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SECTION 4: DISCUSSION AND CHANGE POSSIBILITIES
4.1 REVIEW OF EXEMPTIONS RELATED TO MEDICAL CONDITIONS
The Executive has a Partnership Agreement commitment to review prescription charges for people with chronic medical conditions. This commitment recognised that the current exemption arrangements, which date back to 1968, contain anomalies and need to be reviewed.
4.1.1 There are two approaches to exemptions based on clinical conditions. One is to maintain a list, as at present, of chronic conditions which qualify for medical exemption. The other is to provide exemption against a list of medicines that are deemed 'essential' for the listed conditions, or for the treatment of chronic conditions more generally. One of the consequences of the latter approach could be to change the current position whereby the medical exemption extends to prescriptions that are not related to the chronic condition in question.
4.1.2 The review of the use of co-payments in other countries found 7 countries 2, in addition to the UK countries, where some form of medical exemption exists. In addition, 7 other countries had some form of reduced payment based on medical needs. It also found that the UK is the only country surveyed where medical exemption entitles patients to all prescriptions free of charge.
4.1.3 In Scotland, the medical exemption arrangements are condition-based and in effect apply to people not exempt on grounds of age. In themselves, they take no account of the patient's ability to make a contribution to the cost. The exemption applies regardless of the frequency and number of different medicines needed for the condition and leads to anomalies such as inclusion of those with low thyroid function who require usually only one type of medication but exclusion of those with high blood pressure or asthma who may be on several different forms of medication or inhaler. Thus, for those patients whose condition is not listed but who nevertheless have significant requirements for medication, there is no special provision, unless they are exempt on other grounds.
4.1.4 Change possibilities ( CP) for revision of the current medical exemptions could include the following.
CP 1: Review the criteria by which chronic conditions are defined and consider the therapeutic categories of drugs that are essential to their treatment, where that consideration is carried out by an expert group.
4.1.5 In order to remain fair and effective, the criteria or definitions will require regular review for possible adjustment. However, the finally determined lists may still leave out conditions or medicines that some patients feel should be included. The place of drugs that are used to treat side effects of main treatments would be particularly challenging to codify, and would require further expert judgements to be made.
CP 2: Link exemption to the drug and not the condition.
4.1.6 This would require a similar expert group to define criteria for including drugs for exemption from charges and for ongoing review of the exempted list. It would mean that, unlike the present system, drugs not linked directly to the condition would be subject to a charge: however, to recognise the possible indirect link, the charge could be at a concessionary rate. Under this option it would be possible to widen the range of conditions that attract exemption (and possible concessionary rate) by extending the exempted drug list. The same issues as expressed in 4.1.5 would apply.
CP 3: Convert the medical exemption category to a 'high prescription user' category
4.1.7 This option is discussed at paragraph 4.2.16 onwards.
Views are sought on:
1. Whether exemption from all charges should continue to be given on medical grounds alone, and if so, whether the list of conditions should be reviewed.
2. Whether, where exemption is given on medical grounds, that exemption should relate only to drugs for the treatment of the medical condition in question, rather than (as at present) covering all drugs whether or not they relate to the condition that gives rise to the exemption.
3. Whether it makes more sense to provide exemption based on a list of drugs, or based on a list of conditions.
4.2 ECONOMIC NEED - AFFORDABILITY
The Executive believes that people should not be deterred from obtaining their medication because they cannot afford to pay for their prescription, and that those who have a substantial need for medication for which they pay a contribution should have access to an affordable system of payment.
This section considers the issue of prescription charge affordability and income based systems.
Background
4.2.1 The review of the use of co-payments in other countries revealed that the majority of countries surveyed have reduced payments or exemptions for people on low income, and/or had either caps for how much people pay for prescribed medicines, or reduced payments for high users of prescription medication.
4.2.2 In Scotland, like the rest of the UK, exemption from prescription charges is available to patients receiving income support, income based Job Seeker's allowance, working family and child tax credits, and people who qualify for full help under the NHS Low Income Scheme. These criteria are effectively proxies for low income as they are all means tested benefits.
4.2.3 The NHS prescription charge in Scotland is a flat fee for each prescription and, unless the patient purchases a pre-payment certificate ( PPC), there is no monetary cap to what they pay as the number of prescriptions required by the patient increases. This can result in financial pressures for those who are high users of prescription medication and who fall outside the current exemptions system.
