By Amanjit Jhund / @amanjit
Since devolution we have seen a great number of disparities emerge in the care for patients in different parts of the UK. One of the most harrowing side effects of this has been the increase in postcode lotteries not bound by local areas or Primary Care Trusts but by national boundaries.
One of the most striking examples of this is prescription fees. Whilst in Wales prescription fees have been abolished altogether, in Scotland and Northern Ireland the devolved parliaments have committed to abolishing prescription charges by 2011 and 2010 respectively.
England now remains the only country in the UK to retain the principle of prescription charges. While the government has extended the exemptions on prescription fees to include cancer patients and has instituted a review on long term conditions, many organisations such as the British Medical Association believe that the government should go further and abolish prescription charges altogether, and I agree wholeheartedly with them.
Up until the recent alterations made to include cancer patients our current system had been unchanged since 1968. This has resulted in gross discrepancies within the system. Under our current system patients suffering from treatable conditions such as hypothyroidism are exempt from charges whilst those suffering from long term, terminal illnesses such as cystic fibrosis (CF) are forced to pay prescription charges from the age of 16 onwards. This is a situation that has arisen due to improved medications and increased life expectancy of CF patients (estimated at 31-36 years), many of whom died in infancy in 1968. There are many other injustices in the system with individuals suffering from debilitating long term degenerative illnesses such as Parkinson’s disease denied exemption.
To counter this the government has set up a review of prescription charges in long term conditions but my concern is that this will simply provide us with a new set of arbitrary dividing lines which over time will become unfit for purpose much like the current exemptions. Even developing a system of exemptions is fraught with difficulties. Simply extending the list of conditions which qualify for exemption does not solve the problem as it fails to consider the highly variable nature of disease from person to person and the impact that it can have on life circumstances. Medicine is often described as an art rather than a science and for this precise reason attempting to restrict exemptions along the lines of aetiology is both unjust and unethical
With the current review another concern is that the patient groups with the best funded and active pressure groups such as the British Heart Foundation will lobby for the inclusion of their patients on the exemptions list much in the same way that cancer charities and patient groups have already successfully done, whilst those with rarer and less publicised but no less debilitating conditions will lose out.
One argument often used for the retention of prescription charges is the estimated £435 million a year raised by prescription charges for the NHS. Whilst this is a substantial amount the Department of Health estimates that the cost of excluding cancer patients alone will cost £15.6 million a year. Combine this with the cost of excluding antidepressants estimated by the BMA at £24 million a year, anti-hypertensive medications at £37 million a year and inhaled corticosteroids at £11 million per year and the financial case for retaining prescription charges looks less and less viable.
If a serious and comprehensive review of long term conditions is carried out then not only these medications but hundreds of others will have to be made exempt for long term conditions. We may even reach a stage where the costs involved in policing, enforcing and administering such exemptions will outweigh the revenue generated by the remaining charges.
While we cannot afford to simply drop prescription charges in the current climate. Like the Fabian Society I would like to see a manifesto pledge to reduce prescription charges in the first instance with the aim of abolishing them altogether once our public finances allow it. Ultimately I believe that this is the only way to avoid these inequalities and resolve our current morally bankrupt and ethically indefensible position.
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Free prescriptions in Wales? Paid for by English taxpayers.
Forgive the reality check here.
Someone has to foot the bill unless the pharmaceutical companies are giving the stuff away.
Anything free?
Oh yes please.
Now as Scotland has been shown to be contributing more to the UK exchequer than it takes (including all that 'extra territorial income' that slips past the Treasury's book keeping) then we need to talk about Scottish taxpayer's subsidy of the London Olympics, Wembley, Cross Rail, the Dome.............. or are you the pseudonym of Dr 'Bonkers' Starkey the well known Jockophobe?
The point is William 'who is subsidising who' depends on your accountants (did I mention electrical power from Scotland that keeps Northern England alight...... mmmmm).
Who exactly is it that shows Scotland to be contributing more to the UK exchequer than it takes? On a per capita basis please.
Then there are a number of independent research papers by the likes of KPMG - but of course they know squat diddly....
You could read: http://www.alba.org.uk/scotching/biglie.html but given your Starkeyesque demeanour I would not recommend it as it will likely cause your brain to fry.
Not sure about this one , Not that i think is wrong but on the case of cost , In the proposals we have free car park charges and now free prescriptions this money would have to come out of hospitals budget and not being funny but if people can afford the prescription then they should pay for them , We already have rules that the unemployed and long term sick get there prescriptions for free , so i am not sure who this would help ?
ricki
But free prescription charges is the right idea.
