New Prescription for Prescribing?

Dr Paul Charlson takes an in-depth view at whether it's time to overhaul the prescribing system

There is concern amongst doctors, pharmacists and patient groups that the current prescription charging system in the United Kingdom is unfair.^1,2

The conclusion of the Wanless report was that exemption from prescription charges are "not logical, nor rooted in the principles of the NHS" and should be reviewed.³

85% of all NHS prescriptions are dispensed free and a further 5% going on a prepayment certificates.⁴

Those that are exempt include:

• Children under 16 (under 25 in Wales)
• Young adults 16-18 in full-time education
• Adults over 60
• Patients on benefits

Certain chronic diseases

The cost of a prescription for a single item is £6.65
The cost of a prepayment certificate is £34.65 (for 4 months) or £95.00 (for 12 months)

However, a study conducted by MORI for NACAB revealed around 750,000 people in England and Wales fail to get their prescriptions dispensed because of cost.5

In a separate NACAB survey 37% of clients with long term health problems such as asthma failed to get all or part of their prescriptions cashed.⁵

Examples of Anomalies

1. Patients with exempt conditions eg hypothyriodism may obtain all prescriptions free regardless of whether they are related to their condition
2. Patients with other chronic conditions such as asthma, hypertension, renal failure, AIDS have to pay for prescriptions if not otherwise exempt.
3. A diabetic on diet alone control must pay for his prescriptions but a diabetic on medication can obtain all his prescriptions free.
4. A patient on HRT is charged two charges as there are two separate tablets in the packet yet a patient on a combination anti-hypertensive containing two drugs in one tablet pays one charge.
5. The current system of charges takes little account of disposable income.
6. Low cost drugs are still charged to the patients at £6.20 per item
7. There is no link between cost of medication and prescription charge.

Discussion

Clearly patients requiring chronic, long term or multiple medication need support and those with greatest financial need must be subsidised.

The current system has remained unchanged for 30 years. Recently the Chancellor ruled out reform on the grounds that it would bring little financial gain and was "politically sensitive".

Despite this reform is needed to the system to make it fairer and more patient centred, ensuring as many people as possible benefit whilst maintaining affordability to the exchequer.

Possible solutions - a fairer system.

The GPC put forward several possible solutions in its paper in March 2001.1

1. Scrap all charges.

This would have the benefit of ensuring everyone could get the prescriptions they needed. It would be simple and reduce administration costs. However there would be a cost in lost revenue which would need to be found elsewhere.

It would however encourage wastage as patients would be tempted to obtain medicines "just in case" or simply stockpile them. It is estimated that 50000 kg of drugs at a estimated cost £15 million were incinerated in 2001 6 because of this. This is assumed to be the tip of the iceberg by doctors and pharmacists.

It would also encourage more patients to seek prescriptions from their GP or nurse prescriber rather than self medicating. With primary care consultation rates increasing it is important to encourage self reliance in patients rather than the opposite.

2. Revision of criteria for chronic conditions.

Chronic conditions should be determined by time rather than severity of the illness. This would include patients with long term conditions such as asthma and hypertension.

For patients with long term conditions there could be:

(i) Free prescriptions for medication required solely for the chronic condition.

The problem would be that it would be arguable which medication would constitute solely for the condition. This could create tensions between various groups and may affect the doctor-patient relationship. The list of acceptable chronic conditions and the definitions thereof would have to be clearly defined and this is by no means easy.

(ii) Free prescriptions required for the chronic illness and conditions procured as a direct consequence of the chronic condition to be determined by the prescriber (RDS)

The problem is the same as for (I) only increased. Doctors find it difficult to be placed simultaneously in the position of patient's advocate and policeman of the prescription system. This generally results in the policeman role being relegated.

(iii) Removal of conditional entitlement to free prescriptions but with a single reasonably priced pre-payment certificate for all medication required.

This has merits, the overall cost would have to be taken into account. For those patients with long term medical needs who would not be exempt and were only just above income support level could be charged on a sliding scale.

(iv) Removal of the conditional entitlement to free prescriptions but with reasonably priced pre-payment certificate available for a single chronic illness or for two or more chronic illnesses. These certificates could only be used for medication required for the conditions specified including medication for RDS conditions.

This would work but again there would be problems over defining which medications would be eligible and in what circumstances. It has the potential to become complicated and create tensions within various groups of patients.

