Select Committee on Health Written Evidence

Memorandum submitted by Ellen Schafheutle and Peter Noyce, University of Manchester (CP 25)

  Peter Noyce and Ellen Schafheutle are members of the Drug Usage and Pharmacy Practice (DUPP) group within the School of Pharmacy and Pharmaceutical Sciences, University of Manchester. Ellen Schafheutle is a Research Fellow and Pharmacist, who holds a Post Doctoral Award funded by the NHS R&D Programme and The Health Foundation, to research "Is the prescription charge a barrier to meeting primary health care goals?" Peter Noyce is Professor of Pharmacy Practice and Head of DUPP, whose mission is "to undertake research that addresses issues of importance in informing and shaping practice, governance and policy relating to medicines and pharmacy".

  A major theme of DUPP's research is patient access to medicines: systematically exploring, over the last 10 years, how patients make choices about medicines and routes of access, the barriers to access and how they may be negotiated. Peter Noyce and Ellen Schafheutle were partners in a seven-nation EU Biomed project which addressed the impact of patient charges on medicines on patient and prescriber behaviour and investigated how the cost to patients of commonly prescribed medicines varied across Europe and could be reduced in different cost-sharing arrangements.

  We submit the following evidence under the respective headings of the terms of reference of the Inquiry on Co-payments and Charges in the NHS, and will be willing to give oral evidence.


  Prescription charges are equitable in that:

    —  They are a fixed cost per prescribed item, irrespective of the cost of the medication.

    —  Everyone aged 16 or under, pregnant or within a year of giving birth, or 60 and over is exempt from charges on all medicines prescribed under the NHS.

    —  Everyone who purchases a pre-payment certificate does not incur further charges for NHS medicines prescribed under the NHS during the period covered.

  Approximately 50% of the population of England pay prescription charges—for approximately 13% of items dispensed under the NHS.

  The system is inequitable in that:

    —  If a patient suffers from one of the listed clinical conditions, eg diabetes or epilepsy, then they are exempt from charges on medicines prescribed for them under the NHS, whereas if they have cancer, schizophrenia, HIV or AIDS, hypertension, coronary heart disease, asthma, tuberculosis or require immunosuppressive therapy following transplant, then they are subject to prescription charges.

    —  For many patients, their ability to pay for their prescriptions changes little through the 55-65 age range, yet they are liable to pay charges on NHS prescribed medicines for the first five years, ie before 60, and receive them all free at 60 and over.

    —  Currently, exemption is universal, providing "blanket" exemption from charges for any medicines prescribed under the NHS for patients exempt from prescription charges. For example, people exempt due to a medical condition can obtain any prescribed medication free of charge, even if this is unrelated to the qualifying condition.

    —  The ceiling or cap on prescription charges offered by pre-payment certificates:

        —  Is not available to those who cannot afford—as a lump sum—the advance payment.

      —  Is not foreseeable as beneficial for bouts of acute or episodic illness requiring intensive treatment. Asthma is an example of a chronic condition, which is episodic and unpredictable, thus people may find it difficult to anticipate whether the purchase of a pre-payment certificate would be worthwhile, and may end up paying more in individual charges.

  We have published evidence that patients in England on chronic therapy, who cannot afford to pay some or all of the prescription charges, take a range of avoiding/coping measures. 1-4 This mirrors research in North America, 5, 6 where further work has shown difficulties in affording medicines leads to a decrease in consumption of prescribed medicines. 7 This has been shown to effect an extra burden on health outcomes8-10 and thus resources. 11


  Research in progress provides valuable insights into patients' views on the appropriateness of prescription charges. 12 Many are very supportive of having a National Health Service and appreciate and accept that increasing costs need to be covered. Many articulate that they accept paying for their prescriptions, yet they are aware of many inconsistencies and inequities within the current system.

  Many people—and interviewees are either asthmatic, have hypertension or coronary heart disease—resent the unfairness in the current system of medical prescription charge exemptions. They cannot understand why some chronic life-threatening conditions, such as diabetes, are exempt, yet they have to pay for their prescriptions. There is a clear awareness among interviewees that their conditions are long-term and taking their chronic medication helps to prevent adverse episodes such as asthma or heart attacks requiring hospital admission, or a stroke leading to long-term impaired health. All such adverse outcomes would not only mean worse health for them personally, but have implications for their use of NHS services and thus considerable resource implications. This brings many interviewees to the conclusion that conditions requiring life-long, or at least long-term, drug therapy, should either be completely exempted from charges or at least subsidised. As one patient expressed:

    "It's a false economy, if I can prevent you from getting something, then rather than getting the money off you for a prescription of six pound odd, and putting that into the NHS, if I still fall ill because I can't afford that prescription, that six pound now as when I go into the hospital has gone up to three grand they're spending on me. [. . . ] As an asthmatic, why am I entitled to a free flu jab? To stop me from getting flu products, to stop me from getting more ill and so on. [. . . ] So I can get a free flu jab to stop my illness getting worse, but I can't get the medication that's needed to keep that at bay long term, without having to pay for it." (ID9)

  Many interviewees comment on the level of the prescription charge, saying that it is too high. They demonstrate particular awareness of this causing serious affordability problems for those on low incomes, whose income would be above the level that would exempt them, yet below an income that made prescription charges affordable. Several interviewees suggest that a lower charge would make medicines more affordable and reduce the number of cost-related decisions or choices patients make about their medication.