4.2.4 However, whilst PPCs offer a cost effective way of meeting and capping charges, the initial cost may present difficulties for some patients. Patients are not always made aware of the PPC system and, in any case, may not know in advance when a PPC might be of benefit, particularly if they are at the beginning of an episode of illness which may become chronic or last longer than expected.
Change Possibilities
4.2.5 The approaches that could variously or collectively address these affordability issues include:
- revising the list of low income proxies that attract exemption
- modifying the PPC scheme to be more readily affordable
- introducing a concessionary rate for higher users of medicines
- placing a cap on the charges payable by anyone over a given period of time
- lowering the flat fee for all
Exemptions on Income Grounds
4.2.6 The current income related exemptions are based on means testing criteria that are applied at a UK level.
4.2.7 The policy on the NHS Low Income Scheme ( LIS) and other income related schemes is that the same eligibility criteria should apply throughout the UK so that equity of treatment for all claimants is assured. This unified approach also enables claims, and the associated entitlement for NHS charge exemption, to be processed centrally and cost effectively by the Prescription Pricing Authority ( PPA) in Newcastle.
4.2.8 It would, however, be possible to extend the current NHS Low Income Scheme ( LIS) to cover a wider section of the population in Scotland without administrative changes being required at PPA.
4.2.9 At present, depending on the outcome of the means test under the LIS, applicants will receive either a HC2 or HC3 form. The HC2 entitles the holder to exemption from a number of NHS charges including NHS prescriptions. The HC3 entitles the holder to help with health charges except those for prescriptions. In 2004-05, over 70,400 people in Scotland applied for help under the LIS. Over 41,200 received full help (HC2) whilst 21,500 (and their dependants) qualified for partial help (HC3): 7,700 did not qualify. Therefore:
CP 4: Extend exemption from paying prescription charges to all persons holding a LIS HC3 certificate - which would extend charge exemption in Scotland to over 21,500 people and their dependants.
Pre-payment certificate scheme
4.2.10 The issue of affordability is already addressed to a degree by the availability of pre-payment certificates ( PPCs). These certificates can be cost effective where a patient needs more than 5 items in a four month period (the current charge is £33.90); and where the patient needs more than 14 items in a twelve month period (current charge is £93.20). However, whilst this is effectively a form of financial capping, there are some issues within the current PPC arrangements.
- The patient needs to be aware of the scheme at the beginning of their treatment episode. GP surgeries and community pharmacies should carry publicity material for PPCs, but this may not always be the case, patients may not notice it, or it simply may not attract the patient's attention.
- At the beginning of a treatment episode, neither the patient nor their health advisers may be able to anticipate whether the patient will benefit from a PPC and it is not possible to purchase one retrospectively.
- The patient needs to have available funds of at least £33.90 (for the 4 month PPC) in order to purchase a certificate and gain the cost benefit.
- The cost effectiveness increases further when the patient is able to buy the twelve month certificate, but this requires patients to have £93.20 available as a one-off, upfront payment.
- Patients at the lower end of the income scale may find the upfront financial layout at either level a barrier to using the PPC scheme.
4.2.11 To increase public awareness of the PPC scheme, the Executive is currently in the process of revising its publication and distribution arrangements for patient information on both prescription charge exemption and other NHS charge exemptions. These will extend distribution to more public places, e.g. libraries and citizen advice centres etc., as well as GP surgeries and community pharmacies; and will provide for 6 monthly restocking of the material.
4.2.12 However, in addition to these steps, the change possibilities that to varying degrees could address the issues relating to PPCs include:
CP 5 - issue a PPC retrospectively to patients whose prescription charges over a set period amount to the value of a PPC, ( i.e. based on current charges, once 5 prescriptions have been charged in a 4-month period) or to offset the cost of the PPC by the amount paid over a preceding set period.
4.2.13 This would benefit both patients in the early stages of a chronic illness, where they have not previously required regular scripts, and those who have acute illnesses requiring frequent prescriptions over a short period of time.
4.2.14 Such an arrangement would require patients to retain and present evidence of previously paid charges, which could be administratively bureaucratic and would require built in safeguards to prevent system abuse. An alternative would be to administer the scheme by means of an electronic record. This is discussed further at paragraph 4.2.19 below.
CP 6 - restructure the minimum period for which the PPC applies.
