Prescription charges: change overdue?BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7157.487 (Published 22 August 1998) Cite this as: BMJ 1998;317:487
Britain can learn from systems of copayments based on drugs' effectiveness
- T Walley, Professor of clinical pharmacology.
The NHS prescription charge, currently £5.80, is not related to the cost of the medicine but is a tax for the use of NHS services, intended partly to deter excessive demand for prescriptions. Its deterrent value is currently limited: about half the population are exempt, and only 14% of prescriptions are charged for.1 The charge itself is criticised as a tax on the sick for its rate of rise and high level.2 About 60% of prescriptions cost less than the charge, and many doctors now offer private prescriptions to non-exempt patients, where this will cost less than the charge,3 or advise patients to buy some medicines over the counter.4 Non-exempt patients are less likely to get a prescription dispensed than exempt patients.5 Many anomalies exist: patients with some diseases, such as hypothyroidism, pay no charges even for unrelated medicines, while some groups, such as elderly people, are entirely exempt, irrespective of their financial circumstances.
A recent review concluded that while patient copayments do reduce medicine use, they reduce the use of both desirable and less desirable medicines.6 Experience in Australia suggests that any such detrimental effect is short lived,7 and in the United Kingdom increases in prescription charges lead to only a slight decrease in prescriptions dispensed to non-exempt patients8—in part because the doctor, less sensitive to the charge than the patient, is often the decision maker.
What are the options for reforming the system? In 1994 the House of Commons Health Committee suggested a lower charge but with fewer exemptions.9 Another, less crude, approach is to adopt a more selective policy targeted against medicines that are only marginally effective or cost ineffective.10 Several countries run such systems. In France patient copayments range from 0% for essential medicines to 100% for so called “comfort medicines,” but the potential deterrent is often negated by private health insurance.6 In Italy medicines are classified by an expert committee as A (essential for the treatment of chronic illnesses and fully reimbursed), B (effective, but either not essential or poorly cost effective, and reimbursed at only 50%), or C (effective and inexpensive but used only for short periods, or ineffective, and not reimbursed). This policy reduced annual spending on medicines by a third over two years while apparently improving the quality of prescribing.11
Under a similar scheme in the United Kingdom effective treatment for all major illnesses and conditions could be free while less effective or cost effective medicines12 attracted a payment from the patient. Medicines could be categorised (a job perhaps for the new National Institute for Clinical Excellence) as follows.
The A list would contain a selection of effective medicines, no more than 200-300, but sufficiently comprehensive to allow treatment of all major conditions, and free of charge to all.
B list medicines are either no more effective than A list medicines, or offer minor benefits at a disproportionate cost. These might require a low copayment, perhaps related to the cost of the prescription, to a preset maximum. A maximum cumulative annual copayment per patient should also be set.
C list medicines are those for which effective alternatives are already listed—for example, branded preparations where a generic equivalent is available or which are largely directed at patient convenience, such as many modified release preparations. Patients might pay perhaps 50% of the cost of these medicines.
D list medicines would not be funded by the NHS at all, as in the current selected list.
This system might disadvantage some patients for whom a list B drug was essential. For example, some patients with severe reflux oesophagitis might need a proton pump inhibitor (on the B list) because it is effective to an extent to which an H2 antagonist (on the A list) is not. To avoid this a general practitioner might be allowed to endorse a prescription for exceptional patients, so that a list B medicine would be exempt from the copayment: the criteria for such endorsement would be carefully defined, such as intolerance to or failure of the list A medicine used as part of a therapeutic ladder. Such prescriptions would be audited and if the criteria had not been met the doctor could be held to account. Alternatively prior approval of such prescriptions, as in Australia,13 could be used. The lists should be constructed so as to make any such use relatively rare.
The lists would not be static. Most new medicines would be listed as B or C initially, but a few might reach list A immediately. Medicines could move up or down the lists, as either new evidence or less expensive alternatives became available. The lists could be included in the British National Formulary and in general practice and pharmacy computer systems and updated every six months.
Patient selection need not be abandoned entirely: patients currently exempt might be allowed B list as well as A list medicines without charge in the short term. This would leave much current prescribing unaffected and allow a phased entry of this system, with time for assessment.
How might the various stakeholders react? This scheme should be attractive to the government: all patients would be guaranteed necessary medicines free of charge, but by helping to manage expenditure on medicines the scheme would also maintain patient options for other forms of treatment. But a secretary of state would need to prevent the categorisation being hijacked by vested interests. The BMA has repeatedly called for an overhaul of the prescription charge, and a discussion document suggested that general practitioners might accept limitations to their freedom to prescribe in return for reform of the prescription charge.14 Some limitation of patient choice would occur if the patient were unable or unwilling to pay for a list B or C medicine, but where such medicines were necessary by objective criteria they would be available without charge. The pharmaceutical industry is used to operating in countries with copayment systems. Indeed, the proposal would reward companies for developing innovative medicines of true value and discourage the development of minor variations on existing medicines.
No one system is ever likely to allow complete management of the medicines bill, and a range of policies will be required. There would, for instance, still be a need to encourage high quality of prescribing and for capped medicine budgets. Prescription charges can be part of these options.