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CHAPTER FOUR: ANALYSIS OF RESPONSES TO THE WRITTEN CONSULTATION

This chapter of the report presents an analysis of responses to the written consultation. It describes the main options set out in the consultation document and considers the general level of support and opposition for each, highlighting the key considerations underpinning support and opposition, and any variation in the views of different categories of respondents. Alternative change options suggested by respondents are also considered.

A table detailing the number of responses to each question, and the main category of respondent commenting on each question, can be found in Appendix H.

The consultation document provided some relevant policy background to be considered in relation to each question. For ease of reference, some key points from this background information have been included in this chapter.

Also included are some quotes which illustrate the main arguments and the 'flavour' of responses. Full responses can be found in the Scottish Executive library and a full summary of points made in relation to each question can be found in the digest of responses.

4.1 EXEMPTION ON MEDICAL GROUNDS

BACKGROUND INFORMATION

The chronic medical conditions that currently confer exemption from charges were agreed with the medical profession in 1968 (see page 5 for list of conditions).

The current exemption arrangements contain anomalies which need to be reviewed. In particular:

• many common chronic conditions such as asthma, HIV/ AIDS and cancer are not included in the list of exempt conditions
• the exemption takes no account of the frequency and number of different medicines needed for the condition
• the exemption extends to all of the patient's prescriptions and therefore can include medication for other ailments completely unrelated to the chronic condition in question.

In addition to these issues, current condition-based exemptions arrangements take no account of the patient's ability to contribute to the cost.

Consultation questions and responses

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?

Summary of responses

Roughly equal proportions of respondents were in favour of, and against, continuing to give exemption on medical grounds alone (43 responded on this question).

Most were in favour of reviewing the list of exempt conditions (121 responded).

Exemption on medical grounds alone

Arguments presented in favour of, and against, the option

Respondents who favoured the continuation of exemption on medical grounds alone did not present any specific arguments in support of their position.

Those who were against the option - and this included most of the Health Board representatives and medical bodies who responded to the consultation - highlighted three main considerations. The first was that it would be fairer to base exemption on ability to pay rather than on medical conditions:

… it is not fair that a wealthy individual with a medical exemption should be exempt when a patient just missing out on income-based exemption would be forced to pay.
Individual

The second consideration was that it would be difficult to ensure a comprehensive list of conditions. Thirdly, some felt that the process for identifying which conditions should be included in the list would be highly contentious.

Overall, we believe that exemption on the basis of condition or disease is always going to be fraught with complications and inconsistencies and this is one of the key reasons why [our] members supported total abolition of charges.
Royal College of Nursing Scotland

Review of the list of conditions

Arguments presented in favour of the option

On the question of whether the list of conditions should be reviewed, those in favour highlighted the inequity inherent in the fact that some chronic conditions are exempt when others are not, as well as the difficulties that non-exempt patients can face in affording charges for multiple prescriptions.

In considering the shape of a future list, some respondents suggested that all people who are terminally ill or have a life-long condition should be exempt from charges while others highlighted specific conditions which they felt should be included in the list. Among the most commonly-mentioned conditions were cystic fibrosis, cancer, asthma and mental illness.

In terms of the review process, the need to ensure involvement of key stakeholders, including medical and scientific experts and patient groups, was raised repeatedly as an important issue.

[We] suggest an expert group with representation from various stakeholders is established to undertake this task.
British Medical Association Scotland

The Scottish Association for Mental Health and the National Schizophrenia Fellowship expressed a view that patients subject to a Compulsory Treatment Order ( CTO) should not be expected to pay for their medication and thus that CTOs should also confer grounds for exemption in any new list of conditions.

Arguments presented against the option

Of the minority of respondents who expressed opposition to a review of the list of exempt conditions, almost all were diabetes sufferers and diabetes patient groups. This constituency was concerned that a review might result in diabetes being removed from the list. They argued strongly against such a change, emphasising the extent to which diabetes impacts on people with diabetes' general health and the possible negative impact that the removal of exemption would have on health outcomes among this patient group. The following comment is typical of these submissions.

A reform of the current system which diluted the current level of exemption for people with diabetes will lead to poorer self-management and compromise health outcomes.
Diabetes UK Scotland

Similar comments to the above were made by a patient group with respect to epilepsy, although this group was, in principle, in favour of a review of the list of conditions.

The remainder of respondents who argued against a review of the list included those who were against conditions-based exemption in principle (for reasons outlined above).

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.

Summary of responses

Respondents 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 (87 responded). There were no clear differences in the views of different categories of respondent.

