The Mail is up in arms. “The NHS spends millions handing out toothpaste, Calpol and Berocca vitamin pills,” begins an article in the paper on Monday. “Patients are also routinely prescribed Strepsils, Bonjela, Rennie indigestion pills and even Alka-Seltzer.” Apparently this costs the NHS tens of millions a year, “while vital surgery and cancer drugs are rationed”. What a bunch of scroungers we all are.
But is it true? Are profligate GPs prescribing useless drugs for wanton people and draining the NHS of vital funds? The truth is a bit more complicated.
The data comes from the Health & Social Care Information Centre’s prescription cost analysis, which details the number of items and the net cost of all prescriptions dispensed in the community in England.
In 2015, the cost of these prescriptions was £9.72bn – an increase of 4.68% from £8.85bn in 2014. Some of these items can indeed be bought over the counter, such as paracetamol for pain and fever, antihistamines for hayfever or antacids for heartburn. More worryingly, some prescribed drugs have little or no evidence to support their use – like cough medicines and throat lozenges.
But often there are good reasons to prescribe a product, even if the patient could simply buy it. For instance, the Mail highlights the £17.5m spent on prescriptions of toothpaste as a particularly egregious example of wastefulness. But there’s more to that stat than meets the eye.
Prescription toothpastes may be prescribed for a condition called osteonecrosis of the jaw that can develop as a complication of drug treatment for osteoporosis. This rare but nasty condition causes pain and makes your teeth fall out. Maintaining good dental hygiene is key to preventing and managing it.
Strong sun-blocking creams may be prescribed for people who have skin conditions that mean they are at high risk of developing skin cancer. True, they are available over the counter, but the cost of daily use may be prohibitive – and preventing skin cancer is not only good for the patient but cost-effective for the rest of us.
One factor is prescription charges – or rather the lack thereof. The standard charge is now £8.40 per item in England. However, lots of people get free prescriptions, and more than 80% of all dispensed items are to people who are exempt from them. Everyone who is under 16, 60 or over, is pregnant or has had a baby in the past year does not have to pay. It’s not means-tested; you could have substantial assets in Panama and still get free prescriptions. And there is considerable variation throughout the UK; only England charges for prescriptions. Though it’s worth noting that if you take your English prescription up to Scotland to get it dispensed, they’ll still charge you.
The system is also riddled with exceptions and complexities. In a historic anomaly, if you have an underactive thyroid that means you need to take daily replacement therapy, you get all your prescriptions for free. But if you have an overactive thyroid that requires drug treatment, you pay. Such issues have obviously helped persuade the Welsh, Scots and Northern Irish that it’s simply not worth bothering with charging.
But if most people aren’t being charged for prescription drugs, it’s even more important that GPs prescribe responsibly. The scope for GPs to prescribe drugs like cough syrups is diminishing by the day as local clinical commissioning groups enforce strict prescribing guidelines. GPs have to account for their prescribing costs and justify wayward choices. This is generally a good thing.
In the old days of paternalistic medicine, GPs would hand out prescriptions for vitamins as placebos. That doesn’t happen as much now and is considered ethically controversial. But it can certainly be tempting when a patient clearly expects a prescription and doesn’t accept that there isn’t necessarily a “pill for every ill”.
And there are some grey areas in prescribing drugs that can be bought over the counter. I saw a family with several children today, all covered in chickenpox. The family hasn’t got much money; every penny counts. They needed paracetamol for fever and Piriton for the itch. They’re both available over the counter and many families buy them as a matter of course. But I prescribed them so they get them for free. Is that really so bad?
