Oral evidence - United Kingdom Parliament

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Oral evidence Taken before the Health Committee on Thursday 19 January 2006 Members present: Mr Kevin Barron, in the Chair Mr David Amess Charlotte Atkins Mr Ronnie Campbell Anne Milton

Dr Doug Naysmith Dr Howard Stoate Dr Richard Taylor

Witnesses: Dr Felicity Harvey, Head of Medicines, Pharmacy and Industry Group, Mr Mike Brownlee, Deputy Head of Medicines, Pharmacy and Industry Group, Dr Barry Cockcroft, Acting Chief Dental OYcer, Mr Ben Dyson, Head of Dental and Ophthalmic Services, and Mr Rob Smith, Director of Estates and Facilities Management, Department of Health, gave evidence. Q1 Chairman: Welcome to the first evidence session that we are taking on our inquiry into NHS charges. I wonder if I could ask you to introduce yourselves. Dr Harvey: I am Dr Felicity Harvey and I am head of Medicines, Pharmacy and Industry Group within the Department of Health. My group looks after prescription charge policy and the NHS Low Income Scheme. Mr Brownlee: My name is Mike Brownlee and I am Dr Harvey’s deputy. Mr Smith: My name is Rob Smith. I am Director of Estates and Facilities Management, which covers car park issues and patient telephones and patient televisions. Dr Cockcroft: I am Barry Cockcroft. I am Acting Chief Dental OYcer for England, responsible for professional advice within the Department of Health on dental issues. Mr Dyson: I am Ben Dyson, I am Head of the Dental and Ophthalmic Services Division within the Department of Health.

Q2 Chairman: Thank you very much. I wonder if I could start with the first question, directed to any or all of you. You will have probably heard this comment before: Lord Lipsey of the Social Market Foundation described the current system of health charges as “a dog’s dinner, lacking any basis in fairness or logic”. What are the underlying principles of the system that we currently operate? Dr Harvey: The charges we currently have for prescriptions, dental treatment and ophthalmic services date back to 1951 to 1952. That is the time that charges were first introduced. Certainly, if you look for prescription charges, they remained until 1965, were abolished, and then reintroduced due to concerns, we understand, about the rising drugs bill in 1968. The policy on the individual areas has very much related to the clinical services which they support. Certainly in terms of prescription charges, the policy in terms of the broad levels of exemptions, has been relatively unchanged really since 1968. I do

not know whether my colleagues on the optical and dental services would like to comment from their particular perspective. Dr Cockcroft: From a dental point of view, the system of charges for patients is based very much on the way the clinicians are remunerated for the services they provide. It has been a constant source of complaint for some time, both the complicated way we remunerate dentists and the complicated way in which patients therefore are charged. That has been a really diYcult issue for the last few years. We have just been through a programme of reform of patients’ charges, with significant patient involvement. A significant message from the patients was that we needed a much simpler, clearer system, and that fits very neatly into the reform of the way we remunerate dentists which we are going through at the moment. We are addressing that issue at the moment in the dental charges. Mr Dyson: If you look at charges for dental services and the system of the NHS sight tests, successive administrations have taken the view that it is reasonable to ask those who can aVord to do so to make a contribution to the cost of those services. I think it is also important perhaps to distinguish between some of the factors that may have led the governments of the past to introduce such systems. If you look back, for instance, to 1951, there were special circumstances that surrounded dentistry, with, I think it is fair to say, an unexpected level of demand for dentures, so diVerent factors may have influenced the introduction of those charges in the first place. The decision that has faced administration since then has been more about whether to continue with these systems or whether to abolish or alter them in some way, and of course diVerent considerations then come into play. Governments have had to take into account the contribution which the system of charges makes towards meeting the overall costs to the health service; they have had to take into account the fact that there is little evidence to suggest that those charges produce poorer health outcomes; and they have had to take into account the fact that these

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systems are now well established and, broadly, I think it is fair to say, accepted, in the sense that, where we receive concerns from patients about, for instance, dental charges, as Dr Cockcroft says, these tend to be more about the structure of the system than about the principle of charging per se. Dr Harvey: I think underlying all of this has been the principle, for those areas in which the Government decided that charges should be levied, that those that are able to contribute should do so and those who are unable to contribute should be protected through either benefits or, indeed, the NHS Low Income Scheme. Q3 Chairman: My colleagues will be taking one or two of these matters up on a more individual and focused based later on. Whilst you cover the areas that you have outlined to us, you will not be immune to the debate that is taking place in diVerent parts of the United Kingdom about the potential to abolish prescription charges. I wonder if you have any views on what the costs of abolishing charges would be in terms of prescriptions, optical and dental services. Dr Harvey: In terms of prescription charges, at the moment they bring in an income of about £427 million per year (estimate for 2005–06). Over the last year, that has fluctuated slightly: £422 million (2004–05), £426 million (2003–04), but it is roughly in that sort of area. Mr Dyson: In terms of dental charges, it is always slightly diYcult to predict in advance exactly what level of dental charges are going to be collected, but the aim of the new dental charging system, amongst the benefits it brings for patients, is to make sure that we do not raise a greater proportion of charges than now. That would mean that abolishing that system would mean that the NHS would forego income of up to around £600 million. For sight tests, we estimate that if you were to extend free sight tests to all those who currently pay privately for sight tests, the costs would be about an additional £92 million, based on the current rate of £18.39 per test. Q4 Chairman: Are both of those figures, the £92 million and £600 million, per annum? Mr Dyson: Yes. Q5 Chairman: Was your figure per annum, Dr Harvey. Dr Harvey: It is a per annum figure. Q6 Chairman: That would be the costs of abolition, eVectively, as far as England is concerned. Mr Brownlee: I wonder if I might add, in terms of prescription charges—and I do not have a figure for you—that we believe there might also be an influence on the drugs bill, in the sense that, for some of those people who are currently paying charges and perhaps go to their community pharmacy and buy a medicine over the counter, there might be an incentive to go to their GP and get a prescription. But it is almost impossible for us to forecast potential changes in behaviour, and one has to say that, if you compare the growth of the drugs bill since 2001 between England and Wales, since the

Welsh Assembly decided to start reducing their prescription charge there has not been any noticeable change in trend. Q7 Chairman: Is there any evidence that charges should be increased, on the basis that if they were increased people would seek to take responsibilities for their own health as opposed to relying on the National Health Service? Dr Harvey: From the prescription charge perspective, certainly the prescription charge has been looked at in recent years annually by ministers—I think, in the same way that many of the benefits are—and there has not been any decision to raise them significantly in recent years. Since about 1997, the increase has been 10p per year, which actually, if you look over the period, that particular period, is in fact a real terms decrease of 4.5%. I think the Government is very well aware that there is an issue of aVordability. Certainly, from the work that was done by Citizens Advice and the MORI work back in 2001, we are aware that there are some low-income groups where a huge rise in prescription charges would be very diYcult. In fact, a lot of the work we are doing through the Prescription Pricing Authority is for the prescription charge that we currently have, trying to get better and better at targeting those low income groups, so that they are aware not only of the benefits that are available to them through the Department of Work and Pensions but also the NHS Low Income Scheme. Q8 Chairman: Do you think this is flexible enough at this stage, or do you think there is a level of inflexibility about it leading from that? Dr Harvey: Certainly, in terms of the NHS Low Income Scheme and the information we have been aware of through the Citizens Advice work and other work that is being done by academics such as Professor Peter Noyce, we have tried over that period to make some minor amendments to the NHS Low Income Scheme so that it is slightly more flexible in terms of meeting the needs of those people who have low incomes. Dr Cockcroft: With regard to dentistry, patients’ charges have always been calculated as a percentage of the fee the dentist receives, so there has always been a direct link between the percentage increase in dental fees paid to the dentist and the patient’s charge. That has been there since the dental charges were introduced. From April next year, that link is taken away, but we have been involved with patients’ groups in working out the new system of patients’ charges, and we have not detected the intention to make any increase in dental charges disproportionate in the new system. Q9 Dr Stoate: Just for the record, could I start by reminding the Committee of my declaration in the Members’ interest book that I am still a practising GP. We have heard from Dr Harvey the reasons why we have charges and how it happened, but I have not yet heard the underlying principles behind it. Are we really saying this is about raising money, reducing demand on services or reducing the drugs bill?

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Dr Harvey: The fundamental principle that we had back in 1951–52 is historical. I could not tell you exactly why the charges were decided to be made on those particular things. We do think that back in 1968, when prescription charges were reintroduced, there may have been concerns about the NHS drugs bill at that time. Q10 Dr Stoate: But that does not answer the question as to why particular conditions were singled out. If the Government was simply trying to reduce the cost of prescriptions, why was there not simply a blanket charge for prescriptions? A prescription costs this much—end of story. I still have not understood the principles behind it. Dr Harvey: Historically, in terms of why particular medical conditions were chosen, it is something that happened in consultation with the medical profession back in 1968. Those conditions have been unchanged since that time, even though we have had representations from a number of diVerent chronic disease condition groups. But the principle has really been around that of: those who can aVord to contribute, should do so, and that we protect those who have diYculty in aVording charges. That has really been the basis of the changes that have taken place in recent years. Q11 Chairman: This sounds suspiciously like: We have always done it and therefore we are carrying on doing it. You still have not explained to me. The prescription charge principle having been put in place nearly 40 years ago, no-one seems to have challenged the reason why it was brought in and why we have not changed it. Dr Harvey: From what we understand, the issue of the particular medical conditions that we have at the moment, which date back to 1968, has been looked at on a few occasions but on each of those occasions ministers have made the decision not to add or change the list of medical conditions that are exempt from prescription charges. Q12 Dr Stoate: Does that mean that no serious consideration has been given in that case to a more flexible system or an alternative system completely. For example have we looked in detail at some of the European alternatives? Have we really considered in detail what other countries do, in Scandinavia, for example, or have we simply said, “We do this, therefore we have to carry on doing it”? Dr Harvey: On the occasions when ministers have looked at prescription charges, they have not made any decisions to change from the broad principles that we currently have. I think there is also an issue in terms of the medical conditions that we currently have. Clearly there are now very many chronic medical conditions that we are able to treat and treat very eVectively. I suppose the issue is that, if you have a large number of medical conditions, where might one draw the line? The approach has certainly recently been in terms of aVordability and trying to ensure that those who would have diYculty in paying are protected. The other thing that it would

be worth adding is that certainly with the prepayment certificates that are now administered by the Prescription Pricing Authority (PPA), we now have a maximum charge for prescription charges annually of £93.20, or, for a four month period, of £33.90.1 If you look at the number of prescription items for the exempted groups, they are quite a lot higher than the average. The average number of prescription items per person per year is about 14. If you look at those people who pay for their prescriptions and have the pre-payment certificates, it is about 46 items per person per year, and, if you look at those who are medically exempt, I think it is about 232 prescription items per year. But I think we should also remember that, in terms of prescription items, currently 87% of prescription items are exempt prescription charges. So it is only 13% of prescription items where a charge is paid and in fact 5% of prescription items are paid through prepayment certificates. Q13 Dr Stoate: When you talk about aVordability, which I would like to come on to now, figures we have seen from Which?, for example, show that 6% of those on low incomes fail to take courses of prescribed medications because of cost and 24% fail to consult a dentist for the same reason. Certainly, as a GP I can recount many occasions when people have said to me, “I simply cannot aVord three prescriptions, which one can I do without?” My pharmacist colleagues say exactly the same thing: people will take their prescription to the pharmacist and have quite a diYcult discussion sometimes with the pharmacist about which of the medications they can strike oV, which cannot possibly be good for patient care. You talk about equitable charges and you talk about aVordability and yet there is very good evidence from a number of sources that some people simply are not getting the drugs their doctor says they ought to have because of cost. Dr Harvey: We are very conscious, particularly, of the Citizens Advice work that was done in 2001 and, indeed, Professor Peter Noyce’s work around the same period, and, it is as a result of that, that in 2004 we made the change to the NHS Low Income Scheme which increased the level by which income exceeds requirements for the Low Income Scheme to include half the cost of a prescription. Particularly for those people on incapacity benefit, who are not passported automatically to free healthcare costs and they would have to apply through the NHS Low Income Scheme, we are aware that from that change about 44,0003 additional people within income benefits, who were only able to have partial help before that, became able to have full help. We are very much aware of these issues, which is why there have been the changes to the NHS Low Income 1

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Note by witness: Pre-payment certificates (PPCs) have been available since 1968 and the arrangements have been administered by the PPA since October 2002. Note by witness: Individuals with medical exemption have an average of 33 prescription items per person per year. See answer to Q19. Note by witness: Estimated from a sample, when rounded the final figure is near 45,000.

