Prescription Charges (Exemptions)
The final item of business is a members' business debate on motion S1M-1793, in the name of Brian Adam, on prescription charge exemption for severe and enduring mental illness. It would be helpful if members who wish to participate in the debate would press their request-to-speak buttons.
I invite Mr Adam to introduce his motion. Other members in the chamber—[Interruption.] Order. There should be no conversations, as a debate is about to start.
Motion debated,
That the Parliament welcomes Mental Health Week in the second week in April; notes the omission of severe and enduring mental illness from the scope of the National Health Service (Charges for Drugs and Appliances) (Scotland) Regulations 1974; expresses concern at the incidence of suicide amongst high-risk groups identified in the Mental Welfare Commission Annual Report 1999-2000, and agrees with the conclusion of the Millan report that essential medication for chronic mental conditions is fundamental to successful care in the community.
Although my motion was originally intended to be timed to coincide with mental health week in April, I am glad to present it to Parliament today.
The issues involved in my motion have been raised by a number of members, including Adam Ingram, Jamie McGrigor and David Davidson, in similar motions, questions and letters to successive ministers. We are looking for the inclusion of
"severe and enduring mental illness"
in the list of items that are exempted from prescription charges. For some time, that case has been pressed on a variety of grounds, but ministers have been unmoved. I will go over those grounds and highlight what has changed that should allow reconsideration.
Given that only a minority of people—probably only 10 to 15 per cent—who receive continuing treatment for severe and enduring mental illness do not receive free prescriptions, the financial impact on the national health service of providing free prescriptions across the board to such people would be negligible. However, if that were done, the impact on the affected individuals would be rather significant.
There is a lack of equality in the system in that free prescriptions are provided for people who have chronic physical illness, but not for people who have chronic mental illness. That contrast does not reflect well on a Government that seeks to reduce discrimination. Mental health is one of the three key areas that the Government is trying to tackle. Patients who have epilepsy or hypothyroidism receive free prescriptions. I cannot see any reason for the distinction between those illnesses and enduring and severe mental illness.
When the Deputy Minister for Health and Community Care's predecessor wrote to me, he suggested that people who did not take their medication because they could not afford it—or for whatever other reason—could be hospitalised. That is not exactly a solution to the problem. It is not a reasonable alternative to the free provision of medication. The costs that are involved in hospitalising a patient for a day would be much more than the cost of providing the drugs for a whole year, but the costs that would be involved in hospitalising a patient for a day are far from the end of the story. Weeks—perhaps months—are required for the successful restabilisation of patients. Even then, continuing care in the community might be required, which is provided using psychiatric nursing. The cost of not providing free prescriptions greatly outweighs the cost of providing them.
Continuity of care in the community is of course required as an ideal, but the free provision of medication should be an essential part of that. The Millan report recommends that compulsory medication should be available for those who have mental illness and who receive their care in the community.
People who have enduring mental illnesses are at an increased risk of suicide. Medication is an obvious preventative measure. As I understand it, some mental illnesses have a 15 per cent lifetime risk of suicide. As I understand the research, for patients who have taken themselves off medication for a year, there is perhaps a fivefold increase—it may even be up to twentyfold—in the risk that they will commit suicide.
Under the Mental Health Act 1983, individuals who tend towards suicide cannot necessarily be sectioned. Whether they are sectioned is dependent on their communicating their feelings to somebody else. The problem cannot be identified until it has already happened.
Those arguments have been advanced in the past and have so far not persuaded successive ministers.
Does Mr Adam agree with me that, because Scotland has a higher percentage of suicides per head of population than the rest of the UK, this is a singularly Scottish issue? Is not it a shame that, when the Minister for Health and Community Care replied to my question a few weeks ago, she said that she would not review prescription charge exemptions? Part of her answer indicated that she would work in parallel with the UK Government. Should not we try to overcome this difficulty in Scotland?
I agree with Mr Davidson. The matter is devolved and ministers have the right to act. Indeed, in response to previous questions, motions that I have lodged and letters that I have written, I have received a similar reply to that, which does not surprise me.