Arguments presented against the option

The main argument made against the option was one of practicality: there was a widespread perception that, in some cases, it may be very difficult to determine whether or not one medical condition is related to another and thus for which conditions a patient should and should not receive exemption. More specifically, respondents pointed out that certain conditions frequently cause a number of secondary conditions or affect sufferers' general health, which in turn will increase their susceptibility to other infections and diseases. Respondents tended to present these arguments with reference to specific conditions as the following comment illustrates:

The symptoms affecting people with multiple sclerosis are wide ranging and include fatigue, pain, spasm, depression, incontinence and sexual problems. Drawing a distinction between drugs which relate to MS may therefore be difficult.
MS Society Scotland

Similarly, it was noted that treatment of the main condition may cause side-effects for which a prescription is also required.

Many patients have a number of concurrent-related conditions and also suffer side-effects from those treatments of the main chronic condition, which require separate treatment, and for those patients to have to pay charges would be unfair and unreasonable.
Scottish Pharmaceutical General Council

Furthermore, it was suggested that a patient may suffer from an illness which is unrelated to the exempt condition but which may nonetheless lead to a deterioration of that condition if left untreated.

On a different point, there was also concern that limiting exemption to treatment of the condition in question would require significant changes to be made to current administrative systems, and would thus be very costly.

From a processing perspective it would be very difficult to have some items on a prescription form that were exempt from charges and others that were not. Currently, a prescription form is exempt or chargeable. Hence to have exemption when drug treatment relates to an individual condition would be complicated to administer and would require modification to processes and systems to accommodate.
NHS National Services Scotland

Indeed, a couple of respondents suggested that the changes would cost more than the complete abolition of charges for those with a chronic condition.

Arguments presented in favour of the option

Turning to arguments presented in favour of limiting exemption to the condition in question, the dominant theme was fairness.

There is no logic for applying the exemption to prescriptions that are unrelated to that qualifying for the exemption. That is inequitable.
NHS Ayrshire and Arran

It is important to note, however, that even respondents who favoured limiting exemption to the condition in question acknowledged the practical difficulties that may be involved in distinguishing between related and unrelated conditions .

Question 3: Whether it makes more sense to provide exemption based on a list of drugs or based on a list of conditions.

Summary of responses

Among those providing a response to the question there was overwhelming opposition to the idea of basing exemption on a list of drugs, rather than on a list of conditions (70 responded). There were no clear differences between the views of different stakeholder groups on this issue.

Arguments presented against the option

There were several, related considerations underpinning opposition to the option. First, several respondents (including most of the Health Board representatives who responded to the consultation) argued that, because many drugs are used to treat more than one condition, drugs-based exemption might result in exemption being granted, not just to those with chronic conditions, but also to people with minor ailments or short term acute illness who may be less in need of assistance with charges.

For example, antibiotics can be prescribed to anyone for a cough; for a patient with cystic fibrosis the consequences of not taking antibiotics are severe, this is not the case for a normal person in the population.
Individual

Questions were raised as to how this issue could be addressed without introducing a significant degree of "administrative complexity" into the system.

Potential practical issues associated with maintaining a list of exempt drugs were also highlighted. In particular, it was repeatedly suggested that the extra bureaucracy that would be required (including the convening of an expert group and, possibly, the establishment of an appeals process for patients and companies) may prove very costly to the NHS.

Some Health Board representatives and patient groups expressed concern that there may be a time lag between new drugs coming on to the market and the addition of these drugs to the exempt list, with the effect that patients may have to pay for them in the interim.

The number of new drugs coming onto the market also means that the list would need updated continuously, to ensure that people were not penalised for using the most up-to-date drugs.
Macmillan Cancer Support

Apart from these practical issues, questions were raised as to feasibility of developing a list of drugs that includes all of those medicines required to treat even the common chronic conditions. A number of related issues were raised in this respect.

First, respondents noted that the treatment of individual conditions often requires a vast range of different drugs - both for the direct amelioration of the condition itself and, as was highlighted in responses to the previous question, for any secondary illnesses and side effects of treatments. For example:

There are over 20 different drug preparations for Parkinson's disease symptoms in a wide variety of combinations and release mechanisms. In addition, there are numerous different drugs prescribed for the non-motor complications related to the condition, such as mental health problems, sleep disturbances, constipation, weight loss, genito-urinary dysfunction, hypotension. Lastly, there are the drugs required to manage the side-effects of the long-term use of Parkinson's disease medication.
Parkinson's Disease Society

Secondly, it was noted that two patients with the same conditions may be prescribed different drugs, either because their respective illnesses are at different stages or because they respond differently to the same drugs. Thirdly, a few respondents pointed out that new drugs are constantly evolving resulting in changes in the way conditions are treated and thus to patterns of prescribing for those conditions.

Related to these points, there was some concern that drugs-based exemption might sometimes result in only part of a patient's prescription being exempt, and that this in turn might reduce compliance with drugs regimes, not least where affordability is an issue.

