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Is the HRT pre-payment certificate an April fool or a long-term solution?

The introduction of a hormone replacement therapy (HRT) pre-payment certificate (PPC) has been a bit of a joke – except no one's laughing, says Toni Hazell

If I was a journalist, I think I’d develop a professional interest in women’s health – it would certainly keep me busy. The tabloids seem to love to publish statistically illiterate headlines about the risks of HRT and the contraceptive pill and that has a huge effect on the public.

As a GP trainee in 2001, I prescribed loads of HRT. By the time I qualified in 2004, it had gone out of fashion and I did only a handful of prescriptions over the next 15 years. Now, every other consultation seems to be about the menopause and I spend a large amount of time speaking to my local pharmacist and enquiring as to which patch or gel happens to be in stock this week.

The increased attention given to the menopause has not gone unnoticed by the government, which seems to have decided that cosying up to menopausal women might be a quick electoral win.

Since April 1 – no, it wasn't a joke – women have been able to buy an HRT PPC and get a year’s worth of HRT for two prescription charges, significantly cheaper than the current PPC for other medicines.

The usual care and attention was paid to IT support, so the website inevitably crashed soon after the certificates became available, but hopefully that will be a short-term issue.

Read more: HRT PPC website crashes as more than 37k purchased in first days of scheme

On the face of it, the new PPC is good news. But on closer examination it throws up more issues than solutions.

Firstly, it illustrates the absurdity of the UK prescription exemption system. For example, if you have an underactive thyroid – a condition that is managed by one tablet a day and an annual blood test – you can get all your prescriptions for free, forever.

Conversely, if you have had a transplant, for which you will have to take multiple daily drugs for life and regular clinic visits and blood monitoring, there is no exemption. Similarly, there's no exemption for asthma, cystic fibrosis, inflammatory bowel disease, sarcoidosis or a host of other chronic conditions. The system is illogical and needs proper reform.

Some will argue for the abolition of prescription charges, which has already been done in Scotland, Wales and Northern Ireland. Others are concerned that there is a risk of abuse when there is no charge.

I believe most GPs will have had a consultation by a parent that starts, "I know that he just has a cold, doctor, but I needed an appointment to get the free paracetamol". So many will think that script charges should be applied universally, but be variable and tailored to income and age. I don’t know what the right answer is, but it certainly isn’t the current system.

Read more: DH to hike prescription charges by 30p from next month

Secondly, administration of the certificate has clearly been worked out by someone who has never been near a GP surgery or a community pharmacy. The HRT item has to be written on a separate prescription to other paid prescription items.

With no immediate fix coming from GP computer systems to do this automatically, we face the prospect of multiple returned prescriptions that will need to be re-done. At a time of unprecedented GP workload, with GP numbers plummeting and burnout at a record high, this is all we need.

Finally, the certificate can only be used for HRT that is being used within the terms of the product licence. While this does cover most HRT, it means that some preparations will be excluded. There is, for example, currently no testosterone preparation that has a licence for use in HRT.

And with chronic HRT shortages, it is not unusual to have to change preparations from prescription to prescription. If everything with a licence is out of stock then our last resort might be something unlicensed for a short period of time until the licensed preparation is available – but this won’t be covered by the PPC.

Read more: DH extends 11 HRT and penicillin SSPs until late April

There were many easier changes that could have been made to HRT charges. The government could have stopped the nonsense whereby combined HRT attracts two prescription charges, one for each hormone. Or they could have waived charges for all HRT.

Alternatively, they could have committed to a proper sort-out of a prescription charge system that is not fit for purpose.

What we have is a partial fix, which will bring a load of hassle and stress to already hassled and stressed GPs.

It may also give some women a nasty surprise if not all of their HRT preparations are covered.

Great work.


Toni Hazell is a GP based in a practice in London

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