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Scheme—which include giving people over 65 five-year exemption certificates rather than the 12 months which we have for other people.

Dr Harvey: I am sorry, I apologise I made a mistake. In fact it is 33 items per person per year for those who are medically exempt. My apologies.

Q14 Dr Stoate: People who are 60 do not pay prescription charges at all. Dr Harvey: But they do pay for dental, optical and also health care travel costs.

Q20 Dr Taylor: Even that is still quite low. No, it is just more than two items per month. Then you finish up with a figure that something like only 13% of items are charged. Dr Harvey: They are. In total 13% of prescription items are charged for. In total 8% are paid for by people paying at the point of dispensing and 5% in total have a prescription pre-payment certificate.

Q15 Dr Stoate: Nevertheless, whichever system you bring in, there are going to be people above the threshold level. Whatever you do to the threshold level, there will always be people just above it. Have you considered a tapering scheme to help such people? Dr Harvey: Again, as a result of the work that has been done, the PPA, who took over the administration of the pre-payment certificate in October 2002, have been looking at the recommendations that came from Citizens Advice, which were things such as: Have we considered monthly payments for the pre-payment certificate?4 and also: “Have we considered doing something through the Low Income Scheme in terms of a sliding scale”? These are issues which the PPA has been looking at. We think they are due to be coming to ministers in the not-too-distant future. Q16 Dr Taylor: Dr Harvey, I think you have lost me and I would like to go back over some of this mass of figures you have given us. First, you have said that the principle is that: those able to contribute should and those unable to should be protected. I fear that is going to raise an absolute furore, because there are many who could contribute a great deal more who are exempt and there are many . . . Think of somebody with hypertension, who has to have at least a combination of three drugs, all separate, who is on a low income but not suYciently low for them to be free. Three charges, three times £6.50 a month, is a vast amount. People are exempt, on average, 23 items per year. Is that what you said? Dr Harvey: People who have medical exemption I think have about 235 prescription items per person per year on average. Q17 Dr Taylor: Then, for those who were not exempt, you said it was something like 46. Dr Harvey: Those who have a pre-payment certificate, which is 5% of prescription items, they have on average 46 prescription items per year. Q18 Dr Taylor: Obviously they are people who are not exempt, who know they are going to have to pay an awful lot, pre-paying, so that they pay a bit less Dr Harvey: They pre-pay, which means that the maximum they would pay, with a 12 months certificate, would be £93.20 per annum. Q19 Dr Taylor: I find the 23 items per year for those exempt relatively small. 4 5

Note by witness: Citizens Advice suggested monthly payments for a PPC not a one month PPC Note by witness: Correct figure is 33 prescription items per person per year.

Q21 Dr Taylor: That 13% raises £427 million per year. Dr Harvey: That is correct. The issue is that those people who are medically exempt are medically exempt for the condition they have; but they are medically exempt, as a result of which, they are exempt any prescription charge on any item. That, again, is historical. Q22 Dr Taylor: Which seems pretty unfair. Dr Harvey: Although perhaps I could add that the diYculty, where you have people who have a medical exemption, in deciding which of the medications might be either directly related to their condition or, indeed, partially related to their condition, would need quite a lot of clinical input to make those decisions. Q23 Dr Taylor: Meaning that somebody with diabetes you would argue that their treatment for hypertension was so important for the diabetes that it was related. I see what you mean. Dr Harvey: I think that is probably one of the reasons why, for those who are exempt, all of the prescriptions are medically exempt rather than just those specifically tied to the condition. I am not exactly sure why, but I would surmise that may have been— Q24 Dr Taylor: Dr Stoate rather touched on this, but is there evidence that the prescription charges reduce the take-up of medicines by those who really cannot aVord to pay? Dr Harvey: Certainly, from the Citizens Advice research that was done back in 2001, they were flagging that there was a concern that up to 290,000 non exempt patients might suVer as a result of the charges. Since that time, we have made further changes to the NHS Low Income Scheme. The other thing—and I know this has been flagged—is that there may well be people who could get help through the NHS Low Income Scheme but are not aware of it, and that is why the Prescription Pricing Authority, since they took over responsibility for this—and, indeed, they on behalf of the Department of Health take forward all the publicity—lead with a publication of this particular document. We have provided for the Committee copies of the sort of information that is published. That is why they are working very hard with patient groups, Citizen Advice, and, indeed, the NUS, who are another group, around trying to ensure that we better target

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the information about help with health costs to those who need it. It might be worth adding also that that information is also on the patient’s part of the prescription form—and, again, we have supplied a copy in the information to the Committee. Q25 Dr Taylor: Do you have any feel of the drugs that cost less than £6.50 for the number of people who buy those that are available without a prescription? Was that one of the figures you gave us? Dr Harvey: No. The information I have available is that there is an average net ingredient cost for each of these groupings. If you look at the net ingredient cost for all of those people who pay for prescriptions, whether it be by pre-payment certificate or actually at point of collection, the average net ingredient cost is £14.32, and obviously the prescription charge is about 45% of that. But clearly the prescription items that are prescribed vary in their cost. Some are much more expensive. Q26 Dr Taylor: Is there any regular information given to a patient, “The prescription charge is £6.50. This would only cost you £5 if you bought it without a prescription.” Is there any record of the sorts of people who get that information and take it up? Dr Harvey: I do not particularly know of it, although anecdotally one is aware that sometimes general practitioners might say to patients, “These are the things you need. You might want to get that from your pharmacist.” But I do not have any information on that, I am afraid, no. Mr Brownlee: Chairman, anything that is sold to a patient as an over-the-counter medicine is the private business of community pharmacists and we do not have any remit or record of what takes place. Dr Harvey: But items that are on an FP10, as you know, are the items that are prescribed under the NHS. Q27 Dr Taylor: Would chemists have the right, if something was on an FP10 and they knew it only cost £4, to cross it oV and suggest the patient bought it at £4? Mr Brownlee: I do not think they have the right. I think I am right in saying that, if something is prescribed by a doctor, then that is what they have to dispense. What happens in real life, sometimes, might be diVerent.

patient groups around both the targeting of information about both pre-payment certificates as well as the NHS Low Income Scheme. So they are working quite hard with those groups. Mr Brownlee: Chairman, we know also that there are other reasons why patients either do not go to the doctor or, having been to the doctor and got a prescription, decide not to obtain it, and then, even when they have got it, decide not to take it. We know there is something like probably £200 million worth a year of medicines in people’s medicine cabinets that are not taken, so there is a whole raft of reasons there. Q29 Chairman: Evidence about pre-payment—the £93.20, you said. Dr Harvey: £93.20 for a 12 months pre-payment certificate. Q30 Chairman: That is money up front, is it? Dr Harvey: It is indeed. Q31 Chairman: Is there any evidence that that is a problem in terms of people accessing that system, having to find £93.20. Dr Harvey: We certainly know that in terms of the take up of pre-payment certificates (PPCs) the takeup is increasing year on year. We are aware though, again from the previous research, that there may be issues of aVordability for those who are over the threshold for the NHS Low Income Scheme and that is why the Prescription Pricing Authority is doing work around the possibility of monthly payment for prescription pre-payment certificates, and also the other thing which was raised, a sliding scale for the NHS low income scheme. They are looking at that at the moment and will clearly come to ministers. Is it worth adding, Chairman, that in terms of the average number of prescription items per script (prescription form), the average number is two. If one were able to move to a monthly payment for a prescription pre-paid certificate, in fact that is likely to be less than the cost of two prescription items. Also, once you have 15 or more prescription items per year, then in fact that is the pre-payment certificate paid and that is the level at which it is capped.7

Q28 Dr Taylor: Again anecdotally we hear stories of people who have been frightened to go to the doctor because of the risk of the amount they had to pay and they could not find it. Is there any evidence to back that up? Dr Harvey: The information we have on that dates back to the research that was done by Citizens Advice. That is actually why the Prescription Pricing Authority are working quite hard with Citizens Advice,6 the National Union of Students and other

Q32 Dr Naysmith: I would like to explore with Dr Harvey some things that have already been touched on. It is this question of the logic behind exemptions—not just particular diseases being exempt, some are and some are not, but, if you are in hospital, you get your drugs free, but as soon as you come out of hospital you are back on to paying prescription charges again if you are in a certain category. There are one or two other anomalies of this whole system. For instance, if you are in an exempt category for a particular disease, then you get all your prescriptions free, not just the one that applies to the exemption. It is riddled with anomalies

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Note by witness: Citizens Advice are not currently involved in PPA stakeholder meetings but they do advise on the development of leaflets and posters. There is regular contact between local CA oYces and the PPA on individual cases.

Note by witness: The cost of a 12 month PPC is less than the cost of 15 prescription items. Once a PPC has been purchased no further charge is due, regardless of the number of items dispensed.

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and lack of logic, as we have already touched on this morning, but why does the Department not review this list and get rid of these anomalies now? I have written to them on a number of occasions, often to do with cystic fibrosis, as I know a little bit about it, and I get two replies back, either that this is being held under constant review—but you or the Department or the particular minister does not say that anything has ever happened since 1968 to all these reviews—or they say, “We have recently reviewed it and we are not going to review it again for a while”. These answers from the Department indicate that it is not a priority at least. Why do you not review this list and get rid of these anomalies? Dr Harvey: In response to your comment about whether or not things are being reviewed, it is certainly true to say that when we have issues that are raised in correspondence from yourselves, we do look at the issues, particularly in terms of the aVordability and the feasibility, and it is on the basis of those that actually many changes, particularly to the NHS Low Income Scheme, eg the length of time we have certificates for, et cetera, have indeed been changed. In terms of major reviews of the prescription charge system, this is not something that ministers have asked us to do at the moment. We are not undertaking a major review of prescription charges, although, as I say, we do keep under constant review particular issues around aVordability and making the system work better. Q33 Dr Naysmith: But not the disease categories and that kind of thing. Dr Harvey: These are issues that ministers have asked oYcials to look at on a few occasions over the years, but on each occasion that they have been looked, at the ministers’ decisions have been not to change them, but more around the aVordability issues. Q34 Dr Naysmith: Sticking with this question of the anomalies—and I think you hinted at it earlier on— there have been such diVerences and medical improvements in a number of these conditions, and there is a series of cancers that are very good examples and also cystic fibrosis as well, that people survive much longer. Dr Harvey: Yes. Q35 Dr Naysmith: It is a very diVerent situation, looking at these diseases now to looking at them 20 years ago. Why is the logic not extended? You are not going to say it is the ministers’ fault, are you? Dr Harvey: Absolutely not. The issue is that clearly there are very many very serious chronic conditions and these have not been reviewed for a while. The issue would always be: where would you draw the line? Therefore the approach has very much been around aVordability and capping the cost of prescriptions for those who pay. Again, only 13% of prescription items are paid for; 87% of items are exempt prescription charges through age, medical condition, benefit passporting, NHS Low Income Scheme, or, indeed, maternity certificates.

