Evidence shows no benefit from prescription charges

Mary Harney says prescription charges will raise money and "discourage the overuse of medication". By Sara Burke.

Ten years ago Mary Harney, then tánaiste and minister of trade, enterprise and employment made her political position clear.

"Geographically," she said, "we are closer to Berlin than Boston. Spiritually, we are probably a lot closer to Boston than Berlin." She firmly articulated the then government's chosen economic model which "had a clear tax-cutting agenda" and went on to say that "this model works".

We know now, 10 years on, that the policy of ravishing the tax base, of light regulation and of multiple, generous tax breaks to developers that fuelled the property bubble, doesn't work.

 Last April, Ms Harney stated she was a "fan of co-payments". Co-payments is the jargon for "sharing" the costs of goods or services with the State or others, for instance insurance companies. When the tax base is drastically eroded, governments need to come up with alternative funding sources. Co-payment is one such way.

From October 1st, 1.4 million Irish people will have to pay 50 cent of the cost of each prescription medicine. This charge ("co-payment") is being imposed on people with medical cards – by definition, the poorest and the sickest third of the Irish population.

The charge is capped at €10 a family a month and some people are excluded, such as those on the long-term illness scheme.

Public spending on drugs, in line with international trends, has increased rapidly in the past decade. The prescription charge is part of a package of measures to drive down drug costs, ably championed by Mary Harney as health minister. Many of these initiatives, such as increased use of generics and reduced costs of out-of-patent drugs, are welcome and long overdue.

It is estimated that €24 million will be added to the public purse from the prescription charges. The Department of Health cannot put a figure on how much it will cost to collect this charge but has said that "administration costs, which are not expected to be significant, will be met by the HSE".

Ms Harney has justified the charge on the basis of "two things – we have to raise money and we have to discourage over-prescribing and the overuse of medication". The department has subsequently (contradictorily) said the prescription charge is not envisaged as a "revenue-generating measure" but its purpose is to "influence demand and prescribing patterns".

So, the rationale for this charge seems to be if you charge patients, they will in turn seek fewer prescription items. It is based on the premise that patients demand drugs unwittingly and doctors prescribe drugs unwittingly. Surely, if you want to change prescribing patterns, you start with the doctors, not with penalising the poorest, sickest patients.

Co-payments are widely used across Europe to reduce demand and/or raise money. However, the value of the practice is unsupported by all the international evidence.

Radical bastions such as the World Health Organisation (WHO), the British Medical Association and the Cochrane Collaboration (experts on evidence-based healthcare) have each published reviews in the past year making the case against co-payments. They have independently found that introducing charges for medical care including prescriptions reduces the use of necessary care as much as it reduces the use of unnecessary care. The WHO European Health Observatory published research in the British Medical Journal on September 1st, which found "charges create financial barriers to access, particularly among poorer people and people with chronic conditions".

The research finds that while there may be short-term savings through introducing prescription charges, it costs more in the medium and long term. If people stop taking essential medication, they get sick and in turn need other, more expensive treatment.

These findings were applicable to "life-sustaining" drugs and those prescribed for chronic conditions such as diabetes, asthma and acute psychiatric conditions.

The evidence shows that charging for prescription drugs, even the smallest amount, stops people taking medicines and results in increased admissions to emergency departments, hospitals, mental health services and nursing homes. It particularly adversely affects older people and those with psychiatric conditions.

On the basis of this evidence, in April, Northern Ireland removed the £3 charge on prescriptions. Health minister Michael McGimpsey said the "introduction of free prescriptions is an end of a tax on illness".

Wales abolished the charges in 2007, Scotland is in the process of doing so and in England, just 11.4 per cent of the population pay a charge as there are exemptions for children, older people, people on low incomes and those with certain conditions.

Ms Harney's own expert group on resource allocation, chaired by ESRI director Frances Ruane, questioned the wisdom of the imposition of the prescription charge as the "evidence suggests . . . possible harmful effects on health".

If the Government's decisions were based on evidence rather than on taking a particular political stance, there would be no introduction of prescription charges.