Pharmaceutical contractor fraud involves the falsification or exaggeration of services as well as collusion.
The increase in financial vulnerability can be attributed to an increase in expenditure. Additionally, pharmaceutical contractors are receiving additional funding for expanded patient services, such as the delivery of vaccinations and blood pressure tests.
£130.2m
vulnerable from an expenditure of £13 billion
It is possible for pharmacists to misrepresent activity and inflate funding as they have a good understanding of the essential and advanced services they are required to deliver, the process for reimbursement, and the vulnerabilities present for submitting claims. The current cost-of-living crisis and increased pressure on pharmacists to deliver more services may also impact the threat of fraud.
There is a realistic possibility that some pharmacists are claiming for items which have not been dispensed or claiming for items which the patient has stated are no longer required. Inappropriate claiming of prescription items may extend to some pharmacists charging the NHS for items when a patient has a pre-paid account, when they have already paid the prescription charge, when they are deceased, or when they are exempt. This may also include some exempt patients being charged by the pharmacist, not having all their prescription dispensed, or the pharmacist ordering cheaper products, but claiming for the more expensive option.
Inappropriate claiming can also exist within delivery of patient services, such as COVID-19 and flu vaccinations, where some pharmacists may have claimed despite the patient not receiving the intervention. It is a realistic possibility this method now extends to the hypertension case-finding service where blood pressure tests, which did not occur or were unnecessary, could be claimed for by some pharmacists. There is also the possibility for multiple patient services to be claimed for at the same time for the same patient, such as a vaccination and an accompanying blood pressure test.
It is a realistic possibility that pharmacists may manipulate claims to achieve monetary incentivised targets, such as in the New Medicines Service (NMS) and the hypertension case-finding service. These patient services may encourage activities such as falsifying legitimate patient details or inventing ghost patients. Adopting a target-driven approach to generate profit and hit monetary incentives could also result in staff being encouraged to apply pressure on patients to deliver fee payable services.
There is a realistic possibility that pharmacists and manufacturers have the ability to collude and split profit through collusion of specific medicines, such as ‘specials’, or in patient service areas, such as Out of Pocket Expenses. In such scenarios, the manufacturer or supplier will make ‘kickback’ payments to pharmacists to order products from them with the associated charge reclaimed by the pharmacist from the NHS.
Information reports received for pharmaceutical contractor fraud
The change in the number of fraud reports received in relation to pharmaceutical contractor fraud from 2019 - 2020 to 2023 - 2024 is illustrated in the chart below:
| 2019 - 2020 | 2020 - 2021 | 2021 - 2022 | 2022 - 2023 | 2023 - 2024 |
|---|---|---|---|---|
| 2019 - 2020186 | 2020 - 2021107 | 2021 - 2022157 | 2022 - 202399 | 2023 - 2024201 |
Horizon scanning
The Community Pharmacy Contractual Framework (CPCF) five-year framework concludes at the end of the 2023 - 2024 financial year, allowing the Department of Health and Social Care (DHSC), NHS England (NHSE) and Community Pharmacy England to consider next steps. Although details of a new framework are yet to emerge, all three organisations agree that the best utilisation of the knowledge and skills within community pharmacies whilst expanding clinical services, should be part of any future agreement.
Also, from winter 2023 - 2024 a major expansion to primary care access in community pharmacy will be funded. This includes expanding the pharmaceutical remit so patients can obtain prescription medication for seven common conditionsh under the Pharmacy First initiative. There has also been a significant upscaling in ambition and targets for pharmacists to deliver blood pressure checks through the hypertension case-finding service. As contractors will have to provide all three servicesi by the end of 2024 - 2025 to receive the amalgamated payment, the threat could increase.
- Acute otitis media, sore throat, sinusitis, infected insect bites, impetigo and uncomplicated urinary tract infections.
- Pharmacy First, Pharmacy Contraception Service, hypertension case-finding service.