  From a series of focus groups with GPs in the North West of England we know that they alter their prescribing in various ways to reduce the cost of medication to patients liable to pay. 13 They for instance minimise the changes that they make to patients' regimens—which otherwise would prove costly to patients—when the prescriber is titrating doses or drugs following a new diagnosis or commencement of a new course of treatment. We have further shown in an evaluation of the new NHS repeat dispensing scheme that GPs are writing more prescriptions for two monthly periods for chargeable patients compared with exempt patients. 14 This is reflected in the average net ingredient cost of chargeable prescription items in 2004 being a third higher than those in exempt items for the elderly. 15

  The current prescription charge, being item based, is particularly burdensome, if a patient is prescribed several medicines, either to manage a chronic condition, eg hypertension, or acute exacerbation, eg a chest infection in an asthmatic.

  Despite GPs being concerned about the cost of medicines to patients, 13 our findings—mirrored by a more recent US study16—show patients are reluctant to raise the cost of medicines with their doctors. 1, 2, 12 Instead they wait until they go to the pharmacy before indicating that they are unable to pay for their prescribed medicines and limiting the cost of their prescription to the most important items on it. 4

  As recently announced, both nurses and pharmacists will soon be adopting wide prescribing responsibilities. It will be interesting to see how they deal with the challenges posed by prescription charges. Community nurse prescribers already demonstrate ambivalence in responding to exempt patients' demands for OTC medicines so that they can avoid buying them. 17

  Difficulty in paying for prescribed medicines has been shown to be double the problem for patients suffering from hypertension or dyspepsia in England compared with Italy. 3 Where possible, English patients who paid prescription charges were much more likely than their Italian counterparts to purchase over-the-counter (OTC medicine), rather than pay prescription charges. These differences in patient behaviour were largely attributed to the different levels of prescription charges in the two countries. The prescription charge in England is nearly six times that in Italy.


  Our own research suggests that patients' awareness of the existence of pre-payment certificates is limited, even, and particularly, among those who may benefit. 1 This is supported by a survey of some 1,600 Citizens Advice Bureau clients. 18 Patients thus rely on health care professionals, ie mainly doctors and community pharmacists, to raise awareness of pre-payment certificates. This is also corroborated in our most recent qualitative work, which indicates that it relies on the health professional realising that the patient would benefit from a pre-payment certificate, which may not be the case if a number of single item prescriptions are presented for dispensing over a short period of time. 12


  The criteria that should determine NHS prescription charge exemption are informed by our and others' research:

    —  Prescription charge exemptions ought to discriminate between medicines that are essential for controlling major disease or illness, eg anti-retrovirals (in HIV), anti-psychotics; critical to maintaining public health, eg anti-tuberculosis therapy; or providing proven long-term benefits, eg anti-hypertensives; and those which are not essential, often providing symptomatic relief. A way to address this may be a national formulary or list of drugs that are exempt.

    —  Most European co-payment systems have age-related exemptions. In these countries they are for the young but not necessarily for the elderly, despite these being recognised as the highest users of medicines. Instead, these systems rely more on ensuring that exemptions apply to essential medicines, and low income does not act as a barrier.

    —  Whilst the issue of patients on low incomes having problems affording prescription charges suggests a review of the process of determining low income exemptions, the more obvious point is that it is the level of the charge that presents the challenge, particularly when two or three items are prescribed.

    —  Pre-payment certificates should provide a true cap on the cost of drug therapy (prescription charges). An immediate way of addressing this would be through devising a method of paying by instalments (TV licenses, for example, can be purchased by stamps—"prospective instalments"). Longer term, with community pharmacies being linked into NHS Information Technology, this cap could be equitably and consistently applied electronically, as it is in Denmark. This would address the existing barrier of not being able to afford lump-sum payments for purchasing pre-payment certificates, as well as the unpredictability of medication and cost in episodic conditions.

  Currently, "blanket" exemptions from charges create inequalities, whereas these proposals ensure that essential drugs are free and prescribed medicines are more accessible through caps on total annual drug expenditure and possibly a lower charge.


  Looking at the use of medicines by people currently prescription charge exempt, and how they differ from those that pay, provides valuable insights into the effect a potential abolition of prescription charges may have. The answer to this question can thus be informed by studies that have investigated the behaviour of patients who are already exempt under current conditions.

