Prescription switching

At the end of each month, pharmacy teams are required to sort their FP10 paper prescriptions into either exempt or paid groups before the prescription bundle is submitted to the NHSBSA for pricing. The sorting helps the NHSBSA determine which prescriptions are paid so that the correct number of charge deductions can be calculated. If an FP10 prescription form has been placed in the wrong group, or the patient has completed their declaration incorrectly, the NHSBSA will switch the prescription to the appropriate group. Therefore, switching occurs when the NHSBSA moves a paper prescription from the exempt to paid group or vice versa.

Prescription switching only affects paper prescriptions; electronic prescriptions are not switched by the NHSBSA. This is because electronic prescriptions are not required to be sorted into paid or exempt groups for submission, as they are processed according to the charge status declared in the EPS Claim Notification (CN) message or Electronic Reimbursement Endorsement Message (EREM). The EPS tokens submitted to the NHSBSA are NOT used for pricing purposes. The tokens are scanned and stored for audit purposes only and used by the NHSBSA for exemption checking purposes or as a record of the paid declaration made by patients.

It is important to note that where an exempt status has not been recognised by Real Time Exemption Checking (RTEC) and an exempt/paid status has not been selected on the EREM, some Patient Medication Record (PMR) systems may automatically default the prescription to paid status. If this happens with your PMR system, check with your system supplier if a prompt can be issued to users asking for confirmation of the patient’s paid/exempt status before an EPS claim message or EREM is submitted for payment.

During processing, any potential prescriptions identified for switching are referred to an operator at the NHSBSA to be manually checked before a switch is confirmed. Once confirmed, prescriptions can be switched two ways – from the exempt to chargeable group or vice-versa.

Prescriptions are switched from the EXEMPT TO CHARGEABLE group because:

1. The reverse of the prescription form was left unsigned. Unsigned FP10 paper prescriptions placed in the exempt bundle will be switched to the paid group by the NHSBSA even if there is an exemption reason marked on the reverse of the prescription form. This is the most common reason for prescription switching and has a negative financial impact on community pharmacies. Please note that unsigned prescriptions for age-exempt patients are not switched to paid group if a computer-generated age/date of birth is printed on the front of the form.
2. The prescription contains a charge rate. This occurs when a signed paid prescription includes an amount in the paid box but has been mistakenly placed in the exempt group for submission to the NHSBSA. Such prescriptions are switched from exempt to chargeable group by the NHSBSA as the declaration confirms that a patient paid prescription charges.
3. The prescription with only free-of-charge items (contraceptives and/or FS-endorsed items) was sorted into the exempt group. As there is no exemption category to select for these items on the reverse of the FP10 paper prescription form, the NHSBSA advises that such prescriptions should be placed in the chargeable group, with the FS-endorsed items placed in the red separator (chargeable group), unless the patient is exempt from paying prescription charges for other reasons (for example, has a valid medical exemption certificate). However, the NHSBSA will not deduct any prescription charge for free-of-charge items whichever group they are submitted in.
4. The prescription includes both a paid item and a free-of-charge item (contraceptives and/or FS-endorsed items) and is submitted in the exempt group. The prescription will be switched from the exempt to paid group if no exemption reason is declared on the reverse of the prescription form.

Prescriptions are switched from the CHARGEABLE TO EXEMPT group because the reverse of the prescription form was signed with an exemption declared, but the form was incorrectly submitted in the chargeable group for end of month submission to the NHSBSA. The prescription may also be switched if the prescription has been submitted as paid but there is no amount paid present on the reverse of the form but the patient has signed in the signature box.

If any paper prescription forms are switched from exempt to chargeable group, a prescription charge is deducted for each item dispensed on the prescription (unless the item is a free-of-charge item such as a contraceptive). This can have huge financial consequences for pharmacy owners which can be easily avoided by checking and completing the reverse of all paper prescriptions before they are submitted for payment.

It is important to note that no charge deductions are made for items on a prescription that are switched from the paid to exempt status. We encourage pharmacy teams to ensure the correct number and amount of prescription charge(s) are collected and declared on the FP34C particularly around months where there has been a change to the prescription charge rate.

Financial impact of prescription switching

• In 2024, over 230,000 prescription items were switched from exempt to paid due to unsigned paper prescriptions submitted in the exempt group.
• Based on the prescription charge rates applicable in 2024, we estimate that across all pharmacies, the NHSBSA deducted £2.3m in prescription charges due to switching.
• This equates to an average deduction of approximately £220 per pharmacy from unsigned paper prescriptions submitted in 2024.
• Ten years before (in 2014), there were over 1.2m prescription items switched from exempt to paid due to the reverse of paper prescriptions being left unsigned. Over the last 10 years, there has been an 80% reduction in unsigned prescriptions, mainly attributed to the widespread use of EPS across different healthcare settings.
• The graph below highlights the decline in the number of prescription items switched from exempt to paid over the last two years

Information about any switched prescription items can be found in the FP34 Schedule of Payments under the section ‘Items Transferred Between Exempt and Chargeable Groups’. If any paper prescriptions have been switched, this section will show the number and reasons for any switched prescription items.

