Patient exemption fraud
Fraud vulnerabilities relating to prescription charge evasion, dental charge evasion and optical voucher abuse.
vulnerable from an expenditure of £11.5 billion
Patient exemption fraud covers a range of abuses within main NHS services that require payment upfront in return for access, including within prescriptions, dental, and optical. In addition, it covers general fraud such as the onward sale of prescribed medication.
The increase in financial vulnerability can be attributed to the return of pre-pandemic dental and optical activity once restrictions were lifted, as well as increases in prescription item cost.
The evasion of NHS charges remains a prevalent threat with a realistic possibility that some patients, including repeat offenders, will deliberately avoid paying for medication, and these may remain undetected.
A belief of entitlement to claim these services free, or a belief that it is not the patient’s responsibility to check before claiming, are enablers to this fraud.
Genuine errors and confusion over exemption qualification, such as through benefits, further complicates this area. However, the significant expansion of Real-Time Exemption Checking (RTEC) in pharmacies will help negate confusion surrounding correct exemption claiming for both patients and pharmacists. However, it is possible that some discrepancies and errors are likely to remain within the system as it heavily relies upon the patient to understand their exemption status and keep their NHS record up to date.
The onward trade of prescription or other controlled drugs has been gaining increasing prevalence with the trading of unwanted or unused prescribed items often ending up in the hands of criminal groups. Medication may be traded via online platforms and sold in more lucrative markets abroad. Commonly traded items are prescription opiates or other highly addictive strong pain-relieving medication, making this a lucrative market.
When comparing this reporting period with 2021 – 2022, reports have decreased by 18% (1,089 to 891). This could be explained by the expansion of RTEC, demonstrated by the decrease in reports relating to prescription charge evasion. Other significant decreases have been seen in obtaining prescriptions for another and the registrations of false identities and addresses. However, the largest number of all reports received involve prescription misuse which accounts for 32.5%.
The change in the number of fraud reports received in relation to patient exemption from 2018 – 2019 to 2022 – 2023 is illustrated in the below chart:
|2018 to 2019||2019 to 2020||2020 to 2021||2021 to 2022||2022 to 2023|
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