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 Prescription charges will go up by 10p in Scotland on 1 April. A similar
rise is expected in England. However the Department of Health would only
confirm that an announcement was due to be made this week after The
Journal went to press; it would not provide any details.
Increasing prescription charges is unlikely to be popular since criticism
of charges is now widespread. What is interesting is that this criticism
comes not only from those who have to pay charges but from a broad range
of organisations, including the Royal Pharmaceutical Society. Has the
time come to review the charging system?
In Wales, the answer is a resounding “yes”. The Welsh Assembly
has already committed itself to introducing free prescriptions for everyone
in 2007. The first step towards achieving this aim was made in 2001 when
prescription charges were frozen at £6. This was followed last
October by a cut in charges to £5. And this week a Welsh Assembly
spokesman confirmed that prescription charges will be reduced again in
April to £4 per item.
However, the governments in England and Scotland have not followed suit — not
yet anyway. The Scottish Executive is undertaking a review of prescription
charges for people with chronic conditions and young people in full-time
education. A public consultation is expected later this year. Furthermore,
in January, a Member’s Bill calling for the abolition of prescription
charges was introduced in the Scottish Parliament.
Why the criticism?
It is worth considering why prescription charges attract so much criticism.
Earlier this year, the Society published a report calling for prescription
charges to be abolished (PJ, 15 January, p65). Eileen Neilson, head
of policy development at the Society, says that the report’s
conclusions are clear. “Charges do not just deter unnecessary
use of medicines; they also deter essential use of medicines in people
with non-exempt chronic conditions. That has adverse consequences for
their health and for costs elsewhere in health systems, such as unplanned
hospital admissions,” she explains. The Society sent its report
to the Department of Health but last week received a reply
indicating that the Government has no intention of changing its policy
on prescription charging.
For some people, prescriptions charges are incompatible with the fact
that the NHS was founded on the principle of free health care at the
point of delivery for all. Nye Bevan, who is credited with introducing
the NHS when he was health minister in 1948, resigned in 1951 when the
then chancellor announced his intention to introduce prescription charging.
However, for many people, the crux of the matter is that the current
system of determining who should pay charges is simply unfair. This is
summed up in the Wanless report, “Securing our future health”,
which states: “The present structure of exemptions for prescription
charges is not logical, nor rooted in the principles of the NHS. If related
issues are being considered in future, it is recommended that the opportunity
should be taken to think through the rationale for the exemption policy.”
According to prescription statistics published by the DoH in England
last year, around 50 per cent of the population are eligible for free
prescriptions but for about 87 per cent of all prescription items dispensed
no charge was levied. Those who are exempt from charges include children,
the elderly, people who are unemployed or on a low income, people who
receive certain state benefits and people who are exempt due to medical
conditions. It sounds like a fair list but there are inconsistencies.
For example, a multimillionaire aged 70 years is entitled to free prescriptions
yet a 25-year old with a low income just above the cut-off point for
free prescriptions has to pay. The National Association of Citizens Advice
Bureaux investigated the issue in 2001 and found that 12 per cent of
its clients surveyed failed to get their prescription dispensed because
of the cost and a further 16 per cent only collected part of their prescription.
Medical exemptions are a minefield. The only medical conditions for which
patients are entitled to free prescriptions are a permanent fistula,
hypoadrenalism, hypopituitarism, diabetes mellitus, hypoparathyroidism,
myasthenia gravis, myxoedema, epilepsy and a continuous physical disability
resulting in the patient requiring the help of another person. Pharmacists
are frequently asked why a patient with one chronic condition receives
prescriptions free whereas another patient with a seemingly more serious
condition does not: answering that the categories were set many years
ago is hardly satisfactory. Colin Fox MSP, who is behind the Scottish
Bill to abolish prescription charges, says: “Abolition would bring
to an end a system which only grants exemptions to all the sufferers
of some chronic conditions but denies it to all those others with equally
or more serious chronic conditions. Abolition would thus ensure greater
fairness by enabling all sufferers of chronic illnesses to obtain free
prescriptions.” What should be done?
If it is agreed that prescription charges are unfair, what should be
done? The Society lists a number of options:
· Abolish charges altogether
· Introduce a lower charge with fewer exemption categories
· Introduce reference pricing: a basic medicine is paid for by the NHS
but patients can opt for more expensive treatments if they pay the difference
· Extend the list of chronic conditions exempt from charges
· Make prepayment certificates cheaper
· Make other cost cuts in the NHS, such as increasing the use of generic
medicines
Abolishing charges would be a popular move with the general public,
but it seems it might be less popular with those working in the NHS.
On the positive side, making prescriptions free would increase the uptake
of prescriptions so, providing the right medicines are prescribed and
they are taken as intended, this should prevent illness and cut hospital
admissions. Abolishing charges would also get rid of the current inequity
in the system. However, this has to be balanced against the negative
arguments. Prescription charging brings in an income for the NHS that
would have to be replaced. Greater take-up of prescriptions would have
an impact on workloads for both community pharmacists and GPs. Other
concerns for community pharmacists include the possibility of free prescriptions
cutting the use of (and therefore income from) over-the-counter medicines,
and there are question-marks over what would happen to minor ailments
schemes. In addition, one often-mentioned argument in favour of prescription
charges is that they deter frivolous use of medicines. But the Society’s
report concluded that there is no evidence to support this.
The opinion in Wales is simple: abolishing charges is the only fair approach.
Welsh Assembly health minister Jane Hutt said last year: “To introduce
exemptions to certain groups would be complex. … Our proposals are
straightforward and effective. This way everyone benefits — chronically
ill, the low paid, everyone.” Whether the Scottish and English
governments take the same approach remains to be seen. |
The
Pharmaceutical Journal