CHAPTER FIVE: ANALYSIS OF FOCUS GROUP DISCUSSIONS AND IN-DEPTH INTERVIEWS
Ipsos MORI was commissioned to conduct focus groups and in-depth interviews with key patient groups whose views it was felt were essential to the consultation but who were unlikely to respond to the written consultation.
Eight focus groups were conducted in total among the following groups:
- people on a low income who are currently exempt from charges
- people on a low income who are not exempt from charges
- people with chronic conditions who are exempt from charges
- people with chronic conditions who are not exempt from charges
- students, including some people who were exempt from charges and some who were not trainees
- parents of dependants aged under 20 years
- relatives of people in palliative care.
Additionally, two in-depth interviews were conducted with people with a permanent disability.
The research considered general attitudes towards prescription charges, as well as views on the change options and associated issues outlined in the consultation document. The findings are set out below.
Overview
There was universal support for reform of current prescription charging and exemption arrangements. Virtually all participants felt that the existing flat rate charge is too high and a significant proportion, particularly older people with a chronic condition and those on a lower income, felt strongly that charges should be abolished entirely.
In terms of different options for change, there was a consensus that ability to pay should be the key consideration. Indeed, this was mentioned spontaneously during discussion of each of the change options set out in the consultation document.
Most participants also felt strongly that conditions-based exemptions should continue, and that the list of conditions should be extended. There was a sense in which it is immoral to expect those with chronic or terminal illnesses to pay for their medication. However, the practical difficulties involved in developing a comprehensive list of conditions were also acknowledged.
There was repeated suggestion that any new system of charges and exemptions must be as simple as possible from the point of view of patients. On this basis, the reduced flat fee option was generally preferred to the monetary cap and concessionary rate. While patients clearly understood the latter two options, they regarded them as unnecessarily complicated and potentially difficult to administer.
GPs were generally felt to have a pivotal role to play in 'policing' any new system of charges and exemptions - whether this be in terms of prescribing fewer non-essential drugs or deciding which patients should be exempt on the grounds of their condition.
General attitudes toward prescription charges
As an introduction to the topic, participants were asked if they knew how much a prescription currently costs. Consistent with findings from the omnibus survey, most said they were unsure or made incorrect guesses. These guesses were typically lower than the actual amount. However, and as might be expected, participants who currently pay for their prescriptions were generally more likely to be aware of the cost than those who are exempt.
The moderator confirmed that the actual cost of a prescription is £6.65, before asking participants for their views on this charge. Almost all felt that it was excessive, particularly for people requiring multiple prescriptions and those on a lower income. Participants with a chronic condition who are currently exempt from charges tended to discuss the issue with reference to their own personal circumstances, emphasising the large number of drugs they are required to take at any one time and the high cumulative charge they would incur were they not exempt.
I think it's a lot to be honest. If you've just got your student loan and then, a part-time job or whatever.
Student
If it's for a one off it's reasonable I suppose, but I need a lot of medication so it can get quite pricey. I think they should cut the price back for people like me who need a lot of medication, say more than three items in a month.
Person with a disability, exempt
Well I have nine items currently on my prescription so it'd be £60 for that per each time I have to renew my prescriptions and I'm exempt because I have a thyroid disorder, but I also have cancer, and I wouldn't be exempt on the grounds that I have cancer treatment. And one condition is treated and it gives you a side effect, so you need another medication and it's kind of got like a knock on effect. If I were to have to pay for something like that … it's not really about whether I should or shouldn't get my thyroid medication free, it's a much bigger issue than that for me, as it must be for other people.
Chronic condition, exempt
Several of those who were not exempt from charges, including some of the students, people on a lower income and people with a chronic condition, described occasions on which they or someone they know have not collected a prescription because they could not afford to do so.
Yeah, I've done that before as well. Only because it was like, I've got this amount of money in my pocket to last me a week, or do I get this tablet, and so I didn't get my tablet.
Low income, not exempt
I know my daughter was on medication and she didn't bother getting it because she couldn't afford it. She took only one of the ones she was prescribed, so she didn't take the antibiotic so got ill again.
