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The Review of Prescription Charges which Professor Ian Gilmore was asked to carry out by the Labour government has finally been published.
His remit was to look at how free prescription charges might be progressively given to people with ‘long term conditions’. The government, under pressure because of the anomaly of English patients having to pay for prescriptions when they were being phased out in Scotland, Wales and Northern Ireland, extended exemptions to cancer payments and committed to extend them to patients with ‘long term conditions’, based on savings from the NHS drugs budget.
Considering that the principle on which the NHS was founded was to provide a service free at the point of need, prescription charges have always been an anomaly. They were introduced in 1952 for each prescription form, and then in December 1956 for each prescription item. The Wilson government abolished them in March 1965 only to reintroduce them in June 1968, when the exemptions which are largely still in place today, were also introduced. Prescription pre-payment certificates were also introduced in 1968 to cut the cost for patients who were not exempted. The only change after that was in 1975 with a further exemption with charge-free contraceptive drugs and appliances. The only alteration to the medical exemptions occurred recently when cancer patients were added to the list.
Dr Gilmore points out that the current arrangements “are widely regarded as flawed” and were criticised by the House of Commons Health Select Committee in 2006. They were criticised:
- because in England patients have to pay ￡7.20 per item (many people have to have multiple items) when they were in the process of being abolished in the rest of the UK.
- The list of medical conditions exempted is viewed as out of date, inconsistent and arbitrary. The list is 40 years old.
- Younger people on low incomes are not exempt.
Prescription charge statistics
Many people in England are already exempt from paying charges:
- Around 60% are exempt because of age, medical condition or income;
- Nearly 90% of the 843 million prescription items dispensed each year are free;
- Prescription pre-payment cards are available to patients. A 3 month one costs ￡28.25 and a 12 month one ￡104. Patients have to have 14 items a year to justify the outlay.
The Commonwealth Fund recently carried out a survey in 8 countries looking at the extent to which people with chronic illnesses are deterred from using healthcare because of the cost. It was a study of more than 7,000 people (1,200 in the UK). Of the UK sample 13% said that cost was a barrier to healthcare with 7% reporting that they did not have their prescriptions dispensed or skipped doses, whilst 4% said they avoided visiting the doctor because they could not afford the medication.
Dr Gilmore’s findings
In England 15.4 million people have a long term condition. They are the most intensive users of the most expensive services. They account for 52% of GP appointments, 65% of outpatient appointments and 72% of all inpatient bed days. Gilmore says that “clearly better management of long term conditions should help reduce the use of NHS services”.
“ It is clear from the research…that charges can deter people from having their prescriptions dispensed or seeking treatment. Hence, removing charges could improve access to medicines and patient concordance, which in turn could reduce the need for NHS services in primary and secondary care. Indeed, alongside reducing the financial burden on patients with long term conditions, this is one of the key aims of this policy. There are also wider benefits to society if better management of a health condition enables people to be in work – people with a long term condition that impacts on their day to day activity are twice as likely to be out of work compared with those without a long term condition.”
Gilmore says that it is difficult to quantify the potential savings. He asked his analytical team to look at potential secondary care savings from reduced hospital admissions, for asthma, cardiovascular diseases, other heart conditions and chronic obstructive pulmonary disease in order to have some illustration of the potential scale of cost savings. Estimates based on 2007/8 data show the lack of ‘medicine concordance’ (not taking their prescriptions) could cost between ￡70 and ￡180 million for preventable hospital admissions. If removing prescription charges leads to a level of ‘improved concordance’, having the effect of a 10% reduction in hospital admissions for these conditions, the potential saving would be in the order of ￡7 to 18 million.
Despite the fact that the question of abolition of charges was not in his remit, Dr Gilmore comes as close as he might to recommending such a course. He urges the government to “continue to review the policy”.
“There is the potential for the system to become overly burdensome, with hidden costs, for example in terms of clinical time required in assessment and certification.”
Currently around 40% of patients have to pay for prescription charges. Extending exemption to people with chronic or long-term illnesses would “significantly reduce this number”, leaving charges in place for “short-term, self-limiting conditions”.
“This means that the overall costs of administration could be disproportionate to the level of income raised”.
“There is also the danger that exempting long term conditions could also create perverse incentives towards seeking treatment possibly more so than would total abolition of charges. Patients would be reluctant to give up exemption once they have received it, and there could be an incentive towards seeking ongoing treatment in order to qualify for continued exemption from charges. For this reason I think the policy will need to be reviewed.”
One option he says will be abolition, which is much favoured by patients and clinicians.
“I too favour this view, and I hope exemption for patients with a long term condition is a stepping stone towards total abolition.” (Our emphasis.)
He couldn’t really be any clearer than that, could he?
Gilmore proposes that a ‘long term condition’ should be defined as one which will persist for a period of at least six months, and there is a need for a continuing management of the condition. These will include:
- Conditions that may “resolve over time”;
- “Asymptomatic conditions” (such as hypertension) should be included;
- Continuing management can mean arrange of measures such as treatment with drugs, including drugs for prevention, psychological therapies, periodic monitoring and review;
- Patients currently exempt should continue to be so;
- Terminal conditions with a prognosis of less than six months should be included.
He proposes that a GP should determine whether the patient meets the criteria, though he points out that GP’s are concerned about the potential impact on their relationship with their patients (if they turn them down), and the workload implications of fulfilling this role.
He proposes that the following people are also exempted from payment:
- People who receive incapacity benefit without income support, or
- Contribution based employment allowance, or
- Disability Living Allowance.
The advantage of this, he says, is that it targets those on lower incomes and reduces the burden in terms of the number of cases that require a clinical decision on eligibility.
Gilmore proposes that exemption should last for 3 years, though they could be renewable. In terms of the phasing in of these exemptions Gilmore proposes to utilise the prescription pre-payment cards, progressively reducing their costs.
Finally he urges the government to give priority to the introduction of the new exemptions.
The logic of Dr Gilmore’s review is that if you exempt people with long term conditions the effort required to determine who should and shouldn’t be exempted is a waste of GP’s time and a waste of resources. The cost of extending the exemption he estimates to be in the range of ￡360-￡430 million, when the money raised currently from payment for prescriptions in around ￡500 million a year.
In other words, in order to take ￡70-140 million in revenue a year, GPs’ time would be wasted in policing such a system. Moreover, because of the cost of multiple prescriptions which many people need, some of them do not take their dosages recommended by their GP. This can have a disastrous affect on people’s health, leading to unnecessary hospital admissions as a result, wasting resources.
The review in effect underlines the case for abolition of all prescription charges. Certainly, it is unjust that patients in England alone should have to pay them when they are being abolished in the rest of the UK. From the response Swindon TUC had to its campaign for abolition, we know that the anomalies of the current system create bitterness amongst those people, young and old, who are not exempted. (See http://abolishprescriptioncharges.wordpress.com/)
What will be the response of the new coalition government to the review? We shall see. According to the Department of Health website any decisions on changing the existing system would have to be taken as part of the next spending review which is due in the autumn. Given the current financial situation and the Coalition’s view on the ‘need’ for cuts, they may well refuse to implement it. We need to campaign, therefore, for no retreat from the previous government’s commitment to extend exemptions to people with long term conditions, and to press for complete abolition in England, in line with the rest of the UK.
Can you please write to your MP calling upon them to press the government to abolish charges in the UK, or at the very least to implement the psoposals of Dr Gilmore.
To contact the Swindon MP’s, email:
For anybody outside Swindon, to contact your MP go here: http://www.writetothem.com/
13th June 2010