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Noel Baumber is an independent pharmacy contractor
in Lincolnshire
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Prescription charges have been with us through two generations and 17
increases, but only two virtues come to mind in their favour. First,
they limit the paying patient’s liability to the value of the current
charge (£6.30) although the average cost of the medicine and the
service exceeds £10.89 per item and medicines can cost up to £250
per pack. Secondly, pharmacy contractors’ cash flow improves marginally
by the amount of charges collected in a month. Everything else seems
to be negative and capable of ruining relationships between prescribers,
patients and pharmacists.
Prescription charging becomes more contentious, troublesome and divisive
with every increase, so it is about time someone totted up the “downside” costs
of raising taxes the way we do or, to put it another way, of seeing what
can be bettered by not having to pay charges.
The downside
The downside is quite surprising in its ramifications. Exemptions, for
instance, have always stimulated argument and resentment as they are
unfair and arbitrary. They exist because charges exist and now extend
to 85 per cent of patients, but every exempt patient has to provide
evidence of their claim; a wholly unreasonable task worthy of George
Orwell’s imagination. Charging can affect compliance and mean
that some patients find themselves picking and choosing which prescription
medicines they can afford.
I could not find any statistics on the consequent costs of authorising
exemptions and maintaining records for each and every category, but the
prescription charge is not a clear profit for the Government.
There are problems and knock-on costs borne by the social services, but
what are they? The Prescription Pricing Authority now has to conduct
400,000 compliance checks each year, and has accepted the centralised
task of issuing in excess of a million pre-payment certificates.
There are legal costs, too. So far there have been 163 prosecutions resulting
from charge evasion where patients have had to be pursued through the
courts. These burgeoning problems can be made to vanish by abolishing
charges.
Wales has shown that things can change. In the principality, you pay
for prescriptions only between the ages of 25 and 60 years. The Social
Market Foundation think tank recently called for a new system of charges
and a £90 per year limit; presumably so that patients can accrue “pre-payment” status
as their needs become apparent. There is no simple system of charging
and exempting patients. The Welsh Labour Party goes furthest and wants
to abolish charges completely. This may seem like a return to Aneurin
Bevan’s enthusiastic idealism but it is not a crackpot idea.
Why bother with indirect taxation?
Her Majesty’s Treasury will regard prescription charges as indirect
tax worth £446m in the current year, but this is only levied on
15 per cent of patients, most of whom will be taxpayers who can contribute
either way through direct or indirect taxation. Why bother with indirect
taxation when it amounts to less than 0.5 per cent of income tax revenue,
which stands at £97,500m per annum? Prescription charge income
amounts to only £16 per taxpayer; less than half a tankful of petrol
per year, or two and a half prescription items!
I am not so sure that charging limits the volume growth or medicine costs
in an acceptable way, and the Department of Health, much to its credit,
is positively tackling medicine costs in other ways. Professor Geof Booth,
a former president of the Royal Pharmaceutical Society, showed over 30
years ago that charge increases only have a temporary braking effect,
probably at the expense of those least able to afford higher levels of
charging. In any case, much of the current growth is intentional due
to the introduction of national service frameworks for coronary heart
disease and diabetes in an ageing population. As pharmacy contractors
have seen to their cost, remuneration for providing the service is under
rigid political control and remains unaffected by prescription volume.
Other problems
Pharmacists have other problems with the system. When general practitioners
write prescriptions for two or three months’ medication instead
of one month, pharmacy income decreases substantially. When prescriptions
reduce to one month’s medication, patients who pay charges become
incensed and berate the pharmacist and the GP.
For years I resented having to pay charges when credit cards were presented
in payment for prescriptions. I did not realise how much I resented it
until I discovered that I was being charged over £800 per annum
for the convenience of people who no longer carry cash. Introducing a
credit card charge seems to have minimised the problem for now, but I
suspect that I am not the only one who is losing out from the move from
cash to cards. Even at £500 per annum per pharmacy, this is a loss
of £5m to the infrastructure of community pharmacy.
Repetitive strain injury
All contractors try to avoid placing prescriptions in the wrong bundle
since prescription switching loses them £300,000 per annum, so
I now find myself getting repetitive strain injury from signing more
prescriptions per day than a GP, mostly on behalf of elderly patients
who cannot visit the pharmacy to claim exemption. Going through the
day’s prescriptions is not only tedious and painful, but takes
about an hour to verify and make valid claims for exemption. Even if
this is undertaken by dispensing staff, it amounts to some three million
hours of wasted time every year throughout the country.
A total of £12m goes into the pharmacy contract to recompense prescription
checking, but the true cost to contractors of this inessential bureaucratic
task is somewhere between £30m and £60m, and carries criminal
penalties for getting it wrong. Moreover, while we are scanning prescriptions
for the NHS Counter Fraud and Security Management Service we are losing
our most
valuable asset — time — and not even considering the opportunity
cost of converting those hours into positive patient benefits. Where
are politicians going with this creeping bureaucracy? What will it do
for recruitment? What is the profession doing about it?
New contractual demands
If pharmacists already working 50 to
70 hours a week are expected to find
more time for patients and meet new contractual demands — medicines
management, repeat dispensing, continuing professional development, clinical
governance, competence testing, supplementary prescribing and increasing
service commitments — then abolishing prescription charges comes
high on my agenda as a means to an end. It is a timely and serious matter
for pharmacy contract negotiators. For the political party that cares
about quality of life, it could even help to win the next general election.
They can have my £16 any day! |
