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APPENDIX D: TOPIC GUIDE
Review of NHS Prescription Charges and Exemption Arrangements in Scotland
1) Introduction - 5 mins
- Introduce self and Ipsos MORI.
- Explain purpose of the research:
Ipsos MORI has been commissioned by the Scottish Executive to conduct research among key groups looking at who should pay for prescription charges. The Scottish Executive is currently conducting a review of NHS prescription charges and exemption arrangements in Scotland. In addition to these focus group sessions the Executive has been running a consultation exercise since January, whereby organisations and members of the public have expressed their opinions on the subject. - Emphasise
- We are not expecting people to be 'experts' or even particularly knowledgeable on the subject. We are looking for your personal opinions. We will be talking to a range of people in different locations across Scotland.
- Ipsos MORI's independence and guarantee of confidentiality.
- Explain group should last around 1 hour 30 minutes. Check everyone is ok with this. Tell participants where the nearest fire exits are etc. … and where the nearest toilets are.
- Request permission to tape record (can be turned off at any point).
- Participant introductions (name, what they do for a living, household composition, etc.).
2) General perceptions about NHS prescription charges - 20 mins
FLIPCHART EXERCISE - What words or phrases immediately spring to mind when you think of prescriptions? PROBE FOR POSITIVES AND NEGATIVES. IF MAINLY NEGATIVE, PROBE FOR POSITIVE AND VICE VERSA
- Can I just check does anyone here have to pay for their prescriptions? (depends on the group).
- How much does one prescription currently cost? What does everyone think about that? (too much, about right, too little, for/against prescription charging in principle).
- How much do you think one prescription should cost? ((PROBE: For attitudes towards/against prescription charging in principle).
- As we mentioned one prescription costs £6.65, however some medicines cost less than this and some cost more. What do you think about this?
- Have you ever had trouble or know someone who has had trouble paying for prescriptions? (PROBE: Can you tell us a little more about that, what was their condition/how many prescriptions did they have to take within a certain period of time, how regular was this?).
- Have you ever been given a prescription by your GP and not handed it in to receive medication? If so, why? (PROBE: costs too much, didn't feel they were prescribed the correct medication, wanted to wait and see if they felt better, lost the prescription, cheaper to buy the medication over the counter).
- Prescription charges are intended as a contribution towards the NHS. What do you think of this? Are you happy to contribute to the NHS in this way?
- Some people say that having prescription charges makes people value medicine and NHS resources more. More specifically it has been argued that charges help to ensure that people only obtain medicines that they really need. Do you agree with this? Why/why not?
- A) If charges were dropped and prescriptions became free to everybody, how would that influence your decision to visit a GP for a prescription if you thought you needed medication? (PROBE: visit GP more/less/about the same).
- B) If charges were dropped and prescriptions became free to everybody, how would that influence your decision to visit the doctor for a prescription for something you could buy over the counter without a prescription? (PROBE: visit GP more/less/about the same).
Ask PPC here
PPCs (Prescription Pre-payment Certificate)
At the moment people who need a lot of prescriptions can purchase a PPC (pre-payment certificate) which helps to reduce costs.
Explanation of PPC
A PPC can only be used for your own NHS prescriptions. These certificates are a more cost-effective way of purchasing prescriptions for higher users. People who have to pay for more than 5 prescription items in 4 months, or 14 items in 12 months, could save money by buying a PPC. From 1st April 2006, the charge for a single prescription item is £6.65, whereas a4-month PPC will cost you £34.65 and a 12-month PPC £95.30. Without a PPC 5 prescriptions at £6.65 would cost £33.25 and 6 prescriptions would cost £39.90 (therefore the PPC would be cheaper) for 6 prescriptions.
- Does anyone have experience of using a PPC (Pre-payment certificate)? If so, ask them to explain what it is to the rest of the group. If not, explain what it is.
- If so, how do you find it?
- Is this a good system? Why/why not? How could it be improved?
How do you think the PPC could best be publicised?
3) Awareness of prescription charging - 15 mins
OK, moving on to the types of people who don't have to pay for a prescription.
- Some people do not have to pay for a prescription - do you know which types of people are currently exempt? (GO ROUND THE ROOM - PROBE: on the basis of INCOME, CONDITION or AGE?).
Hand out a list of those who are currently exempt (list will have headings: Medical conditions, Income and Age)
- What are your initial thoughts about the types of people who are exempt? Are you surprised by any of these? Surprised that some aren't on the list? (Don't go into it in too much depth, will be dealt with in the next section).
- What percentage of the Scottish population do you think are eligible for free prescriptions (currently exempt)? (approx 50%). However, because this group includes the elderly, who are 'high users' of medicines over 90% of items dispensed in Scotland are supplied to the patient free of charge.
The Scottish Executive is currently reviewing the extension of free prescriptions to specific groups such as more low income families and people with long-term medical conditions. It is anticipated that this extension would cost approximately £40 million a year.
- Who should pay for this? (PROBE: NHS in Scotland or move money from other areas of government spending?)
4) Options for consideration - 50 mins
This section of the discussion focuses on possible options that the Scottish Executive is considering in reviewing prescription charges and exemption arrangements.
A) MEDICAL CONDITIONS (Refer to list)
People with specified medical conditions can get free prescriptions if they hold a valid Medical Exemption Certificate. The criteria for placing conditions on the list were that they must be recognisable, lifelong and life threatening. All require regular prescribed medication.
- Do you think exemption should continue to be based on a list of conditions? Why/why not? (PROBE: what types of conditions, people who are terminally ill/people who would die if they didn't take their medication/people who are made to take medication (schizophrenia?).
