Prescription Charges
The next item of business is a debate on motion S3M-7423, in the name of Derek Brownlee, on prescription charges.
10:27
The Scottish Conservatives make no apology for returning today to a subject that Parliament has debated on a number of occasions.
There is a clear issue of principle around the question of whether or not to charge some people for their prescriptions. Before I turn to that issue, which divides the Parliament, I will outline some areas in which I think we are united.
Although the Treasury and the Scottish Government use the gross domestic product deflator of 1.9 per cent as an inflation estimate, inflation in health care costs has traditionally been assumed to run ahead of general price inflation. The combination of an ageing population, medical advances and rising public expectations means that since the creation of the national health service in 1948, no Government of any party has managed to limit health-care costs to inflation.
“Of course, with the costs of healthcare rising fast, it would be wrong to say that the NHS doesn’t face any financial challenges. It does.”
Those were Nicola Sturgeon’s words when she addressed the Scottish National Party conference last month. She was not the only one to post a bleak warning on the NHS in October. Jackie Baillie told her conference:
“As the price of drugs rises and demand for services grows from an ageing population it will mean deep cuts in every hospital and every doctors surgery the length and breadth of Britain.”
I had thought, therefore, that the opening line of my motion, which merely asks Parliament to note the financial pressures on the NHS, would provide common ground. Equally, I thought that we might have found common ground on the figures from the independent budget review that the SNP Government established—although admittedly because we told it to do so. I hope that neither Labour nor the SNP disputes the £25 million figure. If they do not dispute it, nor the funding pressures on the NHS, why do the Labour and SNP amendments seek to remove any reference to funding pressures on the health service or the cost of abolishing prescription charges?
I return to Jackie Baillie’s doom-laden speech in Oban, which may well have been one of the lighter moments of the Labour Party conference. She said:
“the SNP are ... Cutting jobs and cutting nurses ... Well Labour won’t stand for it. We will protect our NHS.”
She is right. Labour will not stand for it—it will not stand up for the NHS and it will not stand up to the SNP. Labour members will carp and criticise, and then they will vote with Nicola Sturgeon anyway.
I wonder what has happened to the brave soul who pronounced on the issue of abolishing prescription charges only a month ago that
“At a time when Nicola Sturgeon is cutting 4,000 health workers in Scotland including 1,500 nurses, we need to seriously consider if this is the right priority at this time.”
That was, of course, one Jackie Baillie. She has obviously concluded that it is the right priority at this time to cut 1,500 nurses, because by not abolishing prescription charges she could fund more than 1,000 extra nursing staff. However, that would mean that she would not be able to complain about the SNP cutting them, and it would mean taking a position on prescription charges that might be unpopular—even if it is the same position that Labour supported in the dark days when it was in power. It would mean standing up for the NHS, and that would never do for the only party ever to have cut the NHS.
Our argument is simple: to take the revenue that is raised from prescription charges away from the NHS is the wrong choice. It is a cut that is imposed not by the coalition in London, but by the coalition in Edinburgh. Labour and the SNP, the so-called left-wing parties, are taking money from the NHS and putting it into the pockets of people who can afford to pay.
If the issue is, as the cabinet secretary said in the debate in January, simply that some people are just over the income threshold and not in an exempt group, there is an answer: we could raise the threshold. If the central issue is the principle that there should never be charges in the NHS, we will presumably hear the SNP and the Labour Party discussing the abolition of charges for dental and optical treatment. The truth is that the issue is about one principle only: the SNP is trying to get re-elected, and the Labour Party is helping it.
I turn to the concerns that the cabinet secretary raises in her amendment. Abolishing prescription charges will indeed benefit those who currently pay for them, at least to the extent that they save the money that they would otherwise pay for prescriptions. However, that money comes from elsewhere in the NHS, and that has consequences for the poor and the sick. We never hear about those consequences, but they are consequences nonetheless. If 1,000 nurses lose their jobs to pay for the abolition of prescription charges, does that help the poor or the sick? Abolishing prescription charges takes money from the NHS, and that is what the Government is intent on doing, with Labour Party support.
It is ironic. The Labour Party has spent the past three years condemning the SNP for breaking manifesto promises, and has been particularly vociferous in attacking the SNP for breaking those pledges that Labour did not support. It now appears, however, that Labour is prepared to vote with the SNP to deliver a manifesto promise with which, apparently, it does not even agree. The SNP has been lucky in the incompetence of its main opposition, but Labour’s failure to oppose the SNP when it is wrong will hurt the poor, the sick and the NHS.
That is why the Conservatives have brought this debate to the chamber today. We will oppose the plans because we want to stand up for the NHS, even if Labour and the SNP will not. All those members who are intent on abolishing prescription charges must tell us where that money will come from and which services will be cut, which otherwise would not happen. They must explain what the consequences will be for the poor, the sick and the national health service.
I move,
That the Parliament notes the financial pressures on the NHS and that the Independent Budget Review established by the Scottish Government has estimated that the full abolition of prescription charges would remove a further £25 million of income each year from the NHS and accordingly calls on the Scottish Government to reconsider its position on prescription charges.
10:33
I welcome the debate, although it was only in January that the Tories last brought the debate to the chamber and failed to persuade Parliament of their position.
This morning, I have the opportunity once more to set out the Government’s commitment to abolishing prescription charges and to remind members why that policy is so important to people throughout Scotland.
I believe that all of us in the chamber want to create a healthier country and tackle the health inequalities that blight Scotland. We want to support people to live longer and healthier lives, and to ensure that people have timely access to the health care that they need. Removing prescription charges is an important part of delivering all that.
The reality—whether the Tories choose to see it or not—is that prescription charges are a barrier to health for many people throughout the country. They can prevent patients from collecting their medication, and they even deter some people from visiting the doctor in the first place. I have spoken to patients who have found themselves in that position. If we believe in a fair and equitable society, that situation is simply not tolerable. The policy will ensure that patients with long-term conditions are not prevented from collecting their medicines. We are now only one step away from removing the barrier for all patients, without the invidious exercise of weighing up which of them are more deserving and more worthy than others.
We know from the information that we have on prescription prepayment certificates that patients with long-term conditions are benefiting the most from the policy. We brought the cost of PPCs down more quickly than the cost of single prescriptions. As a result, sales of PPCs are up by 165 per cent. That benefits people who need multiple medications.
