Category Archives: Access to treatment

Barriers which prevent people accessing health care, including charges and co-payments

Recent statistics regarding patient care throughout the NHS have caused widespread concern among numerous agencies and advocacy groups. Recently, figures showed that more than 102,000 individuals had to wait more than two weeks to see a cancer care specialist after their GP referred them. The maximum time from referral for a patient who has suspected cancer is 14 days, and the government aims to meet a 93% target for meeting this timeframe. Unfortunately, 25 out of 157 NHS trusts failed to reach this important threshold, and numbers are down since the 2011/2012 statistics. Exceeding this limit puts patients in an unnecessary state of anxiety and ultimately, puts their health at risk.

When a GP determines that a patient may be suspected of having cancer, seeing a specialist quickly is necessary so that patients may receive the appropriate testing, diagnosis, and recommended course of treatment. Moving past the two-week target delays these critical components of cancer care, and patients and their loved ones are left not knowing what lies ahead. In addition to failing to meet targets to specialist care, the Cancer Research UK organisation found that the target for treating cancer patients has also been missed. Beginning a suggested treatment plan is supposed to take place within 62 days after an urgent referral from a patient’s GP, but currently, that target is at its worst level. Instead of meeting the 85% threshold for treating cancer patients, only 79.9% of individuals actually do so, representing a missed mark by the NHS for the last three years running. More than 2,000 patients waited more than two months to begin treatment, while another 500 waited more than three months.

Growing Pressure on the NHS

The shocking statistics highlighting longer wait times for cancer specialist visits and subsequent treatment are a clear sign of undue pressure placed on NHS. Part of the problem is the chronic understaffing of hospitals and specialist offices that can be correlated to a growing patient population. As more individuals lean on the NHS for healthcare services, added medical staff should be a priority for the organisation. However, the cost burdens placed on the system thanks to extended hours and expanded services make the influx of new medical personnel a challenge. Prolonged wait times are the result.

According to a team of medical negligence lawyers who handle cases involving cancer misdiagnosis and delayed diagnosis, this is often the most challenging battle a patient can face in his or her lifetime, and waiting longer than necessary to get clear answers on their diagnosis and the course of treatment only adds to the stress. Overwhelming feelings of fear and frustration can make individuals more unhealthy at a time when they are most vulnerable, and these emotions do not fade until there are concrete answers from a cancer specialist.

Focusing on a Fix

In response to the lagging wait times cancer and potential cancer patients endure, the government has promised to correct the issues that cause extended waiting periods by the year 2020. A definitive diagnosis should be provided or an all-clear given to the patient within 28 days, and the NHS is piloting a program that would help work toward this target in five areas starting in 2017. Meanwhile, individuals who have been given a referral from their GP to visit a cancer specialist, or already have a diagnosis of cancer may need to seek out support. There are several organisations that provide resources for common stressors associated with receiving a cancer diagnosis and beginning treatment, including financial, emotional, and community help. A diagnosis of cancer is a frightening experience, but with the help of family members, medical teams, and support organisations, patients and their loved ones can feel confident in receiving the care they need.

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The Public Accounts Committee report on patients’ experience accessing general practice medicine says the Government is pushing ahead with extended hours plan without real understanding of issues.

Concerns persist over patient access to GPs

In March 2016 the Committee reported concerns that patients’ experience of contacting and accessing their general practices varied significantly between different groups of patients and between different practices. One year on, these concerns persist.

The Department of Health (the Department) and NHS England have objectives to improve and extend access, and have made some effort to understand the demand for this extended access, but they are moving ahead in rolling out extended hours without really understanding the level of access currently being provided or how to get the best from existing resources.

Overall number of GPs reduced in last year

Last year they also expressed concern that staffing in general practice was not keeping pace with growing demand. Despite the government’s target to recruit 5,000 more GPs, the overall number of GPs has reduced in the last year, and problems with staff retention have continued.

Health Education England has increased the number of trainee GPs recruited, but still did not manage to meet its recruitment target last year. NHS England and Health Education England have several initiatives in place to boost recruitment further, to make better use of other staff groups, and to ease workload and encourage staff to stay. However, they are pursuing these discrete initiatives without a credible plan for how to develop a cost-effective, sustainable workforce.

Full report

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International Women’s Day seems a suitable time to publicize the campaign to decriminalize abortion in the United Kingdom. In February 2016 BPAS the leading charitable abortion organization in the UK launched their campaign “We Trust Women” to scrap cruel and archaic abortion laws. Many people do not realize that under the 1861 Offences Against the Person Act (OAPA), abortion remains a criminal offence unless the criteria set out in the 1967 Abortion Act are followed.

The Director of Public Prosecutions (DPP) decision in October 2013 not to prosecute two doctors caught up in the Daily Telegraph ‘sting’ operation in February 2012, where a woman accompanied by a reporter posed as a patient requesting an abortion on grounds of fetal sex was greeted with fury by the anti-abortion lobby and resulted in a Westminster Hall debate where normally pro-choice MPs deplored the possibility of abortion on these grounds. The DPP decided that although there were grounds to prosecute these doctors it would not be in the public interest to do so (2). Both doctors were referred to the General Medical Council and conditions put on their registration banning them from abortion work. In early 2015 after a private prosecution was brought but failed, one doctor had the conditions lifted and the second was sent to a Fitness to Practice Tribunal where he was suspended from practice for three months. He was not found guilty of recommending an abortion illegally but guilty of a probity issue. The uncertainty and stress of this three year ordeal was considerable but fortunately both doctors had supportive employers. The Chief Medical Officer wrote to all doctors in February 2013 setting out guidance as to how the 1967 Act should be operated although some of us had questions about her interpretation of the law.

These cases and an unrelated investigation about pre-signing the necessary forms under the 1967 Abortion Act have had a chilling effect upon doctors working in the field of abortion.

On 4th November 2014 Fiona Bruce MP introduced a 10 minute rule bill, Abortion (Sex selection Bill) to outlaw this alleged practice which passed by 180-1, the lone dissenter being Glenda Jackson. As a private members bill there was little chance of finding time for the next stage and it was withdrawn and replaced with a new clause in the Serious Crimes Act outlawing abortion on the grounds of fetal sex. This was debated in February 2015. This proposal was a departure from the way the Act had operated successfully for 46 years. Lobbying by pro-choice and women’s organisations helped educate MPs and to defeat this clause by 292 to 201 votes. A motion asking the Department of Health to assess the extent of the problem and if necessary prepare a strategy to tackle this passed almost unanimously by 491 to 2 votes.

The politicization of abortion and the effect of the strong and well organized, well funded anti-abortion lobby makes it difficult for rational decisions to be made about changing the law which is now almost 50 years old. Considerable changes have taken place in the way that abortion is carried out and medical abortions in 2014 made up 51% of the procedures in E&W and 80% in Scotland. Nurses can take the history, examine the woman and administer the pills and should be able to sign the forms required by the 1967 Act.

An investigation was ordered by the Secretary of State for Health into abortion clinics by the CQC (costing over £1million) following an inspection in January 2012 revealed pre-signing of the forms required in order to legalise an abortion. They found fourteen NHS hospitals where this was done, but in July the DPP decided that these hospitals would not be prosecuted as steps had been taken to improve compliance with the law.

In 1990 when the upper limit for terminations was reduced from 28 to 24 weeks a clause was also added to allow terminations in places other than hospitals. Despite research internationally that shows home administration is possible, the DH consider that unlawful and despite two pilot studies done in the community the requirement that women attend hospital persists. It is irrational and against the best evidence but appears to be a response to the furore that occurs whenever abortion is discussed in public.

The OAPA 1861 (itself based on the law first passed in 1803) has also been used recently to prosecute four women. Sarah Catt in 2012 was jailed for 8 years (reduced on appeal to 2½ years) for taking pills to induce labour at 39 weeks. She said the baby was stillborn but has not revealed where the body is. Natalie Towers was jailed for 2½ years in December 2015 for inducing labour at 32 weeks and delivered a stillborn baby at home. In Northern Ireland where the 1967 Abortion Act does not apply, two women are awaiting trial under the OAPA. One obtained pills from the internet for her underage daughter and appeared in court in June 2015 and the second referred herself to the police in January 2016 having taken the pills in 2012. Charge me or change the law was her message and she has been charged, unlike the 215 who wrote to the PSNI in June 2015 or the 100 who did so in 2013 asking to be prosecuted.

In the twenty first century it is extraordinary that women’s control over their own bodies should be constrained by a 19th century law and that women are being jailed for breaking this.

Doctors for a Woman’s Choice on Abortion believes that the woman should make the decision to terminate a pregnancy after consultation with her doctor, a position accepted by 70% of the population and that the OAPA 1861 which makes abortion a criminal offence and the 1967 Abortion Act should be scrapped.

