The Pharmaceutical Journal
Vol 268 No 7202 p833-834
15 June 2002

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Why the Government accepts the hit and miss nature of prescription charges

There are many anomalies in the Government’s current system for entitlement to free prescriptions in the United Kingdom. Debbie Andalo looks at what is wrong with the current system and asks some of the relevant bodies how it could be improved

The system of free prescriptions in the United Kingdom is illogical, irrational and works against the principles of the National Health Service.

These remarks could easily have come from health or welfare rights pressure groups which have been campaigning for years for the exemption system to be changed. But they are in fact the conclusion of Derek Wanless — the former NatWest bank chief executive charged with the unenviable task of looking at the future funding of the health service on behalf of the Treasury (PJ, 27 April, p564). His report, "Securing our future health: taking a long-term view", which was presented to the Chancellor of the Exchequer (Gordon Brown) on Budget day in April, ruled out any immediate changes to the system because it would bring little financial gain and because of its "political sensitivity". His review, which was accepted by Gordon Brown, was the most recent opportunity the Government has had to begin to overhaul a system that has remained unchanged for more than 30 years.

Medical conditions which entitle a patient to claim exemption from NHS prescription charges were agreed following consultation with the medical profession in 1968. Although the list has been reviewed since then — most recently in 1998 as part of the new Labour Government's first comprehensive spending review — it has remained unchanged because of a continued lack of consensus about what other conditions should be added, and on what grounds. The conclusion Ministers drew four years ago was that rather than extend the number of medical conditions, they would concentrate on giving additional financial help to those patients who have difficulty meeting the charges.

The Government's lack of courage in tackling the medical exemptions list means that ridiculous anomalies remain. Under the present system a pregnant millionaire is exempt from charges while people on lower incomes with chronic asthma have to find the money to pay for their inhalers. Patients with epilepsy who require continuous anticonvulsive therapy qualify for free prescriptions while people with HIV/AIDS do not. The system is so muddled that exemption status is even different across the same condition. A diabetes patient who requires medication qualifies for free prescriptions across the board — not just their diabetes medication — but another patient with diet-treated diabetes has to pay for any medicines needed.

Anomalies highlighted

The anomalies were highlighted by the Association of Community Health Councils for England and Wales in its report "A tax on illness" which called for a radical overhaul of the system. The report, which was sent to the Health Secretary (Alan Milburn) in March, said the present system should be abolished along with all prescription charges. ACHCEW is still waiting for an acknowledgement from the Health Secretary. Its legal officer, Marion Chester, says: "I think his silence illustrates two things — a lack of interest in the issue by the Department of Health and, as Secretary of State, it doesn't say much about the Government's patient-centred approach to the health service."

The ACHCEW report is the second study in less than a year to land on the Minister's desk demanding free prescriptions across the board. Last summer, the National Association of Citizens Advice Bureaux presented the results of its survey of the system. The association discovered that 28 per cent of patients who have to pay for their prescriptions could not afford to get all the items dispensed. NACAB social policy officer Liz Phelps admits: "We have made the point to the Government that the system does not seem to be compatible with its health inequality agenda. The Government has a priority of heart and cancer care and there are national service frameworks for these but, if you look at the exemption list, these conditions aren't there.

"Every now and then we get a parliamentary debate about medicines exemptions, but the problem is that if you go down that road then you get into difficulties as you need to update the list, but where are the boundaries? As new illnesses get diagnosed and conditions are classified as chronic do they come in or not? Politicians don't want to go down that road, but the more they do nothing the more the existing exemptions look anomalous."

If the Government is unhappy at a free-for-all on prescriptions then NACAB suggests it brings in a sliding scale for the pre-payment or season ticket certificate. Under the current system, patients are entitled to an unlimited number of prescriptions for a year at a cost of £87.60, or for four months at £31.90, but the money has to be paid in advance.

Introducing a sliding scale of payment would benefit those patients with long-term medical needs whose income is just above income support level (which entitles them to free prescriptions) and would mean they could have the same cap on their prescription costs as patients who are better off.

The Consumers' Association has also added its voice to the call for a comprehensive review of the free prescription system and last December urged the Government to reconsider exemptions and charges.

Pressure from pharmacists

Pressure to change the system is also coming from pharmacists. The National Pharmaceutical Association endorses free prescriptions for all. The NPA's director of pharmacy practice, Colette McCreedy, says: "We have held this position for years. We believe the present system is an unfair system. We have patients who tell their pharmacist that they cannot afford all three items on a prescription and ask which one they need the least. This puts the community pharmacist in a difficult position. The present system creates a sickness lottery which is dependent on what you are suffering from rather than whether you need the medication."

Dr Gordon Geddes, head of information and technical services at the Pharmaceutical Services Negotiating Committee, agrees: "There are too many anomalies in the present system and it is also not a transparent system. That means that the pharmacist has to take additional care to levy the right charges and it's hard for patients to understand.

"With whatever system we have there will always be people who fall through the net, who are borderline. Since charges were introduced in 1952, prescriptions have been a political football. The most reasonable system would be to get away from charging and raise the money through taxation."

Exemption lottery

Charities representing patients who are victims of this exemption lottery are finding ways around the restrictions. Patients with insulin-dependent diabetes who use injection pens — only some of which are available on NHS prescription — are encouraged by Diabetes UK to stock up with supplies at hospital clinics where they are free. "It's not a policy priority for us, but it is a situation which we continue to monitor," a spokesman for the charity says.

However, the issue of medical exemption is high on the political agenda of the National Asthma Campaign since the chronic condition is not included on the medical exemption list.

In a statement the campaign says: "People with asthma are telling us that they cannot afford to pay for their prescriptions. They are limiting their asthma medication and putting their health at risk. Incorrect asthma treatment can increase the frequency of asthma attacks and lead to irreparable damage to the lungs. We want free prescriptions to be given to everyone with asthma. Eradicating unnecessary financial barriers will give people the opportunity to effectively control their asthma in the long term."

The Government's view

The Government has no plans to reconsider the medical exemptions list and the Wanless report comments now make it even more unlikely in the near future. A Department of Health spokeswoman explains the thinking behind the Government's current policy agreed following the 1998 comprehensive spending review when the future of the list was last considered. She says: "It was noted that there was no consensus on what additional conditions might be included in any revised list of medical exemptions, or how distinctions could be drawn between one condition and another — it would not be right to consider one group in isolation."

The solution to the dilemma, Ministers decided, was to focus on boosting financial help to people on long-term medication rather than tackle the medical exemption list.

She adds: "The basis of Government policy is to give priority to helping people who may have difficulty in paying charges, rather than extending the exemption arrangements to people with other medical conditions."

She pointed to the NHS Low Incomes Scheme to which patients can appeal if they do not automatically qualify for free prescriptions. And the pre-payment certificate scheme is also available as a way of reducing prescription costs for the long-term sick, she said.

Joint campaign needed

The Government appears to have taken the easy option. It has lacked the courage to tackle a medical exemption list that is clearly out of date or abolish all charges, which would be in tune with its commitment to a health service based on clinical need and not income and its desire to outlaw health inequalities. The demands for an overhaul of the system and free prescriptions are increasing but unless there is a joint campaign which brings the anomalies of the system into the wider public domain the pleas for a radical change are likely to continue to fall on deaf ears.