I know that there are people, led by the Tories, who say that we should not abolish prescription charges for all and that we should simply extend the list of exempt conditions, but that approach is not simple in reality. The Parliament has previously recognised that it would be fraught with difficulty. When we were considering our approach in the early days of the current session of Parliament, many concerns were expressed to us about the difficulty and delay that would be associated with defining a list that was comprehensive and complete and—more important—which avoided simply creating new anomalies and a new set of invidious choices. That reality has been recognised not just in Scotland but in Wales and Northern Ireland.
In any case, abolishing prescription charges only for people with long-term conditions would also ignore the needs of people on low incomes who are not exempt. Many patients who are not eligible for exemption struggle to pay prescription charges. Again, I have spoken to many people in that position. The Tories suggest time and again that only those who can afford to pay are charged for prescriptions, but that is not the case.
Will the minister give way?
I will give way in a moment.
The Tories need to recognise that 600,000 adults living in Scotland right now earn around £16,000 a year and they struggle to pay for medication that they have been prescribed. However, it is perhaps not surprising that the Tories, yet again, seem oblivious to the reality of poverty. I also think—and on this point I will take an intervention—that it speaks volumes that it was the Tory party’s finance spokesperson and not its health spokesperson who moved the motion. The health spokesperson is not even in the chamber, which perhaps tells us what his view is.
The health spokesman is at a funeral, for the cabinet secretary’s information.
The point that I raised in my remarks is simply this: if there is an issue about people on low incomes, could it not be addressed by raising the threshold, rather than simply abolishing prescription charges for everyone, including people on £50,000 a year? Surely the rate of non-collection of prescriptions by people on £50,000 a year is negligible.
Before I respond to that point, I apologise to Murdo Fraser. I was not aware of his personal circumstances today.
I think that Derek Brownlee makes the point that I am trying to make. We could extend the list of people who are exempt, to include those with long-term conditions, or we could raise the threshold, but in doing so we would simply create a new host of anomalies. The United Kingdom British Medical Association said recently:
“changes to the system short of abolition would still be unfair on the reduced number of patients who do not qualify for exemption ... We really have to question whether the small financial benefit of retaining charges outweighs the many disadvantages of taxing the sick.”
That sums it up exceptionally well.
It has been suggested again today that, given that budgets are tight—and they are—we should spend the money in different ways. That is the very choice that we want to remove from patients, whose own budgets are ever tighter. As we know, the pressures on family budgets are increasing, principally because of some of the decisions that the UK Tory Government is taking. Prescription charges are one pressure that we do not want to impose on the tight budgets of families throughout Scotland.
For all those reasons, total abolition is not just right in principle but the fairest, most cost-effective and most sensible approach to take. That is why we remain committed to it. It is also important to point out that Scotland is not unique. We are not somehow in a stand-alone position on the issue. Wales and Northern Ireland are ahead of us. They have already abolished prescription charges, and I think that it is right that in April we will come into line with them. I hope that, today, the Parliament will reject the latest Tory attempt to play off one part of health funding against another. I hope that the Parliament will unite in supporting free health care for all.
I move amendment S3M-7423.1, to leave out from “notes” to end and insert:
“recognises that the abolition of prescription charges will benefit all those patients with long-term conditions and the 600,000 people on low incomes who are not entitled to exemption and further recognises that total abolition is in the best tradition of the NHS and that poor people and sick people should not be made to pay the cost of the economic and financial situation that Scotland faces.”
10:40
I welcome the opportunity to debate prescription charges again. We last debated the issue in January, on the basis of a Tory motion. Not content with the response then, the Tories are back again today. They are nothing if not persistent.
I have to say that Derek Brownlee is at best confused and at worst deluded. Of course we recognise that there is a tough financial settlement. It is so tough that we have the smallest increase in the health budget since the creation of the health service way back in 1948, and it has been done by a Tory Government. We therefore need to ask what our priorities are and what can be afforded. However, I am flattered that Derek Brownlee listened so intently to all my conference speeches, and I look forward to his learning from them.
In January, we supported the introduction of free prescriptions, and today Labour members will support the ending of prescription charges. We previously favoured an incremental approach that would have meant extending free prescriptions to those with long-term chronic conditions and those on a range of top-up benefits as a result of low incomes. At present, 92 per cent of all prescriptions in Scotland are issued free. Wide categories of people are already eligible, including under-18s, the unemployed and pregnant women. However, there is an issue, because a substantial proportion of the remaining 8 per cent have chronic conditions and they might require substantial amounts of medication that some might struggle to afford. It is therefore not accurate to say that only people who can afford to pay for prescriptions are paying for them.
I repeat something that the cabinet secretary said, because it is valid: something like 600,000 adults in families in Scotland earn less than £16,000 a year, but that puts them slightly over the exemption level, so there are low-income families who are not exempt from paying prescription charges.
Will Jackie Baillie explain why it is that, in the eight years of the Labour and Liberal Democrat Executive, when budgets were rising, Labour never once brought a proposition to reduce and abolish prescription charges, yet at a time when budgets, by her acknowledgement, are static or falling, all of a sudden Labour is in favour of free prescriptions? That makes no sense whatsoever.
David McLetchie’s attempt to rewrite history is inaccurate. We did bring forward proposals to reduce prescriptions. If he had been listening—which is something that the Tories would do well to do—he would know that I described that incremental approach.
We could spend a lot of time today—as would suit David McLetchie—rehearsing old arguments, but that would not be valid. The cabinet secretary and the Scottish Government have reached a judgment about the value and affordability of prescription charges, and it is appropriate to question that policy robustly to ensure that it has been thought through. When we last debated the issue, the total recurring cost was set at £57 million from April 2011. I ask the cabinet secretary whether that figure remains accurate and whether it is in the budget.
Yes.
That is helpful. Given that we witnessed a one-year election budget yesterday, can the cabinet secretary provide assurances that the policy is sustainable? She knows the figures for the next three years. Will she tell us what has been set aside for 2012-13 and 2013-14 and whether percentage growth has been allowed for? There is a possibility of a general increase in demand, which needs to be factored in. That would assure not just the Parliament but the country that the policy is properly costed and sustainable beyond the current year.
Will the member take an intervention?
I do not have time.
You have time to take an intervention if you wish.
Do I? Fine. I am always delighted.