The original purpose of these laws was to save women’s lives and the 1967 Act followed a decade where abortion had become the leading cause of maternal death. In the 21st century when abortion is very safe and available medically there is no place for

a 19th century law which exposes doctors acting in good faith to the risk of criminal prosecution. Prosecuting women who may need help with mental health issues or in the case of Northern Ireland access to legal abortion in their home country is wrong.

In November 2015 a High Court judge in Belfast ruled that the law in Northern Ireland was ’incompatible with human rights’. The EU Charter of Fundamental Human Rights  became binding on member states in 2009 and under article 6 “Everyone has the right to liberty and security of person” and Article 7 “Everyone has the right to respect for his or her private and family life, home and communications” I contend that women do have the right to bodily autonomy. Women do not take the decision to terminate a pregnancy lightly and they are in the best position to decide whether this is the right thing in the circumstances for themselves and their families. Safe abortion is available though the NHS and the requirement to obtain the agreement of two doctors is bureaucratic, outmoded and unnecessary. At the Lords stage during the passage of the 1967 Abortion Act, which set out the conditions for performing an abortion lawfully, a sentence was inserted to say that if “continuance of the pregnancy would involve risk greater than if the pregnancy was terminated” the pregnancy could be terminated. The risk to life is always greater for a continuing pregnancy than if the pregnancy were terminated before 20 weeks so this gives doctors the option of responding to the woman’s request.

It seems extraordinary that in 2016 women do not have control of their own bodies

We think the time has come for the UK to follow the example of Canada, which decriminalized abortion in 1988 without adverse consequences. Anyone who agrees could send a donation to Doctors for a Woman’s Choice on Abortion to help with campaigning-and if every woman who has had an abortion in the last 46 years were to send a pound we would be able to do so more effectively.

This was first published in the Hippocratic Post


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The National Health Service was established in 1948 to provide a comprehensive service designed to improve the physical and mental health of the population of the UK. The relevant legislation (National Health Service Act 1977) provides that services for the prevention, diagnosis and treatment of illnesses must be provided free unless a charge is expressly permitted by statute. The Beveridge report in 1942, which laid the foundations for the post war ‘welfare state’, stated that:

‘a health service providing full preventative treatment of every kind to every citizen without exception, without remuneration limit and without an economic barrier at any point is the ideal plan’.

In many ways, this underlying principle still governs the operation of the modern NHS, despite the strain which it has come under. Some of these pressures emanate from the Treasury or from the changed political landscape of the last two decades associated with the catch phrase ‘rolling back the state’. Some have come from within. Devolved responsibility for budgets, the drafting in of managers from the private sector and the involvement of private companies in the financial management of the health service have inevitably changed the climate in which funds are allocated. Increased running costs and expensive advances in medical treatment place pressure on NHS managers to find ways of generating income. Thus it is that Community Health Councils come to hear complaints concerning unreasonable, inequitable and sometimes illegal charges.

History of NHS Charges

At the outset of the NHS even Beveridge advocated the implementation of charges for ‘hotel’ expenses during hospital stays and contributions towards the costs of appliances such as dental and optical equipment. Since that time debates have persisted over whether and what charges should be levied.

Although the imposition of charges has often been justified as a measure to reduce wastage, much of the pressure for increasing revenue through this means arises not from any internal health policy logic but as an effect of wider political or economic agendas, particularly those driven by the Treasury. The need to prioritise defence spending (1951), win favour with international money markets (1968), comply with IMF loan conditions (1975-9) and generally control public expenditure (1979-97) have all been cited as reasons for increasing NHS charges3.

In many instances, charges have been extended as a concession to the Treasury to enable particular projects to be paid for. A onetime staunch opponent of charges, Richard Crossman, Secretary of State for Social Services in 1969 admitted that the introduction of optical and dental charges within the NHS was to fund school building projects.

Over the last two decades political pressures have not been sympathetic to the principle of basing service provision on need rather than cost. The wider political context has seen public services privatised across the board — Jean Shaoul, lecturer in accounting and finance at the University of Manchester, points out that in1999 57% of total government expenditure was spent on the purchase of goods and services, compared to only 28% in 1977. As privatisation has progressed, there have been growing pressures to recoup the cost of services from the user rather than out of government expenditure. Where this is not possible, means tested exemptions from user charges are preferred to universal subsidised provision. Thus in education, grants have been replaced by loans and tuition fees. In transport, provision has been privatised and fares increased. In housing, subsidies have been shifted from investment in bricks and mortar to (more stringently means-tested) housing benefit.

Yet despite this, the popularity of a free health service has always made the introduction of new or increased charges politically difficult. Thus in order to placate opponents of her plans for an internal market, Mrs Thatcher refused to introduce new charges for GP visits and hospital stays. (Nevertheless, prescription charges increased in real terms fivefold between 1979 — 1997).

For this reason the government is particularly keen to find ways of appearing to preserve the principle of free health care while drastically reducing its scope. One such technique has become increasingly important since the late 1980s. This is the process through which more and more functions formerly associated with NHS non-acute care — particularly of the elderly ­ have been transferred to local social services — enabling charges to be raised.

Social Care

Changes in the responsibilities of different public bodies for the provision of care are reflected in new and ambiguous terminologies: thus long-term care has increasingly come to be redefined as social care, and ‘personal care’ (chargeable) has come to be distinguished from ‘nursing care’ (free). As the Health Select Committee pointed out:

“The confusion is epitomised by the farcical question of whether a person needing a bath in the community should receive a `health’ bath or a ‘social’ bath — the first comes free, the second (in theory at least) has to be paid for on a means tested basis.”

The impact of this change is reflected in NHS bed numbers. Between 1979 and 2000 the number of beds in the NHS in England decreased from 480,000 to 189,000, while the number of beds in the independent nursing care sector, increased from 23,000 in 1983 to 193,000 in 2000.

The number of private residential care beds also increased, reaching 345,600 in 2000. The growth of this sector was initially fuelled by an uncapped social security budget in the late 1980s. This funding was then subjected to much sharper means testing in the NHS and Community Care Act 1990 and in subsequent legislation. Thus, formerly free NHS services became increasingly self-funded social services. It has been estimated that in 1995 40,000 pensioners were forced to sell their homes to pay for care. Under-funding by central government of local social services effectively forces councils to charge pensioners the full cost of their care if their capital exceeds the disregard limit. Even despite this a shortfall of social services beds remains. The result is that many elderly people cannot be discharged from hospital because they have nowhere to go.

The legality of these charges may be in some doubt. The ruling in ex parte Coughlan makes clear that even where an individual had been placed in a home by the local authority, responsibility for provision of nursing care stays with the NHS where the primary need is a health need. The assessment process carried out by social services and health bodies by which eligibility for ‘free continuing care’ is decided is not transparent or open, and not always rigorous. Patients have little say in decisions about where they go and who will pay for it. Support for this vulnerable group of people not easy to come by. A survey produced by the Pensioner’s Campaign Team in April 2001 suggests that only around 20% of social services departments employ patient advocates. After April 2002 assessment for continuing care will be integrated with assessment for nursing care under the Health and Social Care Act. Whether the new regime will improve matters remains to be seen.

Shortly after being elected in 1997, the Labour government set up a Royal Commission to consider the future financing and provision of long term care. This recommended that personal care provided in all settings should be made free at the point of delivery. The Government rejected this proposal. Provisions in the Health and Social Care Act 2000 remove the responsibility for the provision of nursing care from community care services, but limit its availability. The Act also extends the power of local authorities to recover charges for services by laying claim to the sale value of the homes of those receiving care. Despite the fact that this legislative change was introduced with the stated aim of improving the integration of health and social care services, the persistence of two very different funding regimes will ensure that the boundary between them remains hotly contested. 

Social and Health Consequences

If charges simply reduced wasteful overuse of health services across the spectrum of social classes, with no adverse health impact either for particular groups or for the general public, then they could be easily justifiable. Similarly, if the imposition of charges just acted to depress the use of ineffective treatments, they might be reasonable. Yet research has confirmed that such a blunt instrument will not achieve such smart results. In the 1970s the US think tank RAND carried out one of the most comprehensive investigations ever into the effect of user charges involving over 7000 participants. This established that charges reduced the uptake of both ineffective and effective treatments at the same rate. Charges were also found to have a disproportionately adverse effect on low income and vulnerable groups. These same points emerged strongly in a World Health Organisation (WHO) global survey of charges. WHO argued that such a ‘tax on illness’ often impacts adversely upon the control of infectious diseases and undermines preventative medicine while also producing inequality by deterring the poorest from using services.

