Community pharmaceutical contractor fraud

Pharmacists are contracted to deliver essential and advanced services to the public as outlined in the Community Pharmacy Contractual Framework (CPCF). Pharmacists have a good understanding of the services they are required to carry out, as well as the reimbursement process and how to manipulate claims. Increased pressures on pharmacists to deliver more services, as well as reductions in opening hours and staffing levels, alongside a cost-of-living crisis, may impact the threat of fraud.

It is likely that some pharmacists are claiming for items which have not been dispensed or required; for example, a pharmacist claiming for these items and then placing them back onto the shelf for resale. Similarly, pharmacists may not dispense or only dispense part of a prescription and resell profitable items. This may extend to high value and sought after items such as diabetes and weight loss drugs/injections, inhalers and liquid medications.

Pharmacists may also manipulate the NHS Spine by claiming for, but not dispensing the item, resulting in the patient re-requesting the prescription from their GP. Similarly, accessing the Spine and changing the patient’s nominated pharmacy without consent.

Inappropriate claiming of prescription items may extend to some pharmacists:

• dispensing incorrect strengths
• dispensing out of date medication
• swapping generic medication for branded equivalents
• claiming prescriptions for deceased patients
• charging both patients and the NHS for items when the patient is exempt and/or their normal prescription is out of stock, but an alternative is identified

It is probable that inappropriate claiming also exists within delivery of patient services, such as New Medicine Service (NMS) and blood pressure checks, where some pharmacists may have claimed despite the patient not receiving the intervention.

There is also the realistic possibility that multiple patient services are unnecessarily claimed at the same time for the same patient. It is assessed that expansion of services such as Pharmacy First and the Hypertension Case-Finding Service, will likely present an opportunity for some to inflate activity to increase revenue.

It is assessed as likely that inappropriate claiming also exists in other funding streams such as Dispensing Appliance Contractors (DACs). Contractors can have multiple accounts with the responsibility for providing appropriate and sufficient appliances, as well as a remit of providing services in emergency situations. As such, they may manipulate claims to shift prescriptions between accounts and maximise infrastructure payments.

Hitting monetary incentivised targets makes services potentially vulnerable to manipulation. As such, contractors may falsify claims to achieve an activity threshold to receive a payment. Similarly, the introduction of quarterly caps based on service delivery from an earlier period may have increased the threat of claiming manipulations. This may also include falsifying patient details including inventing “ghost patients”; or misrepresenting a brief conversation with a patient as a private consultation in a secure room. In the case of Pharmacy First, manipulations could extend to pharmacists prescribing for different conditions to those approved under the scheme.

It is a realistic possibility that adopting a target-driven approach to generate profit and hit monetary incentives could also result in staff being coerced. Applying coercion on staff may extend to claiming but not dispensing items to patients and staff inflating activity by carrying out patient services on associates and other staff members. Applying such tactics may be more prevalent within commercial chains and may lead to greater vulnerability as they are likely to be used by more patients.

Public awareness of the specific requirements for some services offered to them may also enable manipulation of claiming behaviour. As such, the patient may be unaware as to whether they have received the service fully, partially or at all. The patient may also not know if the service was necessary, and they may not have consented if they were aware of the fee paid to the pharmacy directly from the NHS for its administration.

Manipulation of fee payable services and items extend to specific medicines, such as ‘Specials’, and patient service areas such as out of pocket expenses (OOPE) where it is a realistic possibility that pharmacists and manufacturers may collude and split profit through.

Capacity issues within community pharmacies may also be an emerging vulnerability that leads to manipulation of claiming behaviour of both prescription items and patient services. Some contractors may feel added temptation to remain viable business models.

Information reports received for pharmaceutical contractor fraud

The change in the number of fraud reports received in relation to pharmaceutical contractor fraud from 2020 - 2021 to 2024 - 2025 is illustrated in the below chart:

Horizon scanning

The CPCF five-year framework concluded at the end of the 2023 – 2024 financial year, therefore, the Department of Health and Social Care, NHS England (NHSE) and Community Pharmacy England have been negotiating new funding streams throughout 2024 – 2025 and the following year’s contractual framework.

Separate to the CPCF framework, this reporting period contains the second year of a £645 million investment for a major expansion in primary care access in community pharmacy. This has included the Pharmacy First initiative, an expansion of the pharmaceutical remit so patients can obtain prescription medication for common conditions, such as urinary tract infections.

Contractors must also provide Contraception and Hypertension Case-Finding services to qualify for £1,000 monthly payments. This is against the backdrop of future aspiration within Pharmacy First where an expansion of the service has been touted and estimated to free up GP appointments.

The second half of the 2024 – 2025 financial year has also seen the introduction of quarterly Pharmacy First caps, based on service delivery from a previous three-month period in the year.

13. £8.86 increasing to £9.01