What has changed? The issue was reviewed in 1998 as part of the comprehensive spending review and it was turned down for the duration of the UK Parliament. That Parliament is at an end. Given that the issue was included for consideration as part of the comprehensive spending review, the principal case against it must be financial. The matter is devolved and I ask the minister to consider it for part of the additional unallocated funds from this year's comprehensive spending review, because mental health is one of the Government's three key areas for action.
The Millan committee concluded that essential medication for chronic mental conditions is fundamental to successful care in the community. The logical conclusion of that is to remove any barrier to compliance. By doing so, the logic of the case for making the prescriptions for severe and enduring mental illness free will be understood.
Many people who have severe and enduring mental illness are active participants in their communities. Some are in employment. If, for whatever reason, they stop taking their medication—because many are in poorly-paid employment—not only will society lose them, but we will lose the contribution that they can make to society. That is discrimination against a particular group of people who are already stigmatised. Perhaps we ought to consider whether we can make a separate—possibly Scottish—case for dealing with that, especially if the issue is largely financial, given that the financial costs are fairly small.
Mr Davidson, I think that you may have cancelled your request to speak. Do you wish to speak?
I do, indeed.
I congratulate Brian Adam on securing the debate today. It is unfortunate that it did not take place when he wanted it to. I understand the reasons for the debate. Many organisations in Grampian have written to him and to me as representatives of that area. Mental health support groups of all types are anxious to see movement on the issue.
We face a great difficulty. Many mentally ill people are capable of performing part-time work or, in some cases, poorly-paid work. They fall into the poverty trap because, if they are not on income support, they do not qualify for free prescriptions, unless they happen to have another illness such as diabetes or hypothyroidism.
In considering the matter, I asked the minister a few weeks ago for a total review. Mental health sufferers—possibly up to 20 per cent of the population—have a good case, but it is unfortunate that many other ailments are not covered by the motion.
I would go further and suggest that we need a review of the whole prescription charge exemption system. I do not want MSPs to play the needs of one interest group against those of another. People do not choose to be ill and they do not choose which illnesses to have. Some illnesses require much more medication, in different forms, than others do. I accept that there is an exemption where a drug—for example, chlorpromazine, a common drug for the treatment of mental illness—may be given in different doses and only one charge is made. However, the charges vary according to the drugs and many are very expensive. Some people cannot afford the prescription charge season ticket, which is a fairly major hit that must be paid up front.
As Brian Adam rightly said, medicine is only one part of care for the mentally ill—a large part is care in the community. It is surprising to find that 80 per cent of the funding for mental health is spent in the hospital service, yet 80 per cent of sufferers live in the community. I thoroughly approve of people being out of institutions where possible and if it is good for them, but such decisions are clinical decisions and are not for us to comment on.
I have received support in the form of a letter from the Royal College of General Practitioners to the Conservative health spokesperson. Although the RCGP welcomes the debate, it supports the position that I have stated previously. The RCGP comments:
"a wider debate on prescription charge reform is urgently required in Scotland … The current system for prescription charging is outdated, inconsistent and illogical. Some long-term conditions entitle sufferers to blanket free prescriptions for all their medications".
That is regardless of whether the prescriptions relate to a patient's life-threatening disease. All the GPs and people working in mental health that I have spoken to agree that we need a review.
As I said to Mr Adam, it is within this Parliament's gift to carry out that review. It is important that we are talking about mental health, because no family in Scotland does not recognise the problems of the range of mental health conditions. It falls upon members to decide whether there should be a review. I would like the minister and his colleagues to come forward with the offer of a review so that the Parliament, through its committees and through debates in the chamber, can consider a proper, thorough and fair examination of who should receive free prescriptions.
I said previously that the system is unfair. As I know from my past as a community pharmacist, that unfairness is manifested when people come to a pharmacist with a prescription for multiple items, for which they have to pay, and say, "I can only afford two out of the five. Which ones should I have?" We cannot continue to tolerate that in the 21st century in Scotland.