Q36 Dr Naysmith: You would accept that for some disease areas it is a kind of thing that people cannot understand, why their particular disease is not exempt where others are. Dr Harvey: We do understand that there are many, many patient groups which have major concerns about why, indeed, their condition is not exempt. Q37 Anne Milton: I know this may be slightly tricky for you. You did say at the beginning that you were responsible for prescription policy. I cannot see the policy that makes the diseases exempt that are exempt, and some, as my colleague mentioned, like cystic fibrosis, not exempt. What is the policy that lies behind that? Dr Harvey: As I said, the exemptions date back to when they were brought in in 1968. On the occasions that ministers have looked at them, the list has not been extended but we have been looking at the aVordability issues. Q38 Anne Milton: Nobody is going to change that list of diseases, as far as you know. Dr Harvey: To date there have been no changes in that list of conditions that are medically exempt. Q39 Anne Milton: Are you aware that there is going to be in the future? Dr Harvey: We have not at the moment been asked to do a review of medical conditions. Anne Milton: Thank you. Q40 Dr Naysmith: One of my questions was going to be: When are you going to look at the list again? The other thing you have not answered is whether there is any logic. If someone is on the list and gets the prescription free for that particular condition, if they develop another condition do they get the prescription free as well?—even though they may not be poor. Dr Harvey: I think the issue is one of complexity; that is, to be able to categorise which prescription items, for example, for somebody who is medically exempt, were nothing to do with the underlying condition which gives them medical exemption. That could at times be quite complex and would need a great deal of clinical input to do that. Dr Naysmith: You could almost certainly find a GP who would back up whichever argument you were making. I should not have said that, Howard! Q41 Dr Stoate: You talked about aVordability as being the criterion, if you really are concerned with aVordability the only logical thing is to abolish all prescription charges because then probability goes away. Dr Harvey: Prescription charges do bring in around £427 million a year. Q42 Dr Stoate: If aVordability is your criterion then that is the way of getting round it. Dr Harvey: I think it comes back to the principle of those who are able to contribute.

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Dr Stoate: I do not mean to butt in on this, but I have one final point, a very quick intervention. If I treat someone with an overactive thyroid, I give them Carbimazole and they pay for it. The moment I give them too much Carbimazole and their thyroid becomes under-active—which very frequently happens—they do not pay ever again. Where is the logic in that? Q43 Dr Naysmith: And can it ever make sense for wealthy old-age pensioners like me to get their prescriptions free when some people who are very close to the levels of cut-oV do not get that. Dr Harvey: In terms of the age that we currently have for exemption being 60, the age in fact for men was 65, the age for women was reduced from 65 to 60 in 1974, and in fact it was due to a case within the European Court on equality issues that in 1995 the charges were exempted for men aged 60 as well. Q44 Dr Naysmith: But that is explaining why they got rid of the equality diVerences, not why people who can well aVord to pay for the prescriptions get them free and some people who cannot really aVord to pay for them have to pay for them. Dr Harvey: And I think again the exemption for those—which was age 65 and has now become age 60, as I explained—really goes back to 1968, when the prescription charges were reintroduced. Q45 Dr Naysmith: Continuing on this line in mental health conditions, changes recently –and there are more likely to be more in the future—provide for compulsory treatment in the community under nonresidential treatment orders. The liberty of patients who are involved in this is clearly dependent on their compliance with a medication regime, and yet they have to pay for prescriptions. If they are admitted to an institution they do not pay, but while they are in the community they do pay. Here is another anomaly. What are we going to do about that? Mr Brownlee: The issue has been that over the years these anomalies or things similar to them—and obviously they have changed over the years—have been looked at by successive administrations. The outcome of this, in the main, apart from the areas we have already identified to you, has been to retain broadly the same system. Q46 Dr Naysmith: So it is a series of ministers’ faults. Mr Brownlee: I am not trying to attribute blame. I do not want to give you the impression that this has never been considered by anybody ever in the Department of Health. Q47 Dr Naysmith: I am sure it has, but I am looking to see if there is any real rationale behind it. With people suVering from ill health mental conditions, this is happening because treatment is changing, not because anything else is changing. Mr Brownlee: Every time you are thinking of changing or abolishing, as was mentioned just now, it is a matter of the loss of £420 million or £430 million, or whatever the figure has been at the time, and the priorities that administrations have put to

that income versus the loss of that income to the NHS on other services. If you do something that maintains whatever the level of income is but there are changes to the exemptions, there will be losers to pay for those people who are benefiting. Q48 Dr Naysmith: Have the figures been done to look at what the costs would be for extending the list to include the patients suVering from mental illness that I have mentioned and then cancer patients and then those with cystic fibrosis? Have the costs been worked out for individual conditions and the loss of revenue that would be involved? Mr Brownlee: The answer to your question is no, and I will explain why. Because of the exemption from all conditions, to say what the cost would be is . . . You can do quite a big study through the GPRD database, but we have not done that. Equally, we do not know how many patients suVering from those conditions or any other conditions are already exempt through another basis. It is a very diYcult calculation to do. Dr Harvey: Could I respond to your earlier point on mental health patients? The issue around treatment for mental health patients has been looked at around the Mental Health Bill and is under consideration at the moment. Q49 Dr Naysmith: As a member of the joint Commons and Lords Committee that looked into the Mental Health Bill, some of the costs are going to be tremendous. But maybe that is for another day. Finally, sometimes the argument is used—and I do not think you have used it yet today—that exempting people from prescription charges leads to the frivolous use of medicines and therefore unnecessary charges. Is there any evidence for that? Mr Brownlee: I am not aware of it. On the basis that you have 87% already exempt, clearly we have other measures in the Department in terms of advising prescribers, in terms of what should be prescribed, and that is the way of getting at that; not trying to do it through prescription charges. If we were trying to do it through prescription charges, having exempt 87% to start with, then it would not be eVective. Q50 Dr Naysmith: If there were any evidence for it, then one could get an answer to this question of whether it exists by comparing the two groups, those who are exempt and those who are not, and seeing whether there was an increase in frivolous use of medicines in the groups that were getting them free or exempted. Mr Brownlee: I think the way this has been looked at is through advice on prescribing across the piece, for everybody, not just looking at whether they are exempt or not exempt. Those are the measures the Department has undertaken over a number of years, generic prescribing rather than brand medicines and that sort of thing. Dr Harvey: Perhaps I might add that there is certainly quite a lot of advice to prescribers, both that produced by the National Prescribing Centre but also the Drugs and Therapeutics Committees and also, indeed, prescribing advisers within

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primary care. So there is quite a lot of advice around prescribing and, indeed, the data from prescribing is data that is received by PCTs so that they are indeed aware of the sorts of prescribing habits that are going on. But I think that is very much a clinical issue, since prescribing is very much the domain of the clinical practitioner, primarily doctors, but now also extended to some other clinical groups as well. Q51 Chairman: Could I ask a supplementary, Mr Brownlee, about this situation of people with certain mental illness conditions. By implication, non-residential treatment programmes save quite substantial amounts of money because people are not living in residency. Has that been taken into account when looking round at the issue about whether or not these patients should have free prescriptions, or is that still being looked at now? Mr Brownlee: It still comes under the category of what we said just now: “This area is being looked at”. Q52 Chairman: Has it been costed as to the savings you would make on a non residential treatment programme? Mr Brownlee: Not to my knowledge, but in a sense that is not my area. Dr Harvey: We are not aware of it. Q53 Charlotte Atkins: Moving now to the issue of dental charges, could you identify any broad changes in dental health since charges were introduced for dental examinations back in 1989? Dr Cockcroft: For dental examinations specifically? Q54 Charlotte Atkins: Yes. Dr Cockcroft: The dental health of the nation has been improving at a steady rate for a considerable period of time now, both in children, adults and older people. I do not think there has been any change in that pattern since 1989. The only area where there has been a flattening out of that improvement is in the very youngest children, where the improvement in health is more related to diet and education than it is to the provision of treatment. Of course, the introduction of charges for examinations in 1989 would not have aVected those anyway because they were obviously exempt from charges, but I am not aware of a slowdown in the improvement in the oral health of adults who are liable for charges since they were introduced in 1989. Q55 Charlotte Atkins: You would put the improvement in dental health to better diet and education or to issues like fluoridation. Dr Cockcroft: I think it is a combination of factors. Quite clearly, fluoridation, both of water in some areas where that has happened, and its now almost universal availability in toothpaste has been probably the most significant factor in the improvement of oral health across the board. Obviously patient expectation and increasing awareness of oral health and education have also played a part as well.

Q56 Charlotte Atkins: In April this year, there is a new dental contract coming into eVect. Do you think that will have a significant impact on the dental health of particularly those groups which find dental charges hard to aVord? Dr Cockcroft: I think the contract will have a significant impact on the way services are delivered. The service was eVectively designed in 1948, when dental disease was rampant, and the focus of that system was about the so-called drill and fill and it was appropriate at that time because there was a need for that service. The dental health of the population is so improved now that that particular treatment modality is inappropriate and we want to go to a more preventive phase and build on patients’ expectations. We are clear that we want to make the new system of charges consistent with that and not introduce any perverse incentives into the system that take dentists away from adopting a more preventive approach, and we are keen to maintain that in the new system. We are not changing any of the exemption categories. Obviously there are diVerent areas there about tackling inequalities and addressing the education issues, and we have just published an oral health plan for England which focuses PCTs’ minds on growing preventive services in their local community and making it part of their local development plans. Q57 Charlotte Atkins: The new charging system obviously will simplify the whole situation. There are something like 400 charges at the moment, which are obviously very diYcult for patients to understand. One of the complaints I often get is that a particular procedure that they want is not available on the NHS, but obviously would be available if they paid privately for it. What impact will the new charging system have on that? Will there be a re-look at what procedures are allowable under private arrangements as opposed to NHS arrangements? Dr Cockcroft: One of the diYculties is the complexity of the current system. There is relatively little that is not available on the NHS that is clinically necessary. I cannot think of anything in any particular situation which is clinically necessary which truly the NHS does not fund, whether you have to pay the charges having done the— Q58 Charlotte Atkins: When you are dealing with something like teeth, clearly there can be an overlap between what is necessary and what is cosmetically desirable. Dr Cockcroft: Yes, I think that is absolutely right. One of the things we have said very carefully is that we will pay for what is clinically necessary and the dentist has the freedom to use his clinical judgment in the new system about what is clinically necessary. Also we are going to have a programme of patient information starting relatively soon, to explain to them what is available, when it is appropriate for the NHS not to pay somebody because there is not a clinical need for that, but also the clarity of the charges. The diYculty with the charges at the moment is two-fold. Because you do not know in advance what the charge is going to be because of the

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way it is calculated, that creates a sort of nervousness in patients, and the new banding system takes that away. There is also in some areas a clear diYculty in people diVerentiating between when they are paying for private treatment and when they are paying for National Health Service treatment. One of the clear advantages of the new system is that it is one of the regulations that the dentist has to put in his surgery, in the waiting room where it is clearly visible, what these new banded charges are. It would be very obvious to a patient then, if they are being charged something which is not one of those bands, if this treatment includes an item which is not a National Health Service treatment. Q59 Charlotte Atkins: If we take a particular case, say an older person with a fixed income who needs a partial repair to a denture, would that person under the new system not be paying more than she is at the moment? Dr Cockcroft: The fundamental diVerence between the new system and the old system is that in the old system you were paying individually for every single little item of service and in the new system you are paying for an overall course of treatment. So it is very easy to pick out individual items at the moment that are less than the banded charge and make the comparison. Overall, we considered that when we were looking at the system, and patients groups were very keen on the clarity thing being the most important thing. But if you look at an overall course of treatment, it does not only include the particular item to which you may be drawing attention; it would also include an examination, diagnostic xrays, and, in the case of a partial denture, any other treatment that the patient needs on the rest of the mouth. Q60 Charlotte Atkins: But if that was the only item, then she would be paying more. Dr Cockcroft: There will be instances when that happens, when you go for a fee per item to a banded system. But we have done an analysis of the case and obviously the maximum charge comes down very significantly, from nearly £400 to under £200, and we know that a large number of people in the system, if they are doing that, will pay less rather than more. Q61 Charlotte Atkins: Of course, the big issue as far as dentistry is concerned is the availability of NHS dentists to carry out NHS dentistry. That is obviously the big issue. One issue that has been raised with me very significantly is the situation where parents are possibly bribed to take up a Denplan arrangement so that their children can receive NHS dentistry. Will you tell me what the new contract will do for that and what impact that will have on NHS dentists who are providing NHS dentistry for both parents and children? Dr Cockcroft: First of all, to make acceptance of a child conditional on signing up for private treatment would be a breach of the regulations from April. Q62 Charlotte Atkins: But it happens widely now, does it not?