For people with epilepsy, who also have co-morbidity, this would mean they would be worse off than they are currently. This would concern [us] as this could lead to poorer compliance with drug regimes for people living with epilepsy in Scotland.
Epilepsy Scotland

Arguments presented in favour of the option

Only a very small minority of respondents saw merit in a drugs-based, as opposed to a conditions-based, exemption list. Of this group, a few expressed the view that a drugs list would be fairer, as it has the potential to extend exemption to a wider range of patients with chronic conditions, as well as people who are suffering from short-term illnesses and require medication.

4.2 ECONOMIC NEED - AFFORDABILITY

BACKGROUND INFORMATION

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 ( LIS).

For patients who are not exempt on the grounds of income, but who require many or frequent prescriptions, the prescription pre-payment certificate ( PPC), described in the glossary of terms, presents a more affordable way of paying for those prescriptions. However, it is recognised that the PPC system has a number of shortcomings. In particular the size of the up-front fee may present difficulties for some patients, particularly those on a lower income.

For patients who do not purchase a PPC, there is no monetary cap to what they pay as the number of prescriptions they require increases.

Consultation questions and responses

Question 1: Whether exemption should be extended to HC3 holders.

Currently, and depending on the outcome of the means test under the Low Income Scheme, applicants will receive either an HC2 or an HC3 certificate. The HC2 entitles the holder to exemption from a number of NHS charges including NHS prescriptions. The HC3 entitles the holder to partial help with health charges but no help with prescriptions.

Summary of responses

Only 59 out of 188 responded to this question.

Among those expressing a view, there was near unanimous support for extending exemption to HC3 holders.

Arguments in favour of the option

The main argument presented in support of the option was that, in qualifying for an HC3, people have more than demonstrated their need for assistance with health costs. In essence, it was felt the current distinction between HC2 and HC3 is "a false one".

Exemption should be extended to HC3 holders. The differentiation is a false one - low income is low income.
North Lanarkshire Council Social Work Department

In presenting their views, several respondents also questioned the exclusion of certain sickness and disability benefits, particularly Incapacity Benefit, from the current list of proxy measures of income. It was noted that people in receipt of Incapacity Benefit are among those most likely to be heavy prescription users and thus most in need of assistance with charges.

In relation to all of these points, concerns were expressed that low income patients who are not exempt, and particularly those on the margins of current eligibility criteria, may face difficulties meeting the costs of their prescriptions, and in worst cases, fail to collect part or all of their prescriptions.

… We recognise that there may be a small number of patients who are currently above the threshold for exemption, who have genuine difficulty in making payment for their prescription and who require to be selective about which medications are dispensed. This is an unacceptable scenario for both the individual and the NHS. The assumption that the HC3 certificate would lower the threshold for such patients and increase eligibility for exemption, we support this development.
NHS Greater Glasgow and Clyde Health Board Trust, Medicines Management Team

Arguments against the option

Of the minority of respondents who argued against extending exemption to HC3 holders, a few did so on the grounds that the option 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 prescriptions (but who do not qualify for low income exemption), struggling to meet charges. For example:

… the Parkinson's Disease Society does not believe that this goes far enough and there would still be significant numbers of people with Parkinson's disease for whom the cost of the medication would be a significant financial burden.
Parkinson's Disease Society

From a different perspective, two respondents rejected the option on the grounds that a review of the list of exempt conditions, as outlined in the consultation document, would obviate the need for changes to current income-based exemption arrangements.

Other comments

In discussing income-based exemptions, several respondents commented that the forms applicants are currently required to complete are overly complex and may be a barrier to obtaining exemption. This issue, it was felt, would need to be addressed in any new system.

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?

Summary of responses

61 out of 188 respondents made suggestions for changes that might be made to the PPC system.

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.

Ability to pay in instalments

Abolishing the current system of upfront payment and allowing patients to pay in instalments was by far the most common suggestion for change, with respondents repeatedly highlighting the difficulties some patients, especially those on a lower income, face in meeting even the4th month charge upfront.

There was a clear preference for monthly instalments, with the option to pay by direct debit, standing order or via a 'stamp' scheme similar to that used in TV licensing. The following comments were typical.

… if patients were able to pay for a PPC in instalments, e.g. by purchase of stamps, similar to the system in place for purchasing television licences …
NHS Borders

An option to pay by standing order or on a monthly basis as a means to spread costs, may be attractive to those on a lower income but who are still liable for charges.
NHS Greater Glasgow Area Pharmaceutical Committee

Publicising the PPC

The need for the PPC to be more widely publicised was also commonly mentioned.

Firstly, we advocate a public campaign to raise patient awareness of the benefits of the PPC and ensure recognition of the ceilings on payments for prescribed medicines. Last week The Scotsman ran a series of leading articles which reported on cancer patients having to spend "up to £40 per month on NHS prescription charges". There is clearly an information gap.
NHS Greater Glasgow and Clyde Health Board Trust, Medicines Management Team

Specific suggestions included printing and highlighting relevant information on prescription forms and generally improving the level of information and advice provided at pharmacies.

