Prescription Charges (Long-term Conditions)

Bob Russell Excerpts

Wednesday 10th July 2013 Commons Chamber

[Sir Bob Russell (Colchester) (LD)]

We should rejoice at the wonderful advances in medical science, particularly in the last half-century, which have enhanced the quality of life of people with serious health conditions, and we should give thanks to those whose research made those advances possible. Some people’s lives have been extended, or even saved. The invaluable research work goes on. I pay tribute to those involved; they deserve our gratitude. In the case of cystic fibrosis, I should mention the Cystic Fibrosis Trust, pioneering researchers at places such as the Royal Brompton hospital, and patients and their families, past and present, without whose endurance the present survival rates would never have been achieved.

It is not that long ago that for some conditions, such as cystic fibrosis, life expectancy was so low that few lived beyond their teens. Today, living into the 40s is the average, and that will improve still further; of that I am sure. Although there have been advances in helping those with serious health conditions, to the point that today people are better placed than at any time in history, the reality is that the rules, regulations and bureaucracy of prescription charge exemptions are stuck in a time warp, taking us back to nearly half a century ago. It is astonishing that while we have witnessed medical advances and breakthroughs on a large scale, achieved by those driving forward the boundaries of medical research, successive Governments, wedded to the bureaucracy of the 1960s, have not moved forward an inch when it comes to helping people with serious health conditions to pay for prescriptions. People are forced to pay, in many instances to stay alive, and in every instance to sustain a quality of life that is seriously compromised if the right level of medication is not taken.

I am grateful to the Prescription Charges Coalition, which comprises 27 organisations, including the Cystic Fibrosis Trust, with which I have had an association for 16 years, and Asthma UK, the British Heart Foundation, Crohn’s and Colitis UK, the National Rheumatoid Arthritis Society, Parkinson’s UK, Rethink Mental Illness, the Royal Pharmaceutical Society, the Terence Higgins Trust and the Multiple Sclerosis Society. They cover a wide range of serious conditions, and they are united in calling on the Government to put right an anomaly. I am confident that those who, 45 years ago, drew up the list of exemptions would today, because of medical advances, include on the list those conditions represented by the Prescription Charges Coalition.

Yesterday morning, the associate parliamentary health group held a seminar in the Jubilee Room entitled “Public health killers: tackling obesity, smoking and alcohol abuse”. Why does the national health service treat those who are guilty of abusing their body better, in financial terms, than those to whom mother nature has given serious health conditions? We should contrast what the Prescription Charges Coalition is calling for—free prescriptions for those who need them to live—with the £5 billion spent every year on health problems associated with being overweight or obese, or the £2.7 billion per annum cost to the NHS because of alcohol misuse. Alcohol-related admissions to hospital, according to Department of Health statistics, are rising at a rate of around 11% a year. Smoking is the biggest killer, accounting for nearly 80,000 preventable deaths in England in 2011. What I do not have a figure for, but it must cost the NHS billions of pounds, is dealing with the consequences of people taking illegal drugs.

Given that enormous cost to the public purse as a result of self-inflicted lifestyle choices, I call on the Government to look fairly on those with health conditions whose lifestyle choices are restricted. The cost of what I am seeking is modest in comparison with the huge sums that I have listed for self-inflicted body abuse.

I am pleased that this evening I can raise a serious issue, which I also highlighted in the last parliamentary Session through early-day motion 1, signed by 41 hon. Members, namely the terrible unfairness faced by those with cystic fibrosis who have to pay prescription charges. That also applies to those with other conditions embraced by members of the Prescription Charges Coalition, who I know will understand why, in the limited time available, I will concentrate my remarks on CF; however, my case for CF applies equally to the other conditions.

As I am sure the Minister will be aware, the criteria that determine eligibility for exemption from prescription charges for those with certain medical conditions were laid down in 1968. The only slight amendment was the welcome addition in 2009 of cancer. In 1968, someone with cystic fibrosis was unlikely to live until adulthood. I am pleased to say that, 45 years on, life expectancy is 41-plus. However, the condition continues to claim the lives of younger adults, teenagers and even children. For the 10,000 people in the UK with cystic fibrosis—contrast that relatively low figure with the 945,000 alcohol-related admissions to hospitals each year: 10,000 versus 945,000—their condition is such that they are especially prone to infection and may eventually require a lung transplant.

I therefore support the call made last Friday by the hon. Member for Sheffield South East (Mr Betts), who wants the law changed in respect of organ donations so that there should be presumed consent. This follows the welcome announcement last week by the Welsh Assembly of a move towards presumed organ donation consent significantly to increase the number of organs for transplant. We should do the same in England.