Dr Cockcroft: It does. We are well aware of that. Q63 Charlotte Atkins: How many children are aVected? Dr Cockcroft: I do not think we would have figures about that. Q64 Charlotte Atkins: It worries me that we are having a significant change here in the contract and you are telling me that you do not know how many children potentially might be aVected by the new contract coming in and the possibility that the dentist will not be treating those children on the NHS from next April. Dr Cockcroft: Certainly that was a clear issue for dentists who were operating an acceptance policy, not that it is conditional but they do treat children. If a practice treats adults privately and children on the NHS, that is a decision for them to take. It is a breach of regulations to make one conditional on the other. I think that is diVerent. We are saying, if you want to agree a contract with a dentist or a PCT wishes to agree a contract with a dentist which allows that practice at the moment to contract and provide services to children, it can do that, but it does not allow them to make acceptance of those children conditional on the adults accepting the private policy. Q65 Charlotte Atkins: You are saying they can treat the parents or adults under Denplan and they can also, at the same time, treat any children under the NHS. Dr Cockcroft: Yes. Absolutely clearly. Q66 Charlotte Atkins: But it would be incorrect and against the regulations for one to be conditional on the other. Dr Cockcroft: Yes. Q67 Charlotte Atkins: The idea that dentists cannot treat children on the NHS while still carrying out private practice is incorrect. Dr Cockcroft: Yes. Charlotte Atkins: Thank you. Mr Amess: Witnesses, you must watch yourselves on the parliamentary channel. Dr Harvey apart, up until now you really look as if you are auditioning for a part on The Glums. Do give the impression you are enjoying things a bit! Charlotte Atkins: They are not. Mr Amess: Clearly they are not. Charlotte Atkins: We want you to show the teeth. Q68 Mr Amess: Smile! Before I get to optical services, Dr Cockcroft, why are you only the Acting Chief Dental OYcer? Dr Cockcroft: The previous Chief Dental OYcer, Raman Bedi, went back to his Chair at King’s in October. I was previously Deputy Duty Dental OYcer and I had been leading on the modernisation of primary care. I was asked to carry on the work that I was already doing in terms of leading on the modernisation of NHS dentistry, so it did not seem a very sensible time, certainly to me and I hope the

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rest of the Department, to bring in somebody new to do that. I am acting because I have not been substantively appointed as the Chief Dental OYcer and been through the process to do that. Q69 Mr Amess: But you are in the frame to get the job. Dr Cockcroft: Mr Amess is determined to make me smile, I can see. I think the job has not been advertised. I was substantively appointed as Deputy Chief Dental OYcer. Q70 Mr Amess: Right. Now we turn to Mr Dyson— and you are not related to the vacuum cleaners either. Mr Dyson: No. Q71 Mr Amess: Going back in my parliamentary annals, when I was Edwina Currie’s private parliamentary secretary and she was taking the committee stage of the Bill, I can remember as if it were yesterday when we introduced charges, and Jerry Hayes, who was then an MP, leaked a very embarrassing letter to the Committee. Of course nowadays it has all changed completely. Perhaps you would tell us something about total expenditure on sight tests, because it has obviously changed an awful lot over the last decade. Mr Dyson: The current level of expenditure on NHS-funded sight tests is about £184 million. The most significant step increase over recent years was obviously in 1999–2000, after the Government had reintroduced free sight tests for those aged over 60, and at that point expenditure grew from what had been just over £100 million in the previous year to just under £150 million. Since 1999 expenditure on sight tests has grown steadily each year. In 2004–05 there was a 6% increase over the previous year; the year before that there had been a 7% increase, and so on and so forth. Q72 Mr Amess: You may not have it in your brief there, because I do not know if our wonderful clerk gives you a tip oV, but in real terms what would roughly be the increase in expenditure from 10 years ago? Mr Dyson: First of all, I should emphasise that the increase over the last 10 years will have been heavily influenced by that one year when we re-introduced free sight tests for over 60s. With that caveat, I think the increase—and I would have to check these figures—in cash terms is about 55–60%. I would need to check the real terms increase. Q73 Mr Amess: Perhaps you would write to us about that. The current eye sight test is well below the cost of providing the service and until recently, it was expected to cover the cost. Why has this principle, which we were told was very important, been abandoned? Mr Dyson: It is perhaps worth making a few comments there. First of all, just for the sake of clarity, it is important to be clear that the fee that the NHS pays to those who undertake the sight test has nothing to do with the cost to the patient. In terms

of the fee paid to the optometrist or the ophthalmic medical practitioner, it is true that until about the early 1990s the approach was to have a so-called cost-plus approach to setting fees, where the Department would look with representatives of the professionals and companies who provided sight tests at the costs involved. There were two diYculties with that. First of all, it is quite diYcult to pinpoint the true cost of providing a sight test, because you have to take a number of factors that are common to running an overall business and then make judgments about how you apportion those between the diVerent elements of the business. The second concern was that the cost-plus approach was perhaps over mechanistic. It overlooked, and in some cases maybe even discouraged, eYciency improvements, so that the view the Department took was that rather than a cost-plus approach we should negotiate with representatives of the profession, taking into account recruitment, retention and motivation. On those criteria, the current system works very well. We have what I think almost everyone would accept is a service that provides a great degree of choice for patients, encourages a wide variety of providers, and, indeed, our minister Rosie Winterton has recently oVered fresh assurances to representatives of the profession that that system will continue. Perhaps I could add that it is diYcult to make comparisons but the Federation of Ophthalmic and Dispensing Opticians, which represents a number of providers, recently did a survey amongst their members (so not entirely representative but it is an interesting comparison nonetheless) about the average charge that they levied for private sight tests, and that average sight test fee was on average slightly below the NHS sight test. So, taking 2004–05 as an example, the NHS fee was just under £18 and the private sight test fee was an average £17.68, so very, very similar. Q74 Mr Amess: I shall not take it any further. That is a splendidly crafted argument but it does seem to me that the principle has been abandoned. I am a little bit confused as to your justification of that, but c’est la vie. Deregulation of optical services, which has had a huge, huge impact—not even touching on laser treatment and all that—has it aVected the entry of new providers or waiting times? Mr Dyson: I think it is important to be clear what one means by regulation or deregulation. It remains the fact that any practitioner who provides optical services has to register with the General Optical Council, so they are regulated in that sense. They have to demonstrate that they are properly qualified, that they undertake continuing education and training, that they remain fit to practice. So this is a regulated system in that sense, and of course practitioners also have to be listed with the primary care trusts where they provide services and the PCTs can undertake additional checks. They will take clinical references, they will inspect premises and equipment and so on and so forth. I assume the question is more about—

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Q75 Mr Amess: I wondered, first of all, is the Department happy with deregulation? You can practically go into a petrol station now and pick up a pair of spectacles. Is the Department happy with the way deregulation has turned out in practice? Mr Dyson: I think it is slightly misleading, with respect, to refer to a completely deregulated system. Whether you are an optometrist or ophthalmic medical practitioner who is undertaking a sight test or you are a dispensing optician who is dispensing spectacles or contact lenses or whatever, you have to be registered with the General Optical Council and you have to show that you are fit to practice, and both the conduct of the sight test and the dispensing of appliances is governed by national standards. In terms of the fact that there are no controls, in the sense that the NHS does not say, “We are going to dictate who provides NHS ophthalmic services in this area”, we are not going to have a limit on the number of people; we are not going to place restrictions on patients as to which provider they can go to, provided that the people carrying out the clinical work are registered and appropriately qualified. The Department takes the view that that system works very well, in that it promotes patient choice, and this is an area where we receive very few complaints about the quality of the service they receive. Q76 Mr Amess: Fine. Fourteen years on, it has been a success, the Department is happy with it and it has made a real contribution to waiting times. Mr Dyson: As I have said, the minister recently had cause to oVer some reassurances to representatives of the profession who were concerned that the current ophthalmic provisions in the Health Bill might lead to a degree of tighter regulation. The minister was at pains to point out that this was a misunderstanding of the clauses in the Health Bill. We are satisfied that the current system works well in terms of quality and choice for patients. Mr Amess: Thank you. Q77 Anne Milton: Mr Smith, it is your moment to cheer up, to smile at the camera! The one subject that causes a huge amount of grief in people is car parking charges. Maybe you could tell us what the principles are underlying the provision of car parking in NHS hospitals. Mr Smith: The principles are diVerent from those which have been discussed so far and lie in a number of roots. One is that trusts are able to generate income from a variety of sources—and I think that was put in the note to you from the Department. The other roots are the rise of car ownership and the desire of people to drive to wherever they want to go to and the burgeoning demand on hospitals, the fact that we deal with a whole spectrum of situations from acute hospitals in very tight urban situations that have virtually no car parking, to hospitals in more rural settings that have plenty of land and plenty of availability, and overlaying that—and very importantly, because it is a directive to many trusts that operate the hospitals—is the fact that Crown immunity was lifted and local planning authorities

are able, when hospital developments take place, to impose planning constraints on the hospitals that lead them to implement sustainable travel plans, to try to organise a shift of travel from cars to other means of transport, including for patients. That whole variety of circumstances has led to a situation where it has not been deemed sensible to try to impose central regulation, which could not deal with all the circumstances. Indeed, some hospitals that have undertaken major developments have had to make annual contributions to provide bus services to and from the hospitals. I have worked and been a director of estates in hospitals where, before we introduced car parking controls and charges to pay for those, we were seen as an unoYcial parking site for people who worked in oYce blocks locally. Rather than draw on NHS funding, which was directed for patients, certainly the trust that I worked in chose to levy a charge both on visitors and staV to cover the costs that were incurred in setting that system up and running it—because it required not just materials and controllers to be bought, but staV to be employed to run that. It was a very conscious decision not to place that as a charge against the NHS. Q78 Anne Milton: The issue you raise about hospital car parks being seen as the town centre car park have been a real problem in the past. I think one of the problems now is that they are seen and viewed by many patients and visitors as a cash cow, in that the hospital will maximise any income they can from it, irrespective of the hardship that it causes patients or visitors. Are there any plans to oVer exemptions to specific groups of patients or are you going to leave it simply down to local decision making? Mr Smith: At the moment it is left to local decision making. Again, in the organisations in which I have worked, consideration has been given not to particular people suVering from particular disease groups, but more to the concern: Do people have to attend for a course of treatment on a regular basis? and exemptions have been available for part of the payment. But it is a matter very much for local discussion. I am not aware that the Department has contemplated changing that view. Dr Harvey: Could I add that within the NHS Low Income Scheme you do get help with travel costs and indeed car parking,8 so those people under the NHS Low Income Scheme who are exempt would get a refund from the local trust for their car parking, I think I am correct in saying. Mr Smith: Absolutely true. Dr Harvey: And indeed, for the travel costs for travel to the hospital. Q79 Anne Milton: The burden, if you are attending for a frequent course of treatment, is quite substantial at some hospitals, and actually those people are probably the people least able to make alternative arrangements on public transport because they are not well, obviously, by definition. What about assistance for travel to non-hospital 8

Note by witness: Reimbursement for car park charges is available if the charge was unavoidable.

