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To charge or not to charge?

With England the only home country charging for prescriptions, Chris Chapman looks at how the arguments for and against the cost stack up

There's a postcode health lottery in the UK the moment you step into a pharmacy. If you're a mostly fit and healthy working adult living in England, there's a good chance you'll pay for your prescription: from April, you can expect to pay £7.85 per item – a 20p increase. But if you live and use a pharmacy anywhere else, it will be free.

Pharmacy bodies are adamantly opposed to England's prescription charge, with PSNC's chief executive Sue Sharpe branding it a "tax on the sick".

They cite the unfairness of taxing some but not all, the concern that patients may avoid getting the medicines they need, and the additional workload charges create – which takes up time that could be spend on patients.

But supporters of the charge have arguments too: first, the income generated can support further frontline care, and that abolishing it would see a surge in prescriptions and prescribing of OTC items. So who is right?

The finances

First, let's tackle the finances. The simple reason the prescription charge exists is money. Despite the vast majority of prescriptions dispensed being free of charge, around 51.7 million items were charged at the point of dispensing in 2011 (the latest year with statistics). Even though the charge was a full 45p lower than it will be from April, this still brought in £380 million for the NHS.

There are also pre-payment certificates. Although data on pre-payment certificates for 2011 is not available (since 2008 these have been recorded as "free prescriptions" by the NHS), in 2007 around 34.1 million items were claimed under the scheme – adding to the total income even further.


The latest prescription charges

Prescription charge (England) £7.85 per item from April 1 2013 (up 20p)

Cost of prepayment certificate £29.10 for three months; £104 for a year (no change) Dental, wig and fabric support charges have also increased  

Although the precise total is hard to determine, a £104 annual certificate is cost-effective if you buy 14 or more items; if all certificate users only purchased items this many times, and the number of pre-payment users remained static, this would bring in an additional £250m – a combined total of about £630m.

Although a small fraction of prescriptions by volume (a total of 961.5 million items were dispensed in 2011), the value represents a significant amount of money to the NHS, meaning it's unlikely the charge will vanish; a fact recognised by Ms Sharpe. Although she says the increase is "regrettable" at a time when many people are struggling, she recognises "the NHS is starved of resources and so may not be able to remove the charge".

That said, the NHS drugs bill is hardly static, and the patent cliff is in line to create significant savings without the NHS doing anything. In 2012, drugs such as atorvastatin, quetiapine and donepezil came off patent.

These three drugs alone cost the NHS £487m in 2011, and while the generic versions aren't free, they are a fraction of the cost. However, that the drugs bill is going to fall anyway is unlikely to be a persuasive argument for the government to scrap the prescription charge.

Patients first

Perhaps a stronger argument is patient health, a point pharmacy and other bodies have consistently raised. According to Pharmacy Voice chief executive Rob Darracott, the charge directly harms patients by preventing them from accessing healthcare. "Prescription charges deter many people from getting medicines," he explains, particularly if they are on low incomes. "Patients often have to make the decision of what medicine they can take, based on their finances."

The Royal Pharmaceutical Society (RPS) agrees. "We are deeply concerned that some people have to make choices about their health based on their ability to pay," says RPS spokesperson Neal Patel.

These arguments all allude not only to patient wellbeing, but also increased overall costs to the NHS; if patients decide not to collect medicines for fear of charges, compliance drops and the risk of hospital admissions soars, creating a greater cost to the NHS.

Prescription charges also add to workload. According to Mr Darracott "processing prescription levies is part of the job that adds workload but no patient benefit"; scrapping charges would see a release of pharmacists' and pharmacy teams' time, allowing them to focus elsewhere.

There is also the question of fairness, and equality for patients with long-term conditions. "The nature of the charge and patient groups it targets is inequitable," says Stephen Newbury, of Newbury Pharmacy, Swansea. "It's a tax. It's targeted at people who require medication on the health system but exempts people with some chronic conditions, but not others."

Which is more cost-effective: the money from the charge ploughed into healthcare or the potential savings and benefits brought about by patient compliance and reduced admissions?

The counter-argument is that those who most need medicines are exempt. Indeed, since 2001, the percentage of people paying for prescriptions at the point of dispensing has fallen steadily, from around 10 per cent of all prescriptions in 2001 to 5.4 per cent in 2011.

Although this could be seen as the result of additional prescription exemptions being introduced (such as for cancer patients since 2009), this is, again, misleading; while script volume soared from 587 million items to 961.5 million items between 2001 and 2011, paid prescriptions have only dropped from around 59 million items to 52 million – people who aren't paying are being prescribed more medicines.

The reality is that, currently, exemption due to a medical condition constitutes only a small fraction of free prescriptions. In 2007, the last year with data, around 59 per cent of all medicines dispensed were for those over 60 years of age, with around 5.4 per cent of medicines dispensed to children or older teens in full-time education. Overall, patients were eligible for exclusion for reasons of their medical condition or maternity for only 7 per cent of all prescriptions.

As far as the data shows, more people have to pay for their prescription than are exempt because of a medical condition. The pharmacy bodies have a point.

Alternative arguments

But what about the other arguments? One of the major concerns is that making prescriptions free would result in a rush of patients looking to cash in on free items and more prescribing of OTC treatments that patients could simply buy – adding to the NHS drugs burden.

"When you don't have to pay for something, you don't value it," explains Uma Patel, pharmacist at Dunn's Chemist in Hounslow, who is against free prescriptions for all. "I'm not saying that everybody should pay, but when everything is free at the point of delivery it is less valued by patients."

Yet these suggestions are not backed by the evidence. Three years after implementing free prescriptions in April 2007, the Welsh Assembly looked at the result. Far from seeing a surge in costs, the 2010 report found "no unusual increase [in the number of prescriptions] following the introduction of the policy", and no increase in the net cost of prescription items. Although the number of OTC products bought did fall after prescriptions became free, this was in line with overall trends across the UK. The supposed arguments don't exist.

"There was no sudden deluge of attempts to obtain everything and anything on prescription," says Mr Newbury, whose grassroots experience corroborates the national statistics.

Ultimately, the prescription charge debate is unlikely to be resolved any time soon. While arguments and fears about the impact on prescriptions don't seem to hold water, the NHS is at a stand-off: which is more cost-effective, the money from the charge ploughed into healthcare or the potential savings and benefits brought about by patient compliance and reduced admissions?

As yet there is no clear answer. And, until there is, it seems at least some patients in England will continue to pay for their medicines.

Is the 20p rise fair?

Regardless of whether the charge should exist at all, it's worth looking at the latest increase: is the 20p rise fair? The Department of Health's justification is that it is "broadly in line with inflation". According to the Office for National Statistics, the Consumer Price Index (the measure of inflation) is around 2.7 per cent per year overall and about 2.2 per cent for health; tied to inflation, prescription costs would increase to either £7.86 or £7.82. So, whether or not the charge should exist, it's not an unfair hike based on inflation.

Tips for your CPD entry on prescription charges

Reflect Do you support the prescription charge? Why? Plan List the key arguments for and against charging patients. Act Read the article and discuss with colleagues. Evaluate How has the article shaped your opinion on prescription charges?


Nick Ford, Non healthcare professional

An excellent article but misses one highly important factor in the cost-benefit equation: what is it costing the NHS to administer prescription charges, exemptions, exemption checks and pre-payments? The net result may actually turn out to be an ongoing loss of NHS income, or so small a profit that it really isn't justifiable in terms of the unfairness to both patients and pharmacy businesses.

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