Re-dressing old wounds: The unintended consequences of NHS prescription regulations

The current system for exempting certain patients from paying for their NHS prescriptions is discriminatory, unjust and unfit for purpose.  The high cost of prescription medication deters many patients from engaging consistently with treatment, increasing their risk of adverse outcomes such as strokes and heart attacks. 

When Bevan introduced the NHS in 1948, his intentions were clear and honourable: nobody in this country should suffer from a treatable illness or ameliorable impairment because they were too poor to afford care. 

Unfortunately his advisors had under-estimated the scale of demand for health services.  From every corner of the country, people emerged in droves requesting glasses, false teeth, and wondering whether they could discard their antique trusses if they had their hernias repaired surgically. 

On 1st June 1952, after four years of dismayed contemplation of the rising cost of the NHS, a prescription charge of one shilling was imposed, and a charge of one pound for dental treatment. 

In 1965 prescription charges were removed again, but this was again a short-lived interval and in 1968 they were reintroduced.  The only difference was this time, they were not for everyone.  A list of exemptions was drawn up, based on the state of medical art in 1968, and this list has remained largely unchanged since then.  In 2009 there was one major addition, to exempt people suffering from cancer, but otherwise the list has been embalmed.

As is often the case with overly complex regulations, unintended consequences arise.  The aim of the original list of exemptions was to ensure that people whose lives depended on regular medication should never be unable to afford that medication. 

Exemptions were granted to:

-       People with epilepsy needing continuous medication

-       Myasthenia gravis, a neurological condition which can lead to profound disability and death

-       Certain hormone deficiencies (but only those which were recognised in 1968 and were expensive to treat in 1968)

-       Anyone who had a fistula (a hole causing body fluids to leak from the urinary system or digestive system onto the skin surface), if that hole was permanent.

In 2009 cancer patients were included, not only for their initial phase of treatment, but potentially on a permanent basis.  They are exempt from paying for prescriptions as long as they are having treatment for cancer or for the side-effects of treatment.  So, if they develop a coin-sized patch of dry skin where they had radiotherapy and need an emollient cream for that, then they qualify for all their prescriptions to be free forever. Moreover, like all patients who are exempt for one reason, all other prescriptions for unrelated problems are covered by the NHS.

As a doctor, scenarios like the following are quite typical. This morning I saw Mr A, who has high blood pressure and asthma.  His medical treatment is essential.  Without it he will be unable to work and will be at a much higher risk of strokes, heart attacks and death from asphyxiation. 

He is not exempt from prescription charges and must either pay £8.40 for each of the six medications he has to take; or he can pay £109 for an annual season ticket. He is open about his reluctance to use medication regularly because despite his reasonably high income, he has a dependent family and doesn’t feel able to spend the money on medicine for conditions which do not immediately incapacitate him.  High blood pressure at this level does not produce any symptoms at all until the stroke or heart attack or kidney failure occurs. 

Then I saw Mr B, who also has high blood pressure and asthma, but is also severely obese and has over-taxed his pancreas so he has to take tablets to keep his blood sugar down.  His pancreas does produce insulin, but not enough to cope with what he eats, and the fat around his abdomen produces substances which impede the action of his natural insulin.  A few years ago he managed to stick to a diet and his blood sugar was normal without medication, but then he resumed over-eating and it went out of control again.  He is classified as a type two diabetic, and as a diabetic he can claim all his prescriptions free.  All diabetic people are exempt, except those who change their lifestyle and diet in order to control their blood sugar without medication.  Over-eating saves Mr B £109 per annum, and he gets other benefits such as free eye checks. 

Mr B is not exceptional.  Studies have indicated that the majority of people with type two diabetes mellitus could cure their diabetes by restricting food intake.

This injustice has not passed unremarked.  In 2008, Professor Ian Gilmore was asked to review the current arrangements with a view to extending exemption to everyone with a chronic medical condition. His report suggests that the current list was illogical and unfair, but he was worried about the cost implications of levelling the playing field, observing that the NHS would lose revenue of £500 million per annum if prescriptions for chronic conditions were dispensed free of charge.  Professor Gilmore suggested phasing in the new, less discriminatory system, and used phrases such as “as soon as possible” – but seven years later, no progress has been made. 

Professor Gilmore is appropriately cautious.  An Ipsos Mori poll from 2008 indicates that in the course of one year, 800,000 UK residents did not collect a prescription because of the cost.  One billion NHS prescriptions are dispensed annually, so there would be approximately an 8% increase in the number of prescriptions dispensed if cost were no longer a barrier.  

The NHS could be at risk of a successful class action by one of the minorities who suffer in particular from this system. High blood pressure is much more common in certain ethnic groups; for example, about one in three US black people need medication for it, compared to one in four white people. Alternatively a patient group action might ensue, perhaps by people who have asthma and who need to pay for medication throughout their adult life while they are making an active contribution to the NHS, until they reach sixty and qualify for free medication. 

The NHS is an expensive luxury, but having seen the consequences of living without a well-organised public health care system, nobody would want to make it unsustainable.  The cost of prescription medication is a significant element, so we need a solution which will be more equitable.

If we were to abolish exemptions from prescription charges, the NHS would gain revenue. If we also abolished pre-payment certificates, the revenue would be a significant contribution to the cost of the service.  There would be additional savings because the £8.40 item charge does not cover the cost of paying for the medication and the dispensing service.  In other words, every prescription not dispensed represents a greater saving than the cost of the drugs.  People would no longer collect medications they do not intend to use, whereas when I do home visits and ask about medication, I am frequently introduced to a private pharmacy containing collections of unopened boxes, collected over the years “just in case”. 

It would not be fair, of course, that people with chronic conditions would need to pay for medication.  Indeed, it was never their choice to suffer those conditions in the first place.  However, we are deluding ourselves if we believe we can make life entirely fair.  People would still be protected from much of the cost of their treatment, if there continued to be a flat rate charge per item. 

Finally, people should be free to prioritise the demands on their budgets.  Long-term medications are generally prescribed in quantities to cover a three-month period, so if there were a £10 charge per item, that would equate to less than £1 per week.  Some people choose to prioritise their health needs; they manage their diets; take regular exercise; avoid smoking and drinking to excess – and take regular medication as and when required.  Others place less of an emphasis on health maintenance, and that is a lifestyle choice which they should be free to make.