Former Health Minister Gerald Malone claimed ‘there is no evidence to suggest that charges deter people from seeking the medication that they need”. This view has been shared by successive governments. Yet, if prescription charges were exclusively effective in reducing unnecessary usage, prescription redemption figures would show no differentiation between the financial status of individuals with similar clinical needs (horizontal equity). However, a 1993 study found that disproportionate numbers of patients (33%) who failed to redeem their prescriptions were liable for charges. A survey by ACHCEW in 1996 found that 58% of Community Health Councils (CHCs) had experience of patients failing to redeem prescriptions. This finding was supported by a poll conducted by. Kidderminster and District CHC in 1995, which established that 35% of people who are not eligible for free prescriptions sometimes fail to have their medication dispensed.

Low-income, but not-exempt, users are most disadvantaged by health service charges.

“A Citizen’s Advice Bureau in Northumberland reported a client with severe mental health problems who required three prescription items per month to control his condition. However his income from incapacity benefit left him 5 pence above the level at which he would have been entitled to free prescriptions. He could not afford the £18 per month prescription bill and therefore went without his drugs”

A recent report by the National Association of Citizen Advice Bureaux suggests that 28% of clients failed to get all or part of a prescription dispensed during the last year because of cost. According to the National Pharmaceutical Association “what can I leave out” is a common question asked of pharmacists.

There is no doubt that charges reduce uptake. Treatment figures fell by 25% following the introduction of the new dental charging regime in 1987. The introduction of charges for eye tests in 1989 had a similar effect, while the rise in prescription charges between 1979 and 1984 is estimated to have caused a 40% reduction in the number of chargeable prescriptions dispensed.

The Bristol Eye Hospital detected a fifth fewer cases of glaucoma following the introduction of eye test charges. Although the numbers have since increased, the BMA have estimated that within the introduction of charging, twenty million more tests would have taken place. Many will have lost the chance to have eye diseases such as glaucoma and retinoblastoma diagnosed early enough to be treated. in the case of glaucoma, eye deterioration proceeds slowly — at a rate of 3% per year. The full cost of this short term saving may not become known for some time.

Another instance where the introduction of charges may undermine longer term public health goals concerns the needs of those in their late fifties when ageing may begin to result in deteriorating teeth or eyes. If inadequate intervention occurs at this point the ramifications may undermine general health in old age. The Public Policy Research Unit explored some of the possibilities:

“What might follow, if for instance, people over 50 are deterred from dental treatment?

  • Less conservation of teeth
  • More older people will need dentures
  • More older people will avoid foods that can be difficult to manage with dentures such as high fibre foods, fruit and vegetables
  • The quality of nutrition will fall
  • Illnesses associated with poor nutrition will rise

  • Greater use of health services will follow, made worse because of the higher costs or treating older people who tend to need longer hospital stays

It is illogical to discourage people from receiving health care that might prevent the spread of infectious disease, detect a problem at an early stage, or prevent it arising in the first place. Critics contend that charges do just this.


A Free Service?

The National Health Service Act 1977 (the Act) defines the scope of NHS services and provides the legal foundations for the duties and obligations of both the Secretary of State and health service bodies and professionals. Section 1(2) provides;

`services ….. shall be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed’ (emphasis added)

The powers of the Secretary of State to enact secondary legislation controlling charging tariffs are further defined in sections 77 to 82 and schedule 12 of the Act. Section 77 of the NHS Act states:

`Regulations may provide for the making and recovery…. of such charges as may be prescribed in respect of ….the supply under the Act ….of drugs, medicines or appliances (including replacement and repair of those appliances)’

Chargeable services include:

  • The supply of drugs, medicines and appliances under section 77.
  • Dental appliances such as dentures and optical appliances, for example glasses and contact lenses under section 78.

Other sections allow regulations to be introduced for the supply of more expensive supplies, the repair of appliances in certain specified circumstances and payment of travelling expenses.

These sections do not require the NHS to levy charges, but merely give the Secretary of State the option to introduce charges for these specific services.

Charging Regulations

Since 1977 a complex network of regulations and amendment regulations have been introduced establishing and revising charging mechanisms. New regulations, when enacted, may revoke or partially revoke previous regulations. The result is a lengthy ‘paper trail’ which is both difficult to understand and interpret. CHCs supporting complainants have reported that health service managers have sometimes been unable to identify the correct legal basis for charges.

At present regulations are in force providing charging arrangements for:

  • Dental treatment and appliances – NHS (Dental Charges) Regulations 1989

  • .Optical treatment and appliances – NHS (Optical Charges and Payments) Regulations 1997.

  • Drugs and appliances – NHS (Charges for Drugs and Appliances) Regulations 2000.

  • Wheelchairs – NHS (Wheelchair Charges) Regulations 1996.

  • Treatment to overseas visitors (Charges to Overseas Regulations 1989)

Dental Service

The provision of dental services is divided into two distinct service categories ­ treatment and appliances. The NHS (Dental Charges) Regulations 1989 detail the charging mechanisms and tariffs for both dental appliances (Regulation 2) and dental treatment (Regulation 3). However, neither ‘dental appliance’ nor ‘general dental services’ are defined within the regulations. This lack of clarity hampers interpretation of the legislation.

Dental appliances

Regulation 2 of the 1989 Regulations states:

‘A charge…..may be made and recovered under section 78(1A) of the Act in accordance with these regulations in respect of the supply under the Act of denture and bridges’.

Strangely, it appears that dentures and bridges are the only dental appliances that may legitimately be charged for under this section. However, other appliances, such as the provision of crowns may fall under the umbrella of ‘general dental services’ -and charges made under that section.

More expensive supplies

Under the NHS (Dental Charges) Regulations 1989 an individual may request the provision of appliances which are more expensive than the basic NHS variety. The extra cost to the dentist of both supplying and repairing the non-standard appliance may be recovered from the patient under Regulation 8 (1). Similar provisions do not exist for the provision of superior treatments.

Provision of more expensive supplies must be at the request of the patient being treated and signed request forms must be submitted’. There is, therefore, no scope for dental practitioners to charge for more expensive appliances without the express agreement of the person being supplied.

Repair and Replacement of Dental Appliances

A distinction is drawn between repair and replacement of appliances

‘Replacement’ is effectively the same as (new) ‘supply’. Therefore, whatever charges apply when an appliance is first provided will also apply if a replacement is required, (subject to certain exceptions listed in 5.3 below) Section 25(2) of the NHS Act 1980 widened the meaning of ‘replacement’ to encompass relining, adjusting and alteration of dentures.

‘Repairs’ are not included in the definition of supply, and the regulations do not make specific provision to charge for repairs. They should therefore be free, and Department of Health publications HC11 and HC13 do state that dentures and bridges must be repaired free of charge. However since “relining, adjusting and altering” of dentures may be charged for, it may in practice be difficult to say exactly when a given procedure constitutes an adjustment, and when a repair.

The patient may be charged for any repairs or replacement made necessary by an act or omission on their part. This applies even to individuals who would ordinarily be exempt from charges. Where a Health Authority considers an individual personally liable in this manner it may set up a sub­ committee, to hear oral evidence. The health authority is responsible for the ultimate decision, and it may reduce or discount the full bill if this would cause undue hardship.

General Dental Services

Although general dental services are not defined in the legislation, they are taken to include, check-ups, the provision of fillings, de-scaling, oral hygiene advice, the removal of teeth, work on roots and gums, the provision of crowns and anaesthesia.

Charging Tariffs

General dental services and regular appliances are provided without charge to exempt patients. The dentist is reimbursed the full cost of this treatment by the NHS.

The charging tariffs for both general dental treatment and appliances are laid out under Regulation 4 (as amended 1998) which states:

`the amount of the charge which may be recovered is 80% of the Statement Remuneration….being an amount not exceeding that which the Secretary of State considers to be the cost to the health service of the supply or provision’

The Statement of Dental Remuneration is a lengthy document laying down the amount the NHS will pay the dentist for specific treatments. It is published under regulation 19 of the NHS (General Dental Services) Regulations 1992 and is amended twice a year’. Non-exempt (paying) patients are charged 80% of the treatment amount. The NHS pays the balance. Where a course of treatment attracts charges in excess of an overall ceiling, also laid down in the Statement of Dental Remuneration, the NHS pays the excess in its entirety.


Regulation 3(2) of the NHS (Dental Charges) Regulations 1989 specifies both classes of service and classes of client exempt from charges.

Treatments exempt from Charges

Exempted treatments include: uncompleted occasional treatment; calling an additional practitioner to administer anaesthetics in an emergency; and replacing or repairing within twelve months any defective fillings, root fillings, inlays, pinlays or crowns (subject to certain exceptions). Where a patient sees a dentist out of hours in an emergency or is visited at home any additional costs will be exempt and treatment will be chargeable on the ordinary tariff’.

Exempted Persons

Regulation 3(2)(a) refers us to Schedule 12 of the NHS Act 1977, which contains details of persons exempted from dental charges.