Issuing PPCs retrospectively

The retrospective issuing of PPCs to patients who incur significant but unanticipated charges over a set period was favoured by several respondents. These included a number of medical professionals/bodies as well as individual patients who have found themselves in situations where the ability to purchase a PPC retrospectively would have been helpful.

When I first started taking my medication I had only 3 prescriptions but when I found out I had to be taking medication long-term I couldn't claim back the 3 I had previously bought when I went to get my PPC. This should be changed to claim back if the tablets are the same and within a time limit.
Individual

More specifically, the Royal College of Physicians and Surgeons of Glasgow made the following suggestion:

We would suggest that prescribers ought to be able to declare whether a recipient will [have] serious need for ongoing medication for a period of greater than or equal to six months. If this is not apparent at the first prescription then it should be able to be claimed retrospectively. The term serious is to deter those who ask for simple prescriptions of items that can be bought over the counter.
Royal College of Physicians and Surgeons of Glasgow

It was also suggested that retrospective issuing of PPCs would particularly benefit patients suffering from common conditions, such as skin disease, and also some acute diseases, for which it can be difficult to estimate in advance the amount of medication that might need to be prescribed during treatment.

However, one patient body expressed concern that the need for patients to retain records of prescriptions in order to obtain the PPC retrospectively may serve as a barrier to uptake - particularly for patients who are seriously debilitated.

Other suggestions

A number of respondents suggested either that the overall cost of the PPC should be lowered or that the minimum period payment should be restructured. On the latter point, there were specific suggestions of one, 3 and 6-monthly certificates.

Less common suggestions for reform of the PPC were concerned with making the system more "user friendly" from the point of view of patients. They included introducing automatic updates of PPCs for repeat users and providing patients with the ability to apply for a PPC online.

Other comments

It is worth noting that some pharmaceutical bodies expressed concern that changes to the PPC system might place an additional administrative burden on community pharmacies and that this, in turn, might compromise standards of patient care.

[We] however caution that this must be done in such a way as to not increase the workload to community pharmacy, when the best use of pharmacy time lies in the delivery of pharmaceutical care to patients
Scottish Pharmaceutical General Council

Another organisation, meanwhile, highlighted some of the bureaucratic issues that might arise from changes to the PPC system and, in particular, from a move to monthly or retrospective system.

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.

Summary of responses

57 out of 188 respondents contributed their views on the flat-fee option. Roughly equal proportions of those expressing a view were in favour of and against a reduced flat fee. This division was reflected within each of main respondent groupings. For example, of the ten Health Board representatives who responded to the consultation, five were in favour of a flat fee and five were not.

Arguments presented in favour of the option

A range of arguments were put forward in favour of the flat fee, the most common of which were that universal contributing would provide much needed revenue for the NHS, and that some of those people who are already exempt from charges can probably afford to pay something for their prescriptions.

I don't think for example that all pensioners should get free prescriptions when lots of them can well afford to pay.
Individual

There was also some suggestion that the reduced flat fee option would make for a simpler system - both from the point of view of patients and of pharmacists.

This could be a very good option. There would be very little bureaucracy so little time wasted. Easy for pharmacist to administer, no need to check through counter fraud services.
NHS Greater Glasgow and Clyde Health Board Trust, Medicines Management Team

Some support for the reduced flat fee was contingent upon the option being combined with a payment cap. Respondents' attitudes towards caps are explored more fully in the following section of the report.

With regard to the level at which the flat fee should be set, a range of suggestions were put forward. A few respondents felt that a nominal fee of around £1 would be appropriate, while others suggested a charge of £5.

There was also some support for a variable fee, although views differed on the most appropriate basis for this. For example, one respondent felt that the rate each patient pays should be income dependent, with those earning more than £10,000 per year paying the full current charge and those earning under £6,000 paying no more than £2 per item. Another suggested that different fees should apply for different medicines.

Arguments presented against the option

The main argument made against the reduced flat-fee option was that, under such a system, patients requiring many prescriptions may still incur significant costs over a period of time, even if the fee levied was nominal. Indeed, there was a repeated suggestion that a flat fee would effectively 'penalise' or 'discriminate against' people with chronic conditions. The majority of respondents who raised this issue were patients groups and individual patients.

No, a flat fee would still discriminate against me as I require at least 20 items per month. I am being discriminated against as I am ill.
Individual

Several respondents also reiterated the concern, highlighted in the consultation document, that a reduced fee might result in more people visiting their GPs for medicines which they might otherwise buy over the counter.

Reduced flat fee might have a similar effect to a 0 charge. It could increase demand for prescriptions and prescriber time could be taken up with unnecessary consultations.
NHS Ayrshire and Arran

In addition to these issues, a couple of respondents pointed out that the introduction of a reduced flat fee may result in some patients who have previously been exempt, including those with chronic conditions, having to pay charges for the first time. This, it was suggested, may prove very difficult to justify.

