Examination of Witnesses (Questions 140
- 159)
THURSDAY 2 FEBRUARY 2006
DR ANTHONY
HARRISON, MR
ROBERT DARRACOTT,
DR ELLEN
SCHAFHEUTLE AND
DR HAMISH
MELDRUM
Q140 Chairman: In terms of health
policy objectives, we are seeing some changes taking place at
the moment. We have had proposals earlier this week and many others
about this concept of moving care out of hospitals into the community.
Are there any issues around that in terms of NHS charges that
you can tell us about? I think all four of you agree it does not
steer policy one way or another. Does it hinder policy?
Dr Meldrum: I think it probably
does in that some of the most hard to reach people and the people
who you would want to try and attract for treatment are affected
by charges and are dissuaded. As others have said, it is a blunt
instrument. I think we have quite a lot of evidence, both from
research and also personal evidence, of people who will ask me,
"Do I really need all three of these, Dr? I really can't
afford them. Which are the two most important ones?" That
is the ones who are upfront with me. I know plenty of others who
then ask the pharmacist the same question or who actually just
do not cash in the prescription. I carry on in the ignorance that
I think they are taking it and they do not want to upset me by
telling me they are not. I think, because we are trying to look
at more preventative measures in the announcements this week and
focus more on that and to try and focus on under-privileged areas,
the previously hard to reach places, the present prescription
charges can only tend to act against that.
Q141 Charlotte Atkins: Mr Darracott,
based on what you said earlier and also on your evidence, you
quote various international studies about the deterrent effect
of charges, what evidence is there out there in terms of the detailed
evidence?
Mr Darracott: The Society's review
of the available evidence was done in large part by Dr Harrison.
What that evidence concluded is that the evidence in this country
is fairly sketchy. We collected together the evidence that was
available from around the world on lots of different sorts of
systems, whether they were fixed charge systems, annual maximum
systems or various forms of co-payments or co-insurance. There
is evidence around but it is fairly fragmented and it may only
look at a particular category of patient. There are some very
interesting studies which suggest that the very vulnerable types
of people and those who are a focus for government policy are
the sorts who are inordinately affected by this sort of work.
For example, one of the stories we quoted was looking at some
people with mental health problems in the US, where a cap on the
amount of costs which could be allowed in any patient case actually
led to an increase in hospitalization and the economic examination
then suggested that the total excess costs were 17 times the cost
saved by putting the cap on in the first place. The other thing
that is very interesting and why this particular inquiry is very
timely is that we have a live experiment going on at the moment
in Wales and although we are only part-way through what is a stepped
programme for the removal of charges to the people in Wales, we
are now at £4 and we are going to go down to £3 in April,
there is evidence now beginning to emerge on how that is affecting
the number of prescriptions that is actually coming through. There
is evidence around and we have tried to summarise a lot of it,
but in this country, apart from some other work done at Manchester,
there is not a lot.
Q142 Charlotte Atkins: The Committee
will be taking evidence in Wales. I am interested in why there
is not any evidence in this country. It is not as though we have
not had prescription charges for quite a long time. Why is that?
Has the work not been done or is it not easy to collect? What
is the issue?
Dr Harrison: There is evidence
about the impact of charges on the uptake of prescriptions. Where
we lack evidence is on what the further impact of that is. As
Rob mentioned, a particular study done elsewhere suggested that
the impact could be very considerable. Other studies have confirmed
that hospital admissions may rise as a result of people not taking
up prescriptions because of costs and they may find themselves
going to their GP or doctor more frequently. Those overarching
studies just have not been done in the UK. A few studies were
done on the impact of charges over the years in the Sixties and
so on. So we can be fairly confident that charges do deter some
people and, as Rob has already said, mainly it is people at the
lower end of the income scale, although it is not those right
at the bottom.
Q143 Charlotte Atkins: The indication
that there have not been any studies done implies to me that there
is not a big issue here.