Free treatment is available to

  • Under 18 year olds and 18 year olds in full time education.
  • Women who are pregnant at the commencement of treatment
  • A woman who has given birth within the previous twelve months.
  • Patients undergoing dental treatment necessitated by operative procedure used to combat invasive cancer’.

Additionally, individuals with low incomes or in receipt of benefits may also be entitled to a reduction or refund of dental charges. However, eligibility is dependent on strict criteria under the NHS low-income scheme. This severely restricts access to free or low cost dental treatment. Individuals of pensionable age do not automatically receive free dental care. This is inconsistent with the availability of free prescriptions for the over 60’s.

Ophthalmic Services

The provision of National Health Services is based on the presumption that services are provided free unless express mechanisms exist for the recovery of a charge. By contrast, the provision of ophthalmic services is based on the premise that

charges are levied except where specific exemptions apply.

Sight Tests

A duty to supply free tests only exists under certain specified categories. Originally, these categories were broad and encompassed the majority of the

population, however eligibility has repeatedly been narrowed. In 1989, 12,493 sight tests were carried out on the NHS but this figure fell to 5,280 in 1990 following a change in eligibility rules. At its 1997 AGM ACHCEW passed a resolution calling for the restoration of free eye tests, in particular for the elderly, on the grounds that they are a cost effective means of screening for illnesses. We therefore welcome the government’s subsequent decision to again make eye tests free eye for the over sixties’.

Currently free sight tests are available to individuals who are:

  • over sixty years old, or
  • under 16 years old, or
  • aged 16 — 18 and in full time education or under the care of the local authority, or
  • diagnosed diabetic, or
  • aged 40 or over and the immediate relation of a glaucoma sufferer”,or
  • in receipt of specific benefits (income support, income based Jobseeker’s Allowance, family credit or disability working allowance), or

  • eligible under the low income scheme, or

  • war/MOD pensioners where sight tests are necessitated by their pensionable disability” or
  • people with glasses with at least one complex lens.’

In addition, those patients who need eye tests to manage an eye condition are entitled to have them carried out free of charge. Such tests can be carried out in the hospital or on referral to a retail optician. However simply receiving advice from a hospital to seek a sight test will not secure a free test unless the individual is ordinarily exempt. Any ‘hospital’ sight test must be for the management of an optical condition”.

Contact Lenses / Glasses

Recovering the total cost of NHS optical appliances including glasses and contact lenses supplied on the NHS is permitted under section 77 in conjunction with schedule 12. Only an ‘eligible person’ in receipt of a valid voucher is entitled to receive optical appliances without charge or at a reduced rate. Section 8 (2) of the NHS (Optical Charges and Payment) Regulations 1997 provides:

‘An eligible person is a person who at the time of the supply of the optical appliance is any of the following 

  1. a child
  2. a person under the age of 19 years and receiving qualifying full-time education…

  3. a person whose resources are treated…as being less than his requirements’….

Additionally, under these regulations, individuals who require particularly strong lens or complex lens prescriptions are classed as eligible people.

The redemption value of the voucher is supposed to reflect the minimum cost of supplying the appliance that meets the patient’s clinical need. However, in practice it rarely meets the actual cost of spectacles, and in recent years the difference has been growing, with the result that people with vouchers have to pay increasing amounts towards the price of their optical appliances. The National Association of Citizen’s Advice Bureaux has suggested that opticians providing NHS treatment should be required to sell glasses within the value of NHS vouchers. Problems can also be caused by the limited range of frames and lenses available at the lower end of the cost spectrum. Uncomfortable or unattractive frames may deter individuals – especially children and young adults – from wearing their lenses. Opticians themselves have concerns that failure to wear prescribed lenses can cause deterioration in some optical and medical conditions. Those who want to buy more expensive lenses or frames simply pay the difference between the desired appliance and the face value of the voucher.

No assistance is available towards the purchase price of contact lens fluid, which makes contact lenses an expensive option for most eligible individuals. Individuals who use contact lenses but who are unable to afford the correct cleaning solutions are at increased risk of infections. ACHCEW considers that the unavailability of cleaning fluids on the NHS is a false economy if it results in increased NHS expenditure on treating eye infections.

Repair and Replacement

Assistance towards the costs of repair or replacement resulting from loss or damage is available only in the cases of appliances dispensed to a child. Other eligible individuals are only entitled to help with the cost of repair where the repair is required as a result of an illness. The Health Authority will first make ‘such enquiries as it considers relevant’ to ascertain the true cause of the damage. The cost of making such enquiries is almost certainly greater than the cost of repairing or replacing the appliance. Eligibility for help with the repair or replacement of optical appliances is particularly restricted, as health authorities are reluctant to fund repairs to appliances supplied under the voucher scheme.

The Medicines Act 1968 divides drugs into three categories, prescription only medicines, medicines that can only be dispensed by a pharmacist and general list medicines. Schedule 10 of the National Health Service (General Medical Services) Regulations 1992 stipulates which products are not available on prescription to patients. This list is regularly updated. Any item not available on prescription must be paid for over the counter at its full retail price.

The NHS (Charges for Drugs and Appliances) Regulations 2000 permit charges for the supply of pharmaceutical products supplied on prescription by chemists, doctors, health authorities, NHS trusts and Primary Care Trusts. The provisions governing the supply of drugs and medicines for each service provider are primarily the same. However, there are different restrictions and powers governing supplies by them.

The Regulations (as amended) state that a chemist, doctor, health authority or trust that provides pharmaceutical services to a patient shall make and recover a fee from each patient’. Each item of the prescription attracts the charge. Two separate fees may be payable where an appliance and a drug is prescribed, for example asthma drug plus inhaler or where a combination pack of drugs designed to make dosage easier is used. In resolution 4 at its AGM in 2000 ACHCEW criticised the inequality whereby

“a pre-packaged course (which) contains two separate types of tablet attracts two charges whereas a compound tablet attracts only one charge. We call upon the Government to review the exemptions urgently in order to make equity paramount.”

Regulation 2(3) limits these separate charges. Quantities of the same drug supplied in more than one container, multiple provision of the same appliance or parts of an appliance which are ordered on

Supply by Chemists

Regulation 3 deals with the supply of drugs and appliances by chemists.

Oxygen concentrators were originally supplied under these Regulations. A monthly fee, in line with prescription charges, was levied. This service was altered in 1992 when the provision of oxygen concentrators was removed from the charging regime. Oxygen concentrators are now supplied by commercial oxygen companies under contract with health service providers. Contractual terms often include charges for maintenance insurance, installation and monthly operational costs. The health service provider should meet these charges. In correspondence with ACHCEW in 1999, the NHS Executive confirmed that the provision of oxygen concentrators should be free of charge to all NHS patients.

Supply by Doctors

Doctors who provide pharmaceutical services may not charge for drugs or appliances required for immediate treatment or administered to the patient personally by the doctor. Injections and vaccinations available on the NHS attract no charge.

Doctors must also provide free pharmaceutical services to individuals resident in schools or institutions under certain circumstances. This provision is perhaps less significant than might be thought since many individuals resident in schools or other institutions will be already exempt from NHS charges on other grounds e.g. – age, income or medical disorder.

Supply by Health Authorities, Trusts and Primary Care Trusts

No charge can be recovered for the supply of drugs, medicines and appliances to a patient resident in hospital. However outpatients do pay the prescription charge. The precise moment of discharge thus assumes some importance: patients may find that they are given a prescription on leaving for items which might just as well have been provided and paid for by the hospital.

NHS bodies, providing a hospital outpatient service, may prescribe specific appliances that are not available from other pharmaceutical service providers. Schedule 1 of the NHS Regulation 1989 (as amended) states that charges may be recovered for the supply of surgical brassieres, abdominal supports, spinal supports, stock modacrylic wigs, partial human hair wigs, and full bespoke human hair wigs.

The level of charges for these appliances has been increased regularly since their introduction and prescription prices for wigs and fabric supports are surprisingly high. Even charges for surgical brassieres are at the top end of the price range for high street lingerie. Support tights, ordinarily unavailable on the NHS, may be supplied, where necessary, by a hospital. These too attract charges.

Exemptions from Prescription Charges

Some patients and some courses of treatment are not chargeable. Schedule 12 of the NHS Act 1977 details the circumstances where no charge may be recovered for the supply of pharmaceutical services and provides:

`No charge shall be made….in relation to the supply of drugs medicines and appliances in respect of;

  1. the supply of any drugs, medicine or appliance for a patient who is for the time being resident in hospital, or

  2. the supply of any drug or medicine for the treatment of venereal disease, or

  3. the supply of any appliance [other than those contraceptive in nature] for a person who is under 16 years of age or under 19 year of age and receiving full time qualifying education, or
  4. the replacement or repair of any appliance in consequence of a defect in the appliance as supplied.’

