Friday, 15 June 2018

Extending medical exemptions for prescription payments

I do recognise that the medical exemption list has not been reviewed for many years, apart from the addition of cancer recently, however I believe there are many other exemptions in place to provide support for those with long-term conditions. The prescription charging system is designed to support the most vulnerable of patients, for example children, the elderly and those on low incomes, from the financial impact of accessing potentially life-saving medication. This is not an exhaustive list, however I believe it targets support for those who need it most. It is important to note that nearly 90% of prescriptions are dispensed free of charge and there are also no charges to any patients who are dispended medicines when they are discharged from hospital.

There are a number of issues around extending medical exemptions, particularly with regard to how to define a long-term condition and a clear divide in opinion in terms of who should be responsible for deciding who is eligible. The majority of patients would want this to be decided by their GP, however GPs are rightly concerned that this would create additional pressure and workload and potentially cause a breakdown in the relationship between patient and doctor in cases where a dispute over eligibility arises. There are a huge number of hidden costs associated with the administration of such a system and concerns about whether an appeals process for disputes would have to be put in place, adding further costs.

When exploring options for how to assess eligibility there are no simple answers and many of the options explored are simply too complex and costly to administer and there are concerns about the ways it could influence patient behaviour. For example, if eligibility was based on diagnosis this would unfairly discriminate against patients with symptom-based conditions who have no definitive diagnosis. There is also the practical issues of creating and maintaining a list of all long-term conditions and diseases considering the European Medicines Agency report that 5 new diseases are described every week. If eligibility were based upon the volume of prescriptions required over a period of time, medical professionals feel this could create an incentive for over-medicalisation of a condition and treatment-seeking behaviour to retain this eligibility. There is also evidence to suggest providing free prescriptions, even if this eligibility is not based on the volume of prescriptions, acts as an incentive for patients to seek more medication which may not provide any clinical benefit.  

On top of this, the additional costs that would be incurred due to extending free prescriptions would add further pressure onto the NHS and potentially take resources away from other areas, such as better A&E care, new cancer treatments and better mental health services. As I have detailed above, there is also no way to measure the hidden costs of implementing and administering such a system.

There is also the factor that prescription numbers are significantly rising every year and the drug cost (not including dispensing costs) to the NHS dispensed in the community was a staggering £9.17 billion in 2017 compared to £500 million raised in prescription charges. Whilst the amount raised is a fraction of the amount spent, this is not an insignificant amount and this funding would need to be replaced. The recent review of NHS prescriptions highlighted the high cost of providing prescriptions, and how often free prescriptions are provided for conditions that either require no treatment or could be treated with cheaper over-the-counter remedies. For example the NHS spends £23 million a year on constipation remedies, which could pay for 900 more community nurses and £3 million on athlete’s foot, which would fund 810 hip replacements. There is also an estimated £150 million of unused prescription items returned to pharmacies which cannot be reused due to health and safety, for example because the medications have expired, not been stored correctly or it is impossible to know if they have been tampered with in any way. It is paramount that we are supporting patients with genuine need for medication who would otherwise be unable to fund their treatment, however, we must also address the high levels of waste and ensure good value for money.

There is also already other avenues of support available. For example, benefits such as Personal Independence Payments (PIP) is not means tested and is designed to provide additional financial support, for example medical aids, adaptations and medications for people with long term health conditions and disabilities. Additionally, Employment and Support Allowance (ESA) is a benefit for people whom are unable to work due to their health condition and/or disability and any claimant receiving the income-related component will automatically be eligible for free prescriptions.

There is also a pre-payment certificate which provides a significant reduction in cost per month for patients with more than 1 regular prescription per month and there are a number of payment options to help patients budget accordingly. In addition to this, if someone’s circumstances change and they become eligible for free prescriptions before the end of their pre-payment certificate I am led to believe you can claim for a refund.

Whilst I do understand the case for the reduction in cost to other frontline NHS services by extending free prescriptions to patients with long-term conditions, the majority of the evidence this report is based on appears to be anecdotal evidence. More importantly, it does not fully consider the additional and hidden costs, which are likely to be far in excess of the savings the report suggest, or the many practical issues of implementing such a system and therefore I do not feel I can support this campaign at this time.