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Pharmaceutical Services Negotiating Committee

Switching

As a result of the introduction of CIP, there has been a substantial increase in the ‘switching' of prescriptions. Under the previous manual pricing processes, only a sample of prescriptions from every bundle were checked to confirm that prescriptions were correctly submitted as ‘exempt’ or ‘charge paid’. As part of the CIP process, high speed scanners support the collection of information on the prescription charge status of every prescription. 

‘Switching' of prescriptions occurs if NHS Prescription Services do not agree with the charge group (paid or exempt) in which a prescription is submitted. For forms submitted as exempt: if a declaration of exemption is required, but is not provided, NHS Prescription Services deducts a prescription charge from a contractor's payment for each item on that form. For forms submitted as chargeable: if NHS Prescription Services detects a completed declaration of exemption or the patient is age exempt with the date of birth or age computer generated on the prescription, charges are not deducted for the items on that form.

Investigations by NHS Prescription Services have revealed that the majority of the prescriptions ‘switched' did not have completed declarations of exemption on the prescription forms, where required. This has been independently verified by PSNC. The manual legacy pricing system was less successful at identifying these forms and therefore contractors were not alerted to these problems prior to CIP implementation. In addition, instances of the Prescription Services ‘switching' forms in error due to systems failure have been identified.  A number of measures have been taken to minimise the risk that this problem reoccurs including changes to the pricing system and staff training.  

Ongoing work to monitor the accuracy of perscription switching by NHS Prescription Services can be found in this section of the site - along with guidance on how to prevent prescription switching.  

Quick links:

Ongoing Monitoring of PPD Prescription Accuracy

Preventing Prescription Switching

FAQs


Monitoring PPD Switching Accuracy 

To monitor ongoing accuracy of switching, PSNC regularly undertake audits of the accuracy of prescription switching from the exempt to charge paid groups. A total of approximatley 96 contractor accounts are sampled per month checked, covering the 3 processing sites using the CIP system. The sample includes at least one account from every LPC area. Only the prescriptions that had been switched from ‘exempt' to ‘charge paid' status were reviewed. A record is made of whether the switch was correct or incorrect, reasons for the switch, for example the prescription had not been signed and the financial impact of the switch.     

Correct Switching

The main reason for prescriptions being switched correctly is that there was an indication that a charge had been paid in the ‘charge' box on the back of the form and exemption declarations were unsigned. Individualised feedback is  sent to all contractors who have bundles checked as part of these audits. 

The Department of Health have confirmed that there will be no further concessions made for contractor's failure to ensure exemption declaration are completed, where required, therefore it is essential that all contractors review their processes for ensuring that patient declarations are completed correctly. Guidance on how to avoid prescription switching can be found on the PSNC Website (www.psnc.org.uk/switching).  

Incorrect Switching

PSNC finds that although the switching was correct in the majority of bundles reviewed, in some accounts, prescriptions are identified that have been switched incorrectly and  this information is fed to NHS Prescription Services so that adjustments can be made to the individual contractor accounts concerned. It is always a human decision to ‘switch’ a prescription’s status therefore all errors identified in this study, which considered solely, switching from ‘exempt’ to ‘charge’ status were human errors.

NHS Prescription Services have introduced a number of measures to minimise the risk of switching errors including: Identifying best practice within the batch preparation process to ensure prescription forms are scanned in the appropriate groups. Refresher training has been carried out with those operators involved in confirming the group in which the form should be submitted. In addition, system changes have been introduced to make the process as clear as possible for operators.

PSNC will continue to undertake further audits on switching to monitor whether the measures taken by NHS Prescription Services to improve accuracy have been successful.


Preventing Prescription Switching

The declaration on the back of a prescription form must be completed on all occasions except:

  • Where the patient is aged under 16, or 60 or over and the date of birth is automatically printed on the prescription
  • Where it is a prescription for a prisoner on release where the practice address box on the front of the form includes the printed letters ‘HMP' along with the issuing prison address and PCT allocated number
  • Where the prescription is a ‘Bulk’ Prescription (i.e. an order for two or more patients, bearing the name of a school or institution in which at least 20 persons normally reside. See Drug Tariff Part VIII Note. 9)

If the prescription is submitted to NHS Prescription Services in the ‘exempt’ bundle and the exemption declaration is not completed where required, the prescription will be ‘switched’ to the ‘paid’ bundle and prescription charges may be deducted.

Under the previous manual processes, only a sample of prescriptions from every bundle were checked to confirm that prescriptions were correctly submitted as ‘exempt’ or ‘charge paid’. As part of the CIP process, high speed scanners support the collection of information on the prescription charge status of every prescription. This is the key reason for the recent increase in prescription switching. Where the CIP system’s intelligent character recognition software identifies that a prescription has been submitted in an incorrect bundle, the form is referred to an NHS Prescription Services operator to assess whether the prescription charge status should be ‘switched’ or not. Humans always make the final decision over whether a prescription should be ‘switched’. Key points to note:

  •  Where an exemption declaration is required, the prescription should include a mark (for example tick or cross) in one of the exemption boxes and a signature
  • There is no requirement for the exemption declaration to be completed using a pen with a particular ink colour.
  • The scanner (and NHS Prescriptions Services staff) look for a mark in the exemption boxes, for example this may be a tick or a cross.
  • The signature should be in Part 3 (the signature box), however if the patient has incorrectly signed in the social security details box or on the address line, the prescription will not be switched.
  • It is acceptable to use a pharmacy stamp to provide the address information required on a prescription where a member of the pharmacy staff is signing as a representative of the patient, however a pharmacy stamp alone is not accepted as a signature in a declaration of exemption. Without a signature, a prescription would be switched.
  • Certain patients claiming exemption linked to income are required to declare their NI number in Part 1 the form. However prescriptions will not be switched provided that the appropriate exemption box is marked and the prescription signed. If evidence has not been seen a cross should be marked in the ‘Evidence not Seen’ box.
  • Prescription switching statistics can be found on page 2 of a contractor’s Schedule of Payments. It is important to monitor this closely, for example to ensure that staff are following SOPs and ensuring exemption declarations are completed, where required.