Regulation 6 of the NHS (Charges for Drugs and Appliances) Regulations 1989 (as amended) expands these exemptions to include people over 60 years of age; expectant mothers; women who have given birth in the last 12 months; those on income support, working family’s tax credit, or disability working allowance; war pensioners and individuals suffering from a variety of specified diseases.

The list of medical conditions, which entitles sufferers to free pharmaceutical services is very restricted. Those suffering from epilepsy and in need of continuous anti-convulsive therapy are exempt but individuals suffering from schizophrenia or paranoia are not. Similarly, individuals with insulin dependent diabetes are exempt but asthma sufferers must purchase their inhaler on prescription. Individuals who are HIV positive, exhibit a marked increase in the occurrence of medical conditions requiring treatment with pharmaceutical products, but neither AIDS nor HIV are included on the list of medical conditions that warrant exemption. The reasoning behind such anomalies is unclear, although generally those conditions warranting exemption tend to be less common and carry less social stigma than those where prescription charges apply. ACHCEW considers that the current restrictions on the types of illness which entitle sufferers to free prescriptions creates inequality between individuals with long term illnesses, and passed a resolution to this effect at its AGM in 2000.

Exemptions from charges for wigs, support tights, surgical bras and abdominal or spinal supports are only available to individuals who are under 16; under 19 and in full time education; in receipt of benefits or in possession of a valid exemption certificate detailing the supply of the specific appliance. Expectant mothers, new mothers, and those over 60 are not entitled to the same benefits.

Pre-payment certificates

Individuals who have long-term prescription needs, but who are ineligible for exemption from charges may incur. considerable cost over the course of their treatment. This is particularly problematic for patients using combination drug therapies who have to meet the charge for each item on their prescriptions.

In an attempt to spread the burden of prescription charges, a pre-payment scheme was introduced in the NHS (Charges for Drugs and Appliances) Regulations 1989. Under this scheme, individuals pay in advance and obtain a pre-payment certificate. Thereafter they do not have to pay prescription charges for the duration of the certificate. Certificates are available for four-month and twelve-month periods.

Medical / Surgical Services

Chargeable Equipment

Only equipment specified in the NHS (Charges for Drugs and Appliances) Regulations 2000 or the NHS Drugs Tariffs may be charged for. At present charges above the prescription rate can be made for elastic tights, spinal supports, abdominal supports and wigs. Further appliances available on the NHS but not listed in the drugs tariff must be supplied free of charge.

This includes orthopaedic equipment and prosthetic limbs. Many appliances, such as walking sticks, frames, and crutches are provided free on loan for the duration of the clinical need.


Wheelchairs are loaned to patients for as long as they are required. The NHS pays for maintenance and repair to be carried out by approved repairers. More expensive wheelchairs can be made available through a voucher scheme, which allows the patient to pay the difference between a NHS chair and their preferred model. The NHS (Wheelchair) Regulations 1996 extends this provision by authorising individuals to be charged for the additional costs which may be incurred in maintaining and repairing non-standard wheelchairs.


Many hospitals operate schemes that require a deposit for the supply of walking aids and wheelchairs, on the basis that charges should reduce the number of appliances which become lost or damaged. However, such charges by way of a deposit are almost certainly unlawful. The NHS Executive, referring to a ‘deposit scheme’ proposed by Hastings and Rother NHS Trust, stated:

`if the item is medically required, it must be supplied without charge under the NHS, and such a charge would include the taking of a deposit.’

In subsequent communications the Department appears to have retreated slightly from this position. In a letter of the 30 April 1999 Mr N Turnbull, of the NHS Executive, stated that `NHS Trusts are independent and it is up to them to be satisfied of the legality of any arrangements they may have for providing walking aids on a temporary basis to people who are no longer hospital patients’

While ACHCEW recognises the need to reduce equipment damage and loss, hospitals can always seek compensation for this through the courts. The imposition of deposits is a charge and in many cases will affect the accessibility of care. Any charge not authorised by legislation is unlawful. Audiological Services

As noted above, charges may only be applied if statute and regulations allow. No regulations have been made to provide for charges for the provision of hearing aids supplied by the NHS. These must be supplied, repaired and maintained free of charge.

Unlike the schemes that govern provision of wheelchairs and dental appliances, there is no scope for the supply of superior hearing aids on payment of an extra amount by the patient. The NHS only provides standard models sufficient to meet the clinical needs of the patient. Those seeking more expensive models, for example models which are concealed within the ear, are obliged obtain them from private supplies and pay the full market price.

It is important that patients know about their right to free audiological equipment. Hospital NHS audiological services are often provided by private suppliers. Additionally, hospitals often rent space to private suppliers on their premises. Confusion may arise if patients are unable to distinguish between these services or are persuaded that a non-NHS hearing aid is needed to meet their clinical requirements.Appliances

Section 82 of the NHS Act 1977 allows regulations to be introduced permitting the NHS to recover the cost of repairing or replacing NHS appliances where the loss or damage arises from the patients’ carelessness.

Regulation 6 of the NHS (Charges for Appliances) Regulations 1974 provides for the recovery of costs incurred in repairing appliances damaged by the patient. This is a broad provision incorporating the cost of repairs to any appliance provided by the Secretary of State.

Under these regulations, any request for repair or replacement of a NHS appliance can be referred to the relevant Health Authority for investigation. If enquiries determine that the patient caused the loss or damage, a charge may be recovered.

Road Traffic Accidents

The Road Traffic Act 1988 permits NHS to levy charges for the treatment of road traffic accident victims. Procedures for recovering these charges were changed and simplified by the Road Traffic Accidents NHS Charges Act 1999. Previously hospitals claimed from insurance companies for the cost of treating people injured in road accidents, but the complicated administrative arrangements involved often resulted in the money not being collected. The new Act transferred responsibility for collection to the Compensation Recovery Unit acting on behalf of the Secretary of State. This unit redirects the money raised to the hospital where the accident victim was treated.

Insurance companies, not patients, are liable to pay these charges. When an accident victim makes a successful claim for compensation following an accident, the court will also require the insurer paying compensation to pay for the victim’s NHS care. Where the accident was caused by an uninsured or unidentifiable driver, the Motor Insurers’ Bureau becomes liable for these charges. The patient will have little or no role in this process.

Charges for Overseas Visitors

Regulation 2 of The NHS (Charges for Overseas Visitors) Regulations 1989 provides for charges to be levied on those overseas visitors who receive NHS medical care. Regulation 3 confers exemptions on various types of service, while regulations 4-7 allow exemptions for various types of visitor.

No charges will be recovered from any overseas visitor for:

  • Treatment at an accident and emergency department.
  • Treatment for a sexually transmitted disease (excluding HIV).
  • Diagnostic testing and associated counselling for HIV.
  • Treating an individual detained under the Mental Health Act 1983.
  • Treatment for a mental condition included in a probation order by a court.

All other NHS services (which do not attract charges to UK citizens) are provided without charge to any person:

  • Who has been resident in the UK for 12 months prior to treatment.
  • Who has come to the UK to take up employment or permanent residence.
  • Who is a national (and in some cases a resident) of the European Economic Areas or of countries with whom the UK has a reciprocal agreement, and where the need for treatment arose during the visit, (and in some cases where a person has been specifically referred for treatment).

  • Who is in the UK as a refugee, a prisoner, a diplomat or NATO service personnel.


Miscellaneous Charges

NHS Trusts are permitted to generate income so long as it does not interfere with their main function of providing health services to NHS patients. Charges for car parking, retail outlets, catering, and for the provision of occupational health services to local employers all fall into this category.

GPs, under their service contracts, are allowed to charge for a variety of non-NHS services. These include holiday vaccinations and private consultations. The BMA publishes recommended fees for these services but doctors are under no obligation to follow these scales. Similarly, hospitals often recover charges for the provision of side rooms and leisure facilities such as televisions.

However, attempts by GPs to levy charges for visits to patients in private nursing homes and suggestions made by ambulance trusts that they should be able to charge patients for non urgent transport, are not permissible under current legislation.

Sale of Goods and Services Legislation

The Sale of Goods Act 1979 and the Supply of Goods and Services Act 1982 are pieces of consumer protection legislation. They give consumers rights, for instance to claim damages for deficient goods and services. If patients are required to pay charges for NHS services, arguably they are consumers and should be entitled to the protection these laws afford. However, in the case of Pfizer v Minister of HeaIth (1965), it was held that services provided by health authorities under the authority of the Secretary of State are exempt from the provisions of Acts of Parliament unless those Acts specifically state that they apply to the Crown. Recent changes to the doctrine of crown immunity, the growing emphasis on the patient as consumer, and the decentralisation of the health service could lead a court today to take a different view.


The regulations governing charges are diffuse and difficult to understand. The range of charging regimes that apply confuses patients and health professionals alike.