Dr Harrison: Other people—and
I think they will be giving evidence probably later on this morning—have
collected evidence directly from individuals who say they cannot
afford three prescriptions at one and the same time, and Dr Schafheutle
has done a lot of work on the way people and professionals react
to the existence of charges. So that work has been done and it
is strong enough to suggest that there is an issue. What we could
do with are some more comprehensive and wide-ranging studies than
we have ever had in this country which do trace the impact of
charges through to what happens to those who do not take up their
medicine, who do get a prescription in the first place and they
spin out the prescriptions, ie making them last longer than they
should and all those effects. What is the consequence of that
on health, hospital admissions and other use of services? That
is what needs to be done.
Q144 Charlotte Atkins: Maybe Dr Meldrum
can help us here. Have you picked up if there is a regional dimension
to the impact of charges? One might think that maybe in more prosperous
regions there is not such an issue and in poorer areas there is.
Have you picked anything up from your experience?
Dr Meldrum: I recognise your anxiety
about the lack of evidence. I think some of the reason for that
is that so many who are close to it feel the whole system is so
patently inappropriate, the anomalies within it, who is exempted
and why they are exempted, so why spend a lot of money on getting
evidence when something seems so obviously wrong.
Q145 Charlotte Atkins: Some of us
believe we should have evidence.
Dr Meldrum: Absolutely, and as
doctors we would go along with that too. In terms of effects in
different areas, certainly within a practice one knows that there
is a certain group of patients—not those right at the bottom
end who are often on income support and therefore exempt from
prescription charges—just on the threshold where there is
a real impact on the uptake and the use of medicines. They are
the ones who complain most about having prescriptions and also
wanting prescriptions to be given for six months at a time so
they only have to pay the prescription charges much less frequently
and various other things. So doctors are often under quite a bit
of pressure to try and play the system in order to reduce the
financial impact on patients.
Q146 Charlotte Atkins: What you are
saying is that the group that is most affected is those just on
the edge, is it not?
Dr Meldrum: Yes.
Q147 Charlotte Atkins: If you were
to look at the overall figures—and I am sure the Department
of Health would say this—you would see that only a
small fraction of the population pays for prescription charges.
So is it a big issue?
Dr Meldrum: Yes, 85% of prescriptions
are exempt, but that does not mean to say 85% of people are exempt
and for those who are not exempt it is a very big impact. Yes,
we can argue that because all the young and all the elderly are
exempt—and particularly in the elderly that is where the
bulk of prescriptions are—that it is not a problem, but
of course you are exempt whether you are elderly and a millionaire
or a pauper. It is those in between who have to pay where the
biggest impact is and often it is at a stage in their life when
you can make quite a big impact on them if you treat them adequately.
Q148 Charlotte Atkins: You pointed
out it is the percentage of prescriptions we are talking about
here. Is there any evidence about the percentage of people who
are ill, who regularly take prescriptions and who are not exempt?
Dr Meldrum: I cannot put a figure
on it. Most of my evidence in that sense is anecdotal. In terms
of the number of occasions when patients complain to me about
the number of prescriptions which are necessary and whether they
can have them for longer periods, that is a very frequent occurrence,
and I have found from talking to colleagues that that happens
very frequently.
Q149 Charlotte Atkins: When you say
frequently, do you mean at every surgery or once a week?
Dr Meldrum: Once or twice a week.
Q150 Charlotte Atkins: Is there any
evidence that anyone else would like to bring in on this issue?
Dr Schafheutle: I would like to
pick up on the last point about patients talking to their GPs
and raising the issue of affordability. Based on the work that
we have done at Manchester, it seems that a lot of people do not
raise the problems they may have about affordability with their
GPs as they do not see it as a doctor's job to address those issues.
A lot of people who find the cost of prescription charges to be
a problem do not speak to their GP, but they may speak a little
bit more to their pharmacist because that is the point at which
they have to hand over the money, although a lot of it just goes
on without any awareness. The things that the GPs and the pharmacists
see are probably an under-estimate of what goes on.
Q151 Charlotte Atkins: Have there
been any studies to tease this out?
Dr Schafheutle: We have done some
work to look at the non-dispensing at the point where people pick
up their prescription in commuter pharmacies to see what the impact
is and how much cost comes into this and how much other reasons
play a part and it is quite clear from that that for those that
have to pay cost is quite an important impact. There are other
factors that come into play in people not picking up their prescriptions.