Person with a disability, exempt
Asked what they felt a prescription should cost, a significant proportion of participants, most of whom were older people with a chronic condition or people on a lower income, suggested that charges should be abolished entirely. Citing the founding principle of the NHS they argued that healthcare should be provided free at the point of use and that people have a right or entitlement to free prescriptions by virtue of paying national insurance. Younger participants, in contrast, tended to feel that people should contribute at least something to the cost of their prescriptions in order to reduce the financial burden on the NHS. Among this group there was a consensus that a charge of £5 or less would be more appropriate than the current rate. There was also (spontaneous) support for charging per prescription rather than per item dispensed.
Well I've paid [national insurance] all my life and I'm still paying in, and the only thing I get for nothing now for the past four years has been my medication and I'm going to enjoy it as long as it lasts!
Chronic condition, exempt
I think it's got to have a charge …I'm 19 so like for the last 2 years I haven't had to pay for a prescription and most of my friends are 19 so I think as a general student when they think of like £6.65 for one prescription you think, you feel a wee bit tight towards it … but I think like, probably like the other side of £5.00 people [would be] more sort of happy towards it but I think it's quite good to always keep a charge.
Student
A more exceptional view was that, in the future, the cost of prescriptions should be met via an increase in taxation, rather than through a system of charges and exemptions. Underpinning this perspective was a view that any system of exemptions is likely to contain anomalies or result in some patient groups "losing out".
For simplicity I think it would be a much better system if there were no prescription charges and this had to be financed from somewhere and it should be financed by people like myself who was on a good salary and who can afford to pay it. So I think if the finance is the political issue here, put the tax up for the higher earners to compensate for this.
Palliative care
Why don't they at least raise taxes and it leaves the revenues, part of the whole revenue from the government to subsidise this.
Student
Participants were asked to consider the possible implications of reducing or abolishing prescription charges, and in particular whether they felt this would encourage people to visit their doctor for prescriptions for minor ailments which they might otherwise have purchased from a pharmacy. There was a widely held view that "certain types" of people, particularly those on a lower income and parents of young children, probably would make more use of their GP under such circumstances. However, this was not generally conceived of as a reason for maintaining charges at their existing level. Rather, there was some suggestion that GPs would have to take responsibility for ensuring that the system is not abused. The perceived role of the GP in regulating any new system of charges and exemptions was a recurring theme of the discussions and is returned to below.
They'd ask for aspirin instead of buying it in the chemist. They will. Even a simple thing like, my daughter had suffered in the past from convulsions, grown out of them now but I had a stock of Nurofen and Ibuprofen tablets. I could have gone to the doctor and got that for nothing, but I didn't. I just went into the shop and bought it. £3-4 a time, it does add up but some people, if they're going to get it free, then they're going to go in and see a GP.
Parent
I know in the past it was wasteful in the sense of I can remember people turning round and saying I'm not going to pay £1.50 for a bottle of Calpol for my kids, I'll just go down and get it on prescription. Why should I pay £1 for a packet of paracetamol when I can get it off the doctor?
Chronic condition, not exempt
But surely that's up to the GP to make a professional judgment about whether they need medication?
Chronic condition, exempt
Would it not be possible for GPs to have a list of over the counter medications … which they will not prescribe for one off visits, only prescribe if it was necessary for a long-term condition?
Palliative care
Other participants disagreed that reducing charges would encourage people to visit their GP more often. They referred to the "hassle" involved in getting an appointment at GP practices and suggested that, in most cases, the convenience of being able to "pop into" a pharmacy for medication would outweigh cost considerations.
[My local practice is] a big practice and it's like if you want to see a doctor it's like you can have an appointment in two weeks and you're like well I won't be here by then. And they will say well if it's really urgent tell me what's wrong and I'll tell the doctor. You're telling a secretary who then will tell a doctor and he will phone you back if he thinks it's serious enough. That's the bain of my life is these secretaries.
Low income, exempt
I wouldn't personally, because I'm sure I'd rather pay £4 and just go to the pharmacy … but it might be an issue for some people.
Chronic condition, exempt
Evaluations of change options
Participants were presented with a list of current exemption categories before being asked to comment both upon different bases for exemption (medical conditions, ability to pay and so on) and on some of the specific change options under consideration.
