Patient exemption fraud covers a range of abuses within NHS services that require payment upfront in return for access, including within prescriptions, dentistry and ophthalmology. It also encompasses the onward sale or supply of prescribed medication.
The financial vulnerability has decreased compared to the previous year. However, this is not indicative of a decrease in threat and is because of a change of data parameters used last year. Therefore, due to differences within the previous data set the figure is not comparable.
£230.2m
vulnerable from an expenditure of £11.8 billion
Strategic intelligence picture
The onward trade of prescription medication for personal gain remains highly likely in this area. This can involve selling unwanted or unused medications as well as intentionally obtaining controlled medications via deception e.g. by feigning illness or injury to specifically obtain and sell prescribed items for profit, particularly in lucrative markets abroad. An emerging trend identified was the onward trade of prescriptions relating to weight-loss.
Theft of identity to register for NHS services or medication is highly likely in this thematic area. This MO is most commonly linked to individuals who have entered the UK unlawfully using false identities, stolen identities or identities of their friends or family who have legal status in order to avoid detection. This is enabled by the misconception that they are not entitled to any NHS treatment without charge, or concerns that the NHS may pass their details to Immigration Enforcement. There have been several noted links in using repeated false identities or addresses to claim for state benefits, like Universal Credit, and claiming or registering for NHS services.
Patient charge evasion remains highly likely in this area. This involves patients deliberately and intentionally avoiding charges for services which require payment in the NHS, like prescriptions, dentistry and optical costs. The NHS offers a Low Income Scheme (LIS) as a means tested assessment for patients to demonstrate low income and gain an exemption for NHS charges. However, it is a realistic possibility that some patients withhold some information to qualify for the scheme.
Real-Time Exemption Checking (RTEC)l continues to have a positive effect on charge evasion. However, there were unsuccessful matches at the point of dispensing resulting in challenging the patient or a Penalty Charge Notice (PCN) being issued by the NHS Business Services Authority (NHSBSA) to recover the loss. There is the possibility that unsuccessful validations may go unchecked ‘real-time’ by pharmacists in order to avoid potential conflict with the patient or speed up dispensing. There could also be some confusion amongst patients receiving Universal Credit, who may not be aware that receiving Universal Credit alone does not necessarily equate to free prescriptions, dental treatment and optical costs.
Information reports received for patient exemption fraud
The change in the number of fraud reports received in relation to patient exemption fraud from 2020 - 2021 to 2024 - 2025 is illustrated in the below chart:
| 2020 - 2021 | 2021 - 2022 | 2022 - 2023 | 2023 - 2024 | 2024 - 2025 |
|---|---|---|---|---|
| 2020 - 2021912 | 2021 - 20221,056 | 2022 - 2023871 | 2023 - 20241,404 | 2024 - 20251,238 |
Horizon scanning
Under plans introduced in February 2024 to recover NHS dentistry, dentists will be offered incentives to take on new NHS appointments, with the aim to create an additional 2.5 million NHS dentistry appointments or 1.5 million NHS dentistry treatments. Under the plan the minimum Units of Dental Activity (UDA) rate will be raised, with the aim of making NHS work more attractive and sustainable. This could in-turn lead to an increase in those having NHS dental appointments, which could impact on reporting of charge evasion.
- RTEC enables pharmacies to determine whether an individual is exempt or chargeable for a prescription.