Earlier this year the NHS Business Services Authority (NHSBSA) co-produced with the NHS England Healthcare Inequalities Improvement Team a report ‘Access to NHS prescribing and exemption schemes in England’. (1) The report examines healthcare inequalities in relation to prescribing and uptake of prescription and exemption schemes in England by reference to the Core20PLUS campaign.

The Core20PLUS is a national NHS England approach to inform action to reduce healthcare inequalities across systems. The approach focuses on the Core20, defined as the most deprived 20% of the national population, and PLUS population groups which are inclusion groups locally identified.

The report concluded that the Core20 population received more prescription items and prescribing peaks at an earlier age than the non-Core20 population. This is consistent with the 2016 Health Survey which reported 54% of adults in the most deprived of areas took at least one medicine, compared with 45% in the least deprived areas. Given socio-economic status is inversely proportional to chronic disease prevalence, multi-morbidity is more common and occurs earlier in deprived populations and prescribing is the most common clinical intervention in the NHS this finding may be unsurprising. (2, 3) This blog explores why some of the report findings are a reminder that there is still work to do to understand and tackle unwarranted variation in NHS prescribing and medicines access and why given their skills and placement, pharmacy leaders and pharmacy professionals are well placed to support.

Why pharmacy?

Pharmacy professionals are experts in medicines. They play a key role supporting patients and the public with access to NHS prescribing. One of the major benefits of pharmacy professionals and pharmacy services is that they are well distributed to holistically strengthen care provision through supporting wider determinants of health. They are situated widely across sectors providing multiple patient-interaction touch points on a care pathway to Make Every Contact Count. In England, 89% of the population has access to a community pharmacy within a 20-minute walk and we know there is a positive correlation between community pharmacy accessibility and deprivation decile; community pharmacy bucks the inverse care law in England. (4) Prescribing pharmacists should have access to relevant medical records and social backgrounds to assess high intensity users, co-morbidities, frailty, and social circumstance. This intelligence provides a foundation to support shared-decision making when they prescribe and to potentially signal patients who may struggle to access drug therapies.

Access to drug therapies

The NHSBSA reported that in 2021/22 3% of prescription items amongst the Core20 population were paid for, compared to 5% in the non-Core20 population. The Core20 population are less likely than the non-Core20 population to pay for their prescriptions and more likely to claim non age-related exemptions. (1)

Pharmacy staff have a pivotal role in checking declarations for free or reduced cost NHS prescriptions. (5) With a deep understanding on treatment indications, pharmacy professionals will have an ability to support and sign-post patients to access medical and maternity exemptions. However, beyond signposting, it is not as straightforward for pharmacy professionals to support and advise on the more social-context dependant exemptions e.g. the NHS Low Income Scheme and Tax Credit Exemption Certificate. Connecting patients, when needed, with government programs that offer resources and support to patients is not an explicit Pharmacy Professional Standard or in the Guidance for Pharmacist Prescribers. Such support may well be seen as outside of their professional remit. However, providing person-cantered care is a core duty. On this basis, are prescribers individually and collectively ethically responsible for ensuring patients have access to medicines regardless of their economic means?

If this support is not offered at the point of prescribing, there is a risk that vulnerable patients unable to afford prescriptions and unaware of the financial reliefs available may be discouraged to treatment access.

Conversely the National Overprescribing Review and Prescribed Medicines Review showed that overprescribing may be linked with deprivation, and drugs of dependence (i.e. benzodiazepines, Z-drugs, opioids for non-cancer pain, antidepressants and gabapentinoids) are associated with deprivation. As well as supporting access to therapy initiation or continuation, pharmacists also have a role in rationalising therapies for possible discontinuation if we are to successfully overturn the potential 10% of dispensed primary care items in England that are overprescribed. (6)

There is a clear link between health literacy, shared decision making and better outcomes in healthcare inequalities. (7,8) Pharmacy-led interventions include deprescribing plans, shared decision making and providing alternative interventions to medicines that are personalised and holistic to individual social context. Pharmacy can improve inequalities in medicines access by targeting these interventions to deprived localities and to individuals affected by undetermined polypharmacy or prescribed drugs of dependence, and by supporting patient navigation with financial-access to medicines.

