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CHAPTER SEVEN: OVERVIEW
Taking an overview of all three strands of the public consultation (the omnibus survey, the written consultation and the focus groups), the main areas of consensus and the main areas of disagreement are summarised below.
AREAS OF CONSENSUS
The need for a review
There does appear to be agreement that the current system of charges and exemption arrangements needs to be reviewed. In terms of the system as a whole, none of the respondents to the written consultation advocated the status quo and, among the focus group participants, there was universal support for reform.
More specifically, the omnibus survey found support for an extension of the present exemption arrangements: two-thirds of the public support diverting money from other areas of government spending to pay for the extension of free prescriptions to specific groups such as low income families and people with long term medical conditions.
Reviewing the list of exempt medical conditions
Although there was some disagreement about whether there should be exemption on medical grounds alone (discussed below), on the assumption that such exemption continues, there was agreement among those who responded to the written consultation and among focus groups participants that the list of conditions should be reviewed. It was generally felt that patients with long-term conditions and the terminally ill should be exempt. There was acknowledgement, however, of the practical difficulties involved in maintaining an acceptable list.
Not basing exemption on a list of drugs
From respondents to the written consultation and from focus groups participants, there was overwhelming opposition to the idea of basing exemption on a list of drugs rather than a list of conditions. There were a number of reasons for this which related to fairness and to the practical difficulties involved.
Exemption on the basis of low income
The omnibus survey found very strong support among the general public for exemption for those on a low income: 68% were strongly in favour, with a further 26% slightly in favour. This was echoed in the focus group discussions where strong support for the continuation of income-based exemptions was evident, with participants repeatedly raising the issue of ability to pay and/or means testing when discussing each of the change options. It was also generally agreed that exemption should be extended to more low income groups than is currently the case to ensure that the most vulnerable groups in society are not deterred from obtaining essential medication.
In the written consultation, there was near unanimous support for extending exemption to HC3 holders.
Improving the PPC system
Assuming a continuation of the PPC system, respondents to the written consultation and focus groups participants suggested that it could be improved by allowing payment in instalments and issuing PPCs retrospectively. They also pointed out the need to better publicise the system. Indeed, the omnibus survey indicates that only 56% of the public are currently aware of the system.
Not introducing a concessionary rate
There was general agreement among those who responded to the written consultation that a concessionary rate should not be adopted. Similarly, focus group participants felt a concessionary rate would be overly complicated, too costly to administer and would result in high users of medication still incurring significant charges for their medicines.
The need for a straightforward system
In the focus groups, there was repeated suggestion that any new system must be as simple as possible from the point of view of patients.
Although not specifically asked in the consultation document, several respondents spontaneously emphasised that any changes to the current system should be easy to understand for the patient and should not deter or prevent patients from obtaining the medication they need. Simplicity - from an administrative point of view as well as from the patient's point of view - was repeatedly used as an argument for or against different options.
AREAS OF DISAGREEMENT
Exemption on medical grounds alone
The omnibus survey found very strong support among the general public for exemption on the basis of a long-term medical condition: 87% were strongly in favour and a further 11% were slightly in favour. The qualitative work with different patient groups indicates that this stems from a sense that it is 'immoral' to expect those with serious or terminal condition to pay for their medication.
However, respondents to the written consultation were split on this issue and most Health Board representatives and medical bodies who responded on this point were against exemption on medical grounds alone. The main arguments against were that it would be fairer to base exemption on ability to pay and, in practical terms, it would be both difficult and contentious to ensure a comprehensive list of conditions. Indeed, the practical difficulties were recognised by focus group respondents who were in favour of the principle of medical exemption.
Limiting exemption to drugs for the medical condition in question
Respondents to the written consultation and focus group participants were divided on whether medical exemption should be limited to the treatment of the condition in question. Some argued that limiting exemption to the condition in question was the "fairest" option but others felt that, in practice, it may be very difficult to determine when one condition is related to another.
Reduced flat fee
Roughly equal proportions of respondents to the written consultation were for and against a reduced flat fee. The main argument in favour of the reduced flat fee was that if everyone contributed something it would provide much needed revenue for the NHS. There was recognition that some of those people who are already exempt from charges could probably afford to pay something towards their prescriptions. The main argument made against the reduced flat fee option was that patients who require many prescriptions may still incur significant costs over a period of time.
Concerns were also raised by focus group participants about the reduced flat fee. Although it was preferred to a monetary cap or concessionary rate because it was seen as fairer and simpler, there was a widespread perception that a reduced flat fee would not be financially beneficial to people who require a lot of medication.
Monetary cap
Among respondents to the written consultation, slightly more were in favour of the monetary cap than were against. Those who were in favour of this option felt the monetary cap would be a preferable system to the PPC, because it would be cheaper. It would benefit people who receive regular medication but who would not benefit from using a PPC. The main concern of those who opposed the monetary cap was that it would be too complex and expensive a system to implement and administer.
Although the balance of opinion in the focus groups was against the monetary cap, the arguments in favour and against reflected the arguments made by respondents to the written consultation.
Exemptions for students and trainees
In the omnibus survey, support for all full time students and young people in training receiving exemption was mixed, although a majority were slightly or strongly in favour. Specifically, 79% were in favour of all full time students receiving exemption whilst 83% were in favour of young people in training receiving exemption. However, around a fifth were not in favour of each of these groups obtaining exemption.
Most of those who commented in the written consultation were in favour of extending the threshold to cover tertiary education (and most were in favour regardless of the student's ability to pay). However, a significant minority felt that exemption should be based on the student/trainee's ability to pay.
The same split was evident among focus group participants. On the whole, they felt that students in full-time education and training should not have to pay for prescriptions as this group tends to have either a low, or no income. However, several participants, including some of the students and trainees themselves, felt that charging and exemption arrangements for this group should reflect ability to pay.
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