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CHAPTER TWO: THE PUBLIC CONSULTATION
Changes to the current prescription charging and exemption arrangements may have a significant financial and social impact. Accordingly, it was important to ensure that as wide a range of stakeholders as possible were invited to take part in the consultation and comment on the options for change. In this chapter we describe in detail the three main strands of the consultation.
THE WRITTEN CONSULTATION
The consultation paper Review of NHS Prescription Charges and Exemption Arrangements in Scotland was published in January 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 options under consideration (a copy of the consultation document is provided in Appendix B).
The consultation paper was made available on the Scottish Executive's consultations website in order that interested parties, including individual members of the general public, had an opportunity to contribute to the debate.
The paper was also circulated to 772 stakeholders representing a broad range of interests, including medical and professional bodies, NHS Boards, Local Authorities, patient groups and voluntary sector organisations (the distribution list is provided in Appendix C). These recipients were considered likely to consult within their organisation, creating a 'snowballing' effect and increasing access to the consultation document.
The written consultation was launched on 25th January 2006 and the deadline for responses was 30th April 2006.
Stakeholders who were included in the original circulation list but who had not responded by the official closing date were sent a reminder letter about the consultation and given a final opportunity to respond.
Consultation questions
Thirteen questions were included in the consultation paper. These were divided into three main themes: "Exemptions related to medical conditions", "Economic need - affordability" and "Ability to pay". Table 2.1. below sets out the questions in full.
Table 2.1: Questions included in the written consultation document |
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Exemptions related to medical condition Q1 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? Q2 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? Q3 Whether it makes more sense to provide exemption based on a list of drugs, or based on a list of conditions? Economic need - affordability Q1 Whether prescription charge exemption should be extended to HC3 holders? Q2 What changes to the PPC system would address current barriers to its use, particularly by those on low income, and maximise patient benefit? Q3 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? Q4 Whether there should be a monetary cap to the charges that a patient should be required to pay over a set period of time, after which prescriptions should be free within this period of time? Q5 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? Q6 Whether there are other changes in the arrangements for pre-payment or caps that are not listed above and which would maintain charge income in general for NHS Boards? Ability to pay Q1 Whether there is a case for extending the current 'full-time student' threshold to cover tertiary education? Q2 Whether exemption should be extended to all persons in full-time education or training, regardless of their ability to pay? Q3 Whether there should be concessionary charge arrangements for full-time students or trainees above set age thresholds? Q4 Whether there are other arrangements in the charging system that could remove the need for special arrangements for students? |
Responses
A total of 188 responses to the written consultation were received. The responses cover a range of stakeholder groups (74 organisations and 114 individuals). Table 2.2 below presents a breakdown of the responses.
Five respondents requested that their full comments should remain confidential and this has been respected. A further 88 did not indicate a preference either way. Their responses have also been treated as confidential.
Table 2.2 Summary of responses to the written consultation
Category of respondent | Number of responses received |
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NHS Boards | 13 |
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Chief Executives, Local Authorities | 1 |
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Local Authority Social Work Departments | 5 |
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Medical professionals/bodies | 8 |
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Pharmacist bodies | 6 |
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Academic institutions | 3 |
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Patient groups/voluntary organisations | 30 |
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Other bodies | 8 |
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Individuals | 114 |
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Total | 188 |
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The majority of respondents completed the structured questionnaire provided with the consultation document. Others submitted full written responses or emails. The length of the latter type of submission varied from a single page commenting on selected questions through to very lengthy responses, some of which appended additional materials.
Analysis and presentation of the data
The consultation generated a vast amount of qualitative data from the organisations and individuals involved. Some of the respondents ordered their responses around the questions posed, while others provided more general observations, within which were comments on the specific consultation options. Differing interpretations of the questions meant that different respondents provided comments on the same issues at different places in their responses. The analysis took account of all of these factors while preserving the detail of the data provided.
The analysis was carried out in several stages. Firstly, a database was designed for recording all submissions. This contained fields for basic data in relation to the identification and nature of the respondent, their location and whether or not their response was confidential. The report only contains verbatim comments from individuals and organisations who did not object to having their responses made public (as stated on the Respondee Information Form). No individuals have been named in the report and quotations are therefore attributed as 'individual'. All organisations have been named unless they specifically asked for their response to remain confidential.
Fields were also created for each of the questions posed in the consultation paper, together with additional fields for "alternative suggestions", "other comments" and "comments on the consultation".