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settings which, of course, is going to become more and more relevant with the Government’s drive trying not to treat people in acute hospitals? Dr Harvey: Certainly travel to primary care organisations where a patient is under the care of a hospital consultant, an NHS consultant, is indeed covered within the NHS low income scheme (Hospital Travel Costs Scheme); so if you are being treated under the care of a consultant, wherever that might be, then, indeed, you are covered. Q80 Anne Milton: So even if it is not, I mean for physiotherapy, speech therapy, something like that. Dr Harvey: The stipulation is that you are under the care of an NHS consultant. Q81 Anne Milton: If you are having physiotherapy, are you? Yes, you are. Dr Harvey: It would depend, I presume, whether that is a referral through your consultant. Q82 Anne Milton: Yes, it would be. What about visitors? I think it is particularly relevant for elderly people, particularly the frail elderly, whose contact with visitors could be said to be part of their treatment—they do much better, they get less disorientated if they are out of hospital for care. Are there any exemptions or is there help for car parking for those visitors? Dr Harvey: I think if I might add just from the NHS Low Income Scheme perspective, it does cover patients but also, where those patients require escorting because of the condition that they have, on medical grounds, then those escorts would also be exempt from travel costs. Q83 Anne Milton: But not the visitors. As I say, it is particularly relevant, I think, to elderly people? Mr Smith: I do not believe that the hospital travel cost scheme does cover visitors unless they are escorting people, so that would not help. In terms of visitors in the majority of acute hospitals—we have no collected central information on this, this is just information that I have observed in places that I have worked in or have visited—a reduction in cost is usual. If you have a relative in a critical care unit and there is a recognition that you will be visiting and staying for long periods of time, the local organisation usually provides relief in those circumstances, but the median of charges in hospitals is £1 an hour, the median cost across hospitals in the UK, for the first three hours, so it is only after that time that charges generally start to escalate significantly, but those charges are levied on all visitors. Q84 Anne Milton: Do you have any information about how people get to hospital: because, I think, on the small bits of research I have seen, irrespective of where this problem is, irrespective of how good public transport is, people will always travel by car? They will get a neighbour, they will get somebody to take them to hospital by car.

Dr Harvey: I am not aware of any research personally, but certainly, of course, some people will have travel to hospital covered under the patient transport services—the non-emergency ambulances—and those would be on medical grounds, and that would be that it has been recommended by a doctor that, either due to a physical condition or particularly a medical condition that they have, they would need transport plus or minus an escort, depending on the conditions, and so those people would be covered under the patient transport services. I am not aware of any other issues. I wonder whether it is worth raising that some of these issues have been raised during the consultation, Your Health Your Care Your Say, around the patient transport services and, indeed, hospital travel cost schemes and we know that they are being looked at at the moment. Q85 Dr Taylor: The crucial question to me is where do the profits go from car parking: because they are mostly run by private contractors? Do they get the profits or does the NHS get the profits? Mr Smith: I think it is diYcult to say that car parking situations are normally run by private contractors. I certainly have no evidence for that, but, equally, I find it diYcult to disprove it. Q86 Dr Taylor: You mean many hospitals run their own car parking? Mr Smith: Absolutely. Q87 Dr Taylor: Surely you must have some figures for that, because every hospital I know does not run their own car parking system. Mr Smith: I do not have figures for that, but I am talking from the visits that I have made to hospital. I was going to go on to say that in many cases, although the facilities may be operated by a private company, they are paid a fee for that and, if there is any excess income over and above that fee, it will go to the hospital trust—those are the circumstances that I am used to—other than where the trust, because of space constraints or lack of availability of finance, may have worked with a private car park operator who will have financed and built a car park adjacent to the hospital, and an example of that would be at Queen’s Medical Centre in Nottingham—one exists there—and in that circumstance it is the operator of the car park who keeps the revenue from people using that car park. Q88 Dr Taylor: Would it be possible to have a breakdown of figures across the country, or would that be a huge work? Mr Smith: We do not collect that information at the moment. We ask trusts to tell us whether they charge or not and the level of the charge. We do not ask them to supply the information about is that car park run, operated or where does the finance go. The information is not collected. Q89 Dr Taylor: Maybe it is on the telephone side, because in the information you have given us the cost of incoming telephone calls ranges from 15p to

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49p a minute for somebody who is phoning up the patient at their bedside phone. Where do those profits go to? Mr Smith: It is a diVerent circumstance. The installations have been paid for by private sector companies, who retain the income from the telephone charges, the charges for the television, for the provision of those additional services. They retain a basket of income from those services to pay for the capital investment and the running costs of operating that service. That money does not go to the NHS. Q90 Dr Taylor: Is there any reason why the range of costs is so wide—15p to 49p a minute? Mr Smith: Ofcom have been running an investigation into that which concluded with the closure notice yesterday, and they have asked the Department of Health to work with the providers of those services and with Ofcom to look into that, but they have acknowledged that it is a very complex area and complex issue. The Department of Health has already agreed to undertake that work, working with the private sector providers, working with Ofcom, to look at what can be done about those high charges. Q91 Dr Taylor: If you phone a patient, is there automatically a warning of what it is going to cost you? Mr Smith: It is my clear understanding that when you phone into the hospital you are always given a warning message. Q92 Dr Stoate: This is a fascinating inquiry, because the more we look into this the madder the system becomes. I would like to pick up on something that Dr Harvey has just said about the NHS low income scheme about travel to hospital. It appears, therefore, if I refer a patient for physiotherapy the patient cannot claim the money back for travel to the hospital to get the physiotherapy. If, on the other hand, I waste vast amounts of public money by referring the patient to the rheumatologist, who then refers the patient for physiotherapy, they can claim their travel to the hospital. Therefore, I have got to say to my patient, “I can save you a few quid”, although I am wasting a few hundred quid by referring someone to rheumatology that does not need to see them. The whole point about general practice is that we avoid referring to hospital where possible, but we do access secondary care services on direct referral because that is very eYcient and very quick, but you are now telling me the patient cannot claim the cost. It is daft. Dr Harvey: These are issues that are being raised during consultation with the National Health Service and LHAs and they are being looked at at the moment. Q93 Dr Stoate: The whole system gets madder and madder by the minute. I am genuinely amazed. I did not know about this. I am learning a lot this morning.

Dr Harvey: I think the issue is that the way in which services have been delivered is changing over time, and I think quite a lot of these issues, as I say, have been raised during the consultation period. Q94 Dr Stoate: If under my new practice-based commissioning arrangements I invite the consultant to drop in on a Thursday afternoon, presumably at my expense, and the consultant just signs a load of forms for people to have physio, they can claim the money back for it, whereas if I do not take the trouble to invite the rheumatologist over to do that, the patient cannot get the money back? Dr Harvey: We can certainly send you further information on this, but I know this is an issue that is at the moment being looked at. Dr Stoate: Thank you, Chairman. I am gobsmacked! Chairman: Anne, have you got a supplementary on this? Anne Milton: No, I just have to back-up what Dr Stoate has said. The impression I am left with is that a lot has been attacked, a lot is under consideration but, fundamentally, it is all too diYcult for anybody to ever change anything. You do not have to comment. It sounds like a very diYcult issue. Chairman: Maybe that is an issue we can have when we draw up this report. We are going to the area about information for patients now. Q95 Mr Campbell: There have been many submissions made that patients were not aware of what they can claim and what they can get in relation to prescription charges. Even Citizens Advice submitted that a lot of people are now facing court action because they have been falsely claiming prescription charges. The question is: are you failing to ensure that patients are made aware that they can claim? I know you were brandishing a book before, and sometimes I get worried when I see these because some of these are very complicated and you need a degree to read them. It is like when you get a toy at Christmas, when you get the instructions you need to be a rocket scientist to put it together. Sometimes these information packs that are produced are very heavy for an ordinary person to read. Are you failing, because if Citizens Advice write, and a lot of people are suVering, there is something wrong with the system? Dr Harvey: I think since the Prescription Pricing Authority took over responsibility for the PPCs, and in fact now they cover all the certificates of exemption for those that need passporting, like, for example, tax credits, but they have been working quite hard with Citizens Advice,9 with National Union of Students and with other patient groups because of a concern that some people are not aware that they may well be eligible for help with health costs. The primary publication that they have, which is HC11 “Help with Health Costs”. There are also quick guides. 9

Note by witness: See footnote 6.

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Q96 Mr Campbell: Is it simple to read? Dr Harvey: It is very simple to read, but, in fact, we do also have a number of quick guides. Q97 Mr Campbell: It is 77 pages? Dr Harvey: This one is, but there is another one that is literally a fold-out. Mr Brownlee: It is a small fold-out. Dr Harvey: We have provided the Committee with a pack of the information that is available to patients and the public that the Prescription Pricing Authority publish, but I think to start with one needs to say that there are advice lines both for the Department of Health and for the PPA, through which all of this information can be obtained, there is information on every prescription form, on the patient information side, which also deals with how you can get information about help with health costs and, indeed, pre-payment certificates. There is also this information provided through the Waiting Room Information Services, which many primary care organisations subscribe to, but also information available to all primary care practitioners, including pharmacies. However, having said that, we are still concerned and the PPA are still concerned with making sure that the way in which they are targeting the information does actually get to those groups—particularly one group that has been raised with them and with us those on incapacity benefit who are not passported—so that they are aware of the fact that there is help with health costs. The other thing is that all of the Jobcentre Plus bodies also have these leaflets available for people and there is information on the DWP websites, and lots of other government websites and other bodies that have been working with the PPA also have information on their websites; so we are working quite hard. I think if you look back to October 200410 before the PPA took over all of this, possibly information was not as readily available as it should be, but we are now working and the PPA are working very hard to try and ensure that more people are more aware that they may well be able to have exemption, and, indeed, we know that DWP have done a lot of work around the benefits, many of which are passports to free prescriptions and healthcare costs so that people are aware that they can claim those. Q98 Mr Campbell: How do you monitor the primary care groups regarding information? Dr Harvey: I am sorry? Q99 Mr Campbell: How do you monitor the primary care groups that have to give this information out? I was sat on the select committee for the ombudsman for many years, and in the hospitals there was never a leaflet about how you can complain to the ombudsman. There was a leaflet about how you complain to the hospital, but never the ombudsman.

He was always left out of the loop. I have a funny feeling that sometimes the primary care leaves lot of information out of the loop. Dr Harvey: Certainly, through the PPA, they actually do send information to all GPs’ surgeries who are not members of the Waiting Room Information Service Scheme, but the PPA do have regular discussions with their board and, indeed, with us looking at the eVectiveness of what they are doing in terms of getting the information about health costs to patients, but they are always striving to make sure that they do it better. We know, for example, with the incapacity benefit, when we increased the NHS Low Income Scheme level by half the prescription charge, we did have an estimated 44,00011 people who went from partial help to full help group. I do not know if Mr Brownlee has any additional information. Mr Brownlee: All I would say is that we are aware that the position certainly was not as it should have been two or three years ago, which is why we took the action we did. We are also aware that one can always do more in this sort of area, frankly, in terms of eVort and money spent, and we are in discussion fairly frequently with the PPA on this, although leaving it to them to do it. We are not just saying, “Go away and get on with it”. It is a balance of looking at the overall position. Q100 Mr Campbell: We have got a situation where evidence suggests that the availability of prepayments, PPCs, are not being taken up. In fact the Breast Cancer Care Report said that less than 40% responded to taking up the PPCs. There has got to be something wrong there when cancer patients, who obviously need the medical treatment, are not taking this up. Again, it comes down, I think, to the information. Mr Brownlee: Can I respond by saying that the use of PPCs—I have not got figures for particular conditions, but the use of PPCs has clearly increased over the last five years since the PPA has taken responsibility. They have taken measures in terms of writing to people to remind them when the PPC runs out, campaigns through various organisations to make sure the existence of PPCs are known. The use of PPCs is going against the trend in terms of the reduced percentage of items that are in fact paid for. The use of them over the last five years has gone up by something like 50% in terms of items, and, whereas the growth of items has gone up by about 30% over the last five years—and I have taken five years purely because that is the time when you are trying to do something about it—the use of PPCs has gone up per item in terms of items spent by about 40%. I am not trying to say there is not more that should be done, but it is going in the right direction. Dr Harvey: I think certainly the PPA would say that this is why they are continuing to work with patient groups, and if there are ways they can do things better that is what they will be striving to do.

