The Pharmaceutical Journal
Vol 279 No 7472 p378
6 October 2007

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First impressions of free prescriptions

Six months after prescription charges were scrapped in Wales, Tom Moberly (on the staff of The Journal) asks for some first impressions of the impact of the change on prescribing habits and pharmacists' workloads and considers the lessons it might have for those reviewing charges in England and Scotland

On 1 April 2007, the NHS in Wales took a step into the dark, as prescription charges for all patients registered with a GP in Wales were abolished.

Plans to scrap prescription charges were announced by the Labour Party in Wales ahead of the May 2003 assembly election. The Welsh Assembly Government estimated that the move would cost £29.5m a year (from lost prescription charge revenue) and it allocated budget increases to the local health boards to make up this deficit.

Whether the change would increase or decrease costs overall was not known before the change was introduced, but prescription charges were reduced in stages to allow changes in the number of prescriptions to be monitored and ensure the appropriate budget had been set aside.

Impact

Prescribing data are only available for the first three months after free prescriptions were introduced. Although some fluctuations in the prescribing levels appear to have occurred, these are similar to variations seen each year and it will some time before any hard conclusions about the financial and health impacts can be drawn.

The Welsh Assembly Government will assess whether prescribing patterns have changed because of free prescriptions “when there is proper evidence available”, according to a spokesman. However, he adds, the WAG regards free prescriptions as “a long-term investment in managing conditions and improving health which will ultimately reduce the cost and pressure on the health service from things such as emergency admissions”.

Fears that community pharmacists’ workload would soar when prescription charges were abolished (PJ, 21 June 2003, p856) have not, as yet, been borne out. Mark Griffiths is a community pharmacist with three pharmacies, two in Merthyr Tydfil and one in Bargoed. He experienced a drop in cash flow during the first couple of months when his pharmacies were not receiving cash in the tills for prescription charges, but this has now settled back down.

Mr Griffiths has done some preliminary analysis of the prescription numbers at his pharmacies and looked at changes since April in the numbers of items being dispensed across different drug categories. “Across our three pharmacies there has been approximately a 1 per cent increase in prescriptions,” he says.“That is certainly below what people were expecting.”

He says that his pharmacies have also experienced a slight drop in over-the-counter sales, but that he thinks this may be due to other factors, rather than GPs giving patients more prescriptions for medicines available over the counter. “I do not think doctors have changed their prescribing habits at all,” he says.

In addition, patients do not seem to have radically changed their behaviour in response to the abolition of charges. David Bailey is chairman of the British Medical Association’s Welsh GPs committee. He says that neither he nor the colleagues he has spoken to about the issue have noticed a huge difference in the complaints about which patients are coming into surgery.

“We have had a few more people in for hay fever medicines than normal, but there haven’t been any other major changes,” he says. “And I don’t think things will change significantly as we move into winter. People may still come in with upper respiratory tract infections, but we’re not going to start giving out analgesics. We’ll keep telling them that home remedies are best and to sit it out.”

Deterrents removed

The removal of prescription charges has also meant GPs need not be concerned about patients being deterred from taking medicines because of the cost associated with having a prescription dispensed, Dr Bailey adds. “Under the previous system, patients who were just above the payment threshold and on multiple medicines for conditions like asthma had to spend a large proportion of their monthly income on their medicines,” Dr Bailey says.

“Anecdotal evidence suggested that people would collect a prescription for salbutamol, but not beclometasone, or they would take a prescription with several items on it to the pharmacist and ask which ones they could afford not to have that month, probably because they felt comfortable having that conversation with the pharmacist, but didn’t want to ask their doctor. Now that won’t happen.”

The removal of charges has also made aspects of pharmacists’ job easier, Mr Griffiths says. The reduction in administration now that counter staff spend less time checking the backs of prescriptions has made the biggest difference, he stresses. “It could also be a bit [awkward] and potentially difficult addressing people who had incorrectly completed the back of the forms,” he says. He and his staff no longer have to deal with disputes with customers about exemptions nor do they have to discuss patients’ personal circumstances at the counter.

“A time saving has definitely been made both with the patient and also when counting up the prescriptions at the end of the day,” he says.

England and Scotland

The Scottish Executive undertook a review of NHS prescription charges last year and an analysis of the responses was published in March (PJ, 31 March 2007, p360). However, when the Scottish National Party came to power the agenda changed. The SNP’s manifesto says: “Prescription charges are a tax on ill health and a barrier to good health for many people.”

It goes on to set out the SNP’s aim to phase out all prescription charges by 2012. The manifesto highlights the fact that administration of the charges is expensive, so the Scottish Government is likely to be looking closely at the financial impact of the changes in Wales in terms of administration and pressure on the health service.

Proposals on changes to prescription charges in England are set to be announced by the Department of Health soon. In July 2007, Dawn Primarolo, the minister with responsibility for pharmacy, told Parliament that there would be a public consultation in the autumn to gather views. The long-term impact of the changes in Wales will not be known by then, but Ms Primarolo has stressed that any changes to the system would be cost neutral to the NHS.

The Government has previously considered revising the exemption criteria and if this is the route the proposals follow, the initial impact of the Welsh model (effectively exemption for all) could be of considerable interest.

The Royal Pharmaceutical Society continues to believe that there should be no financial barrier to the use of prescribed medicines, says Eileen Neilson, head of policy development. “That implies either a move to abolition following the example of Wales, or a major reform of the existing charging system in a way which could be shown to have little or no deterrent effect on use,” she says.

“The Society acknowledges that in the light of financial, professional and industry considerations the relevant UK administrations might wish to proceed in a measured way, taking account of the impact of abolition in Wales.”