Patients claiming universal credit who are exempted from prescription charges are receiving penalty notices because prescription forms have not been amended to include the benefit – six years after it was introduced. Some people have reported receiving multiple charge notices. Many people are being penalised for a pharmacy error or because of a misunderstanding. A third of the 2017 penalties imposed were overturned on appeal so far.

Patients who are suspected of wrongly claiming free prescriptions face a penalty of five times the prescription charge plus the charge itself. The maximum is £100; £50 is added if the bill is not settled within 28 days. 

The NHS Business Services Authority (NHSBSA), an arm’s length body of the Department of Health and Social Care (DHSC), says a universal credit tick box should be added “later this year”. Until then, claimants entitled to free prescriptions must tick the “income-based jobseeker’s allowance” box. However, some who did so report they have still been penalised. Furthermore, no one is informing people which box to tick.

Many of the patients who receive penalty notices simply failed to realise that they no longer qualified for free prescriptions and dental treatment. Exemption certificates are automatically issued to those who earn less than £15,276 a year and receive working tax credit, child tax credit, or income support, as well as income related Employment and Support Allowance.

However, apparently, the certificates are only valid for up to seven months and recipients are not notified if they do not qualify for a renewal. The new fraud prevention system seems to be set up to penalise people because of the fact they are not kept informed of changes to their entitlement to free prescriptions, which is categorically unfair.

Moreover, it is creating severe distress and harm.

The devastating impact on vulnerable patients

Last year, Labour called for an overhaul of the system when a woman killed herself after receiving nearly £200 in penalty charges. Penny Oliver, a part-time chef, had not realised her exemption had lapsed after an ESA assessment deemed her fit for full-time work. Because her benefits had been cut she could not afford the penalties. In June 2018, she took an overdose of antidepressants – the medication that had created the debt.

Oliver owed sums of just £8.60 and £20.60. But with penalty fees and surcharges these rocketed – the second one alone soaring to £120.60. That’s ten times the amount for that prescription. After having lost hundreds of pounds a month when her benefits were cut, she simply couldn’t pay. Her housing benefit and council tax reduction were also cut, leaving her facing recovery action for an overpayment. 

She had just a few pounds in her account and was surrounded by payment demands when her family tragically found her dead last in June. Letters from the council, the NHS and Department for Work and Pensions included threats to take her to court and inform her employer if she did not pay.

At the time, shadow Health and Social Care Secretary Jonathan Ashworth said: “This is shocking. Questions have to be asked about the humanity of a system that does this to vulnerable people.

“Penalty charges should be scrapped – it’s a disgrace to exploit vulnerable, ill people in this way. Ministers urgently need to step in and review this system.

“Our NHS is there to help patients get better not make their condition worse by putting ­unacceptable burdens on people like this.”

Single mother Sue Carpenter was ordered to pay £100 after mistakenly claiming a free dental check-up. “I have had an NHS exemption since my daughter was three, but I received no reminder that it would run out when she was 18,” she explains.

“I knew my child tax credit would change, but I’m still eligible for working tax credit and I assumed the exemption was linked to the entire tax credit award, not just to the child component. The dentist didn’t ask to see my certificate, which I now realise expired two weeks before.”

Carpenter says that the expiry date should be made clear. “The NHS exemption seems a unique instance of a status that runs out with no clear warning, allows you to continue using it when it has expired and then incurs a steep penalty without prior notice of the consequences.”

The NHSBSA says it is a patient’s responsibility to check the expiry date on their exemption certificate.

However, recovering costs someone incurred in error is one thing, but fining people because they didn’t read the very small print, especially given that the citizens affected are likely to be ill and also on a low income, is a step too far. While it raises revenue for a cash-starved NHS, it is at the expense of those with the least, as usual. Fining people for a genuine mistake because they are not provided with sufficient information in the first place is outrageously mercenary.