- Just thinking about medical conditions only, using the list provided. Do you think that this list needs to be reviewed? If so, would you take anything off the list or add to it. What? Why?
- At the moment, people who are exempt can get all their drugs free, even if they aren't related to the exempt condition. Do you agree with this? Or do you think exemption should only relate to drugs for the treatment of the medical condition?
- Do you think it would be better to base exemptions on a list of drugs or a list of conditions? Why do you say that?
- How would this affect you?
B) INCOME (Refer to list again)
Explain who are exempt on the basis of low income.
Income Exemption Information
Those receiving the following benefits are exempt:
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 ( LIS) are exempt. (This is an income-related Scheme which looks at you and your partner's weekly requirements and calculates how much if anything you should pay towards your health costs - get either a HC2 or HC3 form).
In addition, those who hold a valid exemption certificate because they receive a War or MOD Disablement Pension receive free prescriptions in respect of medication arising from their disablement.
- As you can see there is list of benefits that are used to decide who has a low income and therefore who is eligible for free prescriptions. What do you think about this? Should the list be extended? Who should it be extended to?
- Are there other/better ways to decide who is entitled to exemption on the grounds of low income? (PROBE annual/weekly salary cut-off point)
- How would this affect you?
FLAT FEE
Reduced Flat Fee
One option would be a reduced prescription charge for everyone other than those currently exempted on income and age grounds.
Scenario
Bob has a condition where he regularly requires 4 prescriptions in a month. Under the current system he has to pay £26.60 (£6.65 x 4) a month. Under this option he would pay four times a reduced flat fee (say £5) = £20.
- Do you think that the prescription charge should be reduced for everyone? Why? (PROBE FOR: Pros and cons of a system like this).
- What do you think the reduced cost should be?
- What things did you consider when deciding on the amount?
- How would this affect you?
Monetary cap (set limit)
Another option would particularly benefit those who have a lot of prescriptions. Basically, there would be a set limit on the amount anyone would have to pay in a particular time frame.
For example, say they set a monetary cap at £8.00 a month, people would pay £6.65 for the first prescription in a month, then £1.35 for the second prescription and then nothing after that.
(The current monthly equivalent of the PPC is around £8.00 (based on the annual PPC cost).
Scenario
Bob has a condition where he regularly requires 4 prescriptions in a month. Under the current system he has to pay £26.60 (£6.65 x 4), under this option he would only pay £8.00 in any month (£6.65 for the first prescription and £1.35 for the second and then nothing after that).
- What do you think about this option? Should there be a limit on 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? Why? (PROBE FOR: pros and cons of system). What period of time in particular and how much?
- How would this affect you?
- Would this be better than the reduced prescription charge? Why/why not?
Concessionary rate
Another option which is specifically geared towards higher users is a concessionary fee. This would mean that a patient would only have to pay the full fee once within a set period of time. A lower charge would be applied to the rest. But no actual cap.
Scenario
Bob has a condition whereby he regularly requires 4 items every month. Under the current system he pays £26.60 (£6.65 x 4). Under this option he would only pay £18.65 (£6.65 for the first prescription and £4 for the second, £4 for the third and £4 for the last).
This would be less than the current 4-monthly PPC and with a lower initial outlay.
- Do you think there should be a concessionary rate for patients who require frequent prescriptions? (PROBE FOR: pros and cons of system). What should the concessionary rate be?
- How would this affect you?
- Would this be better than the reduced prescription charge or the option where there is a set limit anyone has to pay within a particular period of time? Why/why not?
ABILITY TO PAY/STUDENTS
Another set of options is related to exemption for students and trainees.
At the moment, young people aged 16-18 and in full-time education are exempt (but not automatically, they need to complete a form).
However, once a student is 19 they are not exempt. Trainees are also not exempt.
- Do you think the current 'full-time student' threshold should be extended to include all those in higher or further education whatever their age? Why/why not? (PROBE: - regardless of ability to pay).
- What about people in part-time education and trainees, should they be exempt? Why/why not?
- Should there be some age cut-off?
- You have heard about some of the options the Executive are considering. Are there any other changes, perhaps some that you have heard of today that you would make to the system that would remove the need for special arrangements for full-time students or trainees? (PROBE: Extend age limit to 25 years old, reduced prescription fee for all, everyone should be means tested so students should be covered under that).
- How would this affect you?
C) AGE (Refer to list)
All those aged 15 or under (do not have an independent income) are already exempt from paying prescription charges, as are those aged 60 (pensionable age) or over.
- Is this a good thing?
- Do you think the cut-off points should be younger/older? (PROBE: New pension age 65/67).
- How would this affect you?
Other points
Apart from the options we have discussed today, are there any other ways in which the system might be changed/improved?
What are your preferred options for the future of those we have discussed?
SMALL GROUP EXERCISE: Now that we've discussed some of the options the Executive are considering. I'd like you to complete a ranking exercise for me on your own. Looking at the list, what would be your top five components for the review of prescription charges and exemptions?
Ranking exercise
Adding to the list of medical conditions that are exempt
Basing exemption on a list of drugs rather than a list of conditions
Making more people on a low income exempt
Improving/changing the PPC
Reduce the prescription charge for everyone
Introduce a limit on the amount that people have to pay within a set period of time
Introduce a concessionary rate for people who require frequent prescriptions
Make all full-time students in further and higher education exempt from prescription charges
Make all full-time students and trainees ( i.e. on Skill Seekers or Modern Apprenticeships) exempt from prescription charges
OTHER (PLEASE WRITE IN)
Thank participants for their time
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