The creeping privatisation of NHS prescribing

On 1 April this year the NHS prescription charge rose from pounds sterling 4.25 to pounds sterling 4.75. This was an increase of 11.8%, almost six times the rate of inflation, and the 16th rise in the prescription charge since 1979, producing a total rise of over 2000%. A total of pounds sterling300m is raised by prescription charges but the charge is paid for only one in five prescriptions. All the rest are provided to patients in one or other of the exempt categories.1 The burden of this particular form of indirect taxation is falling on a small minority of health service users.

For some reason general practitioners responded to this particular rise in a way they had not done before: they began to issue private prescriptions to non-exempt patients whenever the cost of the medicines was less than the prescription charge. They were supported in this by many community pharmacists.2 Private prescriptions began to be issued on such a scale that family health services authorities sought guidance from the Department of Health on whether general practitioners were in breach of their terms and conditions of service in so doing.3 This guidance arrived in a letter to family health services authorities on 4 May, in which general practitioners were encouraged to continue to issue private prescriptions.4 It made clear that private prescriptions could be issued only to non-exempt patients and that the doctor could not charge for issuing a private prescription in these circumstances. This sequence of events raises several questions. Why did general practitioners react in the way they did? Why did the government decide to encourage their reaction? And what are the dangers?

Each rise in the prescription charge has made doctors, and others, more aware of the inequities of the present system,5 particularly the burden on those on low incomes afflicted with one of the many chronic diseases - such as hypertension, arthritis, and asthma - that, arbitrarily, do not qualify the patient for exemption from prescription charges. Ryan and Birch showed that the policy of increasing prescription charges has led to a significant reduction in the use of prescription medication by non- exempt patients6; these research data are backed up by anecdotal evidence from many ordinary general practitioners, including myself. Ryan and Birch argued that, although the policy had succeeded in reducing government expenditure on prescribed medicines, around two thirds of the savings had arisen from the reduction in the use of services rather than the increased revenue per prescription item. Furthermore, the authors were analysing data from the period 1979-85, by which time the prescription charge had risen by only 490%. Doctors' reaction suggests that they have become increasingly aware that the ability to benefit from medication is being compromised by considerations of ability to pay within the non-exempt group.

The government's encouragement of the initiative by general practitioners is perhaps predictable, given its commitment to privatisation across most areas of social policy. But there are great dangers in this pragmatic solution, which risks compounding the inequities of the present system of charges. The widespread use of private prescriptions for non-exempt patients is one step further towards an irreversible two tier system, with a full, free NHS service for selected groups of exempt patients and a service for non-exempt patients that relies increasingly on private finance. With each increase, the prescription charge has covered a larger proportion of the average cost of medicine and the subsidy required from the government has become less, and now there is a serious possibility that all cheaper medications will be fully privatised. This repeats the pattern set by optical services, which are now fully privatised for non-exempt people, and dental services.7 Both these services have seen a sharp and worrying reduction in use by people who are not exempt. The long term consequences for health and health expenditure may be profound.8

A further danger is the distortion of the data obtained through the PACT (prescribing analyses and cost) monitoring system for general practitioners' prescriptions. If an increasing proportion of cheaper medicines is being prescribed on private prescriptions, these medicines will disappear from the PACT data. PACT data will therefore no longer accurately reflect doctors' prescribing habits, and this will reduce our ability to monitor the use of prescribed drugs by the population.9 The disappearance of cheaper drugs from NHS prescriptions will also increase the average net ingredient cost of those that continue to be provided on NHS prescription, and this increase could well be used to justify further increases in the prescription charge and push us yet further along the road to privatisation. Can we turn back? We should reflect on the consequences of expedient measures taken, with the best of intentions, to help our patients through difficult times.