Scrapping prescription charges is the right priority for the English NHS

It’s time not just to defend the NHS, but to expand it. Labour's policy pledge announced at their party conference this week is an excellent start.

caroline m.jpg
Caroline Molloy
27 September 2019, 1.07pm
Julien Behal/PA Archive/PA Images

This week Labour proposed scrapping NHS prescription charges in England. It’s a move that OurNHS has been demanding for years. Indeed, it was a truly historic moment – the implementation of these kind of charges (including optical and dental charges) that prompted the service’s founder, Nye Bevan, to resign on principle.

It’s a historic move - but hardly Venezuelan-style socialism, rather a policy that the Scottish, Welsh and Northern Irish governments implemented successfully years ago.

Predictably enough, where the right have paid attention to the new policy, they’ve downplayed it as merely another expensive item on Labour’s ‘shopping list’ of policies. In contrast, both Tories and indeed Lib Dems like Shirley Williams have been flirting instead with the idea of scrapping even these exemptions, for example for better off pensioners. Currently, pensioners, children and pregnant women are exempt from prescription charges, which now stand at £9 per item. Some extremely low-paid workers – typically those earning under £13,000 a year – can also claim exemptions, though that process is cumbersome, poorly understood and riddled with errors.

The underlying logic of the right (and even some centrists) is the ‘targeting’ publicly funded healthcare on the poorest, shifting away from the principle of universal access - the same benefits for everyone, regardless of their income and wealth - and the normalisation or even expansion of ‘co-payments’ further into our healthcare system.

Even some of the health policy establishment have fallen into the trap. The normally sensible Nick Timms, writing for the Kings Fund yesterday, suggests that scrapping prescription charges “should not be the top, or even the early priority”. Though his argument is little more than a list of other things in the NHS that also need money.

But - as I’ll explain more below - Timms and others barely acknowledge the cost of increased ill health and the more expensive treatment that follows, and ignore entirely both the cost of administering means-tested schemes and the political cost of the policy.

That’s even without discussing the terrible human cost our current dysfunctional prescriptions system. There’s the stress it causes - including on GPs and pharmacists who have to figure out ways of gaming the system on behalf of hard up patients. But most tragically, on people like 19-year-old Holly Worboys, who died of an asthma attack having not been able to afford her inhaler prescription.

Worboys was not an isolated case. Asthma UK says that of the 2.3 million people who pay for asthma prescriptions, three-quarters struggle with the cost. Other evidence shows nearly a third of patients don’t take meds due to cost. This results in hugely increased costs of treatment further down the line as their condition worsens. In recent years charges have increased dramatically (a large hike was one of Thatcher’s first moves in 1979 after years of only token payment) and are now higher than in many other countries, as Timms acknowledges. People are also paying more because of an increasing number of co-morbid conditions, meaning multiple prescriptions and polypharmacy.

Shadow health secretary Jon Ashworth told OurNHS, “It’s both heartbreaking but also a shameful indictment of our unequal society that people go without their medications, prolonging sickness and risking their life because of the prescription charges.”

The cost of administering prescription charges also seems drastically underestimated [check Pulse]. Earlier this year a National Audit Office report highlighted how the amount of administration in the charging regime had soared in the past few years – from 750,000 checks been undertaken into claimed prescription exemptions in 2014/5, to 24 million in 2018/9. And the NAO sets out how, increasingly, the vast majority of these checks find no wrongdoing - even those that do are overturned on appeal up 30% of the time. Very little money has been successfully reclaimed, and a grand total of one person has been taken to court.

“The way vulnerable people are chased by and pressured with huge fines by NHS bosses for wrongly ticking a box on a form lacks humanity. The fairest and simplest approach would be to scrap these charges as has been done in Wales and Scotland,” adds Ashworth.

Meanwhile, whilst it is difficult to assess fully the cost of administering the whole system of charging, the fining system alone cost £11.2m a year, money that went entirely to the private firm Capita. Labour’s claim that abolishing charges would save £1m in administration costs seems (not for the first time) to be overly cautious.

The problem with the reaction to Labour’s announcement is that we’re entangled in the branches of the ‘magic money tree myth, scratched by kneejerk neoliberal responses about the ‘bottom line’. These ignore the myriad positive multipliers that social spending creates, from improved health to a less stressed-out populace. Where is the media outrage that such calculations are so rarely being done?

Which leads on to the importance of the political costs and benefits to all of this. For the hard right now in the ascendant, prescription charges have – as I’ve previously written - long been an explicit bridgehead to normalising and expanding the kind of ‘co-payments’ that you have in the US system. Take a recent report by ‘pro-market’ think tank Reform (who supplied Cameron’s health advisor): it suggested a raft of co-payments including charges for GP visits, charges for overnight stays in hospital and means-testing of NHS ‘end of life’ care, as well as big hikes to prescription charges (cheerfully suggesting all this will “limit… the role of the State”, “allow individuals to self-fund additional services”, “encourage patients to self-medicate” and “create the clarity needed to encourage private spending and create a market for supplementary insurance”. The accompanying press release focused on the prescription charges proposals, which the report stated were more “politically acceptable” to begin with.

Labour’s offering reaffirms the critical importance of universal, comprehensive benefits rather than targeted, restrictive ones, building on other policies like universal free school meals. Bevan dismissed the attempts to ‘target’ free NHS treatment to the poorest, saying that such a system would result in a two-tier system, with worse care for those “below the salt”. His vision of a universal healthcare service is key to the NHS’s remarkable endurance as our best-loved national institution. It’s great to see that Labour have recognised this, shrugging off their own recent Blairite legacy of targeting, which had its culmination in Scottish Labour shamefully suggesting that free prescriptions for all should be scrapped – explicitly, and politically foolishly, setting up the utterly impoverished against the merely hard-up.

Anyone who doubts Bevan’s relevance, who thinks that making those who supposedly can afford to pay, pay, is somehow fairer needs only to look at the catastrophic impact that system has had on dentistry in this country. This is something Bevan himself acknowledged was unfinished business, and sources close to the Labour leadership say that this is something they are currently looking at carefully.

For it’s time not just to defend the NHS, but to expand it. To restore the NHS to Bevan’s dream of a truly universal and comprehensive system. To finish his unfinished business, to boot. The prescriptions policy is an excellent start.

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