The current government has committed itself to

“Undertake the biggest assault our country has ever seen on health disadvantage… to tackle health inequalities by improving the health of our nation overall and deliberately and determinedly raise the health of the poorest fastest

Yet apart from the welcome restoration of free sight tests for the over 60s, the only significant initiative to date undertaken by the government in relation to tackling the injustice of NHS charges has been to introduce a tougher sanctions regime for individuals found to have wrongly received free NHS treatment.

As an urgent first step the government needs to:

  • Remove eye tests and dental check-ups from the charging regime.

  • Significantly reduce prescription and dental charges.

  • Redesign exemption criteria and voucher schemes to reduce the hardship felt by those on long term medication.

While charging persists, action must be taken to simplify and make transparent the confusing mishmash of applicable rules:

  • Decisions about NHS charges should be brought into the public arena.
  • Charging policies must be firmly regulated at a national level to avoid geographical variations.
  • A major consolidation of the legislation must be carried out.

  • Patients should be told well in advance what charges can be levied and how much each treatment will be.

  • The inconsistencies in the exemption criteria need to be addressed to overcome the inequity whereby certain illnesses warrant free prescriptions while others do not, or certain ways of packaging treatments results in several prescription charges rather than one.

None of this would completely remedy the problems identified in this report. Charges markedly reduce take up by patients on low incomes and those who suffer long-term illness, and they undermine preventative public health. ACHCEW remains committed to the abolition of charging and the restoration of free universal health care.




ACHCEW [1996] NHS Charges — Do They Matter? Health Perspectives April 1996

DoH Publication [1998]. Advisors Guide to Help with Health Costs. HC13

DoH Publication [1996]. Are You Entitled to Help with Health Costs? HC11

NACAB [2001] Unhealthy Charges

Public Policy Research Unit [2000]. Thinking the Unthinkable Health Matters

NHS Executive [1999] Charges for Drugs, Appliances, Wigs and Fabric Supports. HSC 1999/063

NHS Executive [1998] Charges for Drugs, Appliances, Wigs and Fabric Supports. HSC 1998/16

NHS executive [1999] General Ophthalmic Services — Increase to the NHS Sight Test Fee for Ophthalmic Opticians and Ophthalmic Medical Practitioners. HSC 1999/068

NHS Executive [1999] General Ophthalmic Services — Increases in Spectacle Voucher Values, Changes in Definition. HSC 1999/051

Post Magazine [1998]. Bad Medicine from the NHS. 26 Nov 1998

Post Magazine [1998]. Insurance Industry Faces Battle over Law Reforms. 26 Nov 1998

Janice Robinson [2000] Reforming Long-Term Care finances: a continuing saga in Health Care UK, King’s Fund, Winter 2000

Smith L, Ghalamkari H [1998]. Can Prescription Charges be Justified? Pharmaceutical Journal vol. 260:531-534

Webster C [1988,1996]. The National Health Service. Oxford University Press

Produced by  Antonia Ford, Philip McLeish and Marion Chester  for the ASSOCIATION OF COMMUNITY HEALTH COUNCILS FOR ENGLAND & WALES

February 2002


Breaking down language barriers for better medicine on the front line

Access to quality healthcare goes long way in bettering a person’s health, but we often neglect to consider the importance of translation and interpretation as an essential tool for saving and improving lives across language barriers.

Medical translation has many benefits, but perhaps the most important is its ability to advance medical research. Medicine is truly an international field, with researchers all across the globe tackling a wide range of medical issues and sharing their findings with medical professionals across the world.

In each case, the initial research will have been undertaken in the native language of the country in which it was conducted, which is going to have its own particular nuances and specific medical words and phrases unique to that language.

The ability to move between languages not only advances medical research, but truly enhances the sort of medical attention and overall health care provided to individuals. Here, we examine where multilingualism in medicine is key to breaking down barriers for better medicine on the front line.

Hospitals and primary healthcare facilities

Medical translators need a good working knowledge of medical science and treatments to convey information clearly and precisely. As this NPR feature reports, discussions in the hospital room that become lost in translation can have fatal consequences. What’s more, if a patient doesn’t fully understand policies, from insurance to medical history, release forms to billing, accessing medicine can become an administrative nightmare.

The NHS acknowledge that they have a “statutory and moral responsibility to patients” to provide medical translators to all the communities they serve, and aim to offer a strictly confidential service in a wide range of languages. A dedicated administrative team works to supply translators and interpreters in all cases where patients, relatives and carers may have difficulty discussing medical conditions and giving informed consent for procedures.

Luis Asciano is fluent in French and Spanish, and works as a medical interpreter in a clinic in Washington DC. “You are sort of a bridge,” he says. “And it is very important that you do not obscure the context of the conversation.” The role of the interpreter is two-fold: to convey the facts of the situation as accurately as they are able, but to do so empathetically: Medical interpreters must have an ability to convey emotion, tone of voice and assuage patients’ fears too.

However, according to an analysis published in Health Affairs, more than a third of US hospitals in 2013 did not offer patients similar language assistance. In areas with the greatest need, about 25% of facilities failed to provide such services. This despite the fact that over 60 million people in the country do not speak English as a first language. Further, studies reveal that nearly all claims for medical malpractice filed by foreign nationals in the US were the result of poor documentation in the patient’s native language.

The need for specialised translators and interpreters really can be a matter of life and death. A study by the American College of Emergency Physicians in 2012 analysed interpreter errors with clinical consequences, and found that the error rate was significantly lower (12% compared to 22%) for professional interpreters than for ad hoc interpreters. For industry-trained professionals with more than 100 hours of study, errors dropped to 2%.

As leading translation agency Global Voices point out, “Medical and pharmaceutical translation is highly specialised and requires great accuracy and expertise.” To achieve the utmost accuracy, they only work with linguists who have at least 5 years experience performing medical translations and interpretations.

With all of this in mind, then, it becomes apparent that medical translators create a better environment not only for the treatment of patients, but also their sense of ease and comfort when faced with illness or injury.

Crisis Events

Disaster response can be a truly international affair, with medical, support and logistical staff hailing from all corners of the globe. The international staff who comprise the organisation Médecins sans Frontieres work in nearly seventy countries around the world.

Instructions for disaster procedure and relief can be difficult enough to communicate within language borders, let alone across them, which is why translation accuracy is key. The misinterpretation of just one word or phrase can lead to anything from stagnation to outright disaster, highlighting the extreme importance of proper translation in the medical field.

The Translators Without Borders group respond in such crisis events with their Words of Relief Programme, the first crisis relief translation network intended to improve communications with communities during and after humanitarian crisis response efforts by eliminating linguistic barriers that can impede vital relief efforts.

Relying on translators in the field is obviously going to be of great use, but having important medical information, as well as disaster relief information, present in the native language is of great import to the recovery process as well.

In the last year, Translators without Borders have assisted in the translation and dissemination of vital documentation and advice regarding transmission of the Ebola virus and monitored social media and web communications in affected countries in order to detect where support is most needed.

From February 2015 to February 2016, roughly 712 healthcare articles in 54 languages were added to Wikipedia’s medical pages thanks to TWB volunteers. Elsewhere, developers are working to bring a digital translation tool facilitating communication with refugees from the Syrian crisis.

During such disasters, there’s just as much of an emotional and psychological toll wrought on the populace as there is a physical one. Providing support and materials in native languages is truly instrumental in providing those in need with the psychological building blocks necessary for recovering. Breaking down language barriers is therefore instrumental in facilitating medical care around the world, not just in research, but on the front line too.

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but they don’t relieve pressure from A&Es

The rise and fall of the NHS walk-in centre

Walk in health services of one form or another feature in many healthcare systems, including Canada and the United States. In England, the first NHS walk-in centre opened in the late 1990s but only became prominent in the late 2000’s following a policy initiative that led to the opening of around 150 new facilities.

Offering extended hours and with no requirement for patients to pre-book or register, many new centres had proved highly popular with local residents with minor illnesses and injuries such as colds, eye infections, sprains and cuts. But despite this popularity, during the last parliament around a fifth of the facilities shut their doors, with a number of others, for example in Redruth, Hereford, and on Teeside, also currently at risk.

Taking sides

Why the services should have closed in such numbers is not immediately clear: the scale of local opposition to some closures – for example in Jarrow, Worcester and Southampton – was intense. Their supporters argue they reach new groups of patients, provide easy and convenient access to care, and take pressure off other stretched NHS services.

At the same time, commissioners closing centres argue they represent a poor use of funds as many attendees have minor conditions that have little need for medical attention, and those that do could readily be treated elsewhere.  Some have cited the need to fund seven-day-a-week access to GP services as a more pressing priority.

