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Taxing ill health
  1. David Phizackerley
  1. DTB, BMJ Journals, London, UK
  1. Correspondence to David Phizackerley, DTB, BMJ Journals, London, UK; dphizackerley{at}

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Determining whether government income is classified as a tax or a fee is complex and technical.1 Taxes are compulsory and unrequited charges, while fees are requited and should be in proportion to the cost of providing the service. It is unclear whether the NHS prescription charge in England, which is compulsory for many people, is proportionate to the cost of the service provided and should be classified as a tax or a fee. Irrespective of the technical classification, for many people with long-term illnesses who have to pay for their prescriptions it will not only feel like a tax, but also one that is penalising them unfairly for having a problem with their health.

The prescription charge has been levied in England almost continually for more than 71 years and currently stands at £9.65 for each medicine or appliance dispensed. The government has repeatedly refused to bring England in line with Wales, Scotland and Northern Ireland where NHS prescription charges were abolished over 10 years ago as a long-term investment to improve people’s health, and frequently states that the prescription charge is a valuable source of revenue.2 Approximately £600 million is raised from prescription charges annually, which is roughly equivalent to 0.5% of the annual NHS budget or 0.05% of the money that the government raises each year.2 3 To put this in context, it is estimated that the government lost £16 billion through fraud and error within the COVID-19 support schemes and wasted £4 billion on PPE that cannot or will not be used by the NHS.4 5 The government regularly points out that the various exemption criteria mean that almost 90% of prescription items dispensed in the community are free of charge and 60% of the population are not liable to pay the prescription charge.6 Prepayment certificates (PPC) are promoted as a cheaper option for some people who require regular prescriptions. The standard annual PPC will cover all prescriptions and costs £111.60/year, while the recently introduced (and rather illogical) annual hormone replacement therapy (HRT) PPC costs £19.30 but only covers HRT medicines licensed to treat the menopause and excludes some medicines that are being prescribed as a result of a shortage of licensed HRT products. The HRT PPC has reduced the financial burden for some women who pay for their prescriptions but it might have made more sense to treat HRT in the same way as contraceptive medicines and remove the charge altogether.

The Prescription Charges Coalition (PCC) campaigns tirelessly to scrap prescription charges for people with long-term conditions in England. A report commissioned by PCC modelled the effect of extending the prescription charge exemption to people with Parkinson’s disease or inflammatory bowel disease.7 The analysis suggested that the loss of revenue would be more than offset by a reduction in use of healthcare resources. In a recent survey conducted by PCC, people with long-term conditions reported that prescription charges add a significant burden to their lifelong illness, sometimes requiring them to forsake collecting their prescriptions so that they can pay their household bills, resulting in a deleterious effect on their health, greater use of healthcare resources and more time away from work.8 The cost of living crisis will inevitably worsen this situation and may result in more people having to forego their medicines, their health and their ability to work.

DTB has previously argued that the prescription charge is outdated and iniquitous and that its exemption criteria are illogical and inherently unfair to many people.9 10 We continue to believe that it needs to be abolished. Scrapping the prescription charge might not only improve health outcomes but also reduce use of healthcare resources and decrease the number of days lost from work. What’s not to like?



  • Competing interests None declared. Refer to the online supplementary files to view the ICMJE form(s).

  • Provenance and peer review Commissioned; externally peer reviewed.