The text was not scanned as not all of the respondents organised their submissions on the basis of the questions posed or provided specific answers to each question individually. Instead, for each response:
- the submission was read in full
- the data relating to each question was identified from the text
- the data relating to each question was then coded and inputted into the field for that question
- the data relating to respondent information forms was inputted to record respondent consent
- distilled summaries of answers to each question were added to the database.
For each individual question the following analysis was then carried out:
- general levels of support and opposition for each of the options was considered
- the key considerations underpinning support and opposition were identified
- details of which types of respondents raised those themes were identified.
In a summary document such as this, it is not possible to cover every detailed issue raised in every response and this report is not a compendium of points made for each issue at each question. Rather, the report summarises the general level of support for each option, the key considerations underpinning support and opposition, and highlights any variation in the views of different categories of respondents. It also highlights any alternative options suggested by respondents which were not specifically addressed in the consultation document. All of the original responses to the consultation, containing all of the detailed points made in relation to each question are available for consideration by the Scottish Ministers.
It should be noted that although the method allowed a general "count" of the number of respondents identifying each of the broad types of issues and making suggestions, the analysis of the consultation responses presented below is not intended to be a quantitative account, and it is inappropriate to present the data quantitatively for the following reasons:
- The point of a consultation such as this is not to be a 'referendum' on the different options but to inform and enhance the policy process by providing an opportunity for all interested parties to express their views, and most importantly, their reasons for holding those views.
- Many submissions presented the views of several individuals or organisations, making it inappropriate to count the responses in this way (and impossible, generally, to count the number of individuals represented).
- The respondents opted into the consultation and are therefore not necessarily representative of their sector.
- A straightforward "count" would exclude some of the comments which do not necessarily provide a response to a specific question.
Instead, the main focus of the analysis is on reflecting the range of issues which have emerged without attaching weight to particular viewpoints. This allows full consideration of all of these views during the review process. Where proportions have been given, these are only intended as a broad indication of the level of support for an option.
Variations by type of respondent have been identified only where there is a clear difference. For most questions, no such differences were apparent.
Several respondents indicated that their comments should remain confidential. Although for the purposes of this report the views of these respondents have been taken into account, they have not been quoted directly.
Focus groups and in-depth interviews
The Scottish Executive commissioned Ipsos MORI to conduct focus groups and in-depth interviews with key patient groups, whose views it was felt were essential to the consultation, but who were unlikely to respond to the written consultation. Eight focus groups were conducted in total. 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 of people in palliative care. Additionally two in-depth interviews were conducted with people with a permanent disability (see Table 2.3. below).
For each group, quotas were set on gender, age and social class to ensure a range of perspectives were represented. For the groups among people with chronic conditions, an additional quota was set on type of condition.
The groups and interviews were conducted in various locations throughout Scotland.
Table 2.3: Focus groups and in-depth interviews
Stakeholder group | Method of consultation | Location |
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People on a low income, currently exempt from charges | 1 focus group | Glasgow |
People on a low income, not currently exemptfrom charges | 1 focus group | Glasgow |
People with chronic conditions, currentlyexempt from charges | 1 focus group | Edinburgh |
People with chronic conditions, not currentlyexempt from charges | 1 focus group | Edinburgh |
Parents of dependants aged 19 and under (including women who are pregnant or have recently been pregnant) | 1 focus group | Linlithgow |
Students (both exempt and not exempt) | 1 focus group | Aberdeen |
Trainees (both exempt and not exempt) | 1 focus group | Falkirk |
People/relatives of people in need of palliative care | 1 focus group | Edinburgh |
People with a continuing disability who have difficulty leaving their homes | 2 in-depth interviews | Falkirk area |
Recruitment
The recruitment methods varied for each of the focus groups. The low income groups, the parents group and the students group were recruited door-to-door or on campus by experienced Ipsos MORI interviewers. The chronic conditions and palliative care groups were recruited with the assistance of patient groups and charities. The trainees group was recruited through Forth Valley College in Falkirk.
The participants for the in-depth interviews were people who had previously been interviewed for the Scottish Household Survey and who indicated that they would be willing to participate in further research for the Scottish Executive.
