Community pharmaceutical contractor fraud

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:

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