishonesty turns out to be a bit more complex. Behavioural economist Dan Ariely and his colleagues conducted an ingenious series of experiments exploring the nature of dishonesty and found in essence that it is not simply a characteristic of a few “bad apples”—it turns out that most of us cheat in life to some extent, but generally only in a small or moderate way.

In the base experiment, a group of students were given a set of problems to solve within a time limit with the promise of a cash reward for each correct answer. Their written answer sheets were collected which gave the baseline expectation for performance in this test. A second group of students were then given the same task to perform, but were asked to shred their answer sheets prior to announcing their scores to the moderator and claiming their reward. Guess what—their aggregate reported scores were about 30% higher than the first group. The difference was not down to a few individuals grossly inflating their scores, but to a large number claiming a modest increase. Anyone who has marked their own paper in a trivia quiz will recognise the phenomenon. Of course I knew that really—it just momentarily slipped my mind. I didn’t mean to write that, I meant this. I wouldn’t have said that if I hadn’t heard someone else muttering it.

Most of us (myself included here) have the propensity to cheat, at least in a small way—a few miles added to a travel expense claim (after all I didn’t claim last month so I’m owed them anyway), occasional use of office facilities for purposes not related to our work (just think of all the extra stuff I do unpaid), minor inflation of a professional fee (“because I’m worth it”) and so on. The interesting question is what stops us from cheating more? It seems that the limits to the extent of our cheating are not principally determined by considerations of how much we might gain nor by the risks of being caught, but by how much we can do while still retaining a sense of ourselves as moral and fundamentally good people. And we are remarkably good at rationalising our own behaviour, as the examples above illustrate.

So maybe the aggressive pursuit of a few criminals is not the whole answer to combating fraud in the NHS. It is certainly true that the perception of being watched is a factor in promoting more honest behaviour—so there is still a role for the CFA here—but it’s probably not the whole answer.

It might also be worthwhile exploring the conditions in which dishonesty is more or less likely to prevail. General fatigue and cognitive overload—what psychologists term “depletion”—undoubtedly predispose towards dishonest conduct. Another very powerful factor is the behaviour of those around us. If there is a culture of cheating among those with whom we work, it becomes very much easier to rationalise adjusting our own moral baseline to accommodate more dubious practices. The argument that “everyone else is doing it” is frequently cited by those found guilty of dishonest conduct and—if true—may deserve a little sympathy.

In another experiment Ariely explored whether diners in a restaurant who were offered the opportunity to be dishonest would be more likely to take that opportunity if they were given cause to feel in some way disgruntled with the establishment. A relatively minor display of rudeness by an actor posing as a waiter was enough to bring about a sharp increase in the number who decided to avail themselves of the opportunity to cheat (in a small way). It transpires that we are much more likely to transgress if we are feeling aggrieved.  Plenty for the NHS as an employer to reflect upon there.

One of the ways Ariely has found to reduce cheating is by the use of what he terms “moral reminders”—little nudges as close as possible to the moment of temptation. I think we understand this intuitively—I suspect that the photos of our children which many colleagues keep on their desks sometimes serve a purpose other than just reminding us of their existence and the need to keep working to pay for them. I should add that a recent attempt to replicate Ariely’s results was unsuccessful.

Just as we have come to understand that real improvements in the quality of patient care are more likely to come from shifting the mean rather than from weeding out the poorest performers, perhaps some of our efforts in combating fraud should go into attempting to shift the moral baseline of the majority. Is that realistic at a time when many feel that our society is drifting in a less moral direction? Why not? Notwithstanding the cynics, most of us who work in it tend to regard the NHS as an expression of what is best in our society—why should it not lead the way in promoting higher standards of honesty? Fraud in the context of a public service feels particularly despicable—but perhaps there are smarter ways for all of us to respond to help make the NHS a more honest place and maybe even start to recover some of that £1.29 billion for the purpose for which it was intended.

Giles Maskell is a radiologist in Truro. He is past president of the Royal College of Radiologists.

Competing interests: None declared.