10

Note by witness: The PPA took over the publicity work in April 2004, although they have been administering the PPC purchasing arrangements since October 2002.

11

Note by witness: Estimated from a sample, when rounded is 45,000.

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Q101 Mr Campbell: I think we certainly need to see more take up. Can I go to the Social Exclusion Unit Report 2003 Making the Connections. It recommended that the department develop options to provide information and advice assessing healthcare facilities, including transport issues. Is the Department giving any credence to this sort of thing? Dr Harvey: We understand that this is an issue that is also under consideration at the moment and is one of the issues that has been raised around the consultation.12 Q102 Mr Campbell: There are lot of things under consideration here. It was 2003 when that report came out. It is 2006 now. How long are we going to wait for these things to happen? Dr Harvey: I think this is an issue that has been raised again within the consultation and therefore it is one of the issues that is being considered around the White Paper at the moment. Mr Campbell: I am afraid we are going to have to consider it in our report as well. Thank you, Chairman. Q103 Chairman: Could I ask you a general question. The cost of healthcare, I think most people would say, is going to be driven up by technological innovation and by the introduction of new drugs as well. What work has the department done to estimate the likely costs of such developments and assess whether they are aVordable without a significant increase or an extension of charges that we have talked about this morning in terms of the prescription charges, et cetera? Mr Brownlee: Clearly, we do work in terms of forecasting costs, so it does not happen—I mean this is a wider group in terms of our finance colleagues, I think. I do not think that we have been asked to do any specific work in terms of if this happens therefore charges should be at a higher level. What we have said about charges being looked at annually—I do not want to repeat what we said half an hour or so ago—but I do not think we look at the level of the charge in relation to the cost of particular medicines. If the average cost of the medicine was going to go up by X%, therefore charges should go up by a similar percentage. Q104 Chairman: My own PCT is accepting that in the next financial year, not in this one, it could cost them a million pounds more than they currently pay. Has the department looked at that in any sense of charges? Dr Harvey: I think in terms of the costs of new innovations as they are coming forward, clearly the department determines the work programme for the National Institute of Health and Clinical Excellence and through that we do look—a horizon scan—at both those new pharmaceutical agents that are in

development at the moment and, indeed, those new devices that are likely to come to the NHS in the future, and, indeed, we do look within the funding envelope generally for the NHS at the sorts of impacts of those new technologies: because, as you are very well aware, in terms of quality of patient care, the Department is trying to ensure that patients have high quality patient care and, in fact, where innovative medicines should be used for their conditions that they are indeed used, and that is why we have those drugs going through the National Institute of Health and Clinical Excellence so that we can have clinical and cost eVectiveness advice for the NHS on those drugs. What we have not done is specifically looked across at prescription charges in relation to that, but we do, indeed, look and forecast the sort of impacts that those new innovations would have on the NHS. Q105 Chairman: Quite clearly, if there is mention of one particular drug or one technological innovation, if there was a family of drugs coming into the NHS that was going to substantially move, let us say, just the drugs bill up inside the NHS because of this new family of cancer drugs and things like that, would you have to look at the issue that currently you get somewhere in the region of, I think you said, £426 million from prescription charges? Would that inevitably mean an increase in there? Dr Harvey: I think we have very much looked at it in terms of the overall NHS expenditure, what that means in terms of the drug bill growth, and I think I am right in saying that the drug bill growth is round about 8% per annum. At the moment it is relatively flat. We have just made a new agreement on PPRS, the Pharmaceutical Price Regulation Scheme, where, in fact, we have a 7% price reduction on medicines, and that is a five-year scheme. We do, indeed, look at it in terms of growth of the drugs bill and, indeed, the growth of both branded and generic medicines and, indeed, the take up of generic medicines when branded medicines have come oV patent. Q106 Chairman: There is no direct correlation between the drugs bill and the cost of my prescription then? Dr Harvey: We have not specifically looked at the prescription charge in relation to that.

Q107 Dr Naysmith: A chance to ask a couple of tidying up questions really for Mr Dyson and Dr Cockcroft relating to things that they mentioned during their evidence. One is that under optical services you said that there has been some apprehension in the profession about how the new system was likely to work in the Health Bill, and you had met some particularly small practitioners— particularly it is small practitioners in my area that I am interested in—and you were able to reassure them that they misunderstood the qualities in the 12 Note by witness: The White Paper—Our Health, our care, our Bill, and presumably they went away quite happy say: A new direction for community services, Cm 6737, after you had reassured them. Is there any chance of January 2006, has been published and makes reference to transport, including patient transport services etc on pages getting something in writing about what you used to 150–152. reassure them submitted to the Committee?

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Mr Dyson: Of course, yes. The Minister has written to a number of stakeholders to make clear that the purpose in introducing the Bill was to do two things, it was to strengthen controls over redemption of optical vouchers and, more relevantly in the context of sight tests, it was to remove some restrictions on the range of providers who can provide a sight test. The Minister has reassured stakeholders that this is not about altering the current system whereby sight tests are paid for. Q108 Dr Naysmith: It would be nice to see that sort of evidence. Mr Dyson: I am very happy to provide that. Q109 Dr Naysmith: Dr Cockcroft, again talking about dental services this time, there seems to be a bit of apprehension around orthodontics, which I am sure you are aware of, and now that it is moving towards the primary care trust who will be responsible for commissioning services, as I understand it, which was not the case before, how do you intend to oversee this and make sure that services do not just disappear? In particular, there is supposed to be some sort of appeal procedure, which has not appeared yet but orthodontic practitioners would like to see soon. I notice this is a very fast moving situation, but I want to raise it today because I know there is quite a lot of concern. Dr Cockcroft: It is not only orthodontics, even the generalist, this is the first time the PCT has had the responsibility for the whole service. A lot of orthodontic services were provided through general dental practitioners or specialists working in primary care before the system came in. It has been a huge area of uncertainty for orthodontists, and part of my job since I have become Acting Chief Dental OYcer is to go out and meet lots of people, and I am doing that. It has been a specific issue for orthodontists for a couple of reasons. One is because they have to work under PDS agreements if they are only doing orthodontics.

Q110 Dr Naysmith: It is the long-term nature of the contract as well. Dr Cockcroft: Yes, whereas the generalist contract is open-ended. If they are only providing specialist services, it has to be under a PDS agreement, which is necessarily time limited. The legislation does not contain any specific time limit, but in the guidance we have provided to PCTs we have said quite clearly that the starting point for an orthodontic contract will be a five-year contract, and we have been working very closely with the British Orthodontic Society, who seem very reassured by that. Q111 Dr Naysmith: As I understand it, there are some problems to do with appeal procedures about providing future income. Dr Cockcroft: I was not aware of that. We have it very clearly in the primary legislation—and they are all entitled to a contract if they have a contract now—that, if they are unhappy with the terms of that contract, they have a right of appeal to the Litigation Authority, and that is binding on the PCT, although it is not necessarily binding on the clinician. We would hope it would not get to that situation in most cases, but obviously there is a protection for specific people there; but part of the process recently has been a much clearer process of giving information, a real programme of concentrated information provision to practitioners, and I think there is less degree of uncertainty and misinformation—like Mrs Atkins was talking earlier on about the child list thing— than there was relatively recently. Q112 Chairman: First of all, a short apology. We have run on a few minutes longer than we originally said we would do on this. Thank you all very much indeed for coming along and giving us this information. I am sure it is going to be enormously useful for us in terms of the rest of the inquiry and other witnesses as well, including your ministers, I suspect. Thank you very much indeed for your evidence.

Witness: Mr Andrew Haldenby, Director, Reform, gave evidence. Q113 Chairman: Could I welcome you along, and thank you very much indeed. You are sat alone. I am afraid the witness that we were getting from the Socialist Health Association, we were told earlier, is on a train with a fire on it coming from Manchester. It seems to me that, unless it is a steam train, he has got rather a diYcult problem. In those circumstances, I am afraid, you are on your own. I hope this is not too much of a disjointed session, because we wanted to strike a dialogue up with yourselves as well as ourselves. Perhaps I could open up by saying: what are your views on the extension or reduction of health charges and what would be the eVect of greater charges on equity of access to healthcare? Mr Haldenby: Thank you, Chairman. I would like to frame my remarks in the context of the overall funding position of the service, and in that respect I

wonder if these remarks follow on slightly from some of your recent sessions on expenditure. If I may, because I would like to oVer a more positive view about the role of charges, the tone of the session this morning was very much that charges are a necessary evil, if you like, but there is a more positive view, which is that in a world of very great funding restraints, which I think the service is about to enter, additional monies, obviously organised in an equitable way, will perhaps enable the service to develop new areas of treatment and new innovations which it might not be able to do otherwise given the funding constraints. I might even go a little further to say that there are perhaps existing areas of service, existing areas of treatment, which, however much there may seem to be a guarantee for those services, and here I can talk a bit more, but two examples I could raise would be audiology and stroke

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rehabilitation, actually the service does not really provide on any kind of level, so perhaps the introduction of charges in those areas might be a way of developing a service which the NHS does not currently provide. I would perhaps just flesh that out slightly. I do not know if you are aware of the report that Professor Bosanquet and other wrote for us recently which looked at the costs pressures, particularly in the years after 2008 when, as we know, the very rapid spending increases of the last eight years are going to come to an end, and we measured the funding increase between 2006 and 2010, given the fall in funding of about £11.5 billion, and we looked at the cost commitments for that time based heavily on the increases in costs in recent years—PFI schemes, extra staYng, prescribing, did the GMS contracts, new pharmacy contracts, new IT schemes particularly, a number of things which certainly I will be able to tell you I have seen in the report and also new activity to meet the 18-week target and so on—and the total cost of those additional commitments amount to over £18 billion, so by 2010 there is a clear deficit approaching £7 billion. In the responses to that report that we have had there has been a certain amount of discussion about the overall numbers, but the picture has been accepted, and this will be a period of extreme financial pressure for the service. As I say, that said, if we are looking to develop new areas of service and perhaps to look at areas of service which are currently not being provided eVectively, it is not realistic to say we should expect more resources from the tax-payer, because that is really the opposite of the situation in which the NHS finds itself. To take on the second point of your question, Chairman, about equity, I think it is essential that services must be equitably provided, and that is an essential part of the NHS and should remain so, and so I would say that it should remain the case that any system of charges should have a series of exemptions for those who are unable to pay. As Dr Harvey said, the principle should be that those who can aVord to pay should do so and those who cannot should not, and that seems to me to be an appropriate principle for charges. Q114 Chairman: I think you were sat in on the last session and so you will have heard, not our assumption but assumptions of written evidence that have been sent to us that eVectively suggest that the greater the degree of private finance and private payments within our system the higher the levels of inequality. What does Reform say about that? Mr Haldenby: Let us be specific about it. The example of optical care, for example, or, indeed, prescription charges, there are clear exemptions for people who are on low incomes. The evidence this morning demonstrated that it is a very complex system of exemptions and perhaps a slightly illogical one and perhaps one which could be amended in various diVerent ways, but, nevertheless, it does exist and so it does protect those vulnerable groups. Perhaps I can focus on one of the specific areas of care that I mentioned for audiology. Here I am referring to a report by the British Society of

