Labelling Prescription Medication in the UK: Some Personal Preliminary Views
The UK government is proposing to add a label to prescription medications valued twenty pounds or more stating how much they cost along with the words "funded by the UK taxpayer" (see BBC and Guardian articles for details). The stated rationale (extract from the Minister's speech below) behind this is to make salient to patients, in the context of a mostly free-at-point-of-use healthcare system, that the medications they are using are valuable and are funded from tax money. This may then discourage misuse or waste of the medication. It may also presumably bring cost considerations into the discussion between the patient and doctor. I haven't seen this stated but I also presume the rationale is to make the cost of different types of medication more salient in general public debate particularly in the context of negotiations with pharmaceutical companies.
But there is a role for patients here too. There is no such thing as a free health service: everything we are proud of in the NHS is funded by taxpayers and every penny we waste costs patients more through higher taxes or reduced services. Yet estimates suggest that missed GP appointments cost the NHS £162 million each year and missed hospital appointments as much as £750 million a year. That is nearly £1 billion that could be used for more treatments or the latest drugs. On top of which we spend £300 million a year on wasted medicines. People who use our services need to know that in the end they pay the price for this waste.
So today I can announce that we intend to publish the indicative medicine costs to the NHS on the packs of all medicines costing more than £20, which will also be marked ‘funded by the UK taxpayer’. This will not just reduce waste by reminding people of the cost of medicine, but also improve patient care by boosting adherence to drug regimes. I will start the processes to make this happen this year, with an aim to implement it next year.
The purpose of this post is to discuss some potential issues with this policy. I have nothing to do with this policy and no special information other than what is available publicly as to how it was constructed and for what purpose and am posting purely to raise discussion about a policy issue of clear relevance to the public more generally and also the readers of this blog who are interested in the application of behavioural science in policy.
The first question to be raised is how can this policy be tested. If it is rolled out universally and without any time staggering then there are limits to what can be done as any changes could be due to anything else changing during the time period. Perhaps with precise timing it will be possible to see whether usage of medication changes consequent on the policy being rolled out.
The potential for unintended negative consequences arising is worth discussing across a number of different facets. Firstly, it is possible that providing cost information will make people sensitive to it in ways other than wanting to reduce cost and waste of medication or being receptive to doctor's reluctance to prescribe very expensive medication. For example, cost may act as a signal of quality and make patients more likely to want to have expensive medications. It may even act as a signal that the medications are valuable and potentially can be resold. This may seem unlikely in a free-at-use system but given internet trade and the potential for non-medical uses of a number of prescription drugs it is certainly possible that reminding people for the first time that the medications they are using are potentially worth hundreds of pounds may make this more salient to them. I have absolutely no idea how to estimate the extent this will happen in advance and raise it as a possibility worth thinking about and discussing rather than something for which there is concrete evidence to believe it will happen.
Furthermore, there is potential heterogeneity in how this label would affect people. It is possible that some patients will interpret the signal as a statement that they are being a burden. Will there be groups of particularly dutiful people who will feel guilty about taking medication they are legitimately entitled to due to this stark message being salient everytime they take their medication from the box? You could argue that it is also making salient the fact that taxpayers are paying for it. So one benign outcome would be people internalising the cost information but also internalising the fact that they as "taxpayers" have paid for it. But there is clearly a potential for certain groups to perceive themselves as being a burden and it is worth some research or at least the impression of doctors and pharmacists on the extent this is happening. There is arguably a particular duty of care not to stigmatize people who are marginalised due to poor physical and mental health.
More generally, there is now a wide literature on the perverse effects of disclosure that should be thought through when making policies like this. Simply put, there is a strong element of interaction between a message, who delivers the message and the recipient of the message in disclosure contexts. The potential unintended consequences listed above are only a subset of the types of effects these interactions might produce. While I do not have a strong a-priori sense of the relative magnitudes of the different effects it is certainly worth testing them particularly if this is likely to be a long-run policy and potentially applicable to other areas.
It also raises a question as to why prescription medications are a particular focus. Should labelling be introduced for a wide range of public services e.g. pointing out the full economic cost of a college place, a BBC drama or a session of the Commons? It would be worth a lot more discussion as to the principles underlying when such communications are deployed. If only a random subset of public services are subject to this labelling then it may make cost issues more salient in those domains than in others.
There is also the potential for such messaging to be used not for the purpose of promoting efficient allocation but rather to convey broader political messages. The word "taxpayer" in this context has the potential to convey a wide range of messages. In essence pretty much everyone in the UK is a taxpayer. If you purchase a pack of biscuits you pay tax on the transaction. But it is surely possible that the connotation of the word may suggest to some that there is a difference between those in formal employment and those outside the formal labour market. The potential for the message to convey a view that those not working for reasons of illness are somehow not "taxpayers" is certainly worth thinking about. Also the potential for the continuous priming of this message to promote negative sentiment among those in the formal labour market to those not in formal employment is also worth thinking about. The counterargument is that "taxpayer" may genuinely be used to convey "all of our taxes pay for this" and is thus intended to tap into norms of community and reciprocity. Again, I think this is debatable and probably testable.
There is no question that the UK government has been leading in attempts to use non-price forms of intervention in policy. But there is also a potential for such communication-based forms of intervention to be used to make political points, with the case of the "immigration vans" in 2013 being one prominent example. In this particular case, there needs to be more discussion about why this messaging is being used as opposed to other forms and the particular outcomes intended and extent to which the above consequences have been thought-through.