4.2.15 Any intention to make the PPC more affordable at the point of need would require a lowering of the initial payment linked to a reduction in the period covered. Working pro-rata to the current rates, a two month period could be bought for £17.00. Taking this measure to its extreme, a monthly capping system roughly equivalent to the current PPC pricing could augment or replace the current PPC system. A possible option based on this thinking is at paragraph 4.2.21 to 27.
4.2.16 An alternative arrangement would be to provide patients with the ability to pay for their PPC by instalments and so reduce the upfront costs. This would require the patient to enter into a financial commitment but would benefit those patients who are high users and are not exempt on other grounds.
Views are sought on:
1. Whether prescription charge exemption should be extended to HC3 holders.
2. What changes to the PPC system would address current barriers to its use, particularly by those on low income, and maximise patients' benefit.
Capping and concessionary fees for higher users
4.2.17 Introducing a monetary cap at which the patient either pays a concessionary fee, or ceases to pay a fee for a pre-determined period of time, requires the use of a patient specific record or other documentation to record transactions.
4.2.18 At present, patient records are held at GP surgeries and - in many cases - the community pharmacy that the patient regularly visits. Currently these records are not designed to capture prescription and dispensing activity data in a way that would enable the activity to be used for cost abatement purposes. Neither is it currently possible to monitor prescriptions dispensed by different pharmacies and so 'track' the number of charges the patient has to make. Nevertheless, these do not present a barrier to the possible future development and introduction of new charge capping and concessionary rate arrangements.
4.2.19 The increasing use of the CHI (Community Health Index) unique patient identifier on prescriptions 3, coupled to the introduction of patients' electronic health records 4 and the advent of electronic transmission of prescriptions ( ETP) will increasingly provide a database on which patient charge tracking systems can be developed. The ETP facility in Scotland is planned to start roll-out in the latter part of this year 2006. Additionally, it is clear that many of the countries surveyed in the review of the use of co-payments in other countries have systems that enable patient charge capping and the application of reduced co-payments and we might learn from their systems.
4.2.20 A possible option based on capping and concessionary rates for higher users would be to:
CP 7: Introduce a monthly charge cap with the limit set in line with the current cost of pre-payment certificate but with a more affordable entry point.
4.2.21 The current monthly equivalent of the PPC is around £8.00 (based on the annual PPC cost). Under this option, adopting this as the cap level would mean that a patient would pay a full £6.50 for the first script of the month then a reduced rate ( i.e. £1.50) for the second script in the same month and thereafter no further charges that month. This would effectively bring them into the pre-payment system in the first month.
4.2.22 For example, a patient who obtained a script for antibiotics for cystitis in week 1 of the month would pay £6.50, but if they required a second script in week 2 due to unresolved symptoms, they would pay £1.50 for this. A third script for thrush due to the antibiotics in week 3 would be free. If they then had a further attack of cystitis in the following month, they would again pay £6.50 for the first script, and so on.
4.2.23 Patients on regular medication would also benefit under these arrangements. They normally receive enough medication for 2 months at a time, i.e. 6 times a year. Under this arrangement a person who currently requires 2 regular items every 2 months, and therefore does not benefit from the PPC system, would pay £8.00 every 2 months instead of £13.00 as at present. (2X £6.50). For a person on 3 types of medication, issued every 2 months, they too would pay £8.00 every 2 months instead of £33.90 per 4 monthly PPC.
4.2.24 In addition, patients on medication which currently attracts 2 prescription charges because of dual contents, e.g. hormone replacement therapy ( HRT), would be liable for a maximum charge of £8.00 instead of paying £13.00 as at present.
4.2.25 Thus most patients on regular medication would be paying £4.00 per month on average over the year. For patients with acute illnesses, the maximum they would pay in a year if they had more than 1 script each month would be £96.00, and if they had 1 or less than 1 script a month, they would pay £78.00 or less over the year. This is comparable to the current cost regime.
4.2.26 An alternative to CP 7 would be to be:
CP 8: Introduction of a concessionary rate for those patients who require regular repeat prescriptions or acute prescriptions frequently - either with or without some form of capping.
4.2.27 Under this option the full prescription charge would be applied to only one item on any multi item prescription, with a lower charge for the rest. This would financially benefit patients who either regularly or occasionally require multi-item prescriptions. For example, for a patient who regularly requires 3 items every 2 months and with a concessionary rate of (say) £4, the cost in a 4 month period would be £29 (£6.50 + £8, twice). This would be less than the 4 current monthly PPC and with a lower initial outlay.