3. Retain the prepayment certificate.

All patients to be able to purchase these. Payment options in instalments without penalty. Lengths of certificates could be for 3, 6 or 12 months.

This seems a sensible solution.

4. Prescription charges for all patients.

There would be no exemptions. However there should be discounted rates for

(i) those on low incomes would pay a notional amount ( e.g. £1 per item)
(ii) patients with recognised chronic conditions should be able to purchase pre-payment certificates at a favourable rate (see 2 (iii) and (iv).

This could be a possible method. In New Zealand most patients pay a smaller amount per item and the system operates well.

The advantage of a nominal rate for all is that it should reduce wastage and prescription fraud. The first because even a small charge would act as disincentive to stockpiling of drugs and the second because patients would feel less inclined to defraud the NHS for a £1. Clearly for the very poorest a system of reimbursement or exemption could operate.

Another possible exempt group could be the over 75s who tend to have an increased medical need and often reduced financial means.

OTC medications

More patients should be encouraged to visit the Pharmacist rather than consulting their GP. OTC medications can be expensive and discourage self medication.

It may be possible for the NHS to produce and provide "own brand medications" at low cost.

Pharmacists could provide certain OTC medications on a limited formulary to patients using prepayment or exemption rules. This would rely on good communication between GPs and pharmacists.

P medications

P drugs should also be available for dispensing GPs to offer.

More drugs should be transferred from POM to P

P drugs could be provided by pharmacists using exemption rules.

A danger with this system is an increase in wastage of drugs if there are a large proportion of the population exempt as access to pharmacists will be easier than GPs. There is also a possibility of a conflict between the pecuniary interest to the pharmacist conflicting with the prescription of drugs to exempt patients.

GSL Drugs

GPs have to prescribe any drugs which are needed for a patients treatment so long as that is within their competence and unless the drug is blacklisted or used outside the grey list.

This means that household drugs such as antacids or paracetamol have to be prescribed if appropriate. The problem with this is that as a large proportion of patients are currently exempt, it encourages patients to see their GP to obtain a free prescription rather than buying them OTC. This has two effects an increased number of GP consultations and an additional cost to the NHS as the administrative costs are disproportionately high in reimbursing pharmacists.

A proposal could be that all GSL drugs are blacklisted.

Dispensing doctors are currently unable to sell GSL drugs and dispensing patients are disadvantaged as a consequence. This is unfair. Dispensing doctors could be allowed to sell GSL drugs.

Generic Prescribing

Generic prescribing is largely acknowledged as the most cost effective prescribing.
There are instances when patients express a wish to have a branded drug rather than a cheaper generic version despite there being no clinical difference in efficacy.
It should be possible to provide branded drugs and allow the patients to pay the cost difference.

Prescription Fraud

It is estimated that fraud costs the NHS £ 69 million in 2000 7 , which amounts the about one quarter of the total revenue from prescription charges . The current system relies on patients honesty in filling in the back of the FP10 to claim exemption. Policing this system is clearly difficult given the current levels of fraud occurring.

One proposal would be some form of prescription exemption card which would need to be produced in order to obtain exemption. This coupled with a much lower prescription charge encompassing the majority of patients might help to reduce fraud.

Clearly there are many measures that could be applied, some are outlined in the RCGP paper "Prescription Fraud - An efficient scrutiny " 1997 97/08 8. It is not in the remit of this paper to discuss these in detail here.

References

1. "The future of prescribing - Discussion paper" March 2001 GPC
2. "Tax on illness" ACHCEW report - March 2002
3. "Delivering the NHS Plan" - The Wanless report HMSO April 2002
4. Department of Health spokeswomen - BBC News 11 December 2001
5. In "Unhealthy Charges" CAB report June 2001
6. From BBC News 16 August 2002 - "Official figures" quoted
7. Official DoH figures 2000
8. "Prescription Fraud - An efficient scrutiny" RCGP 1997 97/08

Name: Jan Sharp
Comments: As a sufferer from diabetes (insulin controlled for the past 37 years) I am well aware of the cost of my medication. I am also well aware that I am unable to live without my medication! As a nurse I feel that there are many sufferers from long term conditions who are presently not entitled to free prescriptions who should be so. I feel that I am very lucky having free prescriptions. I do feel however that certain drugs e.g. antibiotics should be charged  for all patients as this would perhaps make patients think before visiting GP's and nurse prescribers expecting antibiotics. I know that I would not be able to afford to pay for my diabetic and other long term condition medication but would willingly pay for things like antibiotics.