Those with cystic fibrosis have a great deal to contend with throughout their lives and, on reaching adulthood, they face the additional burden of having to pay prescription charges to stay alive unless—this would be laughable if it was not so serious—they have insulin-dependent diabetes, which gives them an exemption from paying. It is such nonsense, you could not make it up.

Tonight’s debate is about the striking inequality and the significant impact that prescription charges are having on people in England who have a range of long-term conditions, but not those living in Wales, Scotland and Northern Ireland. In support of the Prescription Charges Coalition, I call for a fairer system of exemptions. It is a matter of considerable concern that many people with long-term conditions are not collecting or taking their medicines effectively because of the cost, as is all too clearly illustrated in the Prescription Charges Coalition’s recent report, “Paying the Price”.

Many MPs will be aware of reports of constituents struggling to afford their prescriptions and the impossible choices they have had to make between paying for food, clothing, housing and other bills or their prescription medication. Austerity has added to the problems. People with long-term conditions are not “all in this together”, as the Chancellor would have us believe. For many, it means splitting tablets in half, missing doses or substituting cheaper but less effective alternatives to eke out medication until pay day. Inevitably, individual health suffers and there are numerous knock-on effects. The Prescription Charges Coalition’s survey found, very worryingly, that more than one third of those who pay for each prescription had not collected at least one item because of the cost. Indeed, the Royal Pharmaceutical Society reports that pharmacists are often asked, “Which of these prescriptions can I do without?”

I am advised that the majority of those who reported that they were not taking their medicine as prescribed said that their health had got worse as a result, with additional treatment then being required. Emergency admission to hospital was the dramatic and costly consequence in 10% of cases. For example, one respondent said: “I ended up being hospitalised for two weeks because I missed five days of medication.” Another stated: “I could not afford the prescribed medication, went without, and ended up having panic attacks and losing my job.”

The implications of this are extensive, not only for the individual’s quality of life and long-term health outcomes, but with regard to the impact on their families, on their ability to remain in employment and independent of state support, and also, of course, on the NHS. At a breakfast briefing this morning I was surprised to be told that this is not a matter for consideration by the Care Quality Commission. This suggests a lack of joined-up thinking on the health needs of our country. The stress and anxiety caused by worrying about how to afford prescription costs can exacerbate a condition and the ability to manage it effectively. Individuals also report cutting back on food or utility bills to afford medicines and that could also clearly have an impact on their health.

Those with long-term conditions do not choose to be ill. They face a daily routine of various types of medication and physiotherapy to maintain any quality of life. The Department of Health is aware of the survey by the Prescription Charges Coalition, so I hope that the Minister will tonight confirm that she is personally aware that more than half of those who reported not taking their medicine as prescribed cited cost as the reason. Perhaps she can explain why there is discrimination against those with long-term conditions who live in England. Why cannot they get the same deal as those living in Wales, Scotland and Northern Ireland?

I suggest to the Minister that one way of helping immediately would be to scrap the 28-day prescribing limit for those with stable, long-term conditions on regular maintenance medication. Having to make monthly trips to the doctor and pharmacist for repeat prescriptions is a further and unnecessary inconvenience that means extra cost and additional distress, particularly when errors occur with prescriptions. Patients might need to take time off work, depending on surgery opening hours. Scrapping the limit would also ease pressure on doctors.

In the past, the category of person I am referring to could have a three-month supply, which is cheaper and more convenient for those who require medication. I hope that the new clinical commissioning groups will consider carefully the need for individual prescribing for optimal treatment plans and avoid the rigid 28-day limit. Please may we have central guidance from the Department of Health?

The Secretary of State stated last year that those with long-term conditions and older people with multiple long-term conditions are among his key priorities. In that context, it is important to remember that it is not necessarily older people who have long-term conditions. A number of long-term conditions, such as cystic fibrosis, start from birth, while others, such as Crohn’s disease, rheumatoid arthritis and multiple sclerosis, are commonly diagnosed in the teens and twenties. Those conditions have their most devastating impact just as young people are becoming adults and are attempting to complete their education, entering relationships, learning to balance their budgets and forming their career and life path.

In addition to all the usual challenges that poses, those young people have to face the additional pressure of a lifelong illness that will have a considerable social, emotional, functional and economic impact on their daily lives. A significant aspect for many will be the requirement to pay for their medicine until retirement. Is that fair? I refer to my earlier observation about the billions of pounds the NHS spends treating those whose approach to life has damaged their health. I repeat: is that fair? The prescription prepayment certificate and the NHS low-income scheme are obviously better than nothing, but they are like using a sticking plaster on a gaping wound.

Seven years ago the Health Committee produced a report on NHS charges that concluded:

“The system of health charges in England is a mess.”