Conversations with patients and carers on therapeutic needs and financial means of accessing medicines can be complex. They need to be handled with cultural competence and sensitivity while also maintaining legal and professional duties, particularly as patients could view such conversations as compromising the clinician–patient relationship. (9) The NHS England open-access e-learning for healthcare is an accessible first step to upskilling on cultural competence. Useful tools to support these conversations include the NHS ‘Check Before You Tick’ free prescription eligibility checker and Real Time Exemption Checking software. The NHSBSA also supply printable leaflets and digital resources that promote eligibility checking, albeit these are currently only available in English.

Data quality

The NHSBSA report that 26% of prescribing in the non-Core20 population are charge exempt (excluding age-exemption) compared to 38% in the Core20 population. (1) A limitation to the data is that it has not been adjusted for multiple exemptions-eligibility. Where people are eligible for multiple exemptions, the exemption category selected will be down to patient choice from those that apply. It is not possible to draw conclusions on the uptake of an exemption by a particular cohort. For example, in the most deprived areas the uptake of maternity exemption certificates is markedly lower than in less deprived areas. It is possible a proportion of eligible individuals sought free prescriptions via an income-related support offer or by presenting an NHS tax credit exemption certificate instead of selecting the maternity exemption. Without confounder-adjustment, we cannot conclude that exemption uptake is lower amongst pregnant or post-natal women in the Core20 compared to nonCore20. Ideally, central data could be adjusted to strengthen validity of the association between deprivation and uptake of maternity exemption certificates, but exemption support occurs through multiple agencies (e.g. Universal Credit is a social security support offer from government not the NHSBSA) which presents a challenge to data linking and information governance. Further work could also include qualitative insights into why various patient cohorts apply for exemption certificates or not to provide key intelligence for service design and delivery.

Leadership

The Hewitt review and Fuller Stocktake emphasize tackling healthcare inequalities in access, outcomes, and experience is one of the priority areas for systems, including system leaders and multidisciplinary teams. Additionally the 2023/24 Priorities and Operational Planning Guidance indicates that health and care leaders across sectors should use a Core20PLUS approach to narrow healthcare inequalities. Realising the role pharmacy professionals can have to bridge the inequality gap in prescribing and exemptions requires aligned leadership and collaboration. The Inclusive Pharmacy Practice principles provide a clear professional touchstone for pharmacy leadership, to pursue initiatives that address healthcare inequalities by improving therapy-access, reducing unwarranted prescribing variation and tackling exemption inequity. For example, at a system and local level, pharmacy professionals are leaders with the knowledge, skill and platform to highlight their value in discussions around resource allocation to support local Core20PLUS population groups to access medicines. National, regional and system pharmacy leadership can also support prescription exemption access by promoting the recently launched Department of Health and Social Care Prescription Savings Campaign; a campaign that aims to raise awareness of the Prescription Prepayment Certificate and the Low Income Scheme particularly amongst people living with long-term conditions and those living in deprived areas.

Medicines optimisation

Medicines optimisation is clear national opportunity to ensure safe and effective use of medicines. (3) Local medicines optimisation teams will have access to prescribing data and systems for identifying, reporting, and learning from medicines‑related incidents. Medicine optimisation teams can use these systems alongside a proactive population health management approach to help improve and develop health inequality data metrics. The report’s interactive graphs may offer a starting point and impetus for medicine optimisation teams to delve deeper and interrogate wider data sets and intelligence functions. For example, the report showed the number of prescribed medications associated with the management of chronic obstructive pulmonary disease (COPD) prescribed to adults is higher for the Core20 population than the non-Core20 population and the geographic breakdowns indicate that prescribing rates per thousand of the adult population are generally lower in London than in other regions. To gain actionable insights into COPD service gaps from this data, these findings need to be further interrogated with wider intelligence. This may include primary prevention data (e.g. local smoking cessation service commissioning and air quality), data on early accurate diagnosis (e.g. COPD incidence rate), data on treatment and management (e.g. access to pulmonary rehabilitation and medication reviews) and data on complex or severe COPD (e.g. oxygen prescribing and urgent care, secondary care access).