Other comments

In addition to the arguments presented above, a few respondents felt that there were outstanding questions surrounding the flat fee option which require to be addressed. For example, one Health Board representative pointed out that a similar system has been tried in the past with limited success and questioned whether the present option would be any better.

The Association of the British Pharmaceutical Industry (Scotland) also suggested that an in-depth economic evaluation of the flat fee option is necessary in order that an "optimal" fee can be identified.

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.

Summary of responses

64 of the 188 respondents responded to this question.

Of those who responded, slightly more were in favour of the monetary cap than were against. Opinions from individuals and patient groups and voluntary organisations were split, while almost all health board representatives and medical professional/bodies were in favour.

On the whole, respondents showed a preference for the monetary cap, rather than a concessionary rate.

Arguments for this option

The main argument in favour was that a monetary cap would be preferable to the PPC because it would be cheaper.

Eight pounds (approximately the currently monthly equivalent of the annual PPC) was perceived to be a fair amount to pay in any one month and would benefit people who receive regular medication but who would not benefit from using a PPC.

This is attractive. It would set a monthly cap of around £8. This would benefit those who needed several medications related to one short period of illness, as well as those on regular medication.
Scottish Consumer Council

Related to this was the feeling that a system such as the monetary cap would continue to raise income for the NHS whilst helping to manage demand for medicines. There was a perception by some, not just in response to this question, that if everyone paid something, then the individual monthly charge for the monetary cap or a single prescription charge would be fairly small.

Arguments against this option

The main concern of respondents who opposed this option was that it would be too complex and expensive a system to set-up and administer. This was also a point made by some who were, in principle, in favour of this option.

I do not think any more NHS money should be spent developing any new software/computer system to work this out.
Individual

This would be difficult to administer and again, likely to be more expensive than allowing complete exemption.
National Association for Colitis and Crohn's Disease

A less common argument was that the PPC is a preferable system as it is easier to operate than a system such as the monetary cap. As discussed earlier in this report, the PPC was considered by many to have its drawbacks. However, it had its advocates if it could be improved, mainly because it was already established and easy to understand.

[We] believe that a properly advertised PPC scheme with costs split more reasonably over the year would be easier to operate and still achieve a similar level of effectiveness and involve less administration than a process of capped payments.
Scottish Pharmaceutical General Council

Another reason given against the monetary cap was that it could encourage patients to "stockpile" medication. There was a perception by a few that patients could request scripts with several items on them before they were actually needed, which in turn could encourage wastage and place a greater demand on GPs time and less value on medicines.

From another perspective, concerns were expressed that the monetary cap does not do enough to help people with long-term conditions. It was mentioned by one respondent that patients who require medications for many years may still have difficulty in affording a capped monthly charge each month. As a result, patients may still have to prioritise one medicine over another.

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.³

Summary of responses

55 out of the 188 respondents responded to this question.

There was general agreement that a concessionary rate should not be adopted, although a minority were in favour of this option. Most of those who were against the concessionary rate were individuals, patient groups/voluntary organisations and health board representatives. Most of those in favour of this option were individuals.

Arguments for this option

Those in favour tended to feel that the concessionary rate would benefit patients who are frequent users of medicines: patients who may suffer from a long-term condition or an acute illness.

Rather than a reduced flat fee for all, it is preferable to target concessions or exemptions to meet the needs of vulnerable patients who cannot afford the cost of prescriptions.
Falkirk Council, Housing and Social Work Services

Arguments against this option

However, there was recognition of the fact that, even with a concessionary rate, the cumulative expense could still be high for those who require multiple prescriptions. This point was made by both those who were in favour and those who were against the concessionary rate.

… the multiple prescriptions needed by patients with chronic skin disease could still result in considerable cumulative expense.
British Association of Dermatologists, Dermatology Council for Scotland

Others pointed out that if the system changed to allow for frequent users to be exempt on the grounds of their condition, the need for a concessionary rate for this group of people would be made redundant.

Respondents had some similar concerns about the concessionary rate as they did about the monetary cap. Many of those who oppose the concessionary rate felt that it would be too complex and expensive a system to administer.

The monetary cap and concessionary rate - we consider difficult to administer effectively and fairly and do not consider them to be practicable.
NHS Lothian, Lothian Area Pharmaceutical Committee

There was also a perception that a new system such as the concessionary rate or indeed the monetary cap would place a burden on agencies, such as community pharmacies and Practitioner Services.

As with the monetary cap, another argument against the concessionary rate is that a concessionary rate already exists, in the form of the PPC.

The concession already exists in the PPC. The more medications prescribed on the PPC, the bigger the discount.
National Association for Colitis and Crohn's Disease

A less common reason given for opposing the concessionary rate was that some respondents preferred the monetary cap option. Indeed the balance of opinion between the two options was towards a monetary cap, rather than a concessionary rate. The reasons for this were that it is an easier system for the general public to understand and that it would be more cost effective for regular users of medicines than the concessionary rate.

