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BMA response to Health Committee inquiry into NHS charges

December 2005

In the following paragraphs we make some brief points in relation to prescription charges, which is the area of co-payments and charges that the BMA sees as the priority issue for review. The paragraphs are structured to answer the questions set out in the press release announcing the inquiry. We hope that you might consider calling the BMA to present oral evidence to the Committee to enable us to expand on some of the issues we raise.

What charges are equitable and appropriate?
The argument against charges is that they generate little income as many patients are exempt from the charges. At present 85% of prescriptions are obtained free of charge. However, charges play a role in limiting demand. The prescription charge scheme first came into existence in 1952 and has remained in place apart from a brief period between 1966 and 1968. During that time there was a sharp rise in prescriptions dispensed.

The current system in England is anomalous, unclear and difficult to defend. A fundamental review of the system is needed.

What is the optimal level of charges?
This is a difficult question to answer and needs further exploration. As we say below, there is a case for reviewing exemptions, for removing charges altogether or for removing exemptions and making everyone pay a low amount, say £1. But the answer partly depends upon context. Some argue that in the future the growth of pharmacogenetics will mean drugs will be individually tailored, which is likely to significantly boost production costs and therefore price. Technological advances could change the whole basis of the conversation.

Until this happens, we still see situations in which the current level of charging is a financial challenge. There is some evidence that the charges are too high for some groups. In 2001 the National Association of Citizens Advice Bureaux published evidence from its own survey and related work by MORI, showing that 28% of those who had paid prescription charges had failed to get all or part of the prescription dispensed because of the cost (38% of single parent households and 37% of those with long term problems). MORI estimated that around 750,000 people fail to get their prescriptions dispensed because of cost. [Go to note 1]

The report identified a ‘poverty trap’ in which patients just above the level of income support, for example those receiving incapacity benefit, get no help at all, and those with long term health problems were more likely to find charges difficult to afford, despite the season ticket scheme.

Doctors within the BMA have experiences that reflect this. Patients ask if all the medicines prescribed are really necessary as they are unable to pay for them all. There are patients with chronic chest disease who openly admit they will not be able to afford to have all their treatment dispensed because of the cost. There are also patients who want large amounts of drugs dispensed to reduce the number of prescriptions. There are patients who are unable to pay for all the items on the prescription at once who seek several prescriptions (one for now, one for later). There are cases where there is a failure to use asthma inhalers correctly because of the cost. These scenarios result in an overall increase in morbidity with attendant expense.

Are charges sufficiently transparent?
Charges are not sufficiently transparent.

What criteria should determine who should pay and who should be exempt?
Patients should be exempt from charges on the grounds of income and on the grounds of catastrophic cost associated with treatment.

Exemptions on the grounds of income are important. In 2004 Lexchin and Grootendorst surveyed literature from a range of countries including England and concluded, ‘Virtually every article we reviewed supports the view that cost sharing through the use of co-payments (charges) or deductibles decreases the use of prescription medicines by the poor and the chronically ill.’ [Go to note 2]

At the moment, patients are exempt from prescription charges dependent on their age, receipt of various benefits, pregnancy status, degree of disability or medical exemption criteria. The medical exemptions have remained unchanged since 1968 and there is scope for reviewing this list.

The BMA has long held the view that the current system of medical exemptions do not adequately reflect need as it exists in the community, particularly in relation to people who have chronic conditions or other diseases that rely on multiple and on-going medication. There is no logic behind the exemptions.

• Patients who require thyroxine replacement therapy for their underactive thyroid are prescription charge exempt for all medicines although thyroxine is one of the cheapest produced drugs and patients are unlikely to require other medication related to their condition. However patients with asthma and heart disease who may require multiple medication for a prolonged period, are not prescription exempt and must pay out considerable costs.
• Cystic fibrosis is a long-term condition which means people need to consistently take a large number of drugs throughout their life. When the list of medical exemptions was drawn up in 1968, the condition was not included as sufferers were not expected to survive beyond childhood.

Derek Wanless, in his report of April 2002, concluded that 'the Review believes that 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.” The issue of prescription charge anomalies is periodically raised by politicians but there has been continual resistance to reviewing and changing the current system.

How should relevant patients be made more aware of their eligibility for exemption from charges?
The whole system needs to be made more clear.

Should charges be abolished?
There are three possible directions for changing prescription charges: a revision of the exemption categories; the removal of all charges; lower level payments for all prescriptions. There has been discussion of each option within the BMA.

Revision of exemption categories
The BMA has long supported the policy that the exemption categories should be revised in line with actual burden of illness and the increased need for medication. It is grossly unfair that those who are most in need of medication may fail to access it for financial reasons. There is an enormous amount of information in the NHS relating to health costs, prescriptions costs, and burden of illness, which means that such a revision should not be an impossible task.

Removal of all charges
The removal of charges is already beginning in Wales and a possibility for Scotland. The change in prescription policy in Wales currently means there is no prescription charge for anyone under 25 and the cost per prescription for others is £4. All prescription charges should be removed by 2007. There has not so far been much alteration in the number of prescriptions dispensed.

There is an argument for removing prescription charges altogether. If the health service is to be truly free at the point of delivery, then patients should be able to receive the medicines they need without charge. It would also ensure that those patients who experience inequalities because they are not prescription exempt but nevertheless on a low income do not suffer adversely as is currently the case.

Low level payment on all prescriptions
A third option might be the most realistic alternative to the current system. This would see the removal of all exemptions and the introduction of a low level payment, for example a £1 payment that every patient would pay per prescription or item, with no exceptions. This might mitigate against inappropriate use of the exemption status (ie: for over the counter medicines) but be low enough to ensure that those on low incomes or on multiple medication could still afford it.

The BMA’s view of the Wanless ‘fully engaged scenario’ is that there is likely to be an increased demand for drugs as the population lives longer and has more time to develop chronic conditions, normally associated with older age. Experience from the recently introduced Quality and Outcomes Framework in general practice shows that if you are going to manage conditions such as diabetes and heart disease effectively, you will need to use an increasing range of medicines. Although there is the possibility of improved lifestyles, including diet, smoking and exercise, lessening the incidence of chronic conditions, this is unlikely to stem the demand for drugs because at best, it will delay the onset of these conditions rather than prevent them.

References

1. National Association of Citizens Advice Bureaux. Unhealthy charges: CAB evidence on the impact of health charges, 2001, NACB.
2. Lexchin J and Grootendorst P, Effects of prescription drugs users fees on drug and health service use and on health status of vulnerable populations: a systematic review of the evidence International Journal of Health Services 34:1 pp101-122 2004.
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