While not the whole story, one important question in these debates is whether walk-in centres divert patients from attending busy hospital A&E departments. This may be desirable since crowding at A&E is associated with high mortality and can have knock-on effects by reducing the capacity for hospitals to carry out planned medical treatments. In addition, many attendees at A&E have low severity needs which could be safely treated outside a hospital setting. Treating these patients as emergency cases in hospitals is considerably more expensive than treating them in walk-in clinics.

Building the evidence: do walk-in centres divert patients from A&E?

Until recently there was no conclusive hard evidence – from either side of the Atlantic – either way. When surveyed, around a quarter of patients attending walk-in centres say they would otherwise have attended a hospital A&E. However, academic research using statistical methods has been unable to detect any such effect.

My research provides new evidence that goes some way to filling this gap. Combining detailed information contained in hospital records with difference-in-difference statistical techniques, I provide credible estimates of how patients’ use of A&E departments changes in response to the opening or closure of a new walk-in centre close-by.

Two main findings emerge. The first is that walk-in centres do significantly divert patients away from attending A&E. The second, however, is that relative to the number of patients attending walk in clinics the effect is small, with calculations suggesting only around five to 20 per cent of patients attending a walk-in clinic would otherwise have gone to casualty. The implication is that they only make a small dent on the overall A&E figures.

The research points to something of a dilemma for decision-makers. Easy access services such as Walk-in Centres are popular, which suggests they are valued by patients. The evidence suggests they do make a small contribution to relieving pressure at over-stretched emergency services, but with low diversion rates from A&E they may be an expensive way to do so. The cold reality of a chilly funding climate points to hard choices in allocating scarce NHS resources to best meet local demand. With this in mind, fights over the remaining centres look set to continue.

this article first appeared on LSE Business Review.

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A working party looking into the inclusion of placebos in surgical trials has led to a recommendation for greater use of the controversial method by the Royal College of Surgeons of England.

Although placebo control groups are used in drug trials across the world, placebo-controlled surgical trials are extremely rare, with only 75 such trials published up to October last year.

Often labelled with the misleading term ‘sham surgery’, it has long been argued that because placebo surgery is more invasive than placebo drugs it is difficult to justify its use.

However a new paper resulting from the working party, ‘When should placebo surgery as a control in clinical trials be carried out?’, supports evidence to show they should be increasingly considered as part of surgical studies to produce the very best research evidence and be of the greatest benefit to patients.

The research found that in half of the placebo-controlled surgical trials carried out up to 2013, surgery was no more effective than the placebo, calling into question the surgical procedure for the conditions treated.

Lead author and Deputy Vice-Chancellor (Education and International) at Brunel University London, Professor Andrew George, said: “This is a controversial issue, but the benefit to clinical research of placebo-controlled surgery is just as great as in drug treatment, as long as it follows correct surgical practice.

“The misconception is that this method would replace treatment in a control arm that is known to be effective, but that would not be the case. Placebo surgery should only ever be used when there is uncertainty about the relative benefits of an experimental intervention and placebo, and when any potential harm is minimised and reasonable.

“Most importantly, controlled trials could potentially avoid future harm to patients if they demonstrate that a particular treatment is ineffective and should not be adopted into clinical practice.”

Placebo surgery varies from minor procedures such as making an incision in the skin so that the patient doesn’t know whether they have been treated, to a full surgical procedure.

In all cases ethical guidelines must be followed with patients being made aware of, and giving consent to, being part of a randomised trial.

The paper is published here. The Royal College of Surgeons of England has released a position statement in support of greater use of placebo surgery here.

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Migrants’ free access to the NHS and the perceived health care costs associated with it have generated much debate in the UK and even resulted in the introduction of a fee for certain non-EU citizens. Some politicians have blamed migration for the increase in waiting times, particularly in A&E.

In order to inform this heated debate we have started a new project at the University of Oxford, investigating the relationship between immigration and the NHS. Our first paper investigates the link between immigration into an area and waiting times for A&E, outpatients (referrals) and elective care (pre-arranged, non-emergency care, including scheduled operations).

Using data from 141 local authorities in England, merged with administrative information drawn from the Hospital Episode Statistics (2003-2012), we found no evidence that immigration increases waiting times in A&E and elective care. In fact, we found that higher immigration in an area actually reduces waiting times for outpatients there. On average, a 10 percentage point increase in the share of migrants living in a local authority would reduce waiting times by slightly more than 9 days. Using previous estimates of patients’ willingness to pay for a reduction in waiting times, we estimate that a 10 days reduction in waiting time would be equivalent to a person receiving about £38 in 2013 prices.

The “healthy migrant effect” and UK-born mobility

We look at two alternative explanations for our results. First, we confirm findings from previous research which suggest that migrants are younger and healthier than UK-born individuals, which in turn suggests a smaller impact on the demand for healthcare. Migrants in England are also 8 percentage points less likely to report a long-term health problem than their UK-born counterparts. By using data from the Understanding Society survey we also show that migrants’ likelihood of using hospital services is not statistically different from the UK-born. Moreover, recent migrants (i.e. those who came after 2000) are significantly less likely to use hospital services compared to the UK-born.

Second, we find that higher levels of immigration increase the likelihood of UK-born individuals moving from that area, a conclusion that has also been supported in previous studies. This means the effects of immigration on the demand for health care services are dispersed throughout the country via internal migration.

Evidence for the period immediately following the EU enlargement

We test the robustness of the results by including data up to 2007, to focus on the years immediately following the 2004 EU enlargement. The enlargement induced a sharp increase in the number of recent migrants and it could have affected waiting times, at least temporarily. Our overall results are not affected by this change. Immigration has a statistically significant negative effect on waiting times for the period 2003-2007.

We also explored geographical differences on the impact of immigration on waiting times during this period. We explored two possibilities in this regard. First, we exclude London from the analysis. The exclusion of London results in an insignificant effect of immigration on outpatient waiting times for 2003-2007.

As a second possibility, we analyse differences in our results by level of deprivation of the area, and find that immigration increased waiting times for outpatient referrals in deprived areas outside London during this period. The effect for deprived areas is not significant for the whole 2003-2012 period, but only for the period immediately following the EU enlargement (i.e. 2003-2007).

Immigration not to be blamed in most cases, but location and time matters

The ultimate effect of immigration on NHS waiting times in a specific area depends on the characteristics of that area. For most areas, immigration has no overall impact on waiting times for A&E and elective care, and leads to a reduction in waiting times for outpatients. Yet, this is not true of every single area every single period. Policymakers should take these differences in impact across areas and time into account when creating policies to reduce NHS waiting times and/or manage the consequences of immigration.

It is worth noting that because of its demographic composition, immigration may have a greater impact on maternity services. Effects could also change in the long-run as migrants become older. In particular, as low-skilled immigrants are more likely to work riskier jobs, morbidity in this group may increase in the long-run. Our project is currently looking at these two aspects.

This article by Osea Giuntella, Catia Nicodemo and Carlos Vargas-Silva was first published on the British Politics and Policy blog

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In the 1976 film All the President’s Men, the informant, Deep Throat, advised the investigative journalists, Woodward and Bernstein, to “follow the money” if they wished to get to get to the bottom of what was going on. And the same advice is likely to apply if we are to evaluate national and local government policy priorities in addressing inequalities.

The vast bulk of public spending in Wales is undertaken by local health boards and local authorities. Probably correctly, the Welsh Government has decided that “big is best” in terms of the size of the these bodies to delivery these services.

Whatever the advantages in bigger delivery bodies they can can create problems in terms of transparency and public accountability as power is concentrated further from communities and citizens. And as our public bodies become bigger and more centralised “following the money” becomes more and more difficult.

A substantial amount of Welsh Government funding is allocated to our health boards and local authorities through needs based formulae. But once the money makes its way to these bodies it is very difficult to monitor if it is being spent in line with the allocation principles. And as these recipient bodies get bigger this task becomes even more difficult.

Local authorities in Wales do not like hypothecation of Welsh Government funds. They wish to be free to make local decisions in line with local needs. But the methodology of resource allocation at a local level is often very opaque and it is very difficult to hold our councils to account in terms of their spending priorities.

In this era of austerity there is no doubt that our most disadvantaged citizens and communities are bearing the heaviest burden. The Welsh Government is working hard to mitigate this though a range of policies but it is crucial that this intention is mirrored where it really matters — at the front-line grass-roots level.

At the end of the day it is outcomes that matter most and it is excellent that programmes such as the Foundation Phase and Flying Start are subject to regular independent evaluation. But in many cases evidence of outcomes can take some time to emerge. In these situations intermediate or proxy measures have to be used and resource allocation ( qualitatively and quantitatively) is often an important guide.

Our most vulnerable citizens and communities are more dependent on public services. They are therefore the most vulnerable when vicious austerity programmes are being implemented. It is vital that effective means are put in place to make sure that our reduced levels of public investment goes to where the need is greatest. Our public bodies must have clear and transparent funding streams in place and that both local and national scrutiny take place to ensure that best outcomes are delivered.

