Policy responses and statements

Name of organisation:

Scottish Executive Health Department

Name of policy document:

Review of NHS Prescription Charges and Exemption Arrangements in Scotland

Deadline for response:

30 April 2006

Background: This document has been prepared as part of the Executive's Partnership Agreement commitment to review prescription charges for people with chronic medical conditions, and for young people in full time education or training. This commitment recognised that the current exemption arrangements, which date back to 1968, contain anomalies and are no longer fit for purpose.

The Executive's Health Department undertook a literature search to gain an overview of prescription charge and exemption policies in other countries to help inform consideration and debate on the matter. The key facts from the overview are provided at Section 3 and a copy of the full Executive Summary is at Annex A.

This document:

• Sets out the background and policy context to NHS prescription charge and exemption arrangements in Scotland.
• Discusses options for change to facilitate debate on possible system reforms

Consultation Objectives:

The issue of prescription charges and exemptions is complicated. Changes to the current arrangements will have complex financial and social consequences. The best outcome is likely to involve a combination of changes implemented over a period of time. The purpose of this consultation document is to encourage debate on a range of options. Thereafter, the preferred options will be subject to a regulatory impact assessment. The consequences of the proposed changes will be carefully considered and the Executive will then decide on the changes to be made, and how and when they might best be implemented.

COMMENTS ON
SCOTTISH EXECUTIVE HEALTH DEPARTMENT
REVIEW OF NHS PRESCRIPTION CHARGES AND EXEMPTION ARRANGEMENTS IN SCOTLAND

The Royal College of Physicians of Edinburgh is pleased to respond to the Scottish Executive on its Review of NHS Prescription Charges and Exemption Arrangements in Scotland. 

The College offers the following comments on the clinical implications of changing prescribing arrangements in Scotland.  Comments are influenced by the clear statement in the consultation document that the Scottish Executive is not in favour of total abolition of prescription charges.

The College believes that prescription charges can discourage compliance with treatment and contributes to health inequalities.  However, the College agrees that the current charging scheme is inappropriate and merits significant review, including the impact of options on health inequalities, health promotion and patient access to care.

Medical Exemptions

The importance of addressing inequalities in health should not be overlooked in any policy change on medical exemptions.  Patients in the higher deprivation groups have the additional burden of ill health and may be less compliant with primary prevention measures if exemption from prescription charges is based on medical condition alone eg smoking cessation therapy. Exemptions should continue to take account of income levels.

A condition based rather than a drug based exemption seems preferable, although there are difficulties in determining how to handle preventative therapy and in determining which drugs are directly related to the chronic condition(s).  If exemptions are condition based, the decision to exempt from specific charges should be based on an assessment of whether the drug (or more likely a suite of drugs) relates directly or indirectly to the chronic condition and its co-morbidities, or whether it is a transitory or long-term result of the chronic condition.  For example, treatment of a skin condition or intercurrent infection for a patient with hypothyroidism who requires thyroxine replacement would not be exempt, unless the patient was exempted on grounds of financial circumstances or employment status.  However, there is a good case for exempting drugs prescribed to diabetic cases to control hypertension and dislipidaemia. 

The College recognises that such a system would be hugely difficult to administer fairly and consistently within current information and prescribing records systems, and would impact on medical and pharmacist time.  Maintaining appropriate exemption lists as practice changes will be difficult and labour intensive.

There is a compelling case for reviewing the current medical exemption arrangements which are illogical and anachronistic and which take no account of drugs used in primary prevention eg statins.

 Affordability

The College would be interested to understand better the evidence used by the Scottish Executive in their assertion that payment for prescriptions influences prescribing patterns.

Capping the upper limit paid by those ineligible for exemptions will improve compliance, particularly for preventative therapies if these fall outside the exemption lists.  The College favours restricting the level of payments and ensuring payments are phased to ease affordability.  However, this is a primarily a fiscal rather than clinical issue.  A scheme similar to the “Oyster card” used on the London Underground may be feasible to support implementation of such a policy and ensure an upper limit is not breached, particularly where prescription costs to individuals will vary with occasional unrelated bouts of ill health.

The “Oyster card” approach could be available to trainees, students or those retired from full- time work on reduced incomes (but otherwise healthy) at different prices to reflect income constraints.  For these groups, short-term illness requiring several prescriptions can be financially stressing and may deter some from seeking appropriate medical advice.  This could also address the time deterrents under the current PPC scheme for those with significant but short-term problems.

The College considers an income related approach is preferable to arbitrary age limits (at either end of the age spectrum), particularly given the increasing numbers of students and trainees in their middle years, and variable retirement ages and pension provision.

A simple, cost-effective method of administering such a system is essential, both to support health care professionals and patient understanding and uptake.

Other issues

The Scottish Executive should be aware of cross border difficulties for doctors (particularly those in rural areas who also dispense) of treating patients resident outside Scotland with different prescription charging regimes.

The consultation does not consider strategies to address non-compliance with therapy by those with chronic conditions and the resultant waste of resources.  Any change in policy for prescription charges should factor in ways of reducing this waste.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324    ext 608
Fax: 0131 220 3939

[28 April 2006]