Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 20 - 39)



  Q20  Dr Taylor: Even that is still quite low. No, it is just more than two items per month. Then you finish up with a figure that something like only 13% of items are charged.

  Dr Harvey: They are. In total 13% of prescription items are charged for. In total 8% are paid for by people paying at the point of dispensing and 5% in total have a prescription pre-payment certificate.

  Q21  Dr Taylor: That 13% raises £427 million per year.

  Dr Harvey: That is correct. The issue is that those people who are medically exempt are medically exempt for the condition they have; but they are medically exempt, as a result of which, they are exempt any prescription charge on any item. That, again, is historical.

  Q22  Dr Taylor: Which seems pretty unfair.

  Dr Harvey: Although perhaps I could add that the difficulty, where you have people who have a medical exemption, in deciding which of the medications might be either directly related to their condition or, indeed, partially related to their condition, would need quite a lot of clinical input to make those decisions.

  Q23  Dr Taylor: Meaning that somebody with diabetes you would argue that their treatment for hypertension was so important for the diabetes that it was related. I see what you mean.

  Dr Harvey: I think that is probably one of the reasons why, for those who are exempt, all of the prescriptions are medically exempt rather than just those specifically tied to the condition. I am not exactly sure why, but I would surmise that may have been—

  Q24  Dr Taylor: Dr Stoate rather touched on this, but is there evidence that the prescription charges reduce the take-up of medicines by those who really cannot afford to pay?

  Dr Harvey: Certainly, from the Citizens Advice research that was done back in 2001, they were flagging that there was a concern that up to 290,000 non exempt patients might suffer as a result of the charges. Since that time, we have made further changes to the NHS Low Income Scheme. The other thing—and I know this has been flagged—is that there may well be people who could get help through the NHS Low Income Scheme but are not aware of it, and that is why the Prescription Pricing Authority, since they took over responsibility for this—and, indeed, they on behalf of the Department of Health take forward all the publicity—lead with a publication of this particular document. We have provided for the Committee copies of the sort of information that is published. That is why they are working very hard with patient groups, Citizen Advice, and, indeed, the NUS, who are another group, around trying to ensure that we better target the information about help with health costs to those who need it. It might be worth adding also that that information is also on the patient's part of the prescription form—and, again, we have supplied a copy in the information to the Committee.

  Q25  Dr Taylor: Do you have any feel of the drugs that cost less than £6.50 for the number of people who buy those that are available without a prescription? Was that one of the figures you gave us?

  Dr Harvey: No. The information I have available is that there is an average net ingredient cost for each of these groupings. If you look at the net ingredient cost for all of those people who pay for prescriptions, whether it be by pre-payment certificate or actually at point of collection, the average net ingredient cost is £14.32, and obviously the prescription charge is about 45% of that. But clearly the prescription items that are prescribed vary in their cost. Some are much more expensive.

  Q26  Dr Taylor: Is there any regular information given to a patient, "The prescription charge is £6.50. This would only cost you £5 if you bought it without a prescription." Is there any record of the sorts of people who get that information and take it up?

  Dr Harvey: I do not particularly know of it, although anecdotally one is aware that sometimes general practitioners might say to patients, "These are the things you need. You might want to get that from your pharmacist." But I do not have any information on that, I am afraid, no.

  Mr Brownlee: Chairman, anything that is sold to a patient as an over-the-counter medicine is the private business of community pharmacists and we do not have any remit or record of what takes place.

  Dr Harvey: But items that are on an FP10, as you know, are the items that are prescribed under the NHS.

  Q27  Dr Taylor: Would chemists have the right, if something was on an FP10 and they knew it only cost £4, to cross it off and suggest the patient bought it at £4?

  Mr Brownlee: I do not think they have the right. I think I am right in saying that, if something is prescribed by a doctor, then that is what they have to dispense. What happens in real life, sometimes, might be different.

  Q28  Dr Taylor: Again anecdotally we hear stories of people who have been frightened to go to the doctor because of the risk of the amount they had to pay and they could not find it. Is there any evidence to back that up?

  Dr Harvey: The information we have on that dates back to the research that was done by Citizens Advice. That is actually why the Prescription Pricing Authority are working quite hard with Citizens Advice,[6] the National Union of Students and other patient groups around both the targeting of information about both pre-payment certificates as well as the NHS Low Income Scheme. So they are working quite hard with those groups.

  Mr Brownlee: Chairman, we know also that there are other reasons why patients either do not go to the doctor or, having been to the doctor and got a prescription, decide not to obtain it, and then, even when they have got it, decide not to take it. We know there is something like probably £200 million worth a year of medicines in people's medicine cabinets that are not taken, so there is a whole raft of reasons there.

  Q29  Chairman: Evidence about pre-payment—the £93.20, you said.

  Dr Harvey: £93.20 for a 12 months pre-payment certificate.

  Q30  Chairman: That is money up front, is it?

  Dr Harvey: It is indeed.

  Q31  Chairman: Is there any evidence that that is a problem in terms of people accessing that system, having to find £93.20.