It still is. The Committee also observed:

“The system of medical exemptions to the Prescription Charge is particularly confusing.”

It still is.

I challenge the Minister on why the recommendations set out in the prescription charges review, undertaken at the behest of the previous Government by Professor Sir Ian Gilmore when he was president of the Royal College of Physicians, have not been implemented. They would greatly assist those with long-term conditions. His eminently sensible, measured and practical approach would be likely to have all manner of positive effects. Removing this aspect of health inequality, this barrier to getting and keeping well, would facilitate effective self-management, reducing unnecessary pressure on health professionals’ time and hospital A and E departments. It would also help people stay in work and off benefits and improve their long-term health conditions.

There is no excuse for an inequality that stretches back more than 40 years. The Prescription Charges Coalition, the Health Committee report and Professor Gilmore’s recommendations provide ample justification for this injustice to be put right. I urge the Minister to state tonight that this will happen.

[The Parliamentary Under-Secretary of State for Health (Anna Soubry)]

I congratulate my—I have to say—hon. Friend the Member for Colchester (Sir Bob Russell) on securing the debate, although I do not think that he made much of a friendly speech, and I have no doubt that he will not be much impressed by my response. He rightly brings the subject before the House, as is his right, and so he should. However, I think that we have to be completely realistic and honest about the situation in which we find ourselves. The simple truth is that if we extended the exemptions to all long-term conditions it would cost a considerable amount of money, and, in the words of a member of the previous Government, there is no money. I am very proud of the fact that the coalition has been able to secure the NHS budget at a time when we have had to take tough decisions and cut other budgets. We have not only maintained the NHS budget; by 2015 we will have seen a rise in the amount of money going into the NHS under the tenure of this Government. I am very proud of that.

My hon. Friend asked whether it is right and fair that all these long-term conditions do not receive free prescriptions. He then drew a contrast with people who, in his words, have “self-inflicted lifestyle choices”, referring to those who have drug addition, alcohol addiction, obesity problems and so on. I would challenge him on that. I do not take the view that it would be right in any way, shape or form to make such suggestions about people who are having their prescriptions paid for because of their income status but have those afflictions. I can assure him that addiction is not some lifestyle choice. Many people who are addicts are born addicts; it is a disease that needs treatment, and those who are unfortunate enough to suffer from it need our support. I am sure that he is not suggesting that we should take money away from those unfortunate people in order to give it to those who are, I accept, equally in need.

[Sir Bob Russell]

I regret that the Minister is drawing an inference that I did not intend in any way. I was merely making a comparison in saying that some people have been dealt unfairly with by mother nature in having to pay to stay alive, whereas others who we are told can be treated are, for whatever reason, getting free treatment.

[Anna Soubry]

I am pleased that my hon. Friend has made that point, because some people, I can assure him, would have made such an interpretation. I am pleased that we have set the record straight.

In fact, the current system does provide support for people who need it the most. In 2011, for example, about 94% of all prescription items were dispensed free of charge at the point of dispensing. It is estimated that about 60% of people in England are exempt from charges. A wide range of exemptions exist to help the most vulnerable, those requiring prescriptions the most and those most in need of support. People aged 60 and over, women who are pregnant or are in the 12-month period following childbirth, those on income support, those with pension credit, those on income-based jobseeker’s allowance, those on income-related employment and support allowance, and those in receipt of a variety of tax credits all rightly receive free prescriptions.

As we have heard, people who use prescriptions frequently can buy a prescription prepayment certificate that allows anyone to obtain all the prescriptions they need for the equivalent of £2 per week. The cost of the annual prescription prepayment certificate has been frozen at £104 for the past four years, and the cost of the three-monthly certificate has been frozen at £29.10 for two years. There are options whereby people can pay by direct debit. I concede that the system is not perfect, but it is very good.

My hon. Friend asked, properly, why we have this system in England whereas in Wales, Scotland and Northern Ireland prescriptions are free. I am sure that he knows the answer: health is a devolved matter. It is for those in the Scottish Parliament, the Welsh Assembly and the Northern Ireland Assembly to decide how they will spend their budget. The simple truth is that making prescriptions free for all in those countries has taken money away from other areas of their health budget. We have decided to spend our allocation of money in a different way, and rightly so, especially when we consider that the prepayment certificate of £104 a year is eminently fair for people who are unfortunate enough to have the long-term conditions that my hon. Friend identified and described. It is important to put forward that argument as well.

As it happens, I suffer from a long-term condition—asthma—and have the benefit of an excellent GP. I am sure that that will not win me any extra favours with my hon. Friend—although I am sure he will be grateful for my comments—but I, like most of us, have an outstanding GP who has made sure that my medication is at such a level that I do not now need a prepayment certificate, because we are managing my condition.