Hearing Aid Audiologists from September last year. Perhaps if I could suggest that we have in mind the positive development of optical services that we have seen in a recent years since deregulation—big increase in capacity, instant treatment and so on and then audiology—this report points out that the average waiting time for an NHS patient to have a hearing-aid fitted from beginning to end of treatment is rising steeply. It rose by seven weeks over the last year and it now stands at 47 weeks, so this is an area of the service which is barely provided, and yet in some parts of the country they highlight, for example City Hospital in Birmingham, which has, as I say, the distinction of having the longest waiting time in the UK, patients there can expect to wait three years for their hearing aid to be fitted, so this is an extraordinary diVerence in performance. If one was to suggest, as I might, that this area of treatment might be an area where charges might be introduced, what can we expect to see on the basis of the optical model? You would expect to see that people on low incomes would move from a position—this is particularly elderly people—of having to wait up to a year and rising for their hearing-aids to a position where, once the new capacity had come in they would be seen extremely quickly. That would seem to be a great gain in equity and also making sense, making a reality of the comprehensiveness of the NHS system. If I can just quote, to emphasise the point, Malcolm Bruce, speaking at the British Society conference last autumn, said he failed to understand why, when he had a problem with eyesight, he could walk into his High Street optician and get a pair of spectacles but to be fixed up with a hearing aid he has to see his GP, be referred to a hospital and has to wait for years. It would seem to me that perhaps there will be an example of a service where the introduction of charges with appropriate exemptions would dramatically benefit patients, including those on low incomes. Q115 Dr Stoate: I have been doing a lot of work on hearing aids recently. There is already deregulation. Anybody can ring up Siemens, go and get themselves a hearing test and pay £2,000 for a Siemens top of the range system, no problem at all. We have already got that. The fact of the matter is that hearing aids are fantastically expensive in the private sector. They cost literally thousands, and certainly many hundreds. The NHS can provide the same hearingaid behind the ear for £300 or less—in fact if you bulk purchase you can get them for £150. I do not see what sort of level of charges you are proposing to introduce that could possibly make any meaningful diVerence to that, because you will probably have to introduce very significant NHS charges to provide the increased capacity in the high street availability that you are proposing to level them up with opticians. I do not see how you could possibly get there? Mr Haldenby: All I would say is that, in the context of the current funding diYculty, what we are suggesting on the basis of the status quo is that only people who can aVord to pay £2,000 will be able to

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have a modern hearing-aid with any reasonable length of time for treatment. Another approach may be, and I agree one would have to look at the numbers of it, of course, to take the money that the NHS spends at the moment on care, which I can quite confidently say is not being spent very eVectively, and use it to subsidise patients on low incomes. That would be my response. Q116 Dr Naysmith: I was going to ask this a little bit later on, but since Howard has started oV on it, at what point would you draw the line around services for which core payments would be required? I think in your evidence you talked about, “There are many services at diVerent levels of intensity which are subject to individual choice. Although core services will be tax-funded, there will be many supplementary services at diVerent levels, but there will be an element of co-payment.” How do you define core services? I know you have perhaps done it already, but if this is what we focus in on how do you decide which are the core services? Mr Haldenby: It has been discussed a little bit already in the example of dental care. There was a distinction made between “clinically necessarily” and, as it were, “desirable”. This is a matter for long discussion, but it would seem to me that for services which are clearly medically definable and clinically necessary, they will always remain, as it were, part of the core NHS tax-funded and so, there is no doubt about it, we are talking about the great majority of healthcare, but for services on the margin of that, and obviously dental care and optical care would be examples of that, another example might be infertility treatment, where there is already—I think it varies by the area—but a well developed system of co-payment. Q117 Dr Naysmith: That is when “clinically necessary” comes in. Who decides what is clinically necessary in infertility treatment? Mr Haldenby: I think at the moment those decisions are being taken, for example, on the question of infertility, on a local level, on a PCT level. Perhaps, if they continue to be taken in that way, we would continue to see something of a patchwork provision and perhaps a variety of diVerent charges emerging, as we have already seen. The example of infertility perhaps is something for NICE to consider going forward of what should be core and supplementary. Q118 Dr Naysmith: You would have to set up something like NICE to do it. Mr Haldenby: I suppose the point I am trying to make is that in practice some of these decisions are being taken, so maybe you need to systemise that. Q119 Anne Milton: To come in on the topic of clinical necessity, if you could define that there would probably be a great deal of money in selling it, because it is almost impossible to do, and a lot of the things that I think we as members of this House are facing at the moment is being caught between PCTs who have got huge financial problems and clinicians who say, “This is necessary”, and PCTs

say, “It is not”. The diYculty is when you have got two clinicians who disagree over the clinical necessity, because what we are talking about a lot of the time, and what Dr Stoate was talking about, is suVering. If you do not get a decent hearing-aid, if you do not have two grand to pay on a decent hearing-aid, you end up with the NHS £300 one. You can hear a bit, but you suVer slightly because your hearing, in many instances, is not as good. What we are measuring is not clinical necessity or clinical unnecessity, it is about suVering, and that is a slope, and it is at what point you cut that line. Mr Haldenby: I agree with you. As I say, I think these are discussions that are being played out around the country. I have not got a hard and fast answer, I am sure you agree. All I am saying is that it was clear from discussions that basically there are, we would all understand, a range of treatments between what is obviously core necessity and what could be described as supplementary, and some things are on the margin of that, and those would be the areas for discussion. To talk from a slightly diVerent perspective, as it were, there are some services at the moment which, I suppose, we would say would be clinically necessary, which, as I pointed out, are not being provided, and another area which I said I would cover would be stroke rehabilitation. The National Audit OYce produced a report in November of last year which pointed out that rehabilitation for stroke patients is exceptionally important if they are going to enjoy an improved quality of life after that stroke. However, it is an example, again, of extremely poor and patchy provision. They pointed to data only from South London, but they thought it was representative that only a quarter of patients receive physical and occupational therapy, only a seventh of patients receive speech and language therapy in the year after their discharge. Whether this is clinically necessary or supplementary, it is not happening, no matter how much we may want it to. Q120 Dr Naysmith: The interesting thing about that report is that it also pointed out that basic core services for stroke were very fragmentary and pretty awful in some parts of the country. Maybe if you could get the core services better then there would be more people requiring long-term rehabilitation. Mr Haldenby: Perhaps that is the case. My grandmother has just had a stroke and has just failed to have any physiotherapy up in Aberdeen, and so I am conscious of this. All I would suggest is that if there was an opportunity to pay something towards the cost of private physiotherapy for those patients who need it, with exemptions for those who cannot aVord it, it would enable the service to oVer better treatment, I would suggest. Q121 Chairman: Coming back to infertility treatment, IVF in particular. I have had a personal interest in this as a politician over the past number of years now. It seems to me that even the Government announced two years ago about the IVF treatment that would be brought forward in England particularly, England and Wales, upon the National

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Health Service, because prior to that people who had actually paid wholly for IVF treatment themselves were then discriminated against inside the NHS because they had paid for it and, therefore, they could not have one of the few interventions on the National Health Service. Would not looking at that service about part-payment get us into all sorts of terrible problems? How would you envisage the cost of an IVF treatment having £2,000 being part-paid for? Mr Haldenby: I quote infertility as an example, I think, of where this is already happening. In Lambeth PCT, for example, where I live, the PCT will pay for, I think it is, one full course of treatment and it will also pay for two courses of drugs for people who want to pay privately. Not many couples who have IVF will just want to do it once, unless it happens the first time, it is two or three or four times, so we are already in a position where the Government, the NHS will cover what in truth is part of the treatment but not the whole course of treatment, and this is already moving towards a part payment model where people who want to go private pay for the treatment and not the drugs. Clearly that does raise questions of equity, because some people are able to aVord to pay for those extra courses of treatment, but again I come back to the core point, and here perhaps I would disagree with my absent opponent, as it were. Perhaps he might say all eVorts should be made to take out the charges, all eVorts should be made to have the NHS fund all those courses of treatment. All I would say is that I do not think that is a credible way forward given the funding position. Q122 Chairman: We accept that. For IVF NICE recommended there should be three interventions. There is only one, and that does not happen on some occasions because of the criteria that is laid out by the commissioning body, the Primary Care Trust, anyway. When you say that people pay for it anyway, they pay for it out of the frustration of not being able to get it on the National Health Service. Few people would go and borrow £2,000 from the bank to pay for an IVF intervention if they were not totally frustrated by the lack of ability to have it on the NHS, even when it is recommended now for the last couple of years. There are issues there that are far wider than you can improve that particular service by a bit of co-payment, are there not? There are issues that have to be addressed, major funding issues, under the circumstances of what is recommended as opposed to what is currently aVorded by the NHS. Mr Haldenby: Of course, I accept that, and of course, as I think you yourself would recognise, no matter what the recommendation has been, and I am sure there are equivalent recommendations in the area of audiology and stroke rehabilitation as well, they have not been delivered and people may be acting out of frustration or they may have little alternative. There may be a way to move towards a diVerent way of funding IVF treatment which again uses tax-payers’ funding a diVerent way. Instead of

funding a rather thin service, to focus more funding on people on low incomes. That would be an alternative way of doing it. Q123 Chairman: I do not want to get party political at all, but the last election was fought when one of the major parties had a point that the National Health Service would pay for half of the cost of the private sector. Does Reform go down that road? Do you think that is a feasible way of approaching healthcare needs? Mr Haldenby: We thought that the patients passport was a bad policy because, apart from anything else, for one thing it is an opt out which would only benefit some members of society, which I think was the political point that was made, but also, without increases in supply, all that would happen would be that they would increase the demand for treatment and that would either increase waiting lists or drive up the costs; so it was a badly framed policy. Perhaps there is another trend of policy which enables us to discuss these matters perhaps a little bit more positively and openly, and that is, I would say, the change from a monopoly, uniform NHS towards an NHS full of much greater diversity. This is an argument rather than a fact, I suppose, but it seems to me that it made more sense to have an entirely taxfunded system in a smaller, more uniform, rationed service of the kind that we were used to what is now one or two decades ago in 2008 when it will be a much more diverse system with new kinds of providers, some of them private, profit making, and it is accepted policy for all the parties now for there to be that variety of provision. In that world it would seem to me only to be expected that many of those providers will be charging or oVering the opportunity to charge for their services and it may become a more common part of the health experience. I think the Tory policy was wrong, but the general trend of policy, I think, does perhaps lead us particularly to this discussion. Q124 Chairman: We have this debate now about patient choice and, looking at it not exactly from the outside, it seems to extend just beyond the National Health Service in terms of the use of the independent sector. Do you foresee that co-payment would be one of the issues about patient choice and that you could choose an area with a co-payment that might be more eYcient or might be better for your needs, as it were, than one of the other areas? Mr Haldenby: Kingston Hospital, which I was looking at over the last couple of days, has a private unit where it provides private physiotherapy. Physiotherapy would seem to me to be one of those services that could be provided at diVerent levels of intensity and comfort, and so on, and so might have an element of co-payment. Q125 Chairman: An element of co-payment with protection for opting out? Mr Haldenby: Absolutely. This is slightly more speculative. I think the policy statement is simply that the position is that from 2008 anyone who can provide up to the tariV—I do not need to tell you—

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will be able to be chosen, but in a world of new providers, and I particularly need to emphasise the fact that they are new and they are coming along and oVering new treatment, that would seem to rather inevitably pose the question of whether patients may want to pay a bit extra to access some of those services. Q126 Dr Naysmith: Do you accept that the proposals will mean more investment in the private sector? Mr Haldenby: In the private sector, yes. Q127 Dr Naysmith: Developing more private sector— Mr Haldenby: Yes, as we have seen in the opposite core sector. Q128 Dr Naysmith: You would the expect that to happen? Mr Haldenby: In a way, I think it is almost the point of it really. Q129 Dr Naysmith: Would it not be more likely that that will occur in more aZuent communities where people are more likely to be able to aVord additional payments, and that is the exact opposite really of what we need in the National Health Service, which is investment in other areas where facilities are not very good? Mr Haldenby: All I would say is that this will remain at the margins of NHS activity. As I tried to say at the beginning, this oVers a very positive possible addition to NHS care, but the great majority of NHS care is going to be funded from taxation and so I think decisions over the problems of equity, which others have identified, will remain really a question for that tax-funded part of the NHS, but then, I think, it comes back to the question of exemptions. We have already heard that there are very wide exemptions, and so if those exemptions are concentrated in deprived areas, those are resources that are moving into those areas, so I do not think it is quite as black and white as is suggested. Q130 Dr Naysmith: Possibly it will end up with all sorts of anomalies, such as the ones we were talking about earlier today for prescription charges. For instances, talking about physiotherapy, if you start providing lots of private sector physiotherapy—I happen to think that much more widely available physiotherapy available on the National Health Service would save the National Health Service a huge amount of money, because there have been a number of studies which have shown that if you take people oV orthopaedics waiting lists and give them a bit of free physiotherapy, then they come oV the surgical waiting list without the surgery, but if you are going to spread out lots more physiotherapy units where people go and pay I suppose you will argue they will never get on the orthopaedic waiting list in the first place, but does seem like an argument for the National Health Service to do a bit more investment in physiotherapy.