Background information on Point of Dispensing Checks can be found in the Online Drug Tariff Resource Centre:

Preventing Prescription Switching Factsheet

Point of Dispensing Checks Guidance


Frequently Asked Questions

Will prescriptions for contraceptive medicines or devices be automatically recognised as exempt from charge by the CIP pricing system even if the patient exemption declaration is not completed?

There is no exception from the requirement to obtain a completed exemption declaration on the grounds that the patient has been prescribed a contraceptive. I

If these prescriptions are submitted in the exempt bundle with an incomplete patient exemption declaration, this prescription will be switched but will not be shown on the contractor’s schedule of payments as a switch from the exempt to chargeable group as NHS Prescription Services will not deduct a charge where the prescription is for a contraceptive medicine or device included in the list of products to be supplied to patients free of charge. Care needs to be taken where only one item on the prescription form is a free of charge contraceptive.

Do I have a right to ask the PPD to return switched forms to me?

In accordance with The National Health Service (Pharmaceutical Services) Directions, dated 1 December 2005, PCTs are required to provide pharmacy contractors with reasonable facilities for examining all or any of their prescription forms, together with details of the amount calculated by NHS Prescription Services as payable. For example, to allow a pharmacy contractor to view this information at the PCT Offices. To arrange to view forms, pharmacy contractors should make a request to their PCT (including details of the forms concerned e.g. a particular prescription month). The PCT will then request the forms from NHS Prescription Services. A copy of the Directions can be downloaded by clicking on the link below:

The National Health Service (Pharmaceutical Services) Directions, dated 1 December 2005

Is there a risk that if a patient uses a pen with a font colour other than black to complete the exemption declaration that the scanner will not be able to pick this up and ‘switch’ the prescription to the prescription charge paid bundle?

No, there is no requirement for the exemption declaration to be completed using a pen with a particular ink colour. All forms are reviewed by an exception handler before a prescription is considered for switching.

If the patient is not present, can pharmacy staff sign the exemption declaration on behalf of the patient, if we are told the exemption status by the patient?

This issue is governed by the “Law of Agency” This states that a representative, in this case the pharmacy acts as if they are an extension of the patient. Consequently any liabilities incurred by acting as an “agent” are in fact liabilities of the patient. All liabilities for penalties will always be that of the patient.

The reason for this is that the patient is the original source of information which is provided to the pharmacy and the ultimate beneficiary of a free prescription. Therefore, if the information is incorrect the patient will be liable, not the pharmacy.

In order to act as agent for the patient, the pharmacist would need to be sure that the patient understands that he had asked him to sign as his agent, to create the agency relationship.

The Counter Fraud and Security Management Service advice is that generally, pharmacists should not sign as the patient’s representative as they are financially involved in the transaction.

As part of the exemption checking procedures, before signing an exemption declaration on behalf of the patient, the pharmacist would be responsible for establishing that the patient is exempt from prescription charges. This would necessarily involve seeing the original proof of exemption (as the pharmacist would be acting improperly in signing both as agent, and annotating the prescription with proof of exemption not seen.

Unfortunately, PSNC has been informed of cases where pharmacists or their staff have erroneously signed prescriptions on behalf of patients, where the patient was not present in the pharmacy at the time of dispensing, and the patients have received letters from the Counter Fraud Service seeking repayment where the patient was not entitled to exemption from charges. The signing of the exemption claim is therefore not recommended, unless the pharmacist or his staff see the proof of entitlement to exemption.

Does the PPD have lawful authority to deduct charges from a pharmacy’s reimbursement for a prescription where the reverse of the form has not been completed?

Paragraph 3 (3) of the National Health Service (Charges for Drugs and Appliances) Regulations 2000 states that no charges shall be made and recovered by the Chemist where there is exemption under regulation 7 (which describes the exemption categories) and a declaration of entitlement to exemption is duly completed by or on behalf of the patient. (There are exceptions to the requirement for declarations of entitlement for patients exempt on age related grounds where the date of birth is computer printed on the form, or where the prescription is issued to a newly released prisoner, and the letters ‘HMP’ are printed along with the name of the prison in the address box of the prescriber, or where the prescription is a bulk prescription). If the declaration of entitlement to exemption has not been duly completed and the prescription does not meet any of the exceptions, then a charge is payable, and it is the duty of the Chemist to collect this.

Under Regulation 3(7) of the Charges Regulations any sum payable by the PCT to the Chemist (i.e. reimbursement and remuneration) shall be reduced by the amount of charges which are required to be made. This requirement to deduct the amount equivalent to the charges for all chargeable prescriptions is mandatory, and therefore the PPD not only has lawful authority to deduct the charges, but is required by the Regulations to do so.

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