I am not suggesting that one should always be alert to the financial cost of issuing prescriptions, but I think it is right and fair to say that many general practitioners are aware of it. Increasingly, prescribing GPs—in other words, all GPs—are taking on the huge responsibility of bearing in mind the cost to the national health service of the prescriptions they issue their patients.

I pay tribute to the Prescription Charges Coalition, which has worked with officials in my Department to help raise awareness of the help available to patients with the cost of their prescriptions, particularly the prescription prepayment certificate. The awareness-raising work with the PCC has already had encouraging results. Purchases of certificates in the first quarter of this year were 13% higher—about 50,000 extra—than in the same period in 2012, when this work began. We continue to work with the PCC to consider how we might build further on that awareness-raising activity.

My hon. Friend asked a number of questions and I hope I will be able to answer them all. If not, the usual rules will apply and my officials will, of course, write to him. Since 1968 the only condition that has been added to the list is cancer in September 2008, as announced by the then Prime Minister. I pay tribute to the work of Sir Ian Gilmore. The Health Committee has produced a report and answers have been provided, but I think it is fair to say that this is all about cost. I accept that things have changed a lot since the late 1960s, but the simple reality is that if we extended free prescriptions to all long-term conditions it would cost an incredible amount of money, and I am afraid to say that that is money that we simply do not have.

It would be very difficult to consider particular conditions in isolation and to somehow choose one. My hon. Friend has advanced the case of cystic fibrosis and one can understand why: nobody chooses to have cystic fibrosis; it is a thoroughly unpleasant condition.

[Sir Bob Russell]

I did say that I was using cystic fibrosis as an example of various long-term conditions. All I ask is that the Minister and her officials look at the recommendations of Professor Sir Ian Gilmore, because at least that would give some encouragement to people with long-term conditions that the Government were looking at their situation seriously.

[Anna Soubry]

That is a valid point, well made, but the Government’s attitude is that it would not be right in the current situation to look at just one particular condition in isolation, because others would argue, with vigour—and rightly so—that their condition was as valid of an exemption as any other.

My hon. Friend asked why the Government have not introduced more flexible prescribing patterns and moved away from the 28-day prescribing policy. The responsibility for prescribing, including repeat prescriptions and the duration of prescriptions, rests with GPs and other doctors who have the expertise and who rightly take clinical responsibility for that particular aspect of a patient’s care. Doctors can prescribe flexibly and take decisions about prescribing patterns on the basis of a patient’s need. Ultimately the decision must be left to the doctor, but guidance has been issued by the National Prescribing Centre about prescription terms, encouraging prescribers to be receptive to the needs of patients and to use appropriate prescribing patterns.

My hon. Friend asked about the lack of relevant data on the costs and consequences of the current prescription charging system. At the moment, some £450 million is raised each year by charging people for their prescriptions, which is equivalent to about 13,500 qualified nurses or 3,500 hospital consultants per year. One can see the power of that money from prescription charging, but given the lack of relevant data, more research is needed to inform policy. It is important that we make best use of the available evidence and identify gaps in knowledge. We would, of course, welcome input from groups such as the Prescription Charges Coalition about any evidence it is aware of or studies that may have been undertaken in that area. That would help inform any research proposals that the Department of Health might consider in its assessment of research priorities. I hope that may be of interest and comfort to my hon. Friend.

As I have said, the Government report that 90% of prescription items are dispensed without charge, but up to three quarters of those of working age with long-term conditions are believed to pay for their prescriptions. Current exemptions provide valuable help for those on the lowest incomes. They must always be our priority because they simply do not have the means to pay for a large number of prescriptions.

Older people generally have the greatest need for medicine, and I am sure that my hon. Friend will have visited a pharmacy and seen, as I did in my constituency, the amount of medication that is often required for older people, which can be quite astronomical in size and complexity. Many older people have good, long, happy and healthy lives because of the abundance of medicines they receive, and that is one reason why we have an exemption for older people.

Although people with long-term conditions will continue to pay for their prescriptions, the prescription prepayment certificate ensures that they can pay at considerably reduced cost. By repeatedly freezing the price of a prescription prepayment certificate and introducing a direct debit payment option to spread the cost of a 12-month certificate, we ensure that those certificates are accessible to those who need multiple prescriptions.

I am happy to take an intervention, but I hope I have explained the Government’s current policy. It is right and proper for this issue to be raised, but at the moment the simple truth is—it gives no one any pleasure to say this—we simply do not have the money to do all that my hon. Friend urges on me.

Question put and agreed to.