As usual it is not the poorest that suffer (they are typically exempt) - it is those earning around the national average wage that suffer as the cost of drugs represents a higher proportion of their income; same with dental and optical charges. £20 for drugs is a big hit for a family of four living on a take home of £200 a week after tax and NI.
That is not the socialist ideal of equality of access to care at work, now is it?
Thanks for your comment I appreciate you opinion but Im afraid that I do have to disagree with you on several points.
1) We already have rules that the unemployed and long term sick get there prescriptions for free
Im afraid that this is a fallacy, the point I was trying to raise when I used the examples of cystic fibrosis and parkinsons disease is that often the long term sick are not covered by the current arrangements. Cystic Fibrosis is a case in point despite its increasing life expectancy it is still a condition that will blight an individuals life with illness and hospital admissions. Many Cystic Fibrosis patients will be on up to a dozen different types of medication by the time they reach the age of 16 just to stay alive. This is compounded by the fact that many of these individuals just want to lead a normal life they want to reproduce (made increasingly possible with advances in fertility treatment), they want to have their own home and independence and often they want to work. I have seen first hand 12 year old children with CF desperate to attend school even though they are seriously sick and know that it will make them worse. Despite this resilience and determination many of these individuals will have missed large periods of school due to their illness and may not be able to attain a job that pays well enough make working worthwhile. To ask these patients to then contribute to their prescription charges or to remain unemployed to receive free prescriptions seems both inhumane and nonsensical to me.
Another point to consider is exactly what you mean by long term conditions do we then include acute periods of illness in our calculations or do we exclude them? As an example why is it fair for a patient with hypothyroidism or a woman 7 months after a pregnancy to have a chest infection treated for free when a patient with asthma for whom the same infection can be far more serious should be forced to pay for treatment?
2) Not that i think is wrong but on the case of cost , In the proposals we have free car park charges and now free prescriptions this money would have to come out of hospitals budget
Of course as I mentioned in my article we would have to accept that we would lose the £435 million/year if we abolished the charges. But this as I sought to point out may be rapidly decreased anyway with the governments pending review on long term conditions. Depending on the systems used to define which categories of disease should be included in the exemptions those medications that I mentioned above alone would decrease the figure to £347 million and these medications alone represent the tip of the iceberg. Im afraid I cannot give you any exact figures on how the current review will affect the current funding as we will have to wait for the results of the review itself, but there is an additional cost factor that we need to consider. Ultimately prevention is both more effective and cheaper than cure and even encouraging uptake of medications such as antihypertensives and antidepressants in the current patient populations may well result in savings on resources and battling the physical, social and psychological complications of disease that will vastly out weigh the £435million/year.
In the future this will be even more important as with the advent of increasingly preventative medicine it is likely that we will see the development of "superpills" designed to prolong life. Many have already proposed a combined statin and aspirin as a potential class that should be administered to everyone over 50 years of age many of whom would not be eligible for exemption from prescription charges. While I remain unconvinced about the use of statins in an otherwise healthy individual it is only a matter of time before we do have medications that will reduce morbidity and extend life expectancy in a healthy population. To then ask individuals to pay for such medication will only provide those on low to middle incomes with a significant dilemma as do they pay for medication they may not be able to afford for the possibility of an increased life expectancy. We will then have to pay an increased cost for with hospital admissions, procedures and medical staff required to treat potentially avoidable conditions.
3) not being funny but if people can afford the prescription then they should pay for them
Im afraid that I cannot agree with this statement either. The founding principle of the NHS has always been "a long-held ideal that good healthcare should be available to all, regardless of wealth". If we accept that medication should be means tested or subject to a progressive tax then why not apply this to procedures? Why should those that are able to pay then not pay for their endoscopy or their heart bypass or their neonatal ultrasound scan? Many medications could be said to be far more effective in prolonging life and avoiding mortality than some of these procedures so why should medications be subject to such a means tested charge? Logic dictates that if we follow this argument to its natural conclusion we would then simply have a privatised health care system and the destruction of the NHS.
Its a much repeated quote but Harold Wilson once said that "The Labour Party is a moral crusade or it is nothing." and for me our current stance on prescription charges is immoral and for that reason I would like to see them abolished.