Exemptions related to medical condition
The basic principle of conditions-based exemptions was widely supported. Indeed, there was a sense in which it is morally unjust to expect people with a serious or terminal illness to pay a price for their medication.
There's people who have long-term things wrong with them that need something, you know constantly and they've still got to pay for it. They don't get it for free. I'm not saying its life threatening but it's something that they really need and they've got to pay for it. They've got to go every week or fortnight … and that's not right.
Low income, exempt
I think it is immoral that terminally ill patients, no matter what's the matter with them, have to pay any prescription charges whatsoever. I really do think that's immoral.
Palliative care
There was widespread surprise at the limited number of conditions which currently confer exemption from charges, and the fact that the list has not been updated since 1968 - participants were generally cognisant of the fact that "new" illnesses and conditions have emerged or risen to prominence in recent decades which are equally if not more serious than those currently on the list.
Cancer, in particular, but also HIV/ AIDS, cystic fibrosis, various skin conditions, asthma, mental ill health and Crohn's disease were consistently identified as conditions that should be added to the list. Participants who themselves suffered from one or more of these conditions again described difficulties they have experienced affording their medications.
I need about six a month, so it's very expensive. And even with a prepayment certificate, the cheapest way you can do it is to have to pay £30 odd for four months, but it's really a tax on having a chronic condition.
Chronic condition, not exempt
When it runs out and you need to get whatever drugs you need, if it's not at the end of the month when you've been paid, trying to scrape together that kind of money to pay out, it's almost difficult at times. There's times I know I've actually thought maybe I'll wait a week and go sparingly along with inhalers and stuff and then just pay it when I've got the money.
Chronic condition, not exempt
Notwithstanding the general support for conditions-based exemption, there was spontaneous and widespread recognition of the potential difficulties involved in drawing up a comprehensive list of exempt conditions. Thus, while there was a consensus that all 'serious'/chronic and terminal conditions should be covered in the list, there was also considerable debate as to what constitutes a serious or chronic condition. This led several respondents to suggest that the most appropriate solution may be to abolish the list and empower GPs to grant medical exemption on a case by case basis.
It all depends on how you define chronic. Is it someone who needs lots of prescriptions, someone who can't work, someone who can work but … you know, it's a difficult one to answer.
Chronic condition, exempt
You couldn't really draw a line, could you? There's that many [health] problems in the world these days.
Trainee
I think the doctor should make more decisions about who gets it and who doesn't.
Low income, exempt
As in the written consultation, participants were divided on the question of whether or not medical exemption should extend to all of a patient's prescriptions or only those used in the treatment of the condition in question. On the one hand there were those who felt that the current arrangements are unfair - indeed, a few participants who were themselves exempt from charges reported feeling guilty about receiving non-essential items free. On the other hand, the difficulties of distinguishing between linked and unlinked conditions was commonly mentioned, as was the fact that drugs for chronic conditions often cause side effects which also require to be treated.
If it was the side effect of a drug you were already taking for a recognised condition that's on the list, that's a different matter but for something completely unrelated, then you should have to pay.
Parents
I would expect to get say my inhalers [free], and eczema and asthma generally go together so get your cream for the eczema but then I'd probably expect to pay for, say, antibiotics. But then … sometimes the bronchial infection can be caused because I'm asthmatic, so it's a hard one to call, but I would probably expect to pay for stuff that isn't related to the skin or the asthma. But it's hard to tell what triggers what, so I know what you're meaning. It's a bit of a minefield.
Chronic condition, not exempt
For example, one of the drugs I'm taking, it's knocked my blood pressure all to hell. They're talking about putting me on statins as well because its giving me high cholesterol. This stuff I take for my arthritis has knocked my stomach to hell so I've to take stuff for my stomach. I can't win.
Chronic condition, not exempt
Very few participants saw merit in the idea of basing medical exemptions on a list of drugs as opposed to a list of conditions. The reasons they gave for this mirrored those mentioned in the written consultation: that it would be difficult to ensure such a list is both comprehensive and manageable; and that newly developed drugs may not be added to the list quickly enough with the effect that patients may be required to pay for them in the interim.