Is Jackie Baillie telling us that Labour members are going to vote for free prescriptions today but they have no idea whether the policy is sustainable?
I do not know where Derek Brownlee was yesterday, but the problem is that the Parliament does not know the budgets for future years, in terms of the allocation of funds. On the basis of his question, he will not be voting for anything at all. We need to question the Government and ask it to come forward with those figures, so that the Parliament and the country can be reassured about the sustainability of the policy. I think that it is appropriate to ask for those figures.
Members will know that we encouraged the Scottish Government to introduce free prescriptions for cancer patients in Scotland, in line with the policy in England and Wales. Let us be clear: we are not asking for that to be done instead of addressing prescription charges for other chronic conditions, and it is wrong to suggest so.
The SNP’s manifesto pledge way back in 2007 was to
“immediately abolish prescription charges for people with chronic health conditions, people with cancer, and people in full time education or training.”
We agreed with the approach of prioritising people with long-term illnesses by widening the conditions that are eligible for free prescriptions. However, while I welcome the ending of all charges and have sympathy with the cabinet secretary’s reasoning, it remains the case that while charges for cancer patients were scrapped by the Labour UK Government in April 2009, cancer patients in Scotland were denied that benefit. It was absolutely right to abolish charges for cancer patients. It has transformed the lives of about 150,000 people, who have each benefited by saving up to £100 a year. We would have liked that to apply to Scotland, and it is a matter of regret that it does not.
Voting for the Tory motion will put in jeopardy free prescriptions not just for people with chronic illnesses but for all. We on this side of the chamber will not do that, because we support the abolition of prescription charges in Scotland.
I move amendment S3M-7423.1.1, to insert at end:
“, but regrets that free prescriptions for cancer patients in Scotland were not implemented by April 2009 in line with England.”
10:46
There has been a tinge of unreality about the debate so far. It is almost as if we had huge amounts of as yet undreamed of funding available to us, there was no funding crisis, there were no cuts nor any prospect of cuts to our health service and everything was going on as before, so this is a rather narrow and silly debate.
Liberal Democrats began to wonder whether abolishing prescription charges was the right priority only because of the change in financial circumstances. That is why last year we opposed the move to reduce further the level of prescription charges. Today, strangely, we are told that prescription charges are the only threat to those who are sick and those who have long-term conditions. That is not the world in which I live. There are already serious threats to the condition of many people because—this might be news to some—health boards are making cuts. Perhaps they should not be—perhaps they are making a mistake—but they are making cuts. They are reconfiguring services. They use odd phraseology with nurses: “You will find another job but not necessarily 40 miles from where you live. You will be reconfigured and your grade 5 status will not be required.” That is affecting not only nurses, but patients. Things are also changing for those in our communities, particularly poorer people for whom health care, general practice and other health provision in the community is especially important. Services are being reduced and that is affecting the health of those people.
Another issue is the change in the allocation of specialist nurses. The large number of specialist nurses make a huge contribution to the efficacy of drugs prescribed for patients. It is nonsense to suggest that there is no connection between the reduction in the number of specialist nurses and the efficacy of our drug and prescription policy. As far as Liberal Democrats are concerned, we are not looking at a blank sheet of paper. We are looking at the reality, which is that we have to make choices and we have to be sure about those choices. The decisions that I have talked about are being made before this year’s allocations to health boards are taken into account. Liberal Democrats are very concerned that the claims that there may be adequate provision in the funding of our health service do not stand up to close examination.
We were interested in the proposal by the independent budget review panel that it was right and proper for us to look at the £25 million that would be used for the final step of abolishing prescription charges. In the present financial climate, we found that very difficult, indeed. There was some concern that linking prescription charges with the cost of providing drugs might stray outwith the competence of the motion, and I am grateful for your indulgence in the matter, Presiding Officer, because the independent budget review panel drew particular attention to the level of prescription charges and the fact that the total drugs bill is more than £1 billion. The two are inextricably linked in any consideration of ways in which to make more money available within the health service.
It looks like the Liberal Democrat position is now changing. To quote Ross Finnie, who seemed to be fond of quoting me the other day:
“The Liberal Democrats would support proposals to give protection to those who have long-term conditions.”—[Official Report, 21 January 2010; c 22953.]
The overwhelming majority of the 8 per cent who pay prescription charges have long-term conditions.
I am not sure of the date of that quote—
It was January.
I think that it has been quoted before and I am grateful for that second reading.
People with long-term conditions are the very people who have nurses assisting them with their drugs. Remove that assistance and we imperil how their health care is dealt with. These are not easy, choose one as against another, decisions. I know of many patients—Dr Simpson ought to know of many, too—for whom removing those nurses will not help them one jot to benefit from their prescribed drugs.
I was moving on to the issue—
The member should perhaps move on to sum up.
That is exactly what I am doing, Presiding Officer.
We need to make savings on that £1 billion drugs bill if we are to preserve our position in relation to prescription charging. A 2.5 per cent reduction in that bill is imperative in the current financial circumstances. It is also a way of tackling misuse and abuse of the system. I know that the Government has addressed that, but we need to go further.
I move amendment S3M-7423.2 to insert at end:
“, prescribing practice, medicines management, adverse reactions to medicine and procurement and purchasing of drugs.”
We come to the open debate. Members have up to five minutes each.
10:52
I acknowledge Nicola Sturgeon’s belligerent commitment to the principle of the abolition of prescription charges. She is misguided, but with the virtue of being consistently so. I know that she has been looking forward to the debate all year, probably with as much fervour as she did to her wedding in the summer, because it gives her the opportunity to dust down her Govan soapbox and paint the Conservative position yet again as being that of vampires rising from the grave to suck the last living blood out of the sick.
While I welcome Jackson Carlaw back to the health debates, for the avoidance of doubt I wonder whether he will accept that I made no use whatsoever of my Govan soapbox during my wedding in the summer.
Sadly, the invitation to witness the proceedings not having arrived, I can only take the cabinet secretary’s word for it.
I counter the cabinet secretary’s earlier argument by pointing out that the Scottish Conservatives supported the reduction of the prescription charge in 2008 from £6.85 to £5. We supported the reduction in cost of the prepayment certificate, which at that point was £98.70. We did so for a couple of reasons. First, we accepted that there had been a significant increase in the overall contribution to the health service through the rise in national health insurance contributions from the public. Secondly, we accepted that the accelerated rate of increase in prescription charges had got to a point at which a multiple prescription cost for many people was a considerable financial burden. We supported—and our manifesto committed us to supporting—a reduction in the costs to those with long-term conditions.