    —  When medicines are deregulated to OTC status, patients who are exempt from charges are more likely than those who pay, to access such products through NHS prescriptions, than purchase them as OTC medicines. 19, 20

    —  NHS minor ailments schemes, where exempt patients can obtain listed items directly from community pharmacies at no cost, are effective in transferring the demand for the treatment of minor ailments from general practitioners to community pharmacies. 21

    —  Patients who routinely receive prescribed medicines and are exempt from charges are more likely to request products for the relief of minor ailments on prescription then either patients who do not receive routine medication and/or are not exempt. 20

    —  Exempt patients on repeat medication are less likely to request that an item is not dispensed, on the basis of already having an existing adequate stock, than patients who pay. 4

  The total revenue from prescription charges is currently about £430 million per year, and this makes up about 5% of the net ingredient cost of all dispensed prescriptions. 22 Taking the evidence listed above into account, it is reasonable to assume that abolition of prescription charges will not only result in a loss of this sum, but also to assume some change in behaviour for those people that would now have free access to medication. A complete abolition of prescription charges, ie exemption for all, is likely to distort demand and may unnecessarily overburden GPs.

Professor Peter Noyce and Dr Ellen Schafheutle

School of Pharmacy & Pharmaceutical Sciences

The University of Manchester

7 December 2005


1.  Schafheutle, EI, Hassell, K, Noyce, PR, Weiss, MC. Access to medicines: cost as an influence on the views and behaviour of patients. Health & Social Care in the Community 2002; 10: 187-195.

2.  Schafheutle, EI, Hassell, K, Noyce, PR. Coping with prescription charges in the UK. The International Journal of Pharmacy Practice 2004; 12: 239-246.

3.  Atella, V, Schafheutle, E, Noyce, P, Hassell, K. Affordability of medicines and patients' cost reduction behaviors: empirical evidence based on SUR estimates from Italy and the UK. Applied Health Economics & Health Policy 2005; 4: 23-35.

4.  Schafheutle, EI, Hassell, K, Seston, EM, Noyce, PR. Non-dispensing of NHS prescriptions in community pharmacies. The International Journal of Pharmacy Practice 2002; 10: 11-15.

5.  Cox, ER, Jernigan, C, Joel Coons, SJ, Draugalis, JR. Medicare beneficiaries' management of capped prescription benefits. Medical Care 2001; 39: 296-301.

6.  Cox, ER, Henderson, RR. Prescription use behaviour among Medicare beneficiaries with capped prescription benefits. Journal of Managed Care Pharmacy 2002; 8: 360-364.

7.  Stuart, B, Grana, J. Ability to pay and the decision to medicate. Medical Care 1998; 36: 202-211.

8.  Tamblyn, R, Laprise, R, Hanley, JA, Abrahamowicz, M, Scott, S, Mayo, N et al. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. Journal of the American Medical Association 2001; 285: 421-429.

9.  Rice, T, Matsuoka, KY. The impact of cost-sharing on appropriate utilization and health status: a review of the literature on seniors. Medical Care Research and Review 2004; 61: 415-452.

10.  Lexchin, J, Grootendorst, P. Effects of prescription drug user fees on drug and health services use and on health status in vulnerable populations: a systematic review of the evidence. International Journal of Health Services 2004; 34: 101-122.

11.  Soumerai, SB, McLaughlin, TJ, Ross-Degnan, D, Casteris, CS, Bollini, P. Effect of limiting Medicaid drug-reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. New England Journal of Medicine 1994; 331: 650-655.

12.  Schafheutle EI. Is the prescription charge a barrier to meeting primary health care goals? 2005. Post Doctoral Award, Funded by The Health Foundation and the NHS R&D Programme.

13.  Weiss, MC, Hassell, K, Schafheutle, EI, Noyce, PR. Strategies used by General Practitioners to minimise the impact of the prescription charge. European Journal of General Practice 2001; 7: 23-26.

14.  Ashcroft D, Elvey R, Bradley F, Morecroft C, Noyce P. National Evaluation of Repeat Dispensing by Community Pharmacists. Final Report. The University of Manchester, 2005.

15.  Department of Health. Prescriptions Dispensed in the Community. Statistics for 1994 to 2004: England. London: Health and Social Care Information Centre, 2005.

16.  Piette, JD, Heisler, M, Wagner, TH. Cost-related medication underuse: do patients with chronic illnesses tell their doctors? Archives of Internal Medicine 13-9-2004; 164: 1749-1755.

17.  Hall, J, Cantrill, J, Noyce, P. Influences on community nurse prescribing. Nurse Prescriber 2003; 1: 127-132.

18.  Phelps, L. Prescription charges. Evidence 2002; 8-9.

19.  Schafheutle, EI, Cantrill, JA, Nicolson, M, Noyce, PR. Insights into the choice between self-medication and a doctor's prescription: a study of hay fever sufferers. The International Journal of Pharmacy Practice 1996; 4: 156-161.

20.  Payne, K, Ryan-Woolley, BM, Noyce, PR. Role of consumer attributes in predicting the impact of medicines deregulation on National Health Service prescribing in the United Kingdom. The International Journal of Pharmacy Practice 1998; 6: 150-158.

21.  Hassell, K, Whittington, Z, Cantrill, J, Bates, F, Rogers, A, Noyce, P. Managing demand: transfer of management of self limiting conditions from general practice to community pharmacies. British Medical Journal 2001; 323: 146-147.

22. Department of Health. Personal Communication, Statistics Division. 7-12-2005.

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