Would they have enough paper for that list because you get all different types of insulin and different types of, you know, so there would this great big huge list of everything. And what works for one will not work for another.
Low income, exempt
The whole point is you have a condition … if you have cancer, your drugs have to be free because you could need painkillers, you could need anti-depressants to help you get through it, you could need surgical dressings, you could need anything, over six months, nine months, five years, ten years. It has to be the condition is exempt.
Chronic condition, not exempt
But then what would happen if there was a new drug out, like my aunt who's got the MS, could be very keen to try some new drug that came out, because she's tried so many other ones and they just haven't made any difference to her condition. So how long would it take for these drugs to get added to the list? I mean, would then she have to pay until it was added to the list, and what impact would that have?
Parent
Economic need - affordability
Exemption on the grounds of low income
There was strong support for the continuation of income-based exemptions, with participants repeatedly raising the issue of ability to pay and/or means testing when discussing each of the change options. It was also generally agreed that exemption should be extended to more low income groups than is currently the case to ensure that the most vulnerable groups in society are not deterred from obtaining essential medication.
Participants were shown a list of the proxy measures of income used to determine eligibility for exemption, before being asked whether they felt this was appropriate for purpose. It was commonly suggested that the list should be extended to include Incapacity Benefit and Statutory Sick Pay. Participants with chronic conditions who were not exempt from charges described difficulties they have experienced in managing on statutory sick pay in the absence of other forms of income support.
If an individual has to go onto Statutory Sick Pay but has no access to Income Support, Working Family Tax Credit or whatever, because the Working Family and the Child Tax Credit really only apply to families, whereas an individual in their own right can actually get income related benefit. But it's down to the likes of who can actually afford to drop that amount of money? Ok, it could only be four weeks, it might only be six weeks that they're off, but then again it could be six weeks, back at work six weeks, off six weeks, and you're still having to pay your electricity, you're still having to pay a mortgage, you're still having to pay gas, you're still having to buy food, you're still having to put clothes on your own back, do everything else.
Chronic condition, not exempt
Asked if they could think of any better ways to determine eligibility for income-based exemptions, participants repeatedly suggested that the key criteria should be a person's income per se rather than the benefits to which they are entitled. More specifically, it was felt that those earning below a certain amount should be exempt whereas those earning above that amount should not - one participant suggested a threshold of £10,000 per annum and another suggested £15,000 per annum. This was generally considered to be a fairer, more transparent and easier to understand system. It was, however, generally acknowledged, that whatever the threshold, there will be people who 'just miss out' and have to pay the full prescription charge.
Go back to your simple income. It's just one form for one thing, dead simple, it would give Gordon Brown thousands and thousands of millions of pounds and there would be no civil servants… you could do it six-monthly or something, a simple form. It says has your conditions changed, then you would say no and send it back.
Student
You know, you could have somebody saying ok, I'm on a low income. What do we class as a low income? So if somebody's got an income coming into their household of £150 a week say, and that's classed as a low income, but then they're bringing in £155 so they come out of that category. They may have a situation like you, where they're going to have to pay £60 a month, you know, you can't pay £60 a month off that amount of money.
Chronic condition, exempt
Another, less common suggestion was that instead of having one cut-off point where a person is either exempt or pays the full fee, there should be a sliding scale with the amount a patient pays toward their prescription varying in accordance with their income. Under this system, some low income patients would continue to be exempt, whereas others would have to contribute a small amount to the cost of their prescription.
… but if it was graduated, I don't know if that's - that would be an administrative nightmare probably but if it was, so you'd maybe pay a proportion up to a certain amount if you earned a certain amount of salary then you'd pay half of the prescription charge, or something like that. So that it wasn't quite the full impact but you were then making a contribution.
Parent
Across the groups there was spontaneous suggestion that assessments of eligibility for income-based exemption should focus on individual rather than household income as not all co-habitees share living expenses.
If you've got a partner, you know what your partner's getting paid. If you have a family, you know what you're entitled to have as a minimum coming into the house, but you take your own earnings and you drop that down to £54 a week. If your partner's earnings are above that basic limit, you're entitled to nothing. But you still have all these charges to pay on top - that's unfair.