Pharmacy owners are advised to monitor their monthly switched item figures to ensure that any increase in prescription switching is identified. This may prompt staff training to ensure the reverse of all paper prescriptions are signed and completed in full before sorting them into the relevant exempt or paid groups for submission.

If a pharmacy owner believes there is an issue relating to a potential switching error, they can ask the NHSBSA to recheck a specific month’s switched prescriptions. Pharmacy owners must submit a recheck request to NHSBSA by completing the recheck request form.

The image below shows how the different reasons for prescription switches appear in the Schedule of Payments:

The image below is an example of what the Schedule of Payments will display if unsigned prescriptions have been switched from the exempt to chargeable group:

How to Prevent Prescriptions from Being Switched

• Pharmacy teams must ensure that the reverse of FP10 paper prescriptions are completed in full (please see image below), ideally at the point of handing the dispensed items to the patient. This includes prescriptions for age-exempt patients where their age/date of birth is handwritten on the front of the form.
• The reverse of the paper prescription form must either have a valid exemption reason ticked or if the patient pays for their prescriptions, the amount paid box must be completed showing the total amount of charges collected.
• The patient signature box must always be populated. A line, a cross or a scribble is acceptable as a valid signature.
• If a patient presents multiple paper prescriptions, the reverse of all prescriptions must to be completed in full.
• A pharmacist may act as a representative with the patients consent. If the pharmacist is acting on the patient’s behalf the patient should understand that if any information is incorrect, they will be liable for any penalties, not the pharmacy.
• Ensure paper prescriptions are sorted into the correct exempt or paid group for end of month submission.

The image below highlights each section of the reverse of a FP10 paper prescription form which must be completed:

To monitor on-going accuracy of prescription pricing, Community Pharmacy England undertakes routine audits of pharmacy owners’ prescription bundles, and this also includes monitoring of switched prescriptions. On the rare occasion a prescription is found to have been switched incorrectly by our pricing and audit team, this information is fed back to the NHSBSA so that adjustments can be made to the account of the individual pharmacy concerned.

Q. Where in the prescription bundle should I put a paid prescription which includes a free of charge contraceptive medicine?

In this scenario, the prescription should be placed in the ‘chargeable’ group.

The item itself will be switched to give it an ‘exempt’ status, but it will not be shown on the Schedule of Payments as a switch as the NHSBSA does not deduct charges where the prescribed item is a contraceptive medicine or device included in the Drug Tariff list of products to be supplied to patients free of charge.

Q. Do I have the right to ask the NHSBSA to return switched forms to me?

The NHSBSA will return a sample of switched forms to a pharmacy contractor on one single occasion only for training purposes. Any subsequent requests should be directed to your local NHS England teams in accordance with Direction 7 of the Pharmaceutical and Local Pharmaceutical Services (Prescriptions, Payments and Listings) Directions 2013. Local NHS England teams are required to provide pharmacy contractors with reasonable facilities for examining a sample of their prescription forms, together with details of the amount calculated by the NHSBSA as payable.

To arrange to view forms, contractors should make a request to their local NHS England teams (including details of the forms concerned, e.g. a particular prescription month). The local NHS England teams will then request the forms from the NHSBSA.

Q. 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 therefore, even if the CIP scanner cannot read the signature due to ink colour, the handler will be able to.

Q. 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?

A.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 or penalties incurred by acting as an “agent” are in fact liabilities of the patient. This is because 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 advice from the Counter Fraud and Security Management Service (now known as NHS Protect) is that generally, pharmacists should not sign as the patient’s representative as they are financially involved in the transaction and would also be responsible for establishing that the patient is exempt from prescription charges.

Unfortunately, Community Pharmacy England has been informed of cases where pharmacists or other members of the Pharmacy Team have erroneously signed prescriptions on behalf of patients, where the patient was not present in the pharmacy at the time of dispensing, and then these patients have received letters from the NHS seeking repayment where it has transpired that the patient was not actually entitled to exemption from charges. The signing of the exemption claim is therefore not recommended, unless the pharmacist or the Pharmacy Team see the proof of entitlement to exemption.

Please note, the use of a pharmacy stamp instead of a signature in part 3 of the patient declaration is not accepted, the prescription must be signed by the patient/ a representative.

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

The National Health Service (Charges for Drugs and Appliances) Regulations 2000 as amended requires a pharmacy (and other NHS suppliers ) to collect the prescription charge unless there is a valid claim for exemption (other than the exceptions, such as for oral contraceptives, or the age-related exemptions where the date of birth is printed on the form).

Under Regulation 3(7) of those Regulations, any sum payable by the local NHS England teams to the Chemist (i.e. reimbursement and remuneration to the pharmacy) 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 NHSBSA not only has lawful authority to deduct the charges, but is required by the Regulations to do so.