I want to challenge a point that the cabinet secretary made and explain the argument in slightly more detail. She said that the Conservative position is that those who can afford to pay for prescriptions should do so and that they are the people who currently pay for prescriptions. I do not believe that that is the case: it is a much more complicated position than that.
The basis on which people currently pay for prescriptions is nothing to do with whether they can afford to pay. My mother is a higher rate taxpayer. She is nearly 80 years old. She could well afford to pay for her prescriptions, but because she is a pensioner she does not. There are millionaires who could well afford to pay for prescriptions for their children, but because the prescriptions are for children they do not.
Jackie Baillie made the not unreasonable point that there are people among the 600,000 who still pay prescription charges who do not have masses of money to dispose of and for whom paying a prescription charge is a considerable matter. That is why we supported the original reduction in the overall prescription charge. In an ideal world in which there was no financial consequence facing the NHS—another issue that I will come to—it could be argued that abolishing prescription charges would be a priority for spending, but we are not in that position.
The cabinet secretary has never addressed an issue that has come up in many of the debates. It is a point that I will illustrate with an experience relating to my wife—who said she hoped that I would at least be discreet enough not to say what her prescription was for. I went along to the pharmacy to pick up a repeat prescription on her behalf. The pharmacist said to me, “Mr Carlaw, the cost of this medicine as a retail item is cheaper than what you pay for the prescription. It would be cheaper for you to buy it and tear up the prescription than to pay for the prescription.” That is what I did.
Between the ages of 14 and 40, I was a long-term migraine sufferer. I picked up across-the-counter medicine for migraine—Migraleve—which now costs between £7 and £10, depending on whether someone buys 16 or 32 tablets. I presume that, when I suffered from migraine, I was sick as in the terms of the cabinet secretary’s amendment. Once we have abolished prescription charges, what will be the incentive for people not to go to the doctor for a prescription so that they can get, free of charge, over-the-counter medicines that they currently routinely pay for? What is the cost to the NHS and to GP practices of individuals going to the doctor for a prescription for an over-the-counter medicine? To some extent, that practice has been experienced in Wales and Northern Ireland, and if the health secretary is determined to proceed she owes us at least an explanation of how she will deal with that point.
In the final analysis, I accept that, with all her customary grace, charm and intelligence, the cabinet secretary has been committed to the policy throughout. It was in her manifesto, the SNP supported it, and it intends to deliver it. That is the complete opposite to the position of the party that seeks to be in government next May. There is no principle in the Labour position; we have simply seen a politically expedient act on its part because it is frightened to stand up for what it stood for at the last election and for what Gordon Brown stood for in the rest of the United Kingdom. There is no principle underpinning Labour’s support for the cabinet secretary’s amendment, and it is a poor state of affairs to consider that it should ever be in charge of the nation’s Government if that is how it seeks to operate.
10:58
I will say why I oppose the motion before us this morning. First, I and members of my party believe in a health service free at the point of need. Of course it has to be paid for, but we do that out of our taxes according to our means, and not according to our illness.
There are few health needs greater than the dispensing of a prescription recommended as needed by a highly trained and competent doctor, so why should we select such a prescription for a charge? Where will it end? How many more direct health charges have the Conservatives in mind? Would they charge for self-referral to physiotherapy, which is not assessed by a doctor?
In that spirit, will the member tell us when his Government intends to abolish all the dental and optical charges on the NHS?
It certainly is a long-term aim to do that. I know that Mr McLetchie has great confidence in the SNP Government, but it is a bit much, even for us, to expect us to undo in less than four years the damage that unionists have done in 57 years of running the health service.
Then there is the unfairness of the charges. Although there are many exemptions, I know that there are also many families for whom a prescription charge is a hefty financial burden. Who does not pay the charge? Jackson Carlaw is right: the answer includes well-paid people such as you, Presiding Officer, me, Annabel Goldie, Mary Scanlon, Nanette Milne, Jamie McGrigor, Bill Aitken, Ted Brocklebank, Richard Simpson and Ross Finnie, among others. The Conservatives argue for prescription charges, but the truth is that more than half of the Conservative group in this Parliament who are arguing for others to be charged either are now eligible for free prescriptions or soon will be. As Jackson Carlaw asked, what about the children of millionaires? Are the Conservatives now recommending charges for pensioners? If that is what they intend, they should come clean.
I will make it absolutely clear: we are saying that the Government should not proceed with the abolition of the prescription charges that exist; we are not suggesting that they be extended at all.
I gather that Derek Brownlee says that in the motion, but Jackson Carlaw seemed to say that it is wrong that a lot of very rich people, including more than half of his party, do not pay prescription charges. If the Conservatives want to keep prescription charges, they will have to think of a system whereby people who earn large sums of money are not exempt from them just because of their age.
When there is a prescription charge, some people just cannot afford to have a prescription dispensed—ask any pharmacist working in a deprived area. Some critics even argue that if a prescription is not presented for dispensing it cannot be needed. Let us look at the ramifications of that argument in a little more detail.
The process of a medication being developed and prescribed is about as closely monitored as it is possible for it to be. No medicine is allowed to be used unless it meets the highest standards of safety, efficacy and affordability. Prescribers are highly trained in prescribing matters, and if treatment is prescribed inappropriately, the prescriber can be identified by the health board and counselled. Scrutiny is by expense and by comparison with peers, so that outliers can be identified individually and asked to account for an abnormal prescribing pattern. We can therefore assume that most prescriptions are given appropriately.
Will the member give way?
I am sorry: I need to get on.
What happens if, at the end of that sophisticated process, the prescription is not dispensed? The illness might take longer to get better; it might even get worse. The result may well be more time off work, more sickness benefits paid, more expensive treatment later on to effect a cure, or even costly hospital admission. Charging for the prescription can easily prove to be a false economy, and it makes no sense.
It also makes no sense to expect the patient to decide which medicine to take and which to refuse on the grounds of cost. If members really feel that some prescriptions are not needed, it is the prescriber who should be chased—and that happens already. What the Conservatives are proposing is as scientific as tearing up one in every 100 prescriptions and making prescribing savings that way. At least that would risk the health of all patients equally, not just those in low-income brackets.