Chronic condition, not exempt
I think household income is okay but it would put me in a situation. I mean I personally don't have as much money as the other person in the household and I wouldn't want to be more dependent on him than I would like to be, know what I mean?
Student
On the whole, it was felt that income-based exemptions should operate in tandem with conditions-based exemptions: that is, people with a chronic condition would still be exempt from charges whatever their income. However, a minority of participants expressed a view that people with a chronic condition who are very well off should pay for their prescriptions.
So, if you're earning, as a handful of people are, £200,000-£300,000 a year or more than that, it seems a little bit silly that because you've got diabetes or something else you should be exempt. So maybe there should be an upper limit. Quite high perhaps, say anyone over or in a certain tax bracket or earning over £150,000. You know something quite high, this will actually make a contribution, it doesn't matter what you've got.
Student
Prescription pre-payment certificate ( PPC)
Consistent with comments made in the written consultation not all participants in the focus group sessions were aware of the PPC. However, this tended to be people who were exempt from charges and thus had no requirement for the PPC. Almost all of those participants with chronic conditions who were not exempt, those who had a relative in palliative care and some of those who were on a low income and not exempt were currently using or had experience of using a PPC.
While these participants welcomed the savings they had made with the PPC, the system was widely felt to have its drawbacks. In particular, users commented that they quite often struggled to pay for the 4-month, and more especially the 12-month certificate upfront. As in the written consultation, it was suggested that people should be allowed to spread the cost of the PPC over the year with monthly payments being the preferred option.
My friend was telling me about that today but she said she can't afford to do that because it's like £100 in one go.
Student
Make it on a monthly basis. I mean, I think that's the way most of us manage our finances nowadays anyway, is you kind of try and stagger things on a monthly basis.
Chronic condition, exempt
Another perceived drawback of the PPC system was the fact that patients cannot claim retrospectively. Speaking from experience, some participants in the palliative care group and those with a chronic condition who were not exempt felt that it is often impossible to tell at the beginning of an illness how much medication will be required and whether or not a PPC would be cost-effective. In such cases it was felt that a PPC should be issued retrospectively to patients whose prescription charges over a set period amount to the value of a PPC or to offset the cost of a PPC by the amount paid over a preceding set period.
… you don't know what's going to happen. It may be that you get a couple of prescriptions and then you'll be on something that sort of stabilises you and that will be forever.
Palliative care
Participants with a chronic condition who were not exempt suggested that a retrospective PPC would be particularly beneficial for patients who, at the outset of their illness are too unwell to fill in the necessary forms for a PPC or to find enough money to meet the upfront cost.
When you're too ill, the thought of filling in a three page form is enough to send you into tears. You just can't cope with the thought of it.
Chronic condition, not exempt
The need for greater awareness about the PPC was also commonly mentioned. It was clear that there is a lack of consistency in the way people are informed about the PPC, with some participants having heard about it from their GP, pharmacist or nurse, and others from a friend or family member - often several months, or in one case, several years, after they could have benefited from it. Some participants suggested that the PPC should be advertised in GPs' surgeries and community pharmacies. Others went further, suggesting it should be compulsory for GPs and pharmacists to inform their patients of how they can save money - a specific suggestion in this regard was to have prompts on patients' records reminding the GP or pharmacist to mention the PPC.
Yeah, I think if they advertised it, it would be a good idea - in chemists and doctors' surgeries.
Chronic, not exempt group
Even the likes of if you get more than two items a month, have you considered buying the prepayment certificate? They could even have a database saying that this person's in quite a few times, even turning round to say "you're coming in quite regularly, do you not think a prepayment certificate might be a good idea?".
Chronic condition, not exempt
Attitudes towards the reduced flat fee, monetary cap and concessionary rate options
In addition to being asked about the PPC, participants were invited to comment on the 3 other options concerned with making prescriptions more affordable: the reduced flat fee, the monthly cap and the concessionary rate.
On the whole, participants across the groups had a number of concerns about all 3 options, however the balance of opinion was more in favour of a reduced flat fee than a monetary cap or concessionary rate.