Welsh Health boards cover populations from 132k in Powys to 678k in Betsi Cadwallader. Within health boards 4% of Powys’ population is in the poorest 20% compared to 39% in Cwm Taf and 27% in ABMU. But do we know that within these health boards that resources are allocated in line with this level of need at a local level?

In the recently published policy on primary care workforce, A Planned Primary Care Workforce for Wales, the Welsh Government has highlighted the importance of the emerging 64 “primary care clusters” as a basis for health care planning. These clusters have a population size between 25k and 100k. They are therefore a more sensitive unit size for health care planning on the one hand but also for measuring the level of health care investment and outcomes. Some work has already started on this and the Workforce policy is committed to building on this.

As this information becomes more available it is important that Health Boards “follow the money” and resources to ensure that their allocation is in line with needs and is producing the required outcomes.

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Three months ago my wife contracted lobar pneumonia – out of the blue. One minute she was completely fit and healthy and the next she was in hospital with ITU outreach buzzing around. It was all very, very frightening.

She received brilliant, timely treatment – intravenous antibiotics within an hour of arrival in ED, compassionate and skilled care from excellent doctors and nurses – and was home in three days.

She made a good recovery and there was no paperwork to do or bills to pay. The NHS did what it does best. It was no more or less than I would have expected. My wife and I were both immensely grateful.

But this is not main the point of this story. Please read on.

Last month we were due to go on holiday to the United States. It was just over four weeks after leaving hospital but her consultant had given her the all clear to travel. She was well. Just before we were due to depart I realised that our annual travel insurance policy was due for renewal while we were away. It would run out three days before we were due to return home. We had used the same company for 20 years without ever making a claim.

I attempted to renew on line as usual but immediately hit the question about recent hospital admissions. It was not possible to do it on line – I would have to make a phone call. Then followed the most difficult and upsettinging series of telephone calls that I have had to make for a very long time.

It was just two days before our date of departure and we found the company would not renew the travel policy because my wife was now considered a “high risk”. An early question when talking to alternative providers is “have you ever been turned down for travel insurance”? You have to answer honestly and no surprise, they would you prefer to take your business elsewhere.

Eventually I went back to my original company and told them we would cancel the holiday and claim back the cost against our existing policy. Only then did they agree to cover us for the extra three days until the end of the holiday, but they still refused to renew our annual travel policy.

Insurance companies are risk averse. They only like to insure people they consider to be low risk. They can pick and choose who they take on and you, the customer, have no comeback.

But this is not main the point of this story. Please read on.

Sequencing-Money-300x299-300x299Have you caught up with recent advances in genetic testing yet? It is brilliant. Automated gene walking machines can map your DNA and can tell you your future risk of all sorts of diseases in a matter of days. For £125 you can find out if you are susceptible to everything from cancer to dementia. A bit pricey I know but the technology is developing so fast that in a very few years’ time you will be able to get a comprehensive health risk assessment for a few pence and a bit of spit.

Imagine what the health insurance companies will be able to do with this genetic information. They can tailor your insurance costs to the actual risk of you making a claim. Great news for those with healthy genes but a bit of a blow if there is rogue DNA in the family.

And don’t think they will not do it. They are in business to make the money and they will use any means they can to maximise profits. We are all vulnerable to the health effects of the random throw of our own genetic dice. The new technology will turn genetic bad luck into a personal financial catastrophe.  It will take very strong, new legislation to protect the public from exploitation – unless of course you live in the UK and have a National Health Service which is free at the point of need.

The NHS pools our collective health risk and shares the burden equitably. The cost to individuals is determined by their ability to pay and not their susceptibility to disease. Without the NHS we will be looking forward to a future of increasing inequality of health care provision.

Do not underestimate the importance of this effect. In future our world will be populated by individuals whose wealth as well as health will be determined by their genes. The new technology will create huge distress and social upheaval across the globe.

We in the UK are very fortunate to have the best answer to this problem already in place. We must not squander our NHS just when it is likely to become more import than ever before.

First published on the Big Up The NHS blog

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A long-awaited information standard was launched on July 3 by NHS England that will improve healthcare for millions of people has been welcomed by Action on Hearing Loss (formerly RNID).

The standard requires all NHS and adult social care organisations to meet the communication needs of people with a disability, impairment or sensory loss by 31st July 2016, including the one in six people living with a hearing loss. It will include making sure patients get information in suitable formats and that, if needed, support from British Sign Language (BSL) interpreters is guaranteed.

A survey of over 600 people with different levels of hearing loss to explore the experiences they have when accessing healthcare found:

  • One in seven respondents (14%) had missed an appointment because they had missed being called in the waiting room.
  • more than one-quarter (28%) of people with hearing loss had been left unclear about their condition because of communication problems with their GP or nurse
  • 68% of profoundly deaf British Sign Language (BSL) users asked for a sign language interpreter for a GP appointment but did not get one. 41% of BSL users left a health appointment feeling confused about their medical condition because they couldn’t understand the interpreter.
  • One in seven missed an appointment – the NHS estimates this costs £14 million in England every year due to missed appointments.

Roger Wicks, Action on Hearing Loss’s Director of Policy and Campaigns, said:

“It is vital that everybody understands the information and advice they receive from their GP or hospital. The Accessible Information Standard is the first time the NHS has provided clear guidance on what people with hearing loss and deafness should expect from health and social care services, and what staff should provide. So long as it’s properly implemented, it will enable patients to access services, to understand information they are given, to manage their own health and to participate fully in decisions about their treatment – things that many of us take for granted. While it can’t be denied that these adjustments will come at a cost, it’s now time for providers to acknowledge hearing loss for the serious health issue that it is, and to reap the benefits of enabling proper access.”

1 Comment
Dear Andy
I have read your new Health Manifesto which contains some significant steps forward in our health care but I am deeply concerned that I cannot find how our Manifesto redresses the attack on our District hospital A&E and Maternity Units. As a result there is no equity in provision of acute care, especially in the rural areas.
As Chair of SOS Grantham Hospital and Labour County Councillor for Grantham South (and current District councillor for Grantham St Anne’s Ward) I can advise that we are about to lose what remaining A&E we have.
The Hospital Trust (ULHT) are strapped for funds and are reviewing all acute care in the County. They propose a new Ambulatory Care Unit goes in, that is little more than a minor injuries unit and will not meet the acute medical needs of the population of people living in the East Midlands A1 corridor.
Newark Hospital lost its A&E and now has a Minor Injuries Unit. At the time the cut was justified on the grounds Grantham could provide A&E services. This area has become a vacuum as far as A&E provision is concerned with acute services being ‘sucked’ away into the cities, despite the presence (and therefore associated high risks) of main rail routes, poor internal mainly single carriage A roads, the A1 and a mix of industry including agricultural, oil and mineral extraction. We also have a significantly increasing elderly population as people leave the South East and move up to Lincolnshire and extensive coastal area.
I recall drawing this issue to your attention at your Workshop in Nottingham and understood you were going to address the loss of A&E Units which progressed under our former Government but I cannot see how the current Manifesto achieves this important step.
The whole of Lincolnshire is to see a centralisation of its acute medical care. This is simply unacceptable when we consider it is the second largest county in the country and one of the poorest. It is very simple. If we allow this to happen then the free access to the NHS services we are committed to for all will not be delivered. Only those with a car will seek emergency medical attention unless in a critical condition. Our ambulance crews are already overstretched regularly taking up to an hour to respond (with the added travel time of an hour and more to an A&E Unit).
The Golden Hour, once lauded as vital, especially in stroke situations, will be a thing of a the past for the majority of residents of this county.
We have campaigned against cuts to our services ( a 25k petition went to Downing St) over historic threats (under your watch). The Labour Government did listen and whilst under Labour there were some reductions in service the A&E and Maternity Unit remained.
Under the Tories despite a 7.7k signature petition objecting to the threats to our maternity unit being closed (so now 1000 mums to be a year are forced to travel from the Grantham area in labour) we lost a super Maternity Unit.
Now our A&E unit is facing a death knell in the guise of an Ambulatory Care Unit. Despite thousands of petition signatures the United Lincolnshire Hospital Trust and SW Lincs Clinical Commissioning Group have paid lip service to the views of the  public.
Again, on this front our proposals to sit round a table with the hospital managers seem promising but I doubt will make any difference unless there are real teeth to the proposals that ‘require’ the administrators to take the views of the public into account AND to demonstrate how their views have been reflected in the outcome of any consultation through changes to the proposals. (I am a Business Improvement Consultant). As a councillor I have to send a questionnaire to all households affected by a resident parking scheme and have a majority in favour for changes to go ahead yet the hospital trusts can withdraw vital healthcare provision with no such level of public engagement. This should be addressed.
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