Examination of Witnesses (Questions 20
- 39)
THURSDAY 19 JANUARY 2006
DR FELICITY
HARVEY, MR
MIKE BROWNLEE,
DR BARRY
COCKCROFT, MR
BEN DYSON
AND MR
ROB SMITH
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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