« Previous | Contents | Next »
Listen
EXECUTIVE SUMMARY
1. INTRODUCTION
This report presents the findings of a public consultation to inform the Scottish Executive's Review of NHS Prescription Charges and Exemption Arrangements in Scotland. The consultation took place between January and June 2006 and comprised three main strands: an omnibus survey module (undertaken by TNS System Three), a written public consultation (designed and organised by the Scottish Executive and analysed by Ipsos MORI Scotland) and focus groups with key patient groups (undertaken by Ipsos MORI Scotland).
2. BACKGROUND
The Scottish Executive is supportive of prescription charging in principle on the grounds that it places a value on the medicines that patients require, helps reduce the level of less urgent demands on GPs' time and provides a much needed source of revenue for the NHS.
However, the Executive has acknowledged that current exemption arrangements - which date back to 1968 - contain anomalies that need to be addressed. It was this recognition that led the Executive to make a commitment under the 2003 Partnership Agreement to a review of prescription charges for people with chronic medical conditions and young people in full-time education.
Following a review of prescription charging arrangements in other countries, a public consultation on the Review of NHS Prescription Charges and Exemption Arrangements in Scotland was launched in January 2006. The aim was to encourage debate on a range of specified options for changing current prescription charging and exemption arrangements.
3. OMNIBUS SURVEY
Methodology
The Scottish Executive commissioned a module of 10 questions on the TNS System Three Omnibus Survey to gauge the general public's understanding of, and attitudes towards, prescription charging.
Face-to-face interviews were conducted with 1,077 adults across Scotland between 25th and 30th May 2006. The data were weighted to ensure that the sample was representative of Scotland's adult population in terms of age, sex and socio-economic group.
Main findings
Most people were unaware of the exact cost of a prescription (although for most the estimated cost was close to the actual cost). Just over half were aware of the existence of pre-payment certificates.
Just under one in ten of those who had visited a GP in the last 12 months had a prescription which they had not handed in. Although reasons for not doing so were varied, the most common reasons related to cost - it was cheaper to buy the item over the counter or it "cost too much" in general.
There are indications that between a quarter and a fifth of people would be more likely to go to the doctor for a prescription if prescriptions were free to all. Dropping prescription charges could therefore lead to an increased demand on doctors' time and for prescriptions.
There was some confusion about which groups are currently eligible for exemption from prescription charges. However, the main confusion appeared to lie in the detail rather than the principles, e.g. whether the age threshold for exemption was 60 or 65, or whether people with any long-term medical condition or only specific conditions were exempt.
There was strong support for all people with long-term medical conditions obtaining exemption from prescription charges, with almost nine out of ten people endorsing this suggestion. There was also strong support for those on a low income being exempt. There was not the same degree of support for students and young people in training being exempt.
While the majority supported diverting money from other areas of government spending in Scotland to pay for the extension of free prescriptions, it was clearly felt that this should not come from NHS budget allocations. Free prescriptions should not, in the public view, be provided at the expense of other aspects of NHS funding and performance.
4. WRITTEN CONSULTATION
Methodology
The consultation paper Review of NHS Prescription Charges and Exemption Arrangements in Scotland was launched on 25th January 2006 and the deadline for responses was 30th April 2006. The paper outlined some key issues with respect to the current system of charges and exemptions, provided some of the relevant policy background and posed a number of specific questions relating to the options under consideration.
The paper was circulated to 772 stakeholders representing a broad range of interests. It was also made available on the Scottish Executive's consultations website in order that other interested parties, including individual members of the general public, had an opportunity to contribute to the debate. A total of 188 responses were received (74 from organisations and 114 from individuals).
Main findings
Exemption on medical grounds
Question 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.
Exemption on medical grounds alone
- Roughly equal proportions were in favour and against exemption on medical grounds alone.
- Those who were in favour of exemption on medical grounds alone did not present any specific arguments in support of their position.
- Those who were against this option provided three main reasons: that it would be fairer to base exemption on ability to pay; that it would be difficult to ensure a comprehensive list of conditions; and that the process for identifying which conditions should be included in the list would be highly contentious.
Review of the list of conditions
- Most of those who commented were in favour of reviewing the list of conditions. They highlighted the unfairness inherent in the fact that some chronic conditions are exempt and others are not, as well as the difficulties that non-exempt patients can face in affording charges for multiple prescriptions. It was suggested that all people who are terminally ill or have a life-long condition should be exempt from charges.
- Of the minority who were opposed to reviewing the list, almost all were diabetes sufferers and diabetes patient groups who were concerned that a review might result in diabetes being removed from the list.
Question 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.
- Respondees were divided on the question of whether or not medical exemption should be limited to the treatment of the condition in question, although more were against than in favour of this option.
- The arguments made against this option included the widespread view that, in some cases, it may be very difficult to determine whether or not one medical condition is related to another. In addition, some conditions can cause secondary conditions or affect sufferers' general health, which in turn will increase their susceptibility to other infections.
- The main argument in favour of limiting exemption to the condition in question was one of fairness.
Question 3: Whether it makes more sense to provide exemption based on a list of drugs or based on a list of conditions.
- Among those who commented, there was overwhelming opposition to the idea of basing exemption on a list of drugs, rather than on a list of conditions. There were several considerations underpinning this opposition including: the possibility that exemption might be granted to people with minor ailments or short term acute illness who may be less in need of assistance with charges; the extra bureaucracy to maintain the list of drugs may prove very costly; the potential time lag between new drugs coming on to the market and their addition to the exempt list; and the feasibility of developing a list of drugs that includes all of those medicines required to treat even common chronic conditions.
