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Prescription payments

23 October 2015

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As the number of post-dispensing checks on free NHS prescriptions increases, GPs and practice staff have an important role to play in helping patients get the facts – not a fine

Fraudulent and incorrect claims for free prescriptions cost the NHS in England millions in lost revenue each year. This is money that could be spent on frontline services so checks are increasing following the introduction of a centralised approach to collecting unpaid charges.
Previously, local NHS bodies were responsible for verifying claims for free prescriptions. Now, the Prescription Exemption Checking Service (PECS) delivers improved consistency and economies of scale. PECS is delivered by the NHS Business Services Authority (NHSBSA), on behalf of NHS England, the Department of Health and NHS Protect. Since its launch in September 2014, more than 220,500 penalty charge notices have been issued to patients whose entitlement to free NHS prescriptions couldn’t be verified – and now that the process has been proven as robust, the number of fines issued will increase to around 1.2 million in 2016-17.

The checking process
The NHSBSA provides NHS Prescription Services (formerly known as the Prescription Pricing Authority or PPA), which processes NHS prescriptions for reimbursement and remuneration purposes. Another of its services is NHS Help with Health Costs, which includes the administration of various schemes that help patients access chargeable NHS services either free or at a reduced cost. PECS is essentially a data matching exercise, whereby randomly selected patient declarations from prescription forms are cross-checked against records of prescription prepayment certificates and other exemptions.
For example, if a patient declares that they don’t have to pay because they have a valid HC2 certificate for full help with health costs, the NHSBSA will check its database for a record of an HC2 certificate matching that patient’s name, date of birth and address. If no exact match is found, the patient will receive a letter explaining that they need to pay the original prescription charge(s) – and a penalty charge of up to £100. In line with the NHS (penalty charge) regulations 1999, a surcharge of up to £50 will apply if payment isn’t received within the required timescale.
Alternatively, the charges will be waived if the patient can prove their entitlement to free prescriptions. It may be that they ticked the HC2 box on the declaration by mistake, but they actually have an NHS tax credit exemption certificate. Maybe they’d told their GP practice about their change of address, but didn’t realise that they also needed to inform the NHSBSA so their HC2 record could be updated.

The role of GPs and practice staff
PECS is designed to protect the public purse by identifying and deterring fraudulent claims for free prescriptions. It’s not in place to ‘catch people out’ for making genuine mistakes, but patients need to be aware that when claiming exemption from prescription charges, they’re making a legal declaration. It’s their own responsibility to check their entitlement before doing so, which is why the NHSBSA is working to educate patients on the eligibility criteria and needs your support in doing so.
There are various ways in which GPs and practice staff can help patients to understand who qualifies for free NHS prescriptions – and who doesn’t. Many patients rely on healthcare professionals (both clinical and non-clinical) for this information, so whether you’re a GP, nurse, practice manager or receptionist, the most helpful thing you can do is understand the criteria yourself.
There are some common misconceptions around entitlement. For example, many people wrongly assume that all state benefits entitle recipients to help with their health costs and that all students are exempt from paying NHS charges. The NHSBSA is particularly concerned by the widespread lack of knowledge around medical and maternity exemption certificates that was highlighted by the early phase of PECS.

Medical exemption certificates
Patients with certain medical conditions are entitled to free prescriptions – but only if they have a valid medical exemption certificate (MEC). Certificates are issued by the NHSBSA, on receipt of a completed FP92A application form. The form must be signed by a doctor or a member of the practice staff who can access the patient’s medical records.
There are currently 10 qualifying conditions. Patients can apply for
an MEC if they have:
A permanent fistula (for example, caecostomy, colostomy, laryngostomy or ileostomy) requiring continuous surgical dressing or requiring an appliance.
Epilepsy, for which they need continuous anti-convulsive therapy.
Diabetes mellitus and their treatment is not just by diet alone.
Myxoedema (hypothyroidism requiring thyroid hormone replacement).
Siabetes insipidus or other forms
     of hypopituitatism.
Forms of hypoadrenalism (including Addison’s disease) for which specific substitution therapy is essential.
Myasthenia gravis.
A continuing physical disability, which means they can’t go out without the help of another person (temporary disabilities don’t count, even if they last for several months).
Treatment for cancer, including the effects of cancer or the effects of current or previous cancer treatment.
GPs can help combat the widespread misbelief that these patients are automatically exempt from paying prescription charges by signing and submitting the application form as soon as a qualifying condition is diagnosed. They can also reduce the risk of their patients receiving penalty charge notices by explaining that certificates need to be renewed every five years, and that patients need to notify the NHSBSA as well their GP practice if their name or address changes.

Maternity exemption certificates
Many patients (and healthcare professionals) incorrectly believe that pregnancy automatically exempts them from paying prescription charges. This isn’t the case – only those with a valid maternity exemption certificate are entitled to free prescriptions.
Pregnant women and those who have had a baby in the last 12 months can apply for a maternity exemption certificate by submitting application form FW8 to the NHSBSA. Although it can also be signed by a midwife or health visitor, GPs are encouraged to provide and sign the form as soon as pregnancy is confirmed. This is because many women will not see a midwife until several weeks into their pregnancy, which could result in their entitlement to free prescriptions being delayed. The certificate can also be used as proof of entitlement to free NHS dental treatment.
Depending on when the application is made the certificate will be valid until the day before the baby’s first birthday, or the day before the expected due date. If the baby is born later than expected, the validity of the certificate can be extended.

Prescription prepayment certificates and the NHS Low Income Scheme
Patients who need to pay for more than four prescription items in a three-month period can make significant savings by buying a prescription prepayment certificate (PPC) from the NHSBSA (see Resources). Anyone can buy a PPC, regardless of their medical condition or income.
PPCs are currently priced at £29.10 for three months and £104 for 12 months, and cover all NHS prescriptions dispensed while valid – regardless of how many items are prescribed. They can be bought online, over the phone, using a postal application form or in store at some pharmacies.
Those on a low income could qualify for help with NHS charges through the NHS Low Income Scheme (see Resources). Patients (including students and those receiving contributions-based benefits) can apply as long as their savings don’t exceed £16,000 or £23,250 if they permanently live in a care home. The NHSBSA carries out means-tested assessments to determine the level of help to be awarded, so applicants need to provide details of their current financial position.

Brendan Brown, head of NHS Help with Health Costs.

1 Prescription prepayment certificate.
2 NHS Low Income Scheme.