Memorandum submitted by the British Medical
Association (CP 29)
In the following paragraphs we make some brief
points in relation to prescription charges, which is the area
of co-payments and charges that the BMA sees as the priority issue
for review. The paragraphs are structured to answer the questions
set out in the press release announcing the inquiry. We hope that
you might consider calling the BMA to present oral evidence to
the Committee to enable us to expand on some of the issues we
The argument against charges is that they generate
little income as many patients are exempt from the charges. At
present 85% of prescriptions are obtained free of charge. However,
charges play a role in limiting demand. The prescription charge
scheme first came into existence in 1952 and has remained in place
apart from a brief period between 1966 and 1968. During that time
there was a sharp rise in prescriptions dispensed.
The current system in England is anomalous,
unclear and difficult to defend. A fundamental review of the system
This is a difficult question to answer and needs
further exploration. As we say below, there is a case for reviewing
exemptions, for removing charges altogether or for removing exemptions
and making everyone pay a low amount, say £1. But the answer
partly depends upon context. Some argue that in the future the
growth of pharmacogenetics will mean drugs will be individually
tailored, which is likely to significantly boost production costs
and therefore price. Technological advances could change the whole
basis of the conversation.
Until this happens, we still see situations
in which the current level of charging is a financial challenge.
There is some evidence that the charges are too high for some
groups. In 2001 the National Association of Citizens Advice Bureaux
published evidence from its own survey and related work by MORI,
showing that 28% of those who had paid prescription charges had
failed to get all or part of the prescription dispensed because
of the cost (38% of single parent households and 37% of those
with long term problems). MORI estimated that around 750,000 people
fail to get their prescriptions dispensed because of cost. 
The report identified a "poverty trap"
in which patients just above the level of income support, for
example those receiving incapacity benefit, get no help at all,
and those with long term health problems were more likely to find
charges difficult to afford, despite the season ticket scheme.
Doctors within the BMA have experiences that
reflect this. Patients ask if all the medicines prescribed are
really necessary as they are unable to pay for them all. There
are patients with chronic chest disease who openly admit they
will not be able to afford to have all their treatment dispensed
because of the cost. There are also patients who want large amounts
of drugs dispensed to reduce the number of prescriptions. There
are patients who are unable to pay for all the items on the prescription
at once who seek several prescriptions (one for now, one for later).
There are cases where there is a failure to use asthma inhalers
correctly because of the cost. These scenarios result in an overall
increase in morbidity with attendant expense.
Charges are not sufficiently transparent.
Patients should be exempt from charges on the
grounds of income and on the grounds of catastrophic cost associated
Exemptions on the grounds of income are important.
In 2004 Lexchin and Grootendorst surveyed literature from a range
of countries including England and concluded, "Virtually
every article we reviewed supports the view that cost sharing
through the use of co-payments (charges) or deductibles decreases
the use of prescription medicines by the poor and the chronically
At the moment, patients are exempt from prescription
charges dependent on their age, receipt of various benefits, pregnancy
status, degree of disability or medical exemption criteria. The
medical exemptions have remained unchanged since 1968 and there
is scope for reviewing this list.
The BMA has long held the view that the current
system of medical exemptions do not adequately reflect need as
it exists in the community, particularly in relation to people
who have chronic conditions or other diseases that rely on multiple
and on-going medication. There is no logic behind the exemptions.
Patients who require thyroxine replacement
therapy for their underactive thyroid are prescription charge
exempt for all medicines although thyroxine is one of the cheapest
produced drugs and patients are unlikely to require other medication
related to their condition. However patients with asthma and heart
disease who may require multiple medication for a prolonged period,
are not prescription exempt and must pay out considerable costs.
Cystic fibrosis is a long-term condition
which means people need to consistently take a large number of
drugs throughout their life. When the list of medical exemptions
was drawn up in 1968, the condition was not included as sufferers
were not expected to survive beyond childhood.
Derek Wanless, in his report of April 2002,
concluded that "the Review believes that the present structure
of exemptions for prescription charges is not logical, nor rooted
in the principles of the NHS. If related issues are being considered
in future, it is recommended that the opportunity should be taken
to think through the rationale for the exemption policy."
The issue of prescription charge anomalies is periodically raised
by politicians but there has been continual resistance to reviewing
and changing the current system.
The whole system needs to be made more clear.
There are three possible directions for changing
prescription charges: a revision of the exemption categories;
the removal of all charges; lower level payments for all prescriptions.
There has been discussion of each option within the BMA.
Revision of exemption categories
The BMA has long supported the policy that the
exemption categories should be revised in line with actual burden
of illness and the increased need for medication. It is grossly
unfair that those who are most in need of medication may fail
to access it for financial reasons. There is an enormous amount
of information in the NHS relating to health costs, prescriptions
costs, and burden of illness, which means that such a revision
should not be an impossible task.
Removal of all charges
The removal of charges is already beginning
in Wales and a possibility for Scotland. The change in prescription
policy in Wales currently means there is no prescription charge
for anyone under 25 and the cost per prescription for others is
£4. All prescription charges should be removed by 2007. There
has not so far been much alteration in the number of prescriptions
There is an argument for removing prescription
charges altogether. If the health service is to be truly free
at the point of delivery, then patients should be able to receive
the medicines they need without charge. It would also ensure that
those patients who experience inequalities because they are not
prescription exempt but nevertheless on a low income do not suffer
adversely as is currently the case.
Low level payment on all prescriptions
A third option might be the most realistic alternative
to the current system. This would see the removal of all exemptions
and the introduction of a low level payment, for example a £1
payment that every patient would pay per prescription or item,
with no exceptions. This might mitigate against inappropriate
use of the exemption status (ie: for over the counter medicines)
but be low enough to ensure that those on low incomes or on multiple
medication could still afford it.
The BMA's view of the Wanless "fully engaged
scenario" is that there is likely to be an increased demand
for drugs as the population lives longer and has more time to
develop chronic conditions, normally associated with older age.
Experience from the recently introduced Quality and Outcomes Framework
in general practice shows that if you are going to manage conditions
such as diabetes and heart disease effectively, you will need
to use an increasing range of medicines. Although there is the
possibility of improved lifestyles, including diet, smoking and
exercise, lessening the incidence of chronic conditions, this
is unlikely to stem the demand for drugs because at best, it will
delay the onset of these conditions rather than prevent them.
British Medical Association
4 National Association of Citizens Advice Bureaux.
Unhealthy charges: CAB evidence on the impact of health charges,
2001, NACB. Back
Lexchin J and Grootendorst P, Effects of prescription drugs
users fees on drug and health service use and on health status
of vulnerable populations: a systematic review of the evidence
International Journal of Health Services 34:1 pp101-122 2004. Back