I want finally to turn to Jackie Baillie’s amendment. I understand that she has to try to glean some comfort from the situation, but the fact is that, on analysis, absolving only cancer patients from prescription charges gives us the same problems as exempting other patients. Some people with cancer are not affected severely and have high incomes, while other people have conditions that are as debilitating as some forms of cancer. On those grounds, I support the cabinet secretary’s amendment as the one that encompasses the best for all sections of Scottish society.
11:03
I rise to speak in support of Jackie Baillie’s amendment and all that she said.
I have a number of concerns. As the cabinet secretary said, health care should be free at the point of access for everyone. That is a founding principle of the NHS, but in Scotland today some patients are being denied any treatment whatsoever. In other words, we are seeing free prescriptions for all, but what is the price that some families have to pay? For some families and individuals, there is zero, nil, zilch treatment available if they happen to require certain NHS treatments. Two examples are infertility treatment and bariatric surgery. I would have thought that it was against the law to deny patients NHS treatment when a consultant says that the patient can be treated—
Will the member give way?
I will come back in a minute.
Politics is the language of priorities, and we have to examine that situation. I have a range of questions that I can write to the cabinet secretary about separately, because a lot of questions came up in my mind when I was preparing for today’s debate.
Some of Jackson Carlaw’s points were actually pertinent. When the cabinet secretary issued her first ministerial statement on the issue, on 5 December 2007, she responded to a question from Richard Simpson by saying that announcements about the minor ailments service would follow “in due course”. However, I know from speaking to pharmacists at a recent community pharmacists dinner in Edinburgh that that point has still not been addressed. If costs rise in relation to minor ailments, will that mean rationing of more expensive drugs?
It is vital that the cabinet secretary says, at long last, what is to happen to the minor ailments service. Since the introduction of the service, anyone who receives free prescriptions has been entitled to register with a pharmacist and have a prescription issued to them for minor illnesses. Although the system benefits those who are currently on free prescriptions, if it is extended to the whole population, more people will ask for prescriptions for minor illnesses.
Helen Eadie might have been absent from the chamber on all the previous occasions when I have answered that specific question, but will she accept that I have previously made it very clear that the minor ailments service will continue as it is now? The eligibility for it will continue to be the current eligibility, which is based on the prescription charge eligibility, even when prescription charges are abolished. As I have yet again answered that question, will Helen Eadie and her colleagues finally accept the point?
It is not me who needs to accept the point; it is the community pharmacists’ representatives, with whom we have met and who say that the point is still not crystal clear to them. The cabinet secretary and her officials have a responsibility to pursue that.
I said earlier that politics is the language of priorities. How can it be right for well-off families to pay anything up to £30,000 for infertility treatment, but for some families, such as some of my constituents, to be denied completely any access to that treatment? How can it be right for the Parliament to make choices that deny treatments such as bariatric surgery and infertility services to NHS patients? We are talking about important decisions.
Earlier this year, the Western Mail, reported on the future of the Welsh Assembly Government’s flagship free prescriptions policy. It was once more called into question when it was shown that the number of items that were handed out to patients had reached an all-time high. The NHS in Wales is footing an increased bill for medicines following the abolition of prescription fees. The latest official figures show that the number of prescriptions that were issued last year hit 67.6 million items. GPs told the Western Mail that they probably see patients who would previously have bought medicines over the counter. So some of the points that Jackson Carlaw made are important.
Although the Labour Party can agree with the Government’s policy, we need to know how it can be right that millions of items will be prescribed, including Tesco own-brand ibuprofen caplets, which are priced at just 28p on the shelf, but cost the NHS £3.75 for each prescription. There are important questions. We cannot simply accept the policy without careful scrutiny and questioning. I absolutely support Jackie Baillie’s points, but I can see merit in some of the arguments that the Conservatives have made.
11:08
It will be difficult to bring something fresh to the debate, as we debated the issue in January and I am speaking late in this debate. However, I will try to bring a fresh angle.
I begin by laying it down that, as Ian McKee said, prescriptions are not free—they are paid for through general taxation, and the richer somebody is, thankfully, the more tax they pay. As I came into the chamber, I picked up a booklet from the Long Term Conditions Alliance Scotland, which has a display outside. There is an interesting section called, “Impact of the Economic Downturn on People with Long Term Conditions”. As Jackie Baillie said in the debate in January, 92 per cent of prescriptions are free and 8 per cent are charged for. Many of the people who are charged have long-term conditions. I will try to drift away from the ageing aspect and not take it personally.
About 600,000 people are not eligible for free prescriptions but have an income of less than £16,000. Several issues arise out of that. People with long-term conditions have not only the costs of multiple prescriptions, but higher transport and child care costs because of the need to access services. Interestingly, the booklet by the Long-Term Conditions Alliance states:
“Citizens’ Advice Scotland ... found that 41 per cent of their CAB debt clients listed sickness or disability as a reason for their debt. Furthermore, ‘sick or disabled’ CAB debt clients have greater financial problems and, on average ... Have six debts and owe an average of £20,588.”
So for somebody who is maybe on or just above £16,000, no account is taken of the liability that they already have for debts and other payments that must be made, which greatly reduce the income that they have to pay for prescriptions. That issue has been missed in the debate.
Against that background, it is important to consider the impact of recession on people’s health. There are all kinds of difficulties for people, such as job loss and marriage break-ups. It might be then that they need to go to their GP to access prescriptions. If they are earning above the threshold, they will have to pay for their prescriptions. As Ian McKee said, that might compound their illness and, at the end of the day, cost the NHS a great deal more.
Thresholds are fraught with difficulty. Derek Brownlee suggests raising the threshold, but to what level would he raise it? I invite him to respond.
The Government could consider what the appropriate level was. Yesterday, for example, the Government had no problem at all with imposing a threshold of £21,000 for its cut-off for the public sector pay freeze. If the Government can do that for one thing, why can it not do it for another?
Let us say that Derek Brownlee has suggested that £21,000 should be the threshold. So somebody who was on £21,500 could not access free prescriptions. They might have substantial debts, which would not be taken into account. Raising the threshold is not a simple matter. There are injustices with thresholds, which is why it is better not to have them at that point, but to have them at the point of taxation and to bring in general taxation to pay for the NHS. That is the way to remedy the issue and it is far more just.