The high cost of countering pre-estimated fraud

It is unsurprising to learn that the NHS counter fraud authority was created by legislation, launched in 2017-18, and is subject to direction by the Secretary of State. It’s also worth noting that the majority of health funding goes to the Department’s
arm’s-length bodies. 

In 2016-17 the Health Department had an overall revenue and capital budget of £122.2 billion. Less than 4% (£4.7 billion) of its funding was allocated to the core Department, according to the National Audit Office (NAO). The remainder  (£117.5 billion) was allocated to its arm’s-length bodies. That’s a huge sum of public money that is spent on managing the NHS and not on delivering frontline services. 

Furthermore, amendment was made via statutory instrument to the Regulation of Investigatory Powers (Directed Surveillance and Covert Human Intelligence Sources) to ensure that the senior officers of the NHSCFA will have the power to authorise the conduct of covert directed surveillance. The health authority is directed to carry out the Secretary of State’s functions in relation to counter fraud against or affecting the health service in England.

Usually when Conservatives claim to “counter fraud”, it entails the creation of a hostile environment. Social security, for example, has been transformed from a redistributive system for the public protection from the ravages of poverty to one that administers the discipline, coercion and sanctions, using absolute poverty as a punishment for “non compliance”.

Professional and patients’ bodies have also expressed their concern that the system designed to detect fraud is undermining the whole ethos of the NHS.

Rachel Power, chief executive of the Patients Association said: “Serving penalty notices on patients cannot be a caring way to manage this system.” 

“Some of the people who received these notices will be in vulnerable situations, and the impact of letters threatening court action, particularly for those who are receiving treatment for mental illnesses, should not be underestimated.

“While it’s important that fraudulent and incorrect claims are identified, nearly one in three penalty notices had to be withdrawn because they were issued in error. This shows a system that is highly dysfunctional.”

It also indicates the introduction of an increasingly hostile environment within health services, especially for those ill people on low incomes. 

The health secretary, Matt Hancock, has previously said: “The message is clear. The NHS is no longer an easy target, and if you try to steal from it you will face the consequences.”  

I’m wondering how it is possible to steal healthcare, bearing in mind that the same minister insists that the healthcare in the UK is still “free at the point of access”. I think this systematic restriction of access to public services more generally is precisely what David Cameron meant when he said that he wanted to tackle the “culture of entitlement”.

The public pay taxes and national insurance – “social insurance” – for increasingly little return while millionaires get tax cuts and carrots while everyone else gets the austerity stick, and told to live within our increasingly diminishing means. We are being dispossessed, so the very wealthy can accumulate even more wealth.

This year the NHS is piloting a digitised system that it claims will enable pharmacists to check eligibility instantly. However, surely the same system could be used to inform patients of their eligibility status also. That would reduce error considerably, too. 

The NHSBSA say they are digital by default, and: “We use complex algorithms and data mining tools as a means to identify both normal behaviour and outliers in NHS data, within which fraudulent behaviour may be found.

The resulting “analyses” are used to support ongoing investigations as well as inform the intelligence picture and guide fraud prevention steps.”

The “complex algorithms” are very clearly being used as a blunt instrument, resulting in least one death, to date. Yet one of the highest costs of “highly probable” fraud, according to the NHS BSA is from procurement and commissioning fraud, at an estimated cost of £266m £266m between 2016-17. (See page 8 here). 

The key stakeholders of the counter fraud authority include NHS England, NHS Improvement and the Cabinet Office.

The Royal Pharmaceutical Society and the British Medical Association fear the new system will withhold vital treatment from people on low incomes who remain eligible for free prescriptions but have failed to renew their paperwork.

“Pharmacists don’t want to be the prescription police, spending their time checking exemptions rather than advising on patient care,” says Sandra Gidley, chair of the Royal Pharmaceutical Society’s English pharmacy board.

“It’s very easy for mistakes to happen. Sometimes it’s that the computer says ‘no’, on other occasions people have simply forgotten to renew. Some don’t know if they’re exempt or not, or wrongly assume they are.”

She says that the prescription system should be overhauled to prevent confusion and reflect medical advances. “Medical exemption criteria have not changed since 1968. This means they are completely unjust. For example, those with long-term asthma have to pay for prescriptions, whereas people with diabetes don’t. Many new long-term conditions have been discovered in the past 50 years and they aren’t covered at all.

“It would be much simpler to have free prescriptions for everyone, as is the case in Scotland and Wales, because then no one would have to worry about remembering to fill out the right form.”

Data released under the Freedom of Information Act last year shows that 1,052,430 penalty notices were issued to patients in England in 2017 – about double the level in the previous year. But the data confirms that 342,882 penalty notices were subsequently withdrawn because the patient was entitled to free prescriptions after all, upon further investigation. 

The NHSBSA, the agency in charge of issuing the fines, said it was “continually reviewing its data-matching process and making improvements to ensure eligible patients were not wrongly pursued.”

The agency said it was also trying to educate patients on the importance of keeping the details on both their GP records and their exemption or prescription prepayment certificates up to date. 

It’s yet another public service system that’s been designed to assume people are guilty of fraud, with the onus on patients to provide proof that they are innocent.

“The NHS loses millions each year through fraudulent and incorrect claims for free prescriptions,” said Alison O’Brien, head of loss recovery services at the authority. “On behalf of NHS England, and in discussion with the Department of Health and Social Care, the NHS Business Services Authority checks claims randomly and retrospectively to appropriately recover funds and return them to NHS services.”

However, as the data strongly suggests, in far too many cases, it isn’t appropriate to recover funds and impose fines. Errors are happening all too frequently, creating anxiety, distress and hardship. When accusations of fraud are made which are not true, it causes humiliation and creates scapegoats.

Given that the neoliberal state treats citizens as if they have done something wrong as a starting point – which is the key message embedded in hostile environments; creating stigma and criminalising already marginalised groups –  it’s become a standardised form of political abuse which is entrenched within our public services. It’s designed as a punitive form of resource gatekeeping, resulting in withholding service and support from the very people who those services were designed to support.

Unfortunately, there is a pathological political narrative that tends justify cost cutting measures and punitive policies which portray the state and the mythically discrete class, “the taxpayer”,  as victims, when the state is actually perpetrator, and we all pay taxes for the services that are being dismantled by stealth.

Many of us have raised concerns related to the impact of the government’s various “hostile environment” policies in the health, housing, welfare, finances and banking, education, social services and other sectors, on vulnerable groups and those who share protected characteristics. The Equality Act was originally designed to address this kind of discrimination. But as we have learned over the last eight years, the government regards human rights and equality frameworks as a mere inconvenience. 

Peter Burt, a patient who was wrongly issued with one of the NHS penalty notices, said he worried about how certain patients would react to receiving one. “Some of the people who received these notices will certainly be in vulnerable situations and some will be receiving prescription medication for anxiety and mental health issues,” Burt said.

“They should not be receiving letters threatening court action just because the NHS can’t be bothered to check the records to see whether they have a prepayment card – especially if there is no intention of carrying out the threat. It’s hugely disappointing that, at a time when clinical services are clearly facing financial strains, the NHS bureaucracy is wasting money by sending out hundreds of thousands of inaccurate demands every year.”

Watson said more problems lay ahead if further planned changes to the way medicines were prescribed were introduced.

“The bureaucracy around prescriptions is unfit for purpose, and will only get worse if NHS England introduces its planned restrictions on prescribing over the counter medicines,” she said. “Serving notice of penalties for free prescriptions on patients who may be vulnerable and unwell and are then required to demonstrate their right to a free prescription cannot be a compassionate and caring way to manage this system.”

It certainly seems to be the government’s modus operandi to withdraw compassion and care when it comes to public policy design, which have been templated to implement austerity rather than ensure delivery of public services that are fit for purpose.

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You can check your eligibility for free prescriptions and other health services here: National campaign launches urging patients to ‘Check Before You Tick’ for free prescriptions.

 

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