A large percentage of those that are cost related are where people
can buy something over the counter. So there are quite a few cases
where adequate substitution takes place because an over-the-counter
product is cheaper than a prescription charge, but there are still
a number of prescriptions that would be deemed as necessary or
clinically important that people do not get dispensed because
they cannot afford the prescription charge.
Q152 Dr Stoate: I think we can all
agree from the initial answers to the questions that the current
system is dog's breakfast. It is a question of where we go from
there. I would like to pick up one or two points about health
policy. None of you seem to have had much enthusiasm for any advantage
to health policy. Is it not part of government policy that we
should be encouraging people to use pharmacies? Is there not some
evidence that a prescription charge might encourage somebody
to go to their pharmacist before going to their GP and getting
something over the counter that they might otherwise queue in
their GP's surgery to get? Is that not at least a potential advantage
in terms of policy?
Mr Darracott: Yes, it is potentially.
The figures that we uncovered showed that for every 1% increase
in charges there is a 0.3% decrease in the number of items. You
are absolutely right in that a number of strands of government
policy are promoting that. Not only is there a visible encouragement
of people to access pharmacies, but behind that sits a policy
to examine particular medicines and to decide, for those that
are safe and effective, to move them from a prescription category
and into a pharmacy category and therefore widening the range
of products that is available in that way. Yes, that is an important
part of it. We have had the system now that we have got 40 years
with all its illogicalities. I do not think it has been teased
out as to what the impact of that is on this specifically.
Q153 Dr Stoate: At least potentially
you could argue that there could be an advantage to government
policy if more people saw the pharmacy as appropriate for them
rather than waiting to have an appointment with their GP.
Mr Darracott: Yes. There has been
an encouragement of what is called the Minor Ailment Scheme in
which people who are exempt from charges, who require advice on
something that you put into that category can go directly to the
pharmacy and yet will be treated in the normal charging regime
and obtain the medicines they need without paying for it because
they are automatically exempt. There are a number of strands of
policy which are supporting that.
Q154 Dr Stoate: Hamish, you have
talked already about the inappropriate use of GPs' surgeries.
There may be inappropriate consultations for a number of reasons.
You have already said you do not believe charges are a very good
method of deterring inappropriate consultations. If we can agree
that such consultations exist, how would you feel the best way
of tackling them is?
Dr Meldrum: How do you make sure
that people use the health services most appropriately? That is
mainly about education. At the moment it works both ways with
prescription charges. I get people coming to me rather than going
to the chemist when their child is sick because they can get free
Calpol whereas they should really be going to the chemist when
he has just got the sniffles or a cold. The prescription charges
are a pretty blunt instrument in terms of trying to implement
what I would think is cohesive and comprehensive health policy.
I do not think I would be saying we should just abolish prescription
charges and do nothing else. You would also have to look at the
system, which would encourage people to make use of pharmacists
and perhaps have voucher systems for those who would otherwise
have to pay. We have talked about pharmacy prescribing. The BMA
is actually supportive of pharmacy prescribing for minor ailments
and such like. There are other ways to try to address this to
avoid inappropriate use of various parts of the Health Service
and I think it should be mainly done by education rather than
by a rather crude tax, which is what the prescription charges
are.
Q155 Dr Stoate: Dr Schafheutle, has
any research been done on whether costs elsewhere in the Health
Service are increased purely by having charges in the system?
If somebody has to pay and does not get their medication, have
we any way of measuring what knock-on effect that might have on
other Health Service costs?
Dr Schafheutle: Unfortunately
not in the UK. That evidence is not available for a number of
reasons. We have evidence from the United States and also from
Canada where a very, very large scale study looked at the impact
of co-payments on particularly vulnerable groups, which were the
elderly and welfare recipients in that country, and they found
they reduced their use of essential medication and that had a
direct impact on their health services use. This was a cost-related
impact and therefore it had an impact on the increased use of
acute services, emergency department admissions, admissions to
hospital and also increased mortality, which they linked directly
back to an increase in co-payments in those vulnerable groups.
Q156 Dr Stoate: Is it not rather
important to know that figure? If it turned out the figure was
£450 million a year it would rather wipe out the whole benefit
of prescription charges in the first place. Is it not rather important
we do that research?
