The NHS could be losing £111m every year due to fraud committed by community pharmacy contractors, NHS England has claimed.
In a new fraud, bribery and corruption strategy document released yesterday (16 September), NHS England said contractor fraud accounts for almost a tenth (9%) of the total estimated loss to the NHS of £1.29bn a year due to economic crime. This figure is based on 2016/17 data from the NHS Counter Fraud Authority.
The document said contractor fraud could include claims for prescriptions not dispensed, larger pack sizes, services not performed, inflated drugs costs, excessive handling charges and contract balancing.
However, this figure is only a ‘realistic probability’, NHS England admitted.
‘Gaps in intelligence’
The strategy, which outlines NHS England’s response to fraud until 2021, said community pharmacy was a ‘high’ priority for future action and names primary care fraud as a whole as its third of four key priorities.
However, it added that it was difficult to measure the cost of fraud and that the intelligence it gathers as part of its anti-fraud work will inform its targets further.
It said: ‘There are considerable gaps in intelligence with reference to fraud risks in primary care areas, a significant proportion of current work and future priorities therefore relate to primary care.
‘This is due in part to the lack of available intelligence and the historical data that shows that fraud does occur in these areas. Due to the nature of primary care information and the way it is held, there are a number of barriers that need to be overcome to effectively apply proactive analytics within primary care.’
It added that a key consideration for the strategy was the need to establish a collaborative approach to uncovering fraud.
Regulations, contracts and the drug tariff may undergo revisions to ‘incorporate anti-fraud arrangements’, according to the document.
‘Scope for manipulation’
The document blamed the ‘high trust environments’ within primary care, which it said allow ‘considerable scope for manipulation’.
The strategy said: ‘Primary care services are provided on the whole by independent contractors, who operate as businesses in their own right. They are commissioned by NHS England and CCGs via a variety of contractual arrangements.
‘These high trust environments present considerable scope for manipulation and sharp practice. There is the potential for differing interpretations in relation to clinical opinion and some areas operate historic paper-based claims systems.’
The strategy also reiterated plans for contractors to check patients’ eligibility for free prescriptions at the point of dispensing.
Patient exemption fraud is NHS England’s top priority according to the document, with fraudulent claims for free prescriptions costing the NHS an estimated £256m.
Pharmacy contractor fraud was first revealed as one of the NHS fraud squad’s priorities in June.