Discussion guide and moderation
All of the focus groups and in-depth interviews were moderated by experienced Ipsos MORI researchers. The discussion guide was structured around the consultation document to ensure that participants had an opportunity to comment on the same range of issues as respondents to the written consultation. The guide was designed by Ipsos MORI in close consultation with the Scottish Executive. A copy of the discussion guide is provided in Appendix D.
The focus groups were conducted between 13th June and 14th July 2006.
With the permission of participants, the discussions were recorded and transcribed for analysis.
Analysis and interpretation of the data
The data emerging from the focus groups and in-depth interviews were analysed using a version of the Framework method developed by Social and Community Planning Research.
Throughout the analysis, findings were cross referenced with the written consultation responses to allow for the identification of common and diverging themes, including any variation in the views of different stakeholder groups.
Two of the key strengths of qualitative research are that it allows issues to be explored in detail and enables researchers to test the strength of people's opinions and the underlying rationale for people's attitudes and behaviours.
However, it needs to be remembered that qualitative research does not allow conclusions to be drawn about either the extent to which something is happening among the wider public (although one might surmise that particular opinions appear to be widespread) or percentages of people that have certain attitudes or opinions. Qualitative research is designed to be illustrative rather than providing statistically representative data. This should be borne in mind when interpreting the findings presented in chapter 5.
The omnibus survey module
The Scottish Executive commissioned a module of 10 questions on the TNS System Three Omnibus Survey to gauge attitudes towards prescription charging amongst the general public.
The specific objectives of the research were to:
- examine the degree to which people are aware of what help is available for paying for prescriptions and how the cost to all patients can be limited
- determine if prescriptions are not being dispensed and, if so, why
- examine whether making prescriptions free might lead to more people asking for medication to be prescribed
- explore people's opinions of which groups should/should not get free prescriptions
- assess people's willingness to divert money from other government spending to extend free prescriptions to more people.
The module was developed by TNS System Three in close consultation with the Scottish Executive. A copy of the questionnaire is provided in Appendix E.
1,077 adults were interviewed at 43 sampling points across Scotland between 25th and 30th May 2006. All interviews were conducted face-to-face, in respondents' homes using Computer Assisted Personal Interviewing.
To ensure that the sample was representative of Scotland's adult population in terms of age, sex and socio-economic group ( SEG) 1 it was weighted 2 to match population estimates from the National Readership Survey of January - December 2004. The sample profile, both unweighted and weighted, is shown in Table F.1, in appendix.
All survey results are subject to sampling variability which means that observed differences between sub-groups may not always be statistically significant i.e. they may have occurred by chance. A guide to statistical reliability is provided in Appendix G.
Where percentages do not sum to 100%, this may be due to computer rounding, the exclusion of "don't know" categories or multiple answers. Where "*" appears, this represents a percentage greater than zero but less than 0.5%. The term 'N' refers to the unweighted base sample size.
Other contributions
In addition to responses to the main consultation, detailed above, the Scottish Executive received other contributions to the review of prescription charges and exemption arrangements. First, two Members of the Scottish Parliament sent shortened and simplified versions of the consultation questionnaire to all members of their respective constituencies, with a view to encouraging engagement with the debate. Both versions of the shortened questionnaires addressed a core set of five issues, although slightly different question wording was used in each case (the questions included in the two constituency consultations are listed in Appendix I).
The constituency consultations generated 596 responses in total. The questions posed differed to those listed in the main consultation document so it has not been possible to merge the data with the main consultation responses. Accordingly, the constituency data has been analysed separately and presented in a dedicated chapter of this report ( chapter 6).
Secondly, the Scottish Executive received a range of responses to a campaign launched by The Scotsman newspaper to abolish prescription charges for all people suffering from all life-threatening and chronic conditions. A summary of the responses is provided in chapter 6.
Presentation of the findings
The data from the public consultation is presented in 6 main chapters. The following chapter ( chapter 3) presents the findings from the Omnibus survey module. Chapter 4 presents an analysis of the responses to the written consultation. For the most part, the analysis is ordered around the 13 key questions set out in the consultation document. Chapter 5 presents the findings of the focus groups with key stakeholders and chapter 6 presents the findings of the constituency consultation.
Chapter 7 draws the analysis to a close by giving an overview of how stakeholders view the various options proposed and, as far as possible, their preferences for future charging and exemption arrangements.
To accompany this report a digest of consultation responses is available on the Scottish Executive website. This provides question by question summaries of each of the consultation responses, with the exception of those which have been flagged as confidential.
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