This sounds similar to the monetary cap to me, but maybe too complicated to understand by the general public so I think the monetary cap is better.
Individual

Question 6. 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.

Summary of responses

10 out of 188 respondents put forward other suggestions for changes in the arrangements for pre-payment or caps. However, most of the suggestions had in fact been presented in the consultation document in one form or another.

Suggestions

The alternative suggestions were: patients could save up for a card in a similar manner to the scheme for TV licence stamps or electronic cards could be introduced where an appropriate amount is deducted each time a payment is made. It was suggested that this system could be similar to Transport for London's "Oyster Card", whereby people can top up the amount on the card when they can afford to do so.

4.3 EXEMPTIONS FOR STUDENTS AND TRAINEES

Background to exemptions for full-time students and trainees

Those in full-time education and aged 16 to 18 inclusive are already exempt from charges. However, full-time students aged 19 and above are not exempt under the current system. The Executive has a Partnership Agreement commitment to review prescription charges for young people in full-time education or training. This commitment recognises the Executive's wish to widen access to education.

Question 1. Whether there is a case for extending the current 'full-time student' threshold to cover tertiary education.

Summary of responses

62 out of the 188 respondents responded to this question.

Most were in favour of extending the current full-time student threshold to cover tertiary education. Individuals, patient groups and voluntary organisations, and medical professionals and bodies tended to be in favour of this proposal, whereas Health Board representatives tended to be against.

Arguments for this option

The main argument for this option was that students in full-time education can have difficulty affording prescriptions. This in turn could lead to them prioritising medication which is most important to them or going without medication completely. Respondents who present this argument find this unacceptable and feel that more can be done to help full-time students at this point in their lives. The following comments were typical.

The group of persons who fall into this category often have little income and struggle to pay prescription charges.
Scottish Pharmaceutical General Council

Full-time students face increasing financial pressures, and the issue of student poverty is a well documented one. Having to pay for prescriptions will be a considerable burden for many students.
Stow College

On a similar note, respondents feel that the Government should be actively encouraging people into education and supporting them by removing many of the financial barriers that stand in the way of gaining a university or college education.

As the Scottish Executive is doing its best to encourage more and more people to look to this, it would be a good idea to extend the threshold for this and make it one less thing they have to worry about (speaking from experience!!).
Individual

Stow College considered this to be consistent with the Scottish Executive's Lifelong Learning Agenda and emphasised the effects of good health on effective learning.

There is also a substantial body of evidence which points to the links between good health and effective learning and colleges will all have anecdotal evidence of the damage caused to retention and progression of learners through the intervention of poor health and untreated health problems.
Stow College

From another perspective, respondents were keen to emphasise that exemption should include mature students and those in further education, not just higher education. There was a concern by some that these groups may not be covered (this point of view may have been raised as a result of reading the question on age thresholds at question 3).

These points of view were mainly put across by individuals (who were students, mature students or parents of students) and academic institutions who felt it was important not to discriminate on the grounds of age or institution type. Mature students were perceived as just as likely to have financial barriers placed in front of them when returning to education later in life, whether affording childcare costs, paying the rent/mortgage or other living expenses. With regard to extending exemption to those in further education, there was near unanimous support for this proposal, as there was for those on training schemes, such as Modern Apprenticeships and Skill Seekers and those who study part-time. However, these points will be discussed in more depth at question 2.

Some respondents expressed the opinion that the impact on health care budgets of extending exemption to full-time students would be relatively small, as most students in full-time education are aged between 16-25 years old which is an age group that is less likely to require medical treatment.

Other respondents saw exemption as a preferable system to means testing. Although recognising the relative merits of means testing, it was felt by some that the set-up and administration costs involved with a system like this would outweigh the savings to be made by an exemption system.

There were some respondents who were in favour of extending exemption to full-time students in tertiary education, but only if a number of qualifications were met. These included: exemption for undergraduate students only, exemption should include those who qualify for a maintenance grant, and exemption for this group only after a full costing of this option has been undertaken.

Arguments against this option

Of those who were opposed to extending exemption to students in full-time tertiary education, the most common perspective was that students should be assessed on their ability to pay. There was a feeling among some respondents that students, and indeed all young people, should be means tested on their income. The following comments were typical.

[We] do not believe, however, that exemptions should be extended to all those in full-time education as a rough proxy for income. The financial situations of students vary significantly and should be assessed on an individual basis, i.e. their ability to pay prescription charges should be assessed in the same way as others.
Royal Pharmaceutical Society of Great Britain

If charges must be made at all it must be based on ability to pay regardless of status.
Individual

Some went further, to say that students should be means tested on not only their income, but their parental income also.

There was a feeling by some respondents that if students can afford other items, such as alcohol, cars and holidays, they can afford to contribute something towards prescription charges, even if it is just half the full prescription charge.

