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 chargesfor 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 affordas a lump sumthe 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
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 peopleand interviewees are either
asthmatic, have hypertension or coronary heart diseaseresent
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."
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
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' regimenswhich otherwise would prove costly
to patientswhen 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 findingsmirrored by a more
recent US study16show 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.
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
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
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
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
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;
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
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.