Although the Department of Health & Social Care (DHSC) has yet to make a formal decision on ending free prescriptions in England for most 60- to 66-year olds, an announcement is widely expected next month, when the provision of free lateral-flow covid test kits for everyone bar the extremely vulnerable will also be withdrawn.
Coming just a month after a leading thinktank suggested people should pay for GP appointments, the combination of these moves hints at a new government approach to stem rising NHS costs: charging for items and services that are currently provided to patients for free.
Negative impacts on health and finances
With the over-60s accounting for almost 63 per cent of all prescribed items that are dispensed free of charge, the government risks alienating its traditional electoral constituency if it restricts the provision of free prescriptions. Nevertheless, it put the proposal out to public consultation last year, accompanied by DHSC guidance that detailed its potentially negative financial and health impacts.
This guidance noted that the proposal would mean patients reaching the age of 60 would need to pay charges for six more years than they do now, disproportionately affecting disabled people who are more likely to have long-term health conditions. It pointed out that extra charges could lead to people not taking their prescribed medicines, potentially leading to additional costs in social care in later years. And it recognised that people may stop using medicines as frequently, leading to increased hospital admissions and GP appointments.
The DHSC’s guidance still failed to fully reflect evidence from earlier research on the downside of prescription charges, some of which contradicts the government line on the prescriptions proposal that “an increase to the upper age exemption could generate additional revenue for NHS frontline services”.
In 2000, a review by York University’s Theodore Hitiris concluded, “Prescription charges have an inverse effect on the demand for drugs by patients liable to pay the charge. Increases in charges are associated with a significant reduction in utilisation of prescribed drugs among non-exempt patients.”
He added, “There is also evidence that the short-term target of using charges to raise revenue is pursued at the expense of the long-term health of persons, and this may cost more to the NHS than the increase in revenue. Therefore, the introduction of [charges] is not an efficient policy.”
To offset the financial impact of the prescription proposal, the DHSC last year mooted the introduction of a £108 “prescription prepayment certificate”, but Age UK has dismissed this idea as a stealth tax, describing it an opportunity to extract more cash each year from the estimated 2.4m people aged over 60 who previously didn’t have to pay anything at all.
Charges for lateral flow tests
Meanwhile, the scrapping of free lateral-flow covid test kits from 1 April has already led to these items being sold over the counter in high street pharmacies. Boots is now selling kits online at £5.99 each or four for £17 (and £12 for a pack of five if bought in-store). Superdrug has followed suit, and has set its prices even lower, at £1.99 for a single test and £9.79 for a pack of five bought in-store.
These prices are thought to be broadly equivalent to those charged in Europe, and lower than in the US. But the kits are still not free, and the public health implications of charging for them have been an issue ever since the possibility was first discussed back in January. That same month Liverpool University’s Iain Buchan warned of the associated dangers, notably telling Reuters that, “Viruses move quicker than free market economics.”
Charges for GP appointments?
The suggestion that GPs should charge for appointments to ease pressures on the NHS is certainly radical, and one not – so far – backed by health secretary Sajid Javid. But it’s an idea being promoted by Whitehall thinktank the Institute for Government.
Speaking at a Resolution Foundation event last month, the institute’s chief economist Gemma Tetlow told attendees, “The UK is really unusual in not charging for GP appointments. I know it’s utterly beyond the pale to suggest that here, but it’s extraordinarily common [elsewhere]. And if you think about the incentives for utilisation of healthcare, having some kind of private cost so that someone [thinks], ‘Do I actually really need to go and see the GP?’, could have lots of benefits.”
But despite such free-marketeer enthusiasm, there is scant evidence to justify imposing GP appointment charges. In fact, back in 2005 the King’s Fund thinktank concluded that, to the contrary, there was substantial international evidence of the detrimental health effects of charging, in addition to evidence in the UK that charging actually reduced utilisation of non-exempt services.
And more recently, the Nuffield Trust’s chief economist John Appleby analysed the potential impact of charging £10 per GP visit. Taking as a starting point a 2007 Ipsos MORI poll on access to NHS dental treatment, which had found that 4 per cent of those surveyed mentioned cost as a major factor in not seeking care, Appleby suggested that any cash-raising dividend for the NHS – possibly around £4bn – would therefore be significantly reduced, due to the number of exemptions needed to prevent around 1.7m patients from being deterred from seeking help.
Maternity service shows the negative impact of charging
The experience of pregnant migrant women accessing maternity care in the NHS also offers a sobering perspective on the real-world impact of healthcare charging.
Last week the charity Maternity Action – which helps hundreds of women each year to navigate the health service’s existing, albeit limited, charging system – told the Guardian that one trust asked a migrant woman for a £5,000 deposit for her birth, while another trust demanded monthly repayments of £800 from a woman who could not afford to pay, and then referred her to a debt collection agency while she was still pregnant.
A spokesperson for the charity added that NHS trusts had wrongly assessed charging regulations “many, many times”, and the Royal College of Midwives has now called on the government to scrap the “punitive” NHS charging of pregnant migrant women completely.
NHS revenue unlikely to be boosted by charging
It’s not even clear that charging will significantly add to NHS revenue. Research by healthcare pressure group Docs Not Cops in 2015 found that a third of all NHS trusts in England spent more on the staffing and administration costs of implementing charging than they actually recouped, despite the fact that migrants at that time were charged 150 per cent of standard fees to compensate for such costs.
A ‘return on investment’ review of the public health sector, published five years ago in the Journal of Epidemiology & Community Health, also undermined arguments for the introduction of charging across the NHS. The review found that for every £1 invested in public health, £14 is subsequently returned to the wider health and social care sector, and that cuts to public health services therefore represent a false economy.
A follow-up analysis in the journal BMJ Global Health again appeared to undermine the case for increased charging, concluding that, “The published evidence to date suggests that reducing user charges is likely to have beneficial effects on health outcomes.”
And the 2005 policy paper from the King’s Fund thinktank policy paper mentioned earlier also offered compelling evidence that taxation, not charging, was the fairest and most effective way to pay for the health service generally. It also emphasised that charging was “inimical to the basic principle of the NHS [which was] founded principally on breaking the link between healthcare consumption and ability to pay, in order to promote the socially desirable goal of equity of access to healthcare”.
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