  Dr Harvey: We certainly know that in terms of the take up of pre-payment certificates (PPCs) the take-up is increasing year on year. We are aware though, again from the previous research, that there may be issues of affordability for those who are over the threshold for the NHS Low Income Scheme and that is why the Prescription Pricing Authority is doing work around the possibility of monthly payment for prescription pre-payment certificates, and also the other thing which was raised, a sliding scale for the NHS low income scheme. They are looking at that at the moment and will clearly come to ministers. Is it worth adding, Chairman, that in terms of the average number of prescription items per script (prescription form), the average number is two. If one were able to move to a monthly payment for a prescription pre-paid certificate, in fact that is likely to be less than the cost of two prescription items. Also, once you have 15 or more prescription items per year, then in fact that is the pre-payment certificate paid and that is the level at which it is capped.[7]

  Q32  Dr Naysmith: I would like to explore with Dr Harvey some things that have already been touched on. It is this question of the logic behind exemptions—not just particular diseases being exempt, some are and some are not, but, if you are in hospital, you get your drugs free, but as soon as you come out of hospital you are back on to paying prescription charges again if you are in a certain category. There are one or two other anomalies of this whole system. For instance, if you are in an exempt category for a particular disease, then you get all your prescriptions free, not just the one that applies to the exemption. It is riddled with anomalies and lack of logic, as we have already touched on this morning, but why does the Department not review this list and get rid of these anomalies now? I have written to them on a number of occasions, often to do with cystic fibrosis, as I know a little bit about it, and I get two replies back, either that this is being held under constant review—but you or the Department or the particular minister does not say that anything has ever happened since 1968 to all these reviews—or they say, "We have recently reviewed it and we are not going to review it again for a while". These answers from the Department indicate that it is not a priority at least. Why do you not review this list and get rid of these anomalies?

  Dr Harvey: In response to your comment about whether or not things are being reviewed, it is certainly true to say that when we have issues that are raised in correspondence from yourselves, we do look at the issues, particularly in terms of the affordability and the feasibility, and it is on the basis of those that actually many changes, particularly to the NHS Low Income Scheme, eg the length of time we have certificates for, et cetera, have indeed been changed. In terms of major reviews of the prescription charge system, this is not something that ministers have asked us to do at the moment. We are not undertaking a major review of prescription charges, although, as I say, we do keep under constant review particular issues around affordability and making the system work better.

  Q33  Dr Naysmith: But not the disease categories and that kind of thing.

  Dr Harvey: These are issues that ministers have asked officials to look at on a few occasions over the years, but on each occasion that they have been looked, at the ministers' decisions have been not to change them, but more around the affordability issues.

  Q34  Dr Naysmith: Sticking with this question of the anomalies—and I think you hinted at it earlier on—there have been such differences and medical improvements in a number of these conditions, and there is a series of cancers that are very good examples and also cystic fibrosis as well, that people survive much longer.

  Dr Harvey: Yes.

  Q35  Dr Naysmith: It is a very different situation, looking at these diseases now to looking at them 20 years ago. Why is the logic not extended? You are not going to say it is the ministers' fault, are you?

  Dr Harvey: Absolutely not. The issue is that clearly there are very many very serious chronic conditions and these have not been reviewed for a while. The issue would always be: where would you draw the line? Therefore the approach has very much been around affordability and capping the cost of prescriptions for those who pay. Again, only 13% of prescription items are paid for; 87% of items are exempt prescription charges through age, medical condition, benefit passporting, NHS Low Income Scheme, or, indeed, maternity certificates.

  Q36  Dr Naysmith: You would accept that for some disease areas it is a kind of thing that people cannot understand, why their particular disease is not exempt where others are.

  Dr Harvey: We do understand that there are many, many patient groups which have major concerns about why, indeed, their condition is not exempt.

  Q37  Anne Milton: I know this may be slightly tricky for you. You did say at the beginning that you were responsible for prescription policy. I cannot see the policy that makes the diseases exempt that are exempt, and some, as my colleague mentioned, like cystic fibrosis, not exempt. What is the policy that lies behind that?

  Dr Harvey: As I said, the exemptions date back to when they were brought in in 1968. On the occasions that ministers have looked at them, the list has not been extended but we have been looking at the affordability issues.

  Q38  Anne Milton: Nobody is going to change that list of diseases, as far as you know.

  Dr Harvey: To date there have been no changes in that list of conditions that are medically exempt.

  Q39  Anne Milton: Are you aware that there is going to be in the future?

  Dr Harvey: We have not at the moment been asked to do a review of medical conditions.

  Anne Milton: Thank you.

6   Note by witness: Citizens Advice are not currently involved in PPA stakeholder meetings but they do advise on the development of leaflets and posters. There is regular contact between local CA offices and the PPA on individual cases. Back

7   Note by witness: The cost of a 12 month PPC is less than the cost of 15 prescription items. Once a PPC has been purchased no further charge is due, regardless of the number of items dispensed. Back

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