I believe that it is a far more important subject than hospital car parking fees as it directly concerns the health of our nation and the injustices that can occur (and I say this as someone that as a member of staff has paid his fair share of hospital car parking fees over the years). As a doctor my first and paramount responsibility is always to the health of the nation and this is exactly why I feel that this proposal is so important.
Thanks for the reply
I accept what you say on long term illnes Maybe new guidence should be drwan up , My Partner has just come out of hospital and is in and out often , She has a mental illnes that sometimes requires time in hospital , The last time she had been admitted with pain and dizzyness and sent home twice in 3 days on the 3rd time they admitted her and had to operate , luckly she is home and gettin better now .
What i meant by those can afford should pay , some of my freinds are entilled to free prescriptions but pay instead , they do this because ( i admit ) they are short term usally and they say they do it because they say if they pay for 1 prescription it means that the free prescpition can be used by someone who needs it more .
As to people paying for other ops or proceders they already do with private healthcare and still pay tax , And if i am right ( which i am not that often ) didnt the goverment accept the top-up proposel ? .
I acept my knowledge is only based on personal experince where you have a vast professional knowaledge .
As a Doctor i respect the job you and your colleuges do
Could i ask you, we here about to many mangers in the Nhs may i ask what your own view is ?
ricki
Im sorry to hear about your partner I hope that she gets well soon.
In terms of your friends choosing to pay for prescriptions I respect and commend their sense of social responsibility for doing so I do feel that it is reasonable to allow individuals to opt out of free prescriptions, but to force someone to pay on the basis of their personal wealth would go against the grain of the founding principles of the NHS.
In terms of your contention that people pay for private healthcare and pay tax absolutely they do, but those individuals are currently offered the same treatment as anyone else on the NHS for free. They choose to go private for the private rooms or decreased waiting times or even the better food. But they are not required to pay an additional cost to be treated on the NHS based upon their ability to pay.
This is an important distinction from prescription fees as they represent the one anomaly in this system, if we were to follow the principles of the prescription charge and extend it to the rest of the NHS then we would cease to allow these individuals the same treatment on the NHS for free to which they are currently entitled to.
With regards to top up fees. The fees are in place to allow people to access experimental drugs (currently only in cancer cases) as many experimental treatments cannot receive approval from the National Institute of Clinical Excellence (NICE)in time for many current sufferers to benefit from their effects and the sad nature of postcode lotteries ensures that many individuals are denied treatments granted to individuals in another area. The top up fees were a way of addressing these two problems although I personally feel that our current postition only represents a stop gap measure.
I feel that this is different from the prescription fees as asking an asthma sufferer to pay for antibiotics which could treat a chest infection which if left untreated could lead to a severe illness and possibly death is different from allowing a cancer patient to contribute to an experimental and unproven medication which has not been fully evaluated.
In terms of hospital managers I believe that we need to have less managers but those managers need to be of a higher quality. I hope that you do not mind but i have been asked my opinion on this subject before and have pasted below my reply to Ralph Baldwin on a previous post
One of the biggest problems in the NHS is that the Consultants do not respect or listen to the managers. Part of this problem stems from the fact that in general the managers are both underqualified (1 degree vs 6 or 7 for the consultants) and also the best managers are taken by the private sector.
In terms of reducing the number of incompetent and ill qualified managers again we should look to the US. When I was a medical student I was given the opportunity to intercalate (Gain 1 extra degree for 1 more year at University). Whilst the degree that I and my friends intercalated in ranged from physiology to neuroscience or sports medicine in the United States medical students can intercalate in Law or Business by doing an MBA.
With this system they constantly seek to develop a new generation of Physician leaders and entrepreneurs which if we copied in this country could finally lead to us having a well motivated, well educated level of Physician managers.
I think that by doing this you would have a smaller pool of better qualified managers who would view hospital management as a true vocation much like medicine, nursing or midwifery rather than as just a job.
Thanks again for the full response
Maybe you should be in charge of the Nhs , Thanks for the well wishes for my partner
I have to admit on the prescriptions for long term illnes i think they should be free , Maybe you could write the sec of state and see if he welcomes your ideas , i do find this abit complicated subject .
again thanks for the reply and thanks for the work you do as a Doctor and to all your colleuges in the nhs and private sector .
ricki
Don't worry about the name thing I missed the c in your name on my last post.
Sorry about the size of the response I tend to be a bit long winded but if there is anything that you're not sure about or just want a pointer to further articles just let me know.
Amanjit
Theres nothing wrong with being long winded if your are acutlly answering a question , Its when Mps give long winded answer and fail to answer the question put thats annoying .
ricki