vulnerable from an expenditure of £12.3 billion
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 still receiving additional funding for COVID-19
related services, such as the delivery of vaccinations. As such,
this presents an opportunity for unscrupulous contractors to
exaggerate their activity to receive increased payments.
Pharmacists have a good understanding of each service they are required to carry out, the
process for reimbursement, and the vulnerabilities present for submitting claims, such as
misrepresenting activity and inflating funding. It is assessed likely that some pharmacists
may use their authority to influence others and create a culture for this type of behaviour.
Commercial chains may also adopt a target-driven approach to generate profit by applying
pressure on patients to deliver fee payable services as part of their responsibilities. Used
by more people due to accessibility and size, commercial chains may create greater
vulnerability to exploitation. It is also likely the public will be unaware of the specific
requirements for the service offered to them or the fee paid to the pharmacy from the NHS
for its administration.
A target-driven approach may motivate some pharmacists to manipulate the service
provided by falsifying patient details. Similarly, monthly price fluctuation may enable some
contractors delaying the submission of drug claims to receive payment at the higher price.
There is a realistic possibility that pharmacists and manufacturers may collude and split
profit. ‘Kickback’ payments to pharmacists may also exist where the manufacturer or
supplier pay for their products to be ordered above alternative businesses and the handling
charge reclaimed by the pharmacist from the NHS.
Manipulation of funding streams may become exacerbated after the launch of ‘Pharmacy
First’, new reforms set out to allow patients to get prescriptions directly from pharmacists
for seven common conditions without the need to see a doctor or nurse. These reforms will
also see pharmacists deal with significantly more blood pressure checks and prescribe the
contraceptive pill, alongside patients able to self-refer for services such as physiotherapy.
Information reports received for pharmaceutical contractor fraud
Pharmacy reporting has decreased by 38% this reporting period and is now at its lowest
in the past five years, 47% lower than in 2018 – 2019. Aside from 2021 – 2022, reporting
has also decreased annually. Another year of reporting will determine whether this is a
permanent trend or more a fluctuation as reporting returns to pre-pandemic levels. However,
Post-Payment Verification work by the NHS Business Services Authority may have acted as
a deterrent, resulting in fewer suspicious instances to report.
The change in the number of fraud reports received in relation to pharmaceutical contractors
from 2018 – 2019 to 2022 – 2023 is illustrated in the below chart:
Table showing the number of fraud reports received in relation to community pharmaceutical contractor
fraud from 2018 – 2019 to 2022 – 2023
|2018 to 2019
||2019 to 2020
||2020 to 2021
||2021 to 2022
||2022 to 2023