Conclusion

Overall, the report is a useful start for raising questions and spurring the investigation of healthcare inequalities in relation to NHS prescribing and exemption schemes in England, with a unique lens of cutting prescription data by deprivation. However, due to the limits of data collected on routine prescriptions, the sole use of deprivation presents an incomplete picture because it misses other factors (e.g. ethnicity, cultural nuances, employment status, literacy) that can drive the differences in dispensing and use of exemption certificates between Core20 and nonCore20 populations. The report is a useful initial population health management tool for pharmacy leaders and medicines optimisation teams to provide system-intelligence on medicines usages by deprivation but should be used in conjunction with other local data sets (e.g. clinical and service usage data sets). The report is also a prompt that pharmacy professionals and pharmacy leaders are well placed to support access to medicines alongside and as part of shared decision making and medicines use. For pharmacy and clinical leaders particularly, this may be an opportune time to consider the extent of ethical responsibility prescribers have with ensuring patients can access medicines regardless of their economic means.

References

1. NHSA Business Services Authority. Healthcare Inequalities: Access to NHS prescribing and exemption schemes in England. [Online] 2023. [Cited: July 24, 2023.] https://nhsbsa-data-analytics.shinyapps.io/healthcare-inequalities-nhs-prescribing-and-exemption-schemes/
2. The King’s Fund. Long-term conditions and multi-morbidity. [Online] [Cited: July 24, 2023.] https://www.kingsfund.org.uk/projects/time-think-differently/trends-disease-and-disability-long-term-conditions-multi-morbidity.
3. National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. [Online] March 4, 2015. [Cited: July 24, 2023.] https://www.nice.org.uk/guidance/ng5.
4. The positive pharmacy care law: an area-level analysis of the relationship between community pharmacy distribution, urbanity and social deprivation in England. Todd, Adam, et al. 8, 2014, BMJ Open, Vol. 4.
5. Community Pharmacy England. Exemptions from the prescription charge. [Online] 2023. [Cited: July 24, 2023.] https://cpe.org.uk/dispensing-and-supply/prescription-processing/receiving-a-prescription/patient-charges/exemptions/
6. Department of Health & Social Care. National overprescribing review report: Good for you, good for us, good for everybody. [Online] September 22, 2021. [Cited: July 24, 2023.] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf.
7. Do Interventions Designed to Support Shared Decision-Making Reduce Health Inequalities? A Systematic Review and Meta-Analysis. Durand, Marie-Anne, et al. 4, 2014, PLoS ONE , Vol. 9.
8. Health Literacy and Shared Decision-making: Exploring the Relationship to Enable Meaningful Patient Engagement in Healthcare. Muscat, Danielle M, et al. 2, 2021, Journal of General Internal Medicine, Vol. 36, pp. 521-524.
9. Access to medicines: cost as an influence on the views and behaviour of patients. Schafheutle, Ellen I, Hassell, Karen and Noyce, Peter R. 3, 2002, Health and Social Care in the Community, Vol. 10, pp. 187-195.

Author

Anisha Soni

Anisha is the National Clinical Champion for the NHS England Innovation for Health Inequalities Programme, which aims to drive innovation uptake with a healthcare inequalities improvement approach. Anisha also works in the NHS England System Transformation Population Health Management team. She was the Chief Pharmaceutical Officer’s Clinical Fellow at NHS England, leading work in medicine policy and cardiovascular disease prevention, the Inclusive Pharmacy Practice, diversity in pharmacy leadership, and COVID-19 response for medicines services. Anisha is a specialised pharmacist and prescriber in cardiac critical care, with specialist and academic interests in clinical leadership, governance, drug formulary, deprescribing, prevention and public health. Anisha has a Master’s in Public Health from London School of Hygiene and Tropical Medicine and is a trustee for the Healthy Heart Charity.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None