The reduced flat fee was regarded as the fairest and simplest of the 3 options. It was suggested that in having one rule for everyone, patients would "know where they stood" and there would be less inequity in the system. The option was also viewed as administratively straightforward and thus cost effective.
Asked to consider the level at which a reduced flat fee might be set, those who were amenable to the option felt £2 or £3 per item seemed a "reasonable" amount to pay.
There was a certain level of cynicism among participants as to whether the reduced flat fee would be maintained at an affordable level in the long term. It was commonly felt that while the fee may be set low initially, it would inevitably "creep up" over a relatively short period of time as, it was suggested, has been the case with the current fee.
Well it would start off at £4 and then it would be up to £6 odds before you go very far so I would just push that one out right away.
Palliative care
But the Government would end up putting that back up because they'd be losing money from the NHS.
Trainee
As in the written consultation, there was also a widespread perception that a reduced flat fee would not be particularly beneficial to people who require a lot of medication and thus incur high cumulative charges over time.
It's not fair because some conditions need a lot more drugs than others.
Chronic condition, not exempt
It's still penalising the sick.
Chronic condition, not exempt
Monetary cap and concessionary rate
Arguments presented against the monetary cap and concessionary rate were the reverse of those presented in favour of the reduced flat fee. Thus it was felt that both options were overly complicated and would require patients to complete too much paperwork which in turn could act as a barrier to obtaining medication. There was also a perception that the options would be 'more bother than they were worth, too costly, and that they would just add another unnecessary layer of bureaucracy' to the system.
How much would it cost to link [ GPs and pharmacists and those responsible for administrating the cap and concessionary rate] up. You know if you're talking about the costs of these things, you're saying right we could link these people up and all the rest of it. Have they actually done their homework and are able to produce a costing.
Palliative care
That would be another 1,000 civil servants there!
Low income, exempt
It seems like an awful lot of bureaucracy for not really much benefit.
Parent
It was also commonly felt that, like the reduced flat fee, the monetary cap and concessionary rate could still result in high users of medication incurring significant charges for their medicines.
I still think there'll be a lot of people who would end up not getting their medication if they did that though.
Parent
A concern expressed about all three of the options was that people who are currently exempt from charges on the basis of their condition would suddenly have to start paying. This, it was felt, would be an unacceptable situation.
They need to really look at overall what they want to talk about, disease-wise and illness, because it's the only way they'll get it to work because they can't turn round to people who are long-term and say right from now on you're going to have to pay.
Low income, exempt
Although the balance of opinion was against the flat fee, monetary cap and concessionary rate, a few participants acknowledged that some people would benefit from them if they didn't quite qualify for a PPC. It would enable those who had a short-term illness which required four or five medicines within 4 months to get their medication at a reduced rate. The cap in particular was thought to provide the best 'deal' in this regard.
Exemption for students and trainees
On the whole, participants felt that students in full-time education and training should not have to pay for prescriptions as this group tends to have either a low, or no income. There was a sense from participants that many students already have difficulty affording their day-to-day living expenses and thus would have difficulty meeting the cost of their prescriptions. This was confirmed by student and trainee participants themselves.
I was a student a few years back and I got a student loan of about £4,000. I had to pay for my prescriptions, plus my dental, opticians and everything and it came to the stage where I was like, right, I'm not going to the dentist, I'm not going to the doctors, I'm going nowhere. I just couldn't afford any of them.
Low income, not exempt
The people that are in full-time education, they can make more money working apart-time job than an apprentice can make in a week. You know what I mean, people working in Tescos and what have you, they all actually have better hourly pay than what an apprentice has, so what's the difference in that, you know what I mean? Because if an apprentice is still in education really, they're still attending college, they're still in full-time education, it just happens that they've got a job, but then so's someone in full-time education, they work a part-time job which you'll find's usually more money than an apprentice, so I don't see why apprentices should have to pay.
Trainee
However, several participants, including some of the students and trainees themselves, felt that charging and exemption arrangements for this group should reflect ability to pay. Underpinning this, was a perception that some students and trainees have wealthy parents while others have part time jobs, either of which mean they have a reasonable income.