The notion that students have no money is nuts - if they can afford to go out drinking then they can afford to pay a prescription charge.
Individual

One student remarked that even though they have no parental support, they can still afford to live on a student loan and part-time job and are earning more than some people who have a full-time job. Some pointed out that the perception that all students are poor is incorrect. At present, students can apply for exemption on income grounds and this, according to some, is sufficient.

An alternative suggestion was to extend the age of exemption from 15 years to age 24 or 25 as this, it was thought, would capture the majority of students in full- or part-time education.

Question 2. Whether exemption should be extended to all persons in full-time education or training, regardless of their ability to pay.

Summary of responses

58 of the 188 respondents responded to this question.

Most were in favour of extending exemption to all persons in full-time education or training, regardless of their ability to pay. Individuals, patient groups and voluntary organisations and academic institutions tended to be in favour, whereas Health Board representatives were split.

There was near unanimous agreement that trainees and part-time students should be treated in the same way as full-time students. However, there was a significant minority who 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.

Due to the similarity of the questions in this section, some of the arguments for and against this option have already been presented above. Some of the arguments presented here are therefore a summarised version of those presented at question 1.

Arguments for this option

The main argument made for extending exemption to all full-time students and trainees regardless of their ability to pay was that exemption is a preferable system to means testing. As mentioned previously by one respondent at question 1, means testing was considered to be too complex and costly a system to implement, making exemption appear a less expensive option for this group of people, who are mainly young and less likely to need medication than other age groups.

While ability to pay should be the acid test in eligibility for exemption, assessment appears problematic in this context. We take the pragmatic view that all persons in full-time education or training should be exempt from payment.
Greater Glasgow & Clyde NHS Board, Prescribing Management Group

Another common argument for this option was that students and trainees can have difficulty affording prescriptions. This position is discussed under question 1 in this section.

Many of the other arguments for this option have also been discussed at question 1 and include: exemption for students or trainees should not be based on the grounds of age; mature students should also be exempt and people of all ages should be encouraged into education and training and supported as much as possible throughout the period of study.

Arguments against this option

A significant minority were opposed to extending exemption to full-time students and trainees regardless of ability to pay. As before, the most common argument presented was that students and trainees should be means tested on the income available to them.

Other arguments against this option were that students should still contribute something to the NHS even if it is at a reduced rate, and that students are already covered by low-income provision.

Question 3. Whether there should be concessionary charge arrangements for full-time students or trainees above set age thresholds.

Summary of responses

46 of the 188 respondents responded to this question.

Roughly equal proportions were for and against this option. There were no real differences in opinion by organisation type.

Arguments for 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. For example:

If charges are not waived as in questions 1 and 2, then concessionary charges should be given, i.e. via a PPC at the same rate as those that could be set for people on low incomes.
National Association for Colitis and Crohn's Disease

Another view was that students and trainees aged 19 years and above should continue to contribute something towards the NHS. However, there was a general acknowledgement that many students and trainees have little or no income and that they should therefore receive medicines at a reduced rate.

We have mixed views on this, but essentially are not persuaded that there is a strong case for extending the current 'full-time student' threshold to cover tertiary education… Concessionary charges in these circumstances would seem to be a more reasonable compromise.
Dunfermline & West Fife Community Health Partnership (West Fife Locality)

Another point of view was that wealthier students should have to pay the full rate, whereas students below a certain income threshold would pay a reduced rate.

A young undergraduate or college student with wealthy supportive parents needs a concession less than a woman or man in their thirties or forties with a family who has returned to full-time education or retraining to make a career change.
Individual

Arguments against this option

The main reason respondents opposed this option was that they preferred total exemption for this group for the reasons mentioned above. Others expressed a preference for means testing. A further reason for opposition was the perception that a concessionary rate for this group would not be a cost effective option: it would generate minimal income and cost far more to implement and administer.

Question 4. Whether there are other changes in the charging system that could remove the need for special arrangements for full-time students or trainees.

Summary of responses

16 out of 188 respondents responded to this question.

Suggestions

Most of the suggestions provided to this question were options that were presented elsewhere in the consultation document. The main suggestions were: everyone should be means tested, raise the age of exemption for all young people from 15 years and under to a higher age (21 and 24 were specifically suggested), prescriptions should be free for students and trainees until a set age (21 and 25 were specifically suggested) and considerations regarding arrangements for students would be best addressed under the low-income scheme.

Age-based exemption

The consultation document does not specifically ask any questions related to the age-exemption categories, however, the Executive recognises that many of the options presented in the consultation document are interrelated and indicated that they were happy to consider any views that respondents may have on this matter.

Summary of responses

10 out of 188 respondents commented on the age based exemption in isolation. Others touched on age-based exemptions in relation to ability to pay and these comments have been documented in that section.

