Home 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.
Information on the compensation arrangements (up to May 2008) and 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:
Compensation Arrangements to December 2007
Compensation Arrangements, January - May 2008
Ongoing Monitoring of PPD Prescription Accuracy
Preventing Prscription Switching
Compensation Arrangements: 2007
NHS Prescription Services, the Department of Health and PSNC have agreed compensation arrangements for any error due to NHS Prescription Services system failure and as a concession for contractors who may not have been aware of flaws in their own business processes for checking declarations of exemption on prescription forms, for the period to the end of December 2007.
Each contractor will receive a payment of 90% of the difference in the NHS charge values deducted due to the difference in average switching rates between legacy and CIP processes for each month that a pharmacy's prescriptions were processed through CIP until December 2007. This calculation will be specific to each pharmacy, based on the number of prescriptions switched by CIP in each month.
Affected contractors will shortly receive a letter from NHS Prescription Services to inform them of the compensation that has been calculated for payment to them. The payment will reach contractors in early September 2008. Contractors do not need to take any action – this will be processed automatically. The compensation payments will exclude from the calculation, months where NHS Prescription Services have already checked the switching and made adjustments to payments. The level of compensation recognises the delays in payment reaching contractors.
The Calculation
There has been an increase in the percentage of forms being switched from the exempt to charge bundles from an average of 0.13% under legacy processes to 0.99% under CIP Processes.
To calculate the payment, NHS Prescription Services will take the value of prescription charges deducted in each month that a contractor's account was processed through the CIP System (up to December 2007) and calculate the value of the prescription charges that would, on average, have been deducted by the legacy system in each month i.e.
Step 1: No. of Legacy switched = No. of CIP Switched x 0.13 / 0.99
Step 2: Value of legacy switched = No. of Legacy switched x charge rate.
Step 3: The contractor then receives, 90% of the difference between the CIP switch value and the legacy switch value.
Where a correction has already been made to a contractors payment by NHS Prescription Services, in respect of switching, that particular month will be excluded from the final compensation payment.
Compensation Arrangements: January - May 2008
The Department of Health and PSNC have agreed compensation arrangements for any error due to system failure and as a concession for contractors who may not have been aware of flaws in their own business processes for checking declarations of exemption on prescription forms, for the period from January – May 2008.
The concession is based on a contractor’s first three months of processing through the new system, but only those months between January – May 2008 will be eligible for a compensation payment. This is because compensation payments for months up to December 2007 have already been arranged as part of the agreement between the Department of Health and the PSNC in July.
NHS Prescription Services will take the month that contractors were first processed through the new system as month one. Therefore contractors who were first processed before January 2008 will only receive compensation for any month from January to May which is included in their first three months. For example:
-
Pharmacy accounts first priced under the new system in November 2007 will be eligible for compensation under this agreement for January 2008. Compensation payments have already been arranged for November and December 2007.
-
Pharmacy accounts first priced under the new system from January 2008 will be eligible for compensation for January, February and March bundles.
The payment
Each contractor will receive a payment of 90% of the difference in the NHS charge values deducted due to the difference in average switching rates between legacy and new system processes for a maximum of three qualifying months that a pharmacy's prescriptions were processed through the new system between January and May 2008. This calculation will be specific to each pharmacy, based on the number of prescriptions switched by the new system in each month.
NHS Prescription Services will shortly send a letter to affected contractors to tell them the compensation payment they have calculated for them. The payment will reach contractors in early October 2008. Contractors do not need to take any action – this will be processed automatically.
The compensation payments will exclude from the calculation any months for an account where NHS Prescription Services have already checked the switching and made adjustments to payments. The level of compensation recognises the delays in payment reaching contractors.
How the payment will be calculated
To make payment NHS Prescription Services have to calculate a value for both the numbers switched under the new system and the numbers switched under the legacy processing system.
NHS Prescription Services will take the number of items switched from exempt to chargeable in each qualifying month between January and May 2008 that a pharmacy account was processed through the new system as the basis for the calculation (No.of CIP switched).
Payment = 90% difference between CIP switched value and legacy switched value.
CIP switched value = No. of CIP switched x prescription charge.
Legacy switched value = (No. of CIP switched x 0.13 / 0.99) x prescription charge.
The 0.13 and the 0.99 comes from NHS Prescription Services figures that there has been an increase in the percentage of forms being switched from the exempt to charge bundles from an average of 0.13% under legacy processes to 0.99% under the new system.
As was announced in the July agreement, there will be no further concessions from June 2008 onwards. It is essential that contractors review their processes for monitoring the completion of patient declarations of their charge status. PSNC will continue to work with NHS Prescription Services to audit the system on a regular basis.
Monitoring PPD Switching Accuracy
To monitor ongoing accuracy of switching, PSNC undertook an audit of the accuracy of prescription switching from the exempt to charge paid groups for June 2008 prescriptions. A total of 96 contractor accounts were sampled, covering the 3 processing sites using the CIP system. The sample included 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 was 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 were 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 being sent to all contractors who had bundles checked as part of the audit.
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).
Although the survey included approximately 50% independents and 50% multiple pharmacies, approximately 75% of the correct switches related to multiple pharmacies.
Incorrect Switching
PSNC found that although the switching was correct in the majority of bundles reviewed, in some accounts, prescriptions were identified that had been switched incorrectly and has fed this information 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 be undertaking further audits on switching to monitor whether the measures taken by NHS Prescription Services to improve accuracy have been successful. The results from this ongoing work will be published in due course.
NHS Prescription Services’ new tool to analyse contractor accounts for potential errors is able to review accounts for anomalies linked to prescription switching. PSNC is continuing to call for copies of prescriptions switched to be returned to contractors for information/education purposes.
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
The number of items shown as switched on my Schedule of Payments doesn’t tally with the number of ‘paid’ items I submitted?
In previous months, for contractors priced via CIP there was an error on the Schedule of Payments. Rather than showing the ‘items’ transferred between the exempt and charge paid groups, the Schedule showed the total number of ‘forms’ transferred. This will not affect the accuracy of a contractor’s compensation claim – claims will be calculated based on information held on NHS Prescription Services systems of ‘items’ switched. NHS Prescription Services have confirmed that the error in the Schedule of Payments problem was rectified with effect from April 2008. The Schedule now correctly shows the number of ‘items’ switched.
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
f 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
This process is burdensome and impractical for PCTs and pharmacy contractors. To improve transparency in the system and to restore contractor confidence, PSNC is lobbying for NHS Prescription Services to provide copies of switched prescriptions to contractors for information purposes. NHS Prescription Services have stated they are reviewing whether this is possible.
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.
DOWNLOADS: Some documents are available in PDF format, you will require Adobe Acrobat Reader 5.0 or later for viewing which can be downloaded from the Adobe Website
DOWNLOADS: Some documents are available in ‘Microsoft Word’ format. If you do not have Microsoft Word, you can read these forms by downloading the free 'Word Viewer'. This program can be downloaded at the Microsoft website