However, the students felt strongly that any means testing should focus on their personal income rather than that of their families because not all students receive financial assistance from their families during their studies.
Well, my parents earn so much but I don't get any money from them. I don't ask my parents to give me money so why should I have to put how much they earn on the form relating to me because I don't get anything.
Student
A number of participants questioned whether mature and part-time students would also be exempt from prescription charges. With regard to mature students, there was some concern that there may be an age cut-off point, whereby only 'younger' full-time students would be exempt. In many cases it was felt that mature students can have as much, if not more, difficulty than younger students, financing their way through college or university, as they often have additional burdens of paying rent/mortgage and looking after children.
I was just going to say that I was a mature student and I gave up a job to go to university, that was my choice, but I've gone from having a reasonable income to just the student loans so my situation financially is really no different to a 19 year old.
Student
Well, I'm all for it because I've got a daughter who is a student. She's coming 40 now and her marriage has broken down so she's decided to go back to university and this is when she found all students are getting it for free, but she says I don't… She's got two sons that she's trying to look after, so she's a part-time job plus is a student.
Chronic condition, exempt
With regard to part-time students, participants were a little more ambivalent. Some felt that part-time students should have the same status as full-time students and trainees in any new system of charges and exemptions. They commented on the difficulty of studying part-time whilst holding down a job. It was generally recognised that exemption for students and trainees, no matter if they are part-time or full-time, would help to reduce some of the financial barriers to entering into education.
However, other participants felt that exemption for part-time students should be means tested. There was a perception that they, more so than full-time students, have the opportunity to earn a salary and therefore should be more able to contribute something towards the cost of a prescription.
But a lot of part-time students do work full-time, they maybe just study at night so they are getting a full-time wage.
Low income, exempt
When I was a part time student, but working full time, and I was doing my course distance learning and at weekends, so that qualified me as a part time student, and I had my matric card from the university and everything, but when I was earning a full time salary there was no way I would not pay so that's not very fair I don't think to say that somebody that qualifies as a student like that should get free prescription charges just because they're studying for something.
Parent
Age exemptions
As in the written consultation, participants were also invited to comment on current exemptions for people under the age of 16 and over the age of 60.
On the whole it was felt that age exemptions should continue. With regard to the upper threshold, there was recognition that older people are among those most likely to need assistance with charges, both because they tend to be on a lower income (from pensions) and because they are more prone to illness than younger groups. Again, there was also reference to the fact that older people have paid income tax and national insurance all of their lives and so deserve something back. Still, there was spontaneous support for increasing the upper threshold in line with the state pension age.
Notwithstanding such views, a minority felt that exemption for older people, as for other segments of the population, should be means-tested. Underpinning this argument was a perception that many older people are comparatively well off and can thus afford to contribute at least something to the cost of their medications.
Turning to the lower age threshold of 15 and under, participants were generally content with this. They pointed out that, whereas people 15 and under are typically dependants, those aged 16 and over are legally able to work and consequently to contribute to their own health costs. Few were in favour of extending the lower limit to 25 as in Wales. Once again however, there was suggestion of means testing for young people aged 16 years and over who are not covered by exemption arrangements for those in tertiary education.
Summing up
To conclude the focus groups discussions and in-depth interviews, participants were asked to indicate which of the change options discussed they felt were most worthy of consideration. The most popular option was extending the list of exempt medical conditions. This was followed by extending exemption to all full-time students and trainees and to more people on a lower income. The flat fee option received a moderate level of support while the drugs list, monetary cap and concessionary rate options proved comparatively unpopular mainly on the grounds that they would be complicated to administer. Reform of the PPC also received little mention but in part this reflected low awareness and/or experience of the system.
At this stage of the discussions participants expressed some general concerns about the likely impact of reform to the current system. In particular, they suggested that whatever changes are made, it will be impossible to please all patient groups, with some people inevitably ending up worse off. They also reiterated concerns about the complexity of some of the options, suggesting that this could potentially serve as a barrier to uptake of exemption in the future. A few participants argued that if exemption is extended to a greater number of patients, the amount of revenue that is raised through charges will be relatively small and may not be worth the "administrative bother".