Endeavouring to extend the list of exemptions for long-term conditions is also fraught with difficulty, as we well know. The BMA has examined the issue carefully. In the debate in January—I must now refer to it—I pointed out that the BMA has said:
“Moves have been made to exempt patients with cancer from prescription charges, but already this looks set to create a new set of winners and losers depending on which side of an arbitrary line you fall. If the current system is to continue to exist, then we believe that consideration of more radical proposals is needed rather than a simple extension of the list of medical exemptions.”
So that is not a solution and, for me, a threshold is not a solution.
The issue comes down to the question of why medication should be free for in-patients, when out-patients, who are taking it home, are charged. That seems unjust.
11:13
Although I support the principle of free prescriptions, I, too, have one or two concerns that I want to highlight. The Labour Party in Scotland has long advocated that the Government should make prescriptions free for cancer sufferers prior to the measure being extended to the whole population. Cancer patients in England and Wales now get free prescriptions, so it is a shame that those in Scotland will have to wait until next year before they are on the same footing. Through rebalancing of the phasing process, it would have been possible to extend the measure to cancer sufferers before now.
I absolutely accept the sincerity of Rhoda Grant’s point and the suffering and anxiety that go with a cancer diagnosis, but why would it have been right to have an early exemption for cancer sufferers but not, say, for people with Parkinson’s disease? Is it not the heart of the matter that, if we start picking and choosing, all we do is create even more anomalies, which is why complete abolition is the fairest way?
The evidence that we have received, certainly from cancer charities, tells us that cancer is a special case, because cancer patients tend to suffer from fuel poverty and, when they receive treatment for their disease, they have a lowered immune system, which makes them more susceptible to viruses and the like. Although I accept that people with many other conditions would benefit from having free treatment now, there is certainly a special case to be made for cancer.
The cabinet secretary said in an intervention on Helen Eadie that those who qualify for free prescriptions will continue to qualify for free treatment for minor ailments from a pharmacist. That statement means that those cancer patients who do not qualify for free medication now—as well as people with chronic illnesses who do not qualify for free prescriptions now—will not qualify for access to free minor ailments treatment through their pharmacist in the future. As I said, people who are undergoing chemotherapy have poor immune systems and are susceptible to minor ailments, as are many people with other chronic conditions. If they are to access free medicines for those minor ailments, they will need to go to their GPs to get prescriptions and that will lead to a delay in their being treated and, indeed, to a greater burden on GPs. Although I am sure that that is not the cabinet secretary’s intention, I ask her to consider amending the criteria for access to free minor ailments treatment now so that cancer patients and others with chronic diseases that lead to a predisposition to minor ailments will receive treatment free of charge.
Ross Finnie’s amendment raises a number of good points about prescribing. In yesterday’s health debate, Elaine Smith said that the prescription of thyroxine is problematic for people who require it because they need to be prescribed the same brand if they are to benefit properly. She told us that GPs and pharmacists are unaware of that and that people’s health is being compromised because they are receiving different types of treatment. That issue should be considered. We have the same problem with other generic drugs in that some people are sensitive to a small change in their drug treatment. Although we need to encourage GPs and others to use generic drugs as much as possible, it might be worth pulling together some guidance on the drugs to which people are more sensitive, so that GPs are allowed to prescribe an alternative in such cases while considering generic drugs to be the norm.
Another issue that has been raised before in the chamber, and certainly by Mary Scanlon, is the recycling of underused medicines. Back when Mary Scanlon started raising the subject, there was a problem with the idea because medicines tended to come loose in bottles and could be tampered with easily or become contaminated in some way. However, drugs are now mostly dispensed in blister packs. With a little care, it should be possible to recycle them, which would help to cut costs. Others have touched on the cost of drugs and the inflation in the cost of drug treatments. We need to try to encourage health boards to buy together and look at ways of saving on those costs in order to tackle the inflation in the cost of drug treatments and get value for money for our services.
I ask the cabinet secretary to reflect on the points that have been raised today in a genuine attempt to improve prescribing practice and help the most vulnerable in our society to benefit most from their health treatment.
11:18
I start with a point of clarification for Jackie Baillie, who referred to health spending across the United Kingdom. As there was some reference to rewriting history, I offer the fact that Alistair Darling’s plans on behalf of the Labour Party were to protect health spending in England and Wales for two years out of a four-year period, rather than for the whole period. I am sure that Jackie Baillie is aware of that, but it is worth getting it on the record.
Rather than suggesting that what somebody planned did not come into effect, will the member address the fact that we have the lowest budget settlement ever since the creation of the NHS?
All I am saying is that, over the four years, health spending would have been lower because it would have been protected for only two years.
It is fair to look at the £25 million figure in the Scottish Government’s budget statement yesterday. The Government said that the pay freeze for public sector staff earning over £21,000—given that it does not apply to college or council staff, it is by and large an NHS pay policy—will save approximately £300 million and that that equates to protecting 10,000 jobs. On that basis, the cost of £25 million for the free prescriptions policy equates to around 1,000 jobs in the health service. Although I do not want to labour the point, the Government needs to be consistent in its public messaging when it equates funding figures with job numbers.
The health secretary’s principled argument is that free health care for all is her policy. Changing prescription charges from £3 to zero does not end the charging regime in dentistry other than for check-ups; it does not remove all other care charges; and it does not abolish other elements from the list of charges. Unless I am wrong about the current list of NHS charges, I would be grateful if the cabinet secretary would clarify that, of the items on that list that are charged for currently, only prescriptions will be set at zero.
To build on Dr Ian McKee’s point, does Jeremy Purvis agree that, on this point, as in life generally, just because we cannot do everything, it does not mean that we should not take a significant and important step in the right direction?
I understand that point. Supplying surgical tights, surgical brassieres, abdominal or spinal supports, stock wigs, partial human hair wigs or full, bespoke human hair wigs, which bring dignity to out-patients, is within the bailiwick of this Government’s funding policy under the National Health Service (Charges for Drugs and Appliances) (Scotland) Amendment Regulations 2010, which the Parliament considers. We do not know what the Government’s proposals are for items B to H of the charging regime; we have a Government policy for item A only.