Most commented mainly to present their support for the current age-exemption categories. However, a minority felt that the upper age limit of 60 should increase in line with the pensionable age.

In favour of the current age-based exemptions

Those who commented on the age-based exemption categories generally felt that they should remain as they are for children aged 15 and under. Respondents felt that the lower age limit of aged 15 and under was fair because children are still dependent on their parents at this age. The following comments were typical:

The retention of the prescription charge exemption for children should be supported as they are unable to make their own decisions about obtaining prescribed treatments.
NHS Grampian, Pharmacy Medicines Unit

[We] believe that all children under the age of 16 should be exempt on the grounds of not having independent income.
Scottish Pharmaceutical General Council

The following organisation commented that the upper age limit should remain and that any new system should avoid means testing.

[We] are of the view that the age limit of 60 should not be changed and would not recommend a move towards a situation whereby pensioners might be means tested to establish suitability for exemption.
Scottish Pharmaceutical General Council

Against the current age-based exemptions

The main argument for altering the age exemption categories is that the upper limit of age 60 and over should be increased in line with the pensionable age, on the basis that individuals over 60 but still in employment have the ability to pay.

We question the justification of a blanket exemption for all who are aged 60 years or over. This threshold could be increased to 65 years without hardship for those who are in employment and have the ability to pay.
Greater Glasgow & Clyde NHS Board, Prescribing Management Group

Others went further and argued that many pensioners can afford to pay.

However, there was recognition of the fact that older people are higher users of medicines than other age groups.

We consider it also relevant to note that becoming older does not necessarily equate with poverty, although it is acknowledged that the number of items of prescribed medication used by people over 65 rise significantly compared with the rest of the population.
NHS Lothian, Lothian Area Pharmaceutical Committee

4.4 ALTERNATIVE OPTIONS

A small number of respondents suggested alternative change options to those set out in the consultation document.

One such option - mentioned by a medical professional/body and a Health Board representative, was to replace the current charging and exemption arrangements with a patient co-payment system, similar to those which currently exist in other countries, in which charges would vary for different categories of drugs.

It would be worth looking at experience elsewhere, for instance the current French system where patients receive a higher level of reimbursement for evidence-based treatments than for newer or more expensive medications which are not necessarily more effective.
Royal College of General Practitioners Scotland

The Health Board representative proposed a specific model for such a system:

… the great majority of medicines would be free to the patient, perhaps as much as 90% of all prescription medicines. The proposed model would require all medicines to be categorised […]1) A list medicines - those considered essential, known to be effective and cost effective (free to the patient) 2) B List medicines - alternative medicines to those listed in A (these would require co-payment from patient) and 3) C list medicines - these medicines would be discouraged (too costly for the NHS or less effective) but if prescribed the patient would be expected to pay full price.
Lothian Area Drug and Therapeutics Committee

Other suggestions were less radical and focused on changes or schemes that might be introduced in tandem with some of the change options currently under consideration. For example, one respondent felt that extension of exemption to more people with a chronic condition or on a low income might be offset by increased charges for lower users of medicines.

4.5 OTHER COMMENTS ON THE SYSTEM AS A WHOLE

A number of respondents made comments on the system as a whole. The comments can be grouped into two main themes, namely: that any changes to the present system should be straightforward and easy to understand for the patient and secondly that the impact of these changes should not increase the administrative burden on GPs and community pharmacists.

System should be straightforward

Several respondents emphasised that any changes to the current system should be robust, practical and easy to understand for the patient and should not deter or prevent patients from obtaining the medication they need. It was also felt that any changes made to the current system should be implemented over a period of time.

One respondent felt that the back of prescription forms could be made easier to complete and that one way to achieve this would be to consult with various patient groups.

Administrative burden should not be increased

There was also a concern that any changes to the present system should not increase the administrative burden for GPs and community pharmacists. This was raised by several pharmaceutical bodies.

A further concern was that any changes to the current system may require the GP or community pharmacist to act as a "policeman" by determining the criteria for exemption.

Any means of prescription charging should be such that a Pharmacist or GP is not required to act as a "policeman" to decide whether a patient meets the necessary criteria for exemption.
NHS Lothian, Lothian Area Pharmaceutical Committee

One respondent pointed out that any changes to the current system will need to work within the new community pharmacy contract.

Any proposed payment system will have to work in the context of the pharmacy contract. If the pharmacist is able to issue, for instance, a 6 month supply at once to a stable vascular patient, would this be a single set of charges, or six sets of charges?
Dunfermline and West Fife Community Health Partnership (West Fife Locality)

Other comments were presented by a small number of respondents. One body suggested that a reduced income from prescription charges could be balanced by savings elsewhere in the NHS due to improved compliance such as better disease control.

Another body thought that charging arrangements for in-patient medicines should also be reviewed.

Several organisations also expressed interest in collaborating with the Scottish Executive in any future research set up to review exemption arrangements in Scotland.

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