I would like to endorse much of what Mr Davidson has said, and I would like to thank my colleague Brian Adam for securing this debate. It is just a pity that more of our colleagues are not present. Perhaps other business is in the offing.
Despite the lack of attendance, I am sure that those who rely on medication as part of their care package will be heartened by the fact that we are discussing such a motion in Parliament. Both the Royal College of Psychiatrists and the Scottish Association for Mental Health have intimated their support for this motion to me, as convener of the cross-party group on mental health.
As I have said before, prescriptions for medication can be a vital component of the care programme. That has been reinforced by many of the recommendations in the Millan report. The report noted that:
"It has been the stated aim of Government that the reduction in hospital places would be accompanied by a transfer of resources to community based mental health services, although we received evidence from many quarters that neither service was adequately resourced. Together with changes in medication, these developments mean that it is now possible for many more people, even with severe mental illnesses, to live with support in the community."
My main concern with the current system is the basis set for exemption. I have previously raised parliamentary questions, as have other colleagues, on eligibility for exemption. The minister stated that she would not be reviewing the current criteria for conditions that they
"should be easily recognisable, lifelong and life-threatening".—[Official Report, Written Answers, 15 May 2001; p 184.]
I would argue that many people with a mental illness could be covered by those criteria and that exemption from prescription charges should be conferred on them. The Government surely must review the current list of medical conditions that are eligible for exemption. To my knowledge, the list has not changed since it was drawn up in 1968. Since then, much has changed in society, in the medical profession and in pharmaceuticals. In particular, much has changed in diagnoses and the number of new conditions has increased.
Costs of medication for people who have enduring mental illness can range from just £2 per week to £28 per week. I will cite the cases of two of my constituents. One suffers from clinical depression and has to pay £31.90 every four months. Another suffers from manic depression and has to pay £30.15 every two months. Both are in full-time employment and therefore do not qualify for free prescriptions. Those people already have the anxiety of their illness; they do not need the added pressure of financing their medication. Those examples clearly show a disincentive to take up work opportunities, which runs counter to the Executive's social inclusion agenda.
The Executive has assured the people of Scotland that mental health is one of the three key health priority areas. That has to be reflected in the levying of prescription charges. The Mental Health (Scotland) Act 1984 has been reviewed, and the subject of charging patients on long-term medication was highlighted as an area that should be reassessed. The minister has the opportunity to make changes and the power to extend exemptions on prescription charges. I urge him to take that opportunity and the necessary steps to extend exemptions.
I had not intended to speak, but this is an important debate. Like Adam Ingram, I regret that there are not more members here. The issue of chronic illness and how prescriptions and medication are paid for deserves review, although I do not wish to judge individual cases at the moment.
I am diabetic and I get all my prescriptions for free, but I do not need them all to be free. I get things free that I would be perfectly happy to pay for. Health problems that are chronic and lifelong, and which have a chronic need for medication, should be serious candidates—regardless of whether they are mental or physical health problems—for free prescriptions.
I hope that the minister will keep the issue under review. I agree with almost everything that members have said, including the fact that this is an area that is worthy of discussion. The idea of a review ought not to be put aside.
I congratulate Brian Adam on securing this debate which, in the wording of the motion, brings together several topics, including mental health week, suicide, the Millan report and prescription charges. I begin by assuring Adam Ingram that mental health is one of our three priorities, and we are proceeding with a wide-ranging agenda on it, one part of which, the Millan report, has been referred to on more than one occasion.
I read the report right through earlier this year, and the only reference that I can recall to the subject under debate today was in relation to those who are compelled to accept treatment. The Millan committee felt that medication ought to be free for those people. I cannot give an Executive response to that report, because currently we are considering it with a wide-ranging reference group, which includes users and carers. That group is helping us to work through some of the issues. There will be a statement on that later this year, and a new mental health bill will follow next year.