Dr Schafheutle: It is. The problem
is the lack of evidence. In Canada and the United States it is
generally much easier to access large datasets through their insurance
schemes like Medicare and Medicaid who reimburse patients and
they hold a lot of information about those patients and so they
can relatively easily assess the compliance of people, how often
they refill, what kind of conditions they have and draw conclusions
from that. We do not have one available dataset that we can access
to set up that kind of study in the UK. In GPs' surgeries and
often in pharmacies we do not hold the information on whether
somebody pays or not.
Q157 Dr Stoate: That is remarkable.
The GP dataset is probably the most comprehensive in the world
in terms of the fact that every single prescription is logged
on the computer now. Surely that data must be incredibly easy
to access.
Dr Schafheutle: That data is probably
not so difficult to access. It is linking it with whether somebody
pays or not that is the difficulty.
Q158 Dr Stoate: That cannot be rocket
science, can it? It is very simple to work out if somebody pays.
Dr Meldrum: It is simple in terms
of the age ones, but there are many other exemption categories
as you know. As a GP, I will not always know who pays certainly
within the age group of 16 to 60.
Q159 Mr Burstow: I want to ask about
the research that you have done, Dr Schafheutle, and how that
looks at the current system of exemptions and what effects prescription
charges are having on patients. What kind of things has the research
revealed so far?
Dr Schafheutle: Over the years
we have been involved in a number of studies. It began with a
European study that involved six countries all looking at the
impact of the different co-payment systems in their countries
and obviously we were particularly involved with the UK side of
things. We did focus groups with patients and that included people
with hypertension, HRT, hay fever or dyspepsia, and then we developed
a survey of people who had to pay for their prescriptions in the
UK. Then we did a study on non-dispensing that I mentioned earlier.
More recently, as part of my post-doctoral Fellowship, I have
been doing interviews with people who have asthma or people who
have coronary heart disease or who suffer from high blood pressure.
From all of that research we found people do a number of things.
If prescription charges are a problem—and we have shown
that they are a problem—and if people are below the average
income then they use a lot more strategies to cope with costs,
whereas those that are on higher incomes do not need to use those
strategies to cope with costs. First of all, it prevents people
from going to their general practitioner because they assume it
is going to end up in a prescription and that is going to cost
them a lot of money. The next step is not to get a prescription
dispensed. If somebody has a number of items on their prescription
then that adds up—the current cost of one item is £6.50—to
rather a lot of money for somebody on a relatively low income
and so people try and prioritise. Some of them will ask their
GP or their pharmacist about it or they will decide which one
they need the most without that input. An example of that is asthma
inhalers, where people take a preventer and a reliever and then
choose the reliever at the expense of having their asthma controlled
well. Some people may use a lower dose to make their medication
stretch over a longer period of time and in some cases that may
not be a problem, but if it is a problem they may borrow money
from friends or family, they may use somebody else's medicine
or they will delay it until they have the money available. One
mechanism that is available for people to use is the Pre-payment
Certificate which they can buy either to cover their medication
for four months or for 12 months. We have identified a number
of problems with this and the Citizens Advice Bureau research
has identified very similar issues for those people on low incomes,
the ones that most need protection against affordability issues,
in that the lump sum payment of these Pre-payment Certificates
can be a real problem. So paying out in advance over £30
for four months or over £90 for 12 months is actually a real
issue. Something else we have identified is the predictability
of certain conditions. After somebody has a heart attack, for
example, they are normally on a lot of medication which is prescribed
on a monthly basis, so it is very obvious to them that they will
benefit from having a Pre-payment Certificate and it is very obvious
to the GP and the pharmacist that would then recommend these certificates.
On the other hand, there are conditions—and again I come
back to asthma—where this is a lot less predictable. Very
often for people who are feeling generally well and who pick up
their inhalers every six weeks getting a Pre-payment Certificate
is just not worth their while. They do not know when they are
going to have an infection that may require antibiotics and when
it is not clearing they may need another course of antibiotics
or they may need a course of steroids. These individual charges
add up very quickly. There is no way for them to go back and say,
"Over the last four months I have paid out far more than
this £30". That is another thing that we have identified
as a problem.
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