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Prescription exemptions: Is it fair for GPs to police the system?

Advising GPs to avoid prescribing OTC medicines is all well and good, says Toni Hazell – but how does that tally with good medical practice?

It’s lunchtime. I’ve made phone calls, seen patients face to face, looked at documents and results and managed to grab 10 minutes for a sandwich. Back in my room, the inevitable screen message pops up: electronic scripts ready for signing. I brace myself – how many hundreds of scripts are there today?

In 1996, there were an average of 10 prescription items per person per year in England. Fast forward 20 years and that number had doubled, and every healthcare professional (HCP) should now be familiar with the concepts of polypharmacy and overprescribing. We all try to prescribe wisely, although this can be difficult when alternatives aren’t available.

The National Institute for Health and Care Excellence (NICE) tells us to use talking therapies and group exercise, mindfulness and meditation for less severe depression. It tells us to reject analgesics for chronic pain in favour of supervised group exercise, a personalised care and support plan, acupuncture and psychological therapies. A cynic might summarise this as: don’t use the things that you have, use the things that you don’t have. These services often don’t exist or have waiting times measured in months or years.

Read more: UPDATED: Government to keep prescriptions free for over-60s

The Royal Pharmaceutical Society (RPS) is working with the Royal College of General Practitioners (RGCP) to develop tools and guidance to help with repeat prescribing. If we want to tackle this issue, we need professionals who have the time to do it properly. These professionals must also have the expertise to make evidence-based changes, the consultation skills to take the patient and family with them and the confidence to take medicolegal responsibility for their own decisions.

The flip side of the discussion is that some prescribing is vital and that we need patients to take the medication they are given. There are multiple reasons behind poor adherence, including a lack of understanding, fear of medication, misinformation, complex regimes and adverse effects. The cost-of-living crisis means that the cost of a prescription is likely to become even more of an issue than it has been before. Our patients don’t pay the full cost of medication, so we don’t have a similar situation to the US, where medical bills are the commonest cause of bankruptcy. However, the current £9.65 prescription charge is a significant amount of money for many.

In England, those aged 60 and over are exempt, with a government proposal to increase this threshold age having been rejected. Also exempt are those aged under 16 or under 18 and in full-time education, women who are pregnant or up to one-year post-partum, and a variety of groups who do not have to pay for their prescriptions due to medical conditions or because they receive benefits. Those who have to pay but need more than three items in three months, or 11 per year, can benefit from a pre-payment certificate, but that leaves a number of people who need ad hoc prescriptions that they struggle to afford.

I have written previously about the absurdity of the current list of medical exemptions. But as there seems to be no appetite to change this, would an end to all prescription charges be a proportionate response to the cost-of-living crisis?

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

Ending prescription charges is superficially attractive. It has been done in Scotland, Wales and Northern Ireland, so why is England an outlier? Leaving aside the loss of income to the Treasury, the question of prescription charges isn’t as straightforward as it might seem. Many medicines are available over-the-counter (OTC) or on prescription.

Painkillers and cough and cold remedies are good examples of this. These often treat self-limiting illnesses, which most patients don’t need a doctor for. Most sore throats are caused by viral illnesses and don’t need antibiotics. Most non-specific back pain will resolve on its own and doesn’t need any intervention from a HCP. Primary care is under unprecedented pressure, with year-on-year falls in the number of GPs and increasing demand for appointments. If those who really need to see a doctor are to get an appointment, we need those with a self-limiting illness to take a pharmacist’s advice, which might include buying something OTC.

One incentive to do this might be to avoid paying a prescription charge. Many generic medicines cost less than £9.65 and if this incentive is removed entirely, it seems likely that decision-making processes will change. Parents often tell me that they know their child only has a cold, but they’ve made the appointment to get free paracetamol rather than having to buy it.

I sympathise with the financial pressures behind this, but that appointment now doesn't exist for someone who needs it. NHS England (NHSE) asks us not to prescribe if the item is available OTC, but the list of exemptions to this policy – necessary to protect those who are vulnerable – and the duties placed upon us by good medical practice leave GPs who refuse to prescribe open to complaints.

Read more: RPS: Rise in patients asking pharmacists what meds they can ‘do without’

If I ask someone with self-limiting back pain to buy their own ibuprofen, am I going against the General Medical Council (GMC) advice that I must take all possible steps to alleviate pain and distress? With increasing concerns about the fairness of GMC procedures, and a number of suicides reported by doctors who were under GMC investigation, is it fair to ask GPs to police this system, with no confidence that our decisions will be backed up in the event of a complaint? Would it be wise to open us up to more conflict by abolishing prescription charges altogether?

I don’t have an answer to this. I’ve occasionally prescribed OTC medicines to financially desperate patients. It seemed the right thing to do at the time, to retain my humanity in an individual situation. But every working day, I also divert people to their local pharmacist in the knowledge they’ll have to pay for their medicines because if I didn’t, I’d be harming those patients who really need my expertise but can’t get to see me.

The ultimate solution is for an average wage to be able to support an average person to rent or buy their home, afford their weekly shop, bring up their children and have some spare for OTC medicines when needed. Sadly, it seems that we’re a long way off this situation in the UK.


Toni Hazell is a GP based in a practice in London

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