Brian Adam tried to connect prescription charges with mental health, and I understand and share his concerns, but the reality is that many people with various physical illnesses might well put forward exactly the same case, which is the point that David Davidson made. That highlights the fact that this is a complex issue, which has to be considered carefully. Change would be a major exercise, and it should be remembered that we are in the middle of a much wider programme of change and development in the health service and community care. In view of that, we do not regard reviewing the prescription charge arrangements as a priority at present.
I know that some groups have raised the issue of prescription charges, but in my contacts with mental health groups, and user groups in particular, it has not been at the top of their agendas. We also found that to be the case in our consultations on the health plan last year. While we acknowledge the concerns, we have to retain a sense of perspective on prescription charges. For example, the 1.6 per cent increase in prescription charges this year was the lowest for 20 years. We should remember that the charges bring in £45 million for the national health service. People have to reflect on the hole that would be made in NHS finances if there were free prescription charges for chronic mental illness, although I accept that they have not been arguing for that particular position today.
I recognise that £45 million is a not inconsiderable sum, but will the minister accept that exemption of the group that the motion mentions would involve a much smaller amount of money? If free prescriptions were extended, the amount affected could be counterbalanced by reduced costs, particularly in hospitalisation, and even in care in community.
That is the case for mental health exclusively, but I make the point that many people would not regard it as fair to except only one category. That is the point that David Davidson made.
When medical exemptions were introduced in 1968, only 42 per cent of national health service prescriptions were dispensed free, whereas that figure now is 90 per cent. We can reflect that the majority of people receive free prescriptions.
A pre-payment certificate is available to cover all prescriptions for four months for £31, so I am unsure why the constituent to whom Adam Ingram referred should pay £31 for two months' prescriptions.
The issue was connected to the serious problem of suicide. It was unfortunate that it was perhaps implied that the high rate of suicide was somehow connected to prescription charges. No evidence for that exists. We should also reflect that not everyone who commits suicide has recent experience of mental health services. The confidential inquiry into suicide and homicide that was produced earlier this year showed that 25 per cent of those who had committed suicide had had recent contact with mental health services.
We take suicide seriously. I read the most recent annual report of the Mental Welfare Commission, which highlights the problem. The Executive is committed to developing a framework for the prevention of suicide and self-harm as an urgent priority. I have been pleased to speak at two major seminars on the topic in the past few months. The most recent took place in Dunblane a couple of weeks ago, when we considered the draft framework. I thank the Scottish Development Centre for Mental Health for undertaking much of the work on that. The draft framework is being revised in the light of comments and we will issue the framework for consultation shortly. Work on preventing suicide encompasses the promotion of mental health and well-being and the development of services. Those are the two substantial parts of our mental health agenda.
The motion refers to mental health week. Every April, the World Health Organisation holds a mental health day. Scottish mental health week takes place every October and is run by the Health Education Board for Scotland. It seeks to raise awareness about mental health and helps to tackle the fear and stigma that are often associated with it. Concerted action to deal with stigma is also a major priority for us. I know that the cross-party group in the Scottish Parliament on mental health will welcome that, which is part of our wider work on promoting mental health and well-being. From the health improvement fund, £4 million has been set aside for that work in the next three years. Detailed announcements will be made about what will be done.
I must refer to the service agenda, which complements the promotion agenda, as our health plan said in December. We are accelerating the implementation of the framework for mental health services and have given an extra £2 million this year for projects that are directly linked to it. About a year ago, we established the mental health and well-being support group, which will ensure that the framework is implemented throughout Scotland.
We also said in the health plan that
"severe and enduring mental illness is only the tip of the iceberg".
We seek to extend mental health services in primary care for the wider range of people who can suffer mental health problems at some point.
At least one speaker mentioned employment. Developing employment opportunities for those with mental health problems is critical, and the new futures fund helps in that. Two weeks ago, I was pleased to open a project in Aberdeen that is run by Rehab Scotland. It was a superb demonstration of good practice in working on employment issues with those with mental health problems.
My time is up and I know that Brian Adam will not be pleased with what I said about prescription charges. However, I hope that he will note the points that I made about them and that he will welcome the broader mental health initiatives that we seek to drive forward.
Meeting closed at 16:15.