2005 Submission to the Health Select Committee enquiry on Co-payments and charges in the NHS

We believe the NHS should be organized in such a way as to minimize disparities in quality of service between the socially excluded and the most advantaged sections of society. Ideally it should be organized in such a way that all such disparities disappear.

We have campaigned for many years for a free health service without any charges.

Spectacles and teeth

1. Whether charges for treatments, including prescriptions, dentistry and optical services; and hospital services (such as telephone and TV use and car parking) are equitable and appropriate?

As Aneurin Bevan said in the debate about the introduction of prescription charges in December 1949: “The proposal to have a charge up to 1s. creates no administrative difficulty at all. The administrative difficulties arise out of the necessity of exemption.” It is apparent from the debate at that time that charges were imposed primarily as a method to restrict demand. It is not clear to us why it is still thought necessary to restrict demand specifically for medication prescribed outside hospital, wigs and trusses, dentistry and spectacles, but only for poorer people of working age. Since we established the National Institute for Clinical Excellence there are criteria for the prescription of medication and other treatments. It is difficult to see what positive role these charges play.

“What evidence is there that user charges, known to health economists as co-payments, have the selective effects on consultation rates required to restrain over-use, even if that were a real problem? Obviously user charges discourage use, but economists have good evidence that consulting behaviour has little elasticity. Poor people will give higher spending priority to consulting a doctor than to food, if they believe medical advice is needed. The effect of user charges is simply to reduce all consultations across the board, regardless of the nature of the problems that prompt them. The effect is selective only for those with lowest incomes, least able to afford them, but most likely to be sick. In the early years of the African AIDS pandemic, user charges were imposed at state-funded Sexually Transmitted Disease (STD) clinics in Kenya on advice from the World Bank and as a precondition for international aid. Consultation rates fell by 60%. Public care systems have collapsed throughout Africa: no money, no treatment. User charges are advocated not to promote more rational behaviour, but to shift public behaviour “corrupted” by experience of a free public service back to a “normal” commercial pattern.” ”

2. What is the optimal level of charges?

In our view zero is a proper level of charge for treatment or services which are clinically required. If a treatment or service is not clinically required then we would not consider that it should be within the scope of the NHS and charges might properly be made.

3. Whether the system of charges is sufficiently transparent?

The Director of the SHA worked for ten years as a Welfare Rights Officer in a large teaching hospital giving advice to patients and their families. He can give evidence that the Hospital Travel Costs Scheme in particular is not understood by those who are intended to benefit from it or those who administer it. In many hospitals determined efforts are made to prevent patients from claiming the help with fares to which they are entitled. The offices concerned are hidden away in obscure parts of the hospital, there is no publicity given to the scheme and the offices are often closed at times when patients would reasonably want to access them . Although the research upon this work was based is now dated we have reason to believe that little has changed.

There are particular problems with the cost of taxi fares. Many hospitals refuse to pay for taxis. The official guidance on this point states:

“In a few cases, where there is no alternative (for example, in cases where patients have restricted mobility, or public transport is not available for all or part of the journey), patients may have to use a taxi or volunteer car service for the whole or part of their journey.” This does not correspond with the law, which states:

“The amount of any NHS travel expenses to which a person is entitled under these Regulations –

(a) must be calculated by reference to the cost of travelling by the cheapest means of transport which is reasonable having regard to the person’s age, medical condition and any other relevant circumstances;”

It seems to us perfectly reasonable that patients should attend hospital using a taxi, and indeed that they should be encouraged to use taxis, which are a form of public transport, rather than use their own vehicles for which car parking provision should be (but rarely is) made.

4. What criteria should determine who should pay and who should be exempt?

“The present system of NHS charges is a dog’s dinner lacking any basis in fairness or logic” Lord Lipsey, Social Market Foundation. In reply to this comment, made in the SMF’s report in 2003 the Department of Health said it regularly reviewed its prescription policy. It is difficult, however, to discern any evidence of such reviews having any influence on the real world. The list of conditions which give exemption from prescription charges appears to have been laid down in 1950, on the basis that these were conditions where medication was then permanently required. We are not aware that there has been any subsequent change. As stated above we feel that the fairest and most efficient system would be to abolish charges altogether. We defy the Department to produce a fair and acceptable system of charges to replace the present embarrassing mess.

5. How should relevant patients be made more aware of their eligibility for exemption from charges?

If there are no charges we will not have to worry about this matter. If there were a fair and comprehensible system of charges and exemptions it would be much easier to explain. The lack of awareness of exemptions, particularly in respect of Hospital Travel Costs, acts in practice as a system of rationing by ignorance which is perhaps the most indefensible of all rationing systems.

6. Whether charges should be abolished?

A long series of reports have established that charges on patients are the worst possible method of financing a health service. These include both the NHS Plan, and the Wanless Report . The National Consumer Council in 2003 pointed out that around 750,000 people in England and Wales fail to get their prescription dispensed because of the cost and how little clarity there is on the purpose of NHS charges. The National Association of Citizens Advice Bureaux in 2001 described how the “fundamental contradiction at the heart of the National Health Service is the existence of charges for essential items such as prescriptions, dental and optical treatment, within a service which claims to provide health care free at the point of delivery” .

Further reports have described in detail the inequitable consequences of the present system for cancer patients, and the importance of tackling travel costs effectively. In our view the development of a more complex system of healthcare provision such as is now proposed, requires this problem to be tackled now. Many of our members and many NHS staff have formed the view that this government intends to privatise the NHS. If the government wants to prove wrong those critics who assert that the widespread introduction of charging is next on the agenda then it would do well to sort out this mess.

“The availability of good medical care tends to vary inversely with the need for the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.”

We do not accept that it is desirable to deter the population, particularly the poorer members of it, from seeking medical attention:

“The myth that consultations for retrospectively diagnosed “non-illness” represent over-use or abuse is refuted by evidence, but this has not deterred advocates of NHS “reform” from using it as a weapon in argument. Bosanquet and Pollard confirmed its grip on public opinion in their survey noted on p.5. Apparently unconcerned about whether it was true, they identified it as their best entry point for eroding persistent public support for an inclusive NHS funded through social solidarity:

“…. almost two-thirds say that people visit their GP when there is no real need, simply because the service is free at point of use … it is the public’s readiness to concede over-use … that points the way forward. … With 64% saying that there is over-use, there is a strong moral as well as practical case for a charge …”

There is no way that any care system can function without the number of people consulting about worries greatly exceeding the number whose worries eventually prove justified. For example, rectal bleeding is an important signal of possible bowel cancer, for which early surgery is life-saving, but it still commonly presents too late. About 20% of adults have some rectal bleeding each year, but less than 1% of them consult a GP, and the proportion referred to a hospital specialist for further investigation is ten times less even than this. For this example alone, and there are many others, there is overwhelming evidence that patients use the NHS too little rather than too much……….”

We urge the Government to take a bold step by abolishing charges. If it is felt necessary to restrict demand for NHS services then let us devise a rational way of doing so which does not discriminate on the basis of personal wealth.

“The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged.”

What do you think?

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