Mr Haldenby: All I am trying to do is perhaps to try and be practical and to recognise that, certainly to take the two examples that I have mentioned, however much one would wish the additional investment to be there to improve those services, the recent years of kind of maximum spending increases, and I do not think we can expect any more ever, not ever, but for the foreseeable future on the scale, have not solved these problems and, as I said at the beginning, I am not sure, however much we might want to, we can realistically expect too much more funding, and so that might be a reason to look at a diVerent route. Q131 Dr Stoate: You have given examples of audiology and physiotherapy being possibles for copayment, but in order to make a meaningful diVerence to the level of service provided by these two things, we would have to have far more audiologists, far more physiotherapists. I am not against that, but the level of co-payment needed to generate that extra capacity would be enormous. We would not be talking about £6 something for a prescription, we would be talking about hundreds if not thousands of pounds more in order to stimulate enough of a growth in these diYcult areas. I cannot see anybody but the richest even vaguely being able to pay for it, and even the Conservative Party’s passport scheme with 50% being paid by the NHS, we are still talking about the majority of people being priced completely out of private physio or private audiology. I cannot see how co-payment would ever even begin to dent the scale of the problem. Mr Haldenby: I think one would need to look at the extent of the funding that has already been committed to those services. Q132 Dr Stoate: The answer is, not much, and that is the reason why we have got such shortages. To make a meaningful change to physiotherapy and a meaningful change to audiology would mean very large spending and significant investment indeed, which would have to come from somewhere, and I simply cannot see how co-payments for the rather better oV in society could even begin to scratch the surface of those areas. Mr Haldenby: Perhaps then we are not talking about co-payment for the most expensive services, we are talking about co-payment for a certain level of service which is aVordable but which cannot be provided on a certain level. I am not in any way suggesting that in an ideological sort of way— everybody must be expected to pay for the most expensive services—not at all. All I am trying to do is to suggest that in this period of extreme high pressure, however much we may regret the reality of services and the unlikeliness of extra funding, that is the reality. I am sure there will remain services at the top end of the cost which almost nobody will be able to aVord, but perhaps there may be something we can do at the aVordable end.

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Q133 Dr Stoate: The point is that things like audiology and physiotherapy are not expensive high end services. They are actually very basic and cheap services. The fact of the matter is that people in this country, I do not think, have not got a real grasp of just how much even basic NHS services cost. I do not think many people in this country realise what a day in hospital costs—we are not talking about a few quid—and even though physiotherapy and audiology are basic relatively low cost services, they are not high tech in any way, nevertheless, the true cost of those services is very high. I do not want to go on. I want to look at something slightly more philosophical from the argument that you have been putting forward, and that is that currently copayments have been used either to prevent frivolous use of services or, for pure economics, to try and put a lid on expenditure or simply to generate some income through the NHS. I want to move beyond that and I want to ask you should charges be used as a deliberate instrument of health policy, and if so how? Mr Haldenby: I think I would agree with the muddle to compromise that we heard about this morning. We are where we are, and although other people will put forward the theory of charges, I suppose what I am trying to put forward as we sit here today is why we are having this discussion—because of the financial position—and what might be the benefits, and I do not think we are wrong to discuss this. If I might quote one or two, but not take very long, the Social Market Foundation did a report on charges 18 months ago, and they said, no introduction, “Ultimately the case for reform of the existing charging system might seem weak in an era when the NHS is enjoying unprecedented levels of increased funding. However, we can expect the arguments for reforming that we present here to take on greater savings when this increased funding levels oV, as at some point it inevitably will.” It is not a philosophical, it is just it is a very practical point. Then Patricia Hewitt, the Secretary of State for Health, in 1996 was the Deputy Chairman of a health commission which concluded, “We are committed to general taxation being maintained as a political source of funding health services. However, we believe it is not possible to expect the continuing gap between resources and demand to be closed through increased tax-funding alone.” This is a debate which we have had before and which, it seems to me, recurs at times of real pressure. So rather than a philosophical nature, I think it is a more timely reason for it. Q134 Dr Taylor: I want to go on really exploring this, but, starting from what we heard in the first session that it is only 13% of items that are actually charged, even though that raises 427 million, with all the anomalies that we have heard about, to me the only answer to that is to abolish those charges altogether. That leaves us with an even bigger gap. If you had a blank piece of paper, you have told us we could raise a little bit with direct payments for

audiology and stroke rehab, what else could we charge people for within the NHS, people who have got the money? What else could we charge them for? Mr Haldenby: I am going to stick to the examples. When I was preparing my evidence, rather than present an absolutely exhaustive list, because I think this will always be part of negotiation and can always be determined really by levels of funding almost year by year, I thought I would present those examples, particularly in areas of service, which, however much they appear to be guarantees to provide at the moment, are not properly provided and that also refers to the previous remarks about the diVerence between core and supplementary services. Q135 Dr Taylor: Would you not be prepared to theorise a little bit? There are so many other things that perhaps could be charged for: hotel charges always come up, insurance for sports injuries, the SMF in their thing thought that prescription charges should be linked to the therapeutic value of the medicine? Mr Haldenby: Since you mention Social Market Foundation, one of the ideas they proposed was charges for out of hours, what they call “convenient GPs appointments” as an example of an area of service which is not currently being provided eVectively but which some professionals may wish to pay to visit the a GP on a Sunday afternoon, which is more convenient for them. I do not think I am prepared to theorise on some of the detail, but I might just confine myself to my previous remarks. Q136 Dr Taylor: I would like to come out of this inquiry with some ideas for other ways because the deficits are so enormous. Mr Haldenby: Chairman, perhaps I could say we will give it more thought and submit written work. Q137 Chairman: We would more than appreciate that. Already the debate has started, although we should be asking questions and taking answers, but I think that the areas that you have brought up are quite right. I have to say that I buy private acupuncture for my problems at work that were not dealt with many years ago by the National Health Service to my satisfaction. I do not have a problem with that, but I have the requisite income as well and the time and availability to be able to go and have treatment as and when I feel fit. These areas are not closed oV, I do not think, at all, and may be coming out of this report when we have ideas. Can I thank you for giving us this evidence session, particularly because, certainly as far as you are concerned, with no other witnesses there is absolutely no respite whatsoever, whereas at least we can sit back and gather our thoughts before we ask the next question. Thank you very much indeed—I found that very enjoyable—and we would appreciate any further written submissions you could give us. Thank you very much. Mr Haldenby: Thank you.

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Thursday 2 February 2006 Members present: Mr Kevin Barron, in the Chair Mr David Amess Charlotte Atkins Mr Paul Burstow Mr Ronnie Campbell Jim Dowd

Anne Milton Dr Doug Naysmith Dr Howard Stoate Dr Richard Taylor

Witnesses: Dr Anthony Harrison, King’s Fund, Mr Robert Darracott, Head of Corporate and Strategic AVairs, Royal Pharmaceutical Society of Great Britain, Dr Ellen Schafheutle, Research Fellow and Pharmacist, Drug Usage and Pharmacy Practice Group, The University of Manchester, Dr Hamish Meldrum, Chairman of the General Practitioners Committee, British Medical Association, gave evidence. Q138 Chairman: Good morning. Could I welcome you to our second evidence session on our inquiry into NHS charges. I wonder if you would mind introducing yourselves for the record. Dr Schafheutle: My name is Ellen Schafheutle. I am from the University of Manchester. My colleague Peter Noyce and I have submitted written evidence. Dr Meldrum: I am Hamish Meldrum. I am a GP in Bridlington in East Yorkshire and I am Chairman of the GPs Committee of the BMA. Dr Harrison: I am Tony Harrison. I am a Research Fellow at the King’s Fund. Mr Darracott: I am Robert Darracott. I am Director of Corporate and Strategic Developments at the Royal Pharmaceutical Society. I am responsible for our Policy Unit. Q139 Chairman: Thank you. Apart from raising revenue, what contribution do charges make to health policy? Dr Schafheutle: It is about £450 million that comes from prescription charges. That only makes up about 5.5% of the total net ingredient cost of all NHS prescribed items and that is due to a high number of prescriptions actually being exempt. Around about 13% of our items are exempt from prescription charges. There is no real data available on the cost of administering the current system of prescription charges and exemptions. In Scotland a figure of £1.5 million was quoted. I have gone through some of the Hansard records of last year and tried to tot up some of the figures there and it came to around about £6.5 million, but that is a really rough guestimate. Dr Meldrum: Apart from a financial contribution, my own view is there is little evidence of any beneficial contribution to health. There may be some evidence that it may reduce a little bit of inappropriate demand. I think the downsides of the present system far outweigh that small potential benefit. Dr Harrison: I cannot really enlarge on that. I cannot say what contribution charges make to any health policy objectives. They are inconsistent with objectives which the Government has vigorously promoted. Let me make just a small point on inappropriate use. I think the general evidence, not in this country but where the eVect on appropriate

and inappropriate use has been tested, suggests that both are aVected by charges. So charges do not distinguish between frivolous or inappropriate or unnecessary use, they are too blunt an instrument to do that. Mr Darracott: Based on the examples where eVectively charges are being removed and the evidence we quoted in our paper of Italy in 2001, there was a large increase in the number of prescriptions that year. I was involved in some work in Italy at the time. In the January that the charges were removed prescription numbers increased by 18% and they increased so rapidly that charges were reintroduced nine months later. Every system is a dynamic one. It would be wrong to extrapolate too far from that. It is not just about frivolous use, it is about who does not get the benefit of medicines they really need. Q140 Chairman: In terms of health policy objectives, we are seeing some changes taking place at the moment. We have had proposals earlier this week and many others about this concept of moving care out of hospitals into the community. Are there any issues around that in terms of NHS charges that you can tell us about? I think all four of you agree it does not steer policy one way or another. Does it hinder policy? Dr Meldrum: I think it probably does in that some of the most hard to reach people and the people who you would want to try and attract for treatment are aVected by charges and are dissuaded. As others have said, it is a blunt instrument. I think we have quite a lot of evidence, both from research and also personal evidence, of people who will ask me, “Do I really need all three of these, Dr? I really can’t aVord them. Which are the two most important ones?” That is the ones who are upfront with me. I know plenty of others who then ask the pharmacist the same question or who actually just do not cash in the prescription. I carry on in the ignorance that I think they are taking it and they do not want to upset me by telling me they are not. I think, because we are trying to look at more preventative measures in the announcements this week and focus more on that and to try and focus on under-privileged areas, the

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previously hard to reach places, the present prescription charges can only tend to act against that. Q141 Charlotte Atkins: Mr Darracott, based on what you said earlier and also on your evidence, you quote various international studies about the deterrent eVect of charges, what evidence is there out there in terms of the detailed evidence? