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Fraud checks: give patients the benefit of doubt

"I can see why some C+D readers are angry over my views but, frankly, I’d be more worried about causing a fatality"

We are creating a profession of risk-averse pharmacists unwilling to make a decision that goes against the rules, even when in the patient’s best interest, says Sid Dajani

I stirred up controversy at a C+D webinar last month by saying that patients should come before government recommendations when dispensing prescriptions. I was talking about the proposed introduction of an electronic fraud check system in pharmacies by 2018, intended to root out those illegitimately claiming free prescriptions. But it seemed not everyone was with me when I said pharmacists should dispense a free prescription to a patient in need, even if the government’s computer system said they were not entitled to it.

 

This prompted a barrage of criticism calling me out of touch and on another planet. Whether it is fair or not, one thing seems obvious: we are creating a profession of risk-averse pharmacists unwilling to make a decision that goes against the rules/SOPs/management, even when in the patient’s best interest. That, to me, is unprofessional. I’m proud to stand with the 16 per cent of 153 readers in last month’s C+D poll who said they would take the risk of being waterboarded for championing patients over the out-of-date prescription tax system.


Why do I believe this? Well, there are three issues that explain my stance. The first is: what if the patient and the new exemption checking system disagree? Clearly, some patients will play with the truth but equally some computer systems could be inaccurate, out-of-date or just offline, so who would you believe? I suggest that, in this case, we essentially do what we do now: take the patient’s word, provide their potentially life-saving medication and tick a box to say the patient disagreed with exemption status.

 

The second issue is: what happens if a paying patient can’t afford the medication? Here, I suggest using common sense and professional discretion to recommend pre-payment certificates, offer to take payment from a third party over the phone or advise on choosing between medicines. For regulars, I’d also consider providing part-supply until payday - but I’d never advocate pharmacists paying the fee or fraudulently ticking an exemption box, as some have suggested.

 

The third issue is something we can all agree on: the current prescription charge system flies in the face of our clinical role, equality, fairness and adherence. No-one really knows how much the charges rake in because we don’t know cost of policing, prosecuting, managing and governing them. The controversial part is whether we replace it with a much smaller blanket charge, spreading the tax collection beyond opticians, dentists and pharmacists and including nurses, A&E and GPs.

 

All I’m suggesting is that every option is considered and impact assessments are measured from the viewpoint of patients, the NHS and healthcare professionals like us. We should investigate how any change would affect workloads, sustainability, efficiency and governance.

 

Although I’ve been accused of being out of touch, I am an independent contractor and a pharmacist at the coalface on most days. I can see why some C+D readers are angry, incandescent and bloody furious over my views but, frankly, I’d be more worried about causing a fatality by refusing to give the patient the benefit of doubt.


Sid Dajani is a contractor and member of the Royal Pharmaceutical Society’s English Pharmacy Board

 

14 Comments

Gerry Diamond, Primary care pharmacist

Sid, you're great just for the entertainment value alone.!

Sultan Dajani, Community pharmacist

:0)

Leon The Apothecary, Student

Sid, respectfully I tend to agree with the evidenced overwhelming opinion that you are out of date, and perhaps out of touch, with how legal systems work. It's the equivalent of speeding down the road with good intentions. Rules and regulations are there for a reason. If the rule doesn't make sense to you, it's not up to you to ignore them because it doesn't suit you and decide you want to do 70mph down a 30mph because it is in the best interest of the patient if you got to work quicker. No, it's up to you to work towards having the rule changed through a majority democratic process. What you invite with a laissez-faire approach is one where there are no clear guidelines, and with that a far greater risk of harm, criminal activity, and clinical mistakes. It's a car crash waiting to happen.

Sultan Dajani, Community pharmacist

Nobody is asking to break rules or regulations, just to think use clinical naus and think of the patients wisely when matters are grey (ie if the system says one thing but the patient says another or even if the System is down). secondly if the law works against the patient then we shouldn't just moan and groan but lobby to change it. So if an e-system comes in where there is no exemption disputes you can flag up then the system has to change. Thirdly I'd rather be right than rapid so you won't find me being reckless and going at 70mph and finally refusing to give a patient medicines where there is a dispute of eligibility could lead to more clinical harm, mistakes and reputational risks. And no one is saying promote criminal activity. So if I'm unreasonable for wanting a good system that's a useful tool that helps us and helps our patients then so be it. Others may deem that to be professional.

Leon The Apothecary, Student

Do you believe that it is perhaps an issue with the system to allow a situation like that to occur in the first place and that is an issue that we should be working towards fixing? Universal Script Fees is a far better reductive approach to your problem with less paperwork, system requirements, and administration, not to mention the boon it provides to the NHS budget as I have previously stated in an earlier article this week.

Sultan Dajani, Community pharmacist

Of course the issue is with the system and ideally we would be allowed to shape the final tool. I think the discussion is what we would do in the worst case scenario. Some side with bad SOPs over-ruling the patient if there's a dispute and others inc me are saying we side with the patient, sign the exemption box, Change the SOPs and if all else fails - whistleblow. Otherwise how would you define a 'Professional'?