- Only a small minority saw the merits of a drugs-based exemption list. They felt that such a list would be fairer and had the potential to extend exemption to a wider range of patients.
Economic need - affordability
Question 1: Whether exemption should be extended to HC3 holders.
- Among those who commented, there was near unanimous support for extending exemption to HC3 holders. The main argument in support of this option was that, in qualifying for an HC3, people have more than demonstrated their need for assistance with health costs.
- Only a minority argued against extending exemption to HC3 holders. They felt that this proposal was not sufficiently far-reaching and would still leave some categories of patients, including those who are unable to work or those who are high users of medicines, struggling to meet charges.
Question 2: What changes to the PPC system would address current barriers to its use, particularly by those on low income, and maximise patients' benefit?
- The most common suggestions were abolishing the system of upfront payment and allowing patients to pay in instalments, publicising the PPC more, issuing PPCs retrospectively, reducing the cost of the PPC and restructuring the minimum payment period.
Question 3: 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.
- Roughly equal proportions of those expressing a view 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, even if the fee levied was nominal.
Question 4. 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.
- Slightly more of those who commented were in favour of the monetary cap than were against.
- On the whole, respondents showed a preference for the monetary cap, rather than a concessionary rate (see question 5 below).
- 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 and 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.
Question 5. 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.
- There was general agreement that a concessionary rate should not be adopted, although a minority were in favour of this option.
- The main reason given in support of the concessionary rate was that such a system would benefit patients who require a great deal of medication.
- Concerns raised about the concessionary rate were similar to those raised with respect to the monetary cap option. In particular, it was felt that such a system would still be too expensive for frequent users of medicines.
Exemptions for students and trainees
Question 1. Whether there is a case for extending the current 'full-time student' threshold to cover tertiary education.
- Most of those who commented were in favour of extending the current full-time student threshold to cover tertiary education. The main argument for this option was that students in full-time education can have difficulty affording prescriptions.
- The most common perspective in opposition to this option was that students should be assessed on their ability to pay.
Question 2. Whether exemption should be extended to all persons in full-time education or training, regardless of their ability to pay.
- Most of those commenting were in favour of extending exemption to all persons in full-time education or training, regardless of their ability to pay. The main argument for this option was that total exemption is a preferable system to means testing.
- However, a significant minority felt that payment of prescription charges should be based on ability to pay and students or trainees should be treated no differently to other groups in society.
Question 3. Whether there should be concessionary charge arrangements for full-time students or trainees above set age thresholds.
- Roughly equal proportions of those commenting were for and against this option.
- Many of those who were in favour of concessionary charge arrangements for full-time students and trainees preferred total exemption for this group. However, they felt that if exemption was not possible, a concessionary rate would be acceptable.
- The main reason respondents opposed the concessionary rate for full-time students and trainees was that they preferred total exemption for this group.
5. FOCUS GROUPS AND IN-DEPTH INTERVIEWS
Methodology
Eight focus groups and two in-depth interviews were conducted in various locations around Scotland between 13th June and 14th July 2006. These were among people on a low income, people with chronic conditions (exempt and not exempt), students, trainees, parents of dependants aged under 20 years, and relatives/carers of those in need of palliative care. Two in-depth interviews were conducted with people who have a permanent disability.
The research considered general attitudes towards prescription charges, as well as views on the change options and associated issues outlined in the consultation document.
Key findings
There was universal support for reform of current prescription charging and exemption arrangements. Virtually all participants felt that the existing flat rate charge is too high and a significant proportion, particularly older people with a chronic condition and those on a lower income, felt strongly that charges should be abolished entirely.
In terms of different options for change, there was a consensus that ability to pay should be the key consideration. Indeed, this was mentioned spontaneously during discussion of each of the options set out in the consultation document.
Most participants also felt strongly that condition-based exemptions should continue, and that the list of conditions should be extended. They felt there was a sense in which it was "immoral" to expect those with chronic or terminal illnesses to pay for their medication. However, the practical difficulties involved in developing a comprehensive list of conditions were also acknowledged.
There was repeated suggestion that any new system of charges and exemptions must be as simple as possible from the point of view of patients. On this basis, the reduced flat fee option was generally preferred to the monetary cap and concessionary rate. While patients clearly understood the latter two options, they regarded them as unnecessarily complicated and potentially difficult to administer.
GPs were generally felt to have a pivotal role to play in 'policing' any new system of charges and exemptions - whether this is in terms of prescribing fewer non-essential drugs or deciding which patients should be exempt on the grounds of their condition, and so on.
6. CONCLUSIONS
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:
- there is a need for a review
- if medical exemption continues, the list of exempt medical conditions should be reviewed
- exemption should not be based on a list of drugs
- there should be further exemption on the basis of low income
- if the PPC system continues, it should be improved by allowing payment in instalments, issuing PPCs retrospectively and better publicising the system
- a concessionary rate should not be introduced
- the revised system should be administratively straightforward and easy for patients to understand.
Areas of disagreement:
- whether exemption on medical grounds alone should continue
- whether, if medical exemption continues, it should be limited to drugs for the medical condition in question
- whether there should be a reduced flat fee
- whether there should be a monetary cap
- whether students and trainees should be exempt, regardless of their ability to pay.
« Previous | Contents | Next »