All that I am asking for is an understanding. We heard from Christine Grahame that the difference between an in-patient and an out-patient prescription is unjust if what we get free in hospital we have to pay for as an out-patient. That applies to elastic hosiery, including stockings, and it applies to tights if, like my granny, someone is an in-patient or older person. She was supplied with those for free because she is a pensioner, but if someone is not a pensioner or in the exempt category, surely that injustice continues. All I am asking for is to know the Government’s position. It is not a case of saying, “We would like to do it if we were independent”—
That is not what I said.
It was Ian McKee’s point. We are dealing with the charging regime that we have now and I just want to know what the Government’s position is.
Choices are being made. I have had casework involving patients who could not understand why provision of hyaluronan injections for their arthritis had been removed by NHS Borders. They can still get the drug if they pay for it, but they can get free painkillers to treat the symptoms, although that could be a long-term situation because of the pain that they are in. However, they are asked to pay for injections that could mean being pain free for three months. That is the point that Ross Finnie made, which I support entirely. Health care is not just about the prescription transaction in isolation from all other parts of care and prescribing. That is why we have raised unashamedly issues to do with prescribing practice, the overall drugs bill, which has grown, and the current health care regime. It is easy to look at one aspect of the whole in isolation, but we would prefer to look at it holistically.
11:23
We have rehearsed the history of prescription charges on many occasions and I do not think that we should do so again, except to say that they have been in and they have been out. The basic principle is that charging for health care is not regarded as appropriate in this country. On practical grounds, charges have been introduced from time to time and co-payment systems have been used. The privatisation of dentistry by the Conservative party created a massive charging system, whose potential for being rolled back has been difficult to examine.
I wonder whether I have this wrong, but I thought that we still had NHS dentistry—I seem to be married to an NHS dentist. [Laughter.] Well, she tells me that she is an NHS dentist, but Richard Simpson tells me that she has been abolished. What is the difference between an independent general dental practitioner and an independent GP? They have exactly the same status, do they not?
Contractually they do, but the number of private dentists who were established as a result of the charging system has been massive. Oral ill health has been a real problem as a result and our Government and the SNP have been trying to roll that back.
The problem with the prescription charges system is that it is hugely flawed, as many members have said. For example, an MP colleague of mine who does not get free prescriptions on the ground of age does get them because she has diabetes—she gets free prescriptions not just for diabetes drugs but for all drugs. Wealthy people are therefore exempt from all charges if they have certain specific conditions.
I am scarred by the fact that, when I was a general practitioner, one of my student patients died because he failed to fulfil the three prescriptions for asthma that had been prescribed for him, and chose the wrong one to drop. He did so because he was one of the 600,000 people who were marginally ineligible for exemption. That is an important group. Those people have low incomes and they are about to have an additional VAT charge of £200 a year on their lives as a result of the Con-Dem coalition. Therefore, measures that we can take to try to relieve that are appropriate.
The other point is that the system is hugely bureaucratic, given the massive administration costs. We spend time on addressing fraud in relation to prescription charges, which is a complete waste of time. There are substantial costs. The bureaucratic element is a problem.
Will the member take an intervention?
I really do not have time. I am sorry.
We and the SNP both started from similar positions in our manifestos in 2007. On page 40 of its manifesto, the SNP pledged that it would immediately abolish
“prescription charges for people with chronic health conditions, people with cancer, and people in full time education or training.”
Will the member take an intervention?
The cabinet secretary can respond in summing up.
The SNP then decided to change to a system of gradual abolition, which was the eventual policy that was to be introduced by 2012 and is now being introduced earlier. The SNP therefore chose a different route when it came into government.
Ian McKee asked why we focused on cancer patients. Read the Macmillan Cancer Support report: when people get cancer, they are so financially challenged, because of their change in circumstances, that we felt that free prescriptions could be extended to that group, even if we could not extend them to all long-term conditions immediately.
Will the member take an intervention?
No. I am sorry, but I do not have time. I am answering the question that Ian McKee asked. The Government should have introduced that.
In Wales, prescription charges were abolished for the under-23s immediately. That was sensible, because the proportion of under-23s who were not eligible for exemption on income grounds was tiny. Again, that step could have been taken immediately.
Ross Finnie referred to the Liberal policy that free prescriptions should have been extended to people with long-term conditions. Alasdair Allan made a very cogent point in the previous debate on prescription charges, that there were 2,623 prepayment certificates in the Western Isles. We are talking about people with long-term conditions. A high proportion of the 8 per cent of people who pay for prescriptions have long-term conditions. The policy is unfair and bureaucratic and it does not produce the income that could be produced from that area if there really were a fair policy of charging only the rich, as Jackson Carlaw has suggested. It is appropriate to get rid of the policy on principled and practical grounds.
The question of prescribing costs is important. We need to have generic substitution automatically. We need to reduce waste. We need to stop prescribing non-evidenced treatments such as homeopathic medicines, on the health service. We need to stop prescribing medicines that are found not to be working for the patient. There are many things that we can do, but the one thing that we should do now is abolish prescription charges.
11:28
I guess that we just have to accept that there is a disagreement between us and the Tory-Liberal coalition on this issue. It is an honest disagreement. People out there will make their own judgment, but we have to agree to differ.
I will make an important point at the outset that I do not think is made often enough when any of us—myself included—talks about universal benefits, including in relation to prescriptions. We have a tendency to talk about them as things that are free, but they are not free. People pay for these things through their taxes. Abolishing prescription charges simply ensures that they are not asked to pay for them twice. That point could do with being made more often.
I will respond directly to a couple of points. Jackie Baillie asked about the funding. This policy has been fully funded in every year of this parliamentary session, including in the budget that was published yesterday, with a built-in assumption for increased demand. The whole point of the policy is that if we argue that prescription charges are a barrier to people getting their prescriptions, we would expect to see demand increase if charges are abolished or reduced; otherwise, the policy would not be doing its job. If the SNP is re-elected next year, as I hope and expect that we will be, the policy will be fully funded for the future, too.
Jackson Carlaw said that, instead of paying for medicines over the counter, people will go to their GP. I have to be honest with him: I do not find the notion of people with busy lives who can afford to pay for over-the-counter treatments suddenly choosing to make an appointment with their GP to get a prescription a very credible one. If that were a credible notion—this might answer the point that Jackson Carlaw is leaping to his feet to make—as prescription charges have reduced, we might have expected to see a significant impact in the way that he suggests, but we have not. Of course, as with all aspects of this policy, we will monitor the impact.
Will the cabinet secretary give way?