Hackney Drug Dealer, Community pharmacist

Agreed! However the world is run by accountants and lawyers. So, yet again, we've been negotiated (further) into a 'policing' role. The costing of the inception & management of this role will probably be greater than the dividends. Scrapping the £8.20 levy wasn't considered or replacing with a cost/item/month treatment wasn't either (for all patients, especially some of the wasteful 'free' recipients). So, as an independent practitioner I can afford to be 'pragmatic' for petients needs. Could I advise any employee/locum to be so professionally minded when the GPhC/HMRC are waiting to swoop with a proctoscope without lube...and all for the sum of £8.20... Nah. Accountants and Lawyers. And the GPhC. And the HMRC.

Sid, labelling many pharmacists unprofessional for following laws, rules, SOPs etc in the face of the current working atmosphere is beyond unhelpful. The majority of pharmacists desperately want to put patient care first, but we're lumbered with a regulatory system that is most definitely not on our side. Would the GPhC spend time understanding the working conditions that would push us to make a decision against the law? Would multiples and superintendent pharmacists back us up for ignoring SOPs if we thought it benefited patient care? Do I have confidence that, if the worst case scenario happened, I would be tried in a just, professional manner by a regulatory body who upheld the fundamental principle of guilty until proven innocent? Of course I don't. Perhaps you- and the RPS, and the GPhC, would like to work together to provide a more robust, fair, and professional regulatory system before you start blithely labeling people as unprofessional.

Sultan Dajani, Community pharmacist

Hello Hayley, You flag up several issues here. The case in point is if the IT system says one thing about an exemption and the patient says another what will you do? For me, the system is a tool and not a replacement for a clinicians mind, experience, expertise and intelligence otherwise we may as well be a profession of semi-robotic beings. Besides which we already have a system now where there's a patient exemption not checked box but its paper-based. I'd expect the IT based system to be roughly the same. Secondly, I'm not criticising pharmacists at all for following regulation and SOPs or I'd be a hypocrite because my pharmacy has around 70 and of course we need them but they have to be fit for purpose. SOPs are meant to be tools for consistent and best practice, not to dumb down standards or replace the pharmacists brain. If there's a world of difference between a pharmacy's SOPs you raise concerns or you have your own. The GPhC premises standards includes the propriety of SOPs. The third issue is workforce pressures where a pharmacist is at odds with usually, a non-pharmacist manager who is not regulated like us and who puts undue pressure. This is a massive issue. There is no pharmacist empowerment, locums and employees are isolated, bullied, unnecessarily reprimanded and can only imagine, it'll get worse as graduate numbers increase. I know the PDA and the RPS are treating this as a high priority action point and lobbying the DH. For me this is THE major issue of professional progress and sits above funding and profession parity. The GPhC is not there to make sure you are blindly following bad SOPs - I'd speak to your inspector and learn a little about them, what they do and how they can help you if you have any problems. All of the things you raise are valid but have little to do with refusing a patient a rx if they're exempt but the computer tells you they're not.

I'm responding to your much more general points, e.g. "we are creating a profession of risk-averse pharmacists unwilling to make a decision that goes against the rules/SOPs/management", which clearly takes a wider stance than simply exemption checking. My point re the exemption checking, which I made on another post to you as well, is that at this point we have no idea what the service will look like. You're working on the basis that there will be an "exemption not check" tick box, and that there will be some sort of underlying checking mechanism beyond the pharmacist. If that's the case, then of course the scenario you describe would be the norm. BUT, at this point, we actually have no idea what the system will look like- its therefore very unfair to use words like unprofessional, or to appear so surprised at the hesitation many pharmacists have expressed when all there is to go on is speculation.

Sultan Dajani, Community pharmacist

Hayley - If we have an exemption not checked box now, why speculate it will go when we move to an electronic version? Services have to be intelligently designed around patients and tools have to be both useful and usable otherwise it will be a wholly unworkable environment - so I'd wager there will be one! Niall - It is and the RPS flagged up this issue many times at its meeting this week.

So you're speculating that the government are willing to put in an extra (no doubt extremely expensive) tier of exemption checking at the pharmacy stage, but still keep all of the existing processes in place at the NHSBSA as well, for the odd occasion when the computer says no but the patient says yes? Or who will be expected to check those cases? Admittedly government are all about wasting money here there and everywhere, but such a flagrant waste of cash seems ridiculous even for them.

N O, Pharmaceutical Adviser

Sid, common-sense says that if we still have that box then why force pharmacists to check the exemption online ???

Really? Wow, Superintendent Pharmacist

You both make some very valid points. I do agree that in general we are un-empowered, and this is significantly due to pharmacy becoming a profession of employees, rather than self-employed/independent profession in my opinion. What this really says to me is that we need to be in at the design stage of any system. Sid, are the RPS pushing on this point to get involved? Your webinar and points above really demonstrate that its a professional issue where I believe the RPS should be having influence. We need to ensure that there is an option still to have an exemption not seen.

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