Flat Fee
4.2.28 An administratively straightforward way of making prescription charges more affordable to patients might be to:
CP 9: Introduce a lower flat rate charge that would be payable by all, except those with low income or age exemption.
4.2.29 A possible consequence of reducing the flat rate fee for all (other than those currently exempted on income and age grounds) is that more people would seek a GP appointment in order to reduce the cost that they might otherwise expect to pay for over the counter medicines. Annex C reports the possible cost consequences of this 'increased demand' factor in relation to a total abolition of prescription charges. It can be assumed that the estimated cost consequences of reducing the flat fee will be less, but that it will be relative to the level of reduction. Reducing the flat fee for all (as qualified above) would lead to a reduction in charge income to NHS Boards.
Views are sought on:
1. Whether there should be a reduced flat fee for all (with current income based exemptions) and, if so, the level at which affordability to the patient and cost to the NHS can be balanced.
2. Whether there should be a monetary cap to the charges that a patient is required to pay over a set period of time, after which prescriptions should be free within this period of time.
3. Whether there should be a concessionary rate for patients who require frequent prescriptions, and whether the concession should be triggered by the costs incurred over a set period of time.
4. Whether there are other changes in the arrangements for pre-payments or caps that are not listed above and which would maintain charge income in general for NHS Boards.
4.3 ABILITY TO PAY
The Executive has a Partnership Agreement commitment to review prescription charges for young people in full time education or training. This commitment recognised the Executive's wish to widen access to full time education and training.
Young people in full time education or training
4.3.1 The review of the use of co-payments in other countries found little evidence of exemption for young people in full time education.
4.3.2 People in full time education and aged 16 to 18 inclusive are already exempt in the UK. However, those entering full-time tertiary education where undergraduate courses last up to 4 years fall outside this age category for at least part of their course. Not only do they have to find fees and living expenses, but they also have little time to earn any income. Prescription charges, although a relatively small part of their expenditure, can seem prohibitively high. Exemption on income grounds can be difficult to obtain for the full length of the course resulting in repeated claims and excessive bureaucracy.
CP 10: Extend exemption to (a) persons up to the age of 24 or (b) all persons, in full time education or training.
CP 11: Introduce concessionary charges for persons aged 19 or over in full time education or training.
CP 12: Improve system for exemption on income grounds for persons aged 19 and over in full time education or training.
4.3.3 The category of 'people in full time training' covers a very broad spectrum. It will include people on apprentiships where either or both their training and salary costs are met by their employer, and those on full time vocational training as part of the paid process for obtaining a necessary qualification.
4.3.4 Any extension to the current exempted group (16 to 18) to include full time students or others in full time training will bring benefits to the persons concerned but reduce the level of charge income to the NHS, although people in this category are generally young and low medicine users so the loss would be relatively small.
Views are sought on:
1. Whether there is a case for extending the current 'full time student' threshold to cover tertiary education.
2. Whether exemption should be extended to all persons in full time education or training, regardless of their ability to pay.
3. Whether there should be concessionary charge arrangements for full time students or trainees above set age thresholds.
4. Whether there are other changes in the charging system that could remove the need for special arrangements for full time students or trainees?
Age Exemptions
4.3.5. In Scotland, persons aged 60 or over, and under the age of 16 are exempt from prescription charges. The review of the use of co-payments in other countries found that many of the countries surveyed had exemptions or reduced payments for older people or pensioners, however the age threshold tended to relate to pensionable age or was higher than that in Scotland e.g. those over 70 in Ireland.
4.3.6 Eight of the countries in the review had some form of exemption or reduced payment for children and younger persons, but the threshold for this varied. As reported above, Wales now has a young people's age exemption threshold of 25.
4.3.7 As already stated, the Executive's policy position remains that patients who can afford to do so should make a contribution to the costs of prescribing and dispensing - on the basis that exemption arrangements are in place for those most likely to have difficulty paying charges. A straightforward age exemption is, therefore, anomalous in terms of this policy.
4.3.8 Children under the age of 16 do not have an independent income and therefore will be exempted on those grounds. Also, childrens' access to medication should not be dependent on their parents' decisions on use of their income. Such circumstances do not, however, apply to people above the upper age limit. This section lists no options with regard to the issue of age exemptions but the Executive would welcome any views that consultees may wish to express on this matter.
The Executive recognises that it may be difficult to provide narrow responses to the consultation and will therefore be happy to consider replies which are not strictly limited to chronic conditions and young people in education and training.
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