I might do later, but I want to make some progress. I want to stick with Jackson Carlaw, because his speech today reminded us of what we are missing in health debates. I am really sorry—I feel that I need to put this on record—that Jackson Carlaw did not receive the invitation to my wedding. I can only conclude that the invitation was lost in the same post as his wedding gift—we are quits.
However, Jackson Carlaw made an important point. He seemed to recognise that the prescription charges system that we have just now is not fair and that change is therefore needed. That leads us to ask what kind of change. The Tories and the Liberals—I think—have made two suggestions. The first is to extend the list of long-term conditions. I have been very open about the difficulty that we encounter with that. Richard Simpson is right to quote our manifesto because that was our starting position. However, when we looked at the reality of that, we realised that we would sort some anomalies but in the process create others. Why should one long-term condition be more deserving or more worthy than another?
The other suggestion from the Tories was to raise the financial threshold. Christine Grahame asked the key question: what would they raise it to at a time when family budgets are already under so much pressure? A threshold of £17,000, £18,000 or £21,000 appears to be the suggestion from Derek Brownlee, but the reality is that the higher we go and the more long-term conditions we add to the list, the less cost-effective the remaining system of gathering prescription charges becomes. That is the very point that the BMA made in the quotation that I read out earlier on.
Will the cabinet secretary give way?
I do not have much time just now.
I want to address one of the other central points that have been made. I know all too well how tight times are, but I guess that the fundamental difference between this Government and the Tory UK Government is that we do not believe that it is right to make the most vulnerable in society bear the brunt of those difficult times. That is why we have protected the health service. It is also why we are directing more of the budget to the front line—with the 25 per cent reduction in managers, the higher efficiency targets for some of our special boards and efficiencies in prescribing, which are extremely important.
Ross Finnie said that the policy does not exist in isolation and he is absolutely right, but he has to accept that that argument cuts both ways. Richard Simpson made this point very powerfully: if people with long-term conditions do not take the appropriate prescription medicine, the knock-on effect on their health and on the NHS can be significant.
Will the cabinet secretary give way?
I am coming to Jeremy Purvis’s point. The Liberal argument appeared latterly to be that, because we cannot remove all charges, we should not remove any. Jeremy Purvis will be interested to know that the tights and wigs and so on that he mentioned will also be free and their cost has been reduced in line with prescription charges. This policy is the right one.
11:34
The arguments for and against the abolition of prescription charges have been well rehearsed in this chamber in recent years, since the Scottish Socialist Party proposal was roundly defeated in 2006. Today, we have heard the same arguments again, save that the Labour Party’s stance is radically different from its position at that time. In 2006, the Lib-Lab Executive robustly opposed the abolition of charges, with Andy Kerr, as health minister, describing the proposal as unfair on the NHS and unfair on the patients and saying that it would in effect rob the poor and the unwell and give to the rich. I am not normally very critical but, as with its U-turn yesterday on the Patient Rights (Scotland) Bill, Labour’s attitude today smacks of opportunism and electioneering.
Where was Nanette Milne in January, when we debated prescription charges on a motion from Mary Scanlon? Our position then was clear and it remains consistent today.
That position is nonetheless a radical departure from where Labour was in 2006, when it was in government. That is a significant change.
The Liberal Democrats initially agreed with their Labour colleagues, went on to support abolition and then returned to opposing it last year. I am pleased that the Liberal Democrats appear finally to have made up their minds and to have made a reasoned decision on the issue. Ross Finnie’s speech was measured. He demonstrated clearly the harsh realities of the choices that the NHS faces in the present financial climate and the need to spend resource wisely throughout the service. We have no difficulty in supporting his amendment.
As we have said, removing prescription charges for everyone has superficial appeal. The existing exemption criteria have inequities and it would be nearly impossible to produce a fairer list of exempt categories, as the cabinet secretary said. That is why we supported the initial reduction of the charge in 2008 from £6.85 to £5, which brought the cost of a 12-month prepayment certificate down to £48. As that was less than £1 a week and more than halved the previous cost, it was affordable and a significant help to people who require multiple and long-term drug treatment. The increasing take-up of such certificates shows that that was the case.
The initial reduction cost the NHS about £17 million, which was justifiable at the time. We opposed further reductions because of the increasing loss of revenue, which amounts to about £32 million this year. We do not support the final move next year to a zero charge, because to remove a further £25 million a year from the NHS is inappropriate given that it is under severe financial pressure, although its budget is protected, and given that the report of the Government-commissioned IBR referred to
“a pressing need to reconsider the planned abolition of prescription charges”.
As we know, the vast majority of people who require help to pay for prescriptions receive it. As 92 per cent of prescriptions are exempt from the charge and a further 6 per cent are issued to people with prepayment certificates, that leaves a small percentage of prescriptions subject to the full charge. Removing that charge completely would subsidise the prescriptions of people who can well afford to pay for them with money that could be better spent in the NHS. However, to avoid doubt, as Derek Brownlee said, we do not intend to put the clock back and to charge the elderly, the young or those who are in full-time education.
The cabinet secretary mentioned Wales. The Welsh experience of free prescriptions is of increasing demand for prescriptions for drugs such as paracetamol, Gaviscon and Calpol, which are readily available over the counter at low cost. That not only takes money out of the NHS but increases the demand on GP time that could be better used. I know that some members of the National Assembly for Wales regret the policy, particularly at this time.
Some people do not hand in a prescription that they have been given because they find—as Jackson Carlaw did—that buying the drug over the counter is cheaper. That is not uncommon.
Our resolve to keep prescription charges has, if anything, been strengthened by the current tough financial future that we face as a result of Labour’s mismanagement of the UK economy. It is more important than ever to spend public money as efficiently and effectively as possible. If revenue is removed from the NHS to pay for free prescriptions, something else in the service must suffer.
Many health services could benefit from the income that is derived from prescription charges. As the Parliament knows, a priority for us is the restoration and development of a universal service of practice-based health visitors, which would be of incalculable benefit to many families and young people. When one hears of malnourished children presenting in hospital, surely it is more important to spend money on health visitors who can advise vulnerable families and pick up problems before they have a serious impact on a child’s welfare than it is to spend scarce resources on providing free prescriptions.
Government is all about priorities, particularly in difficult times. Opening up the NHS to another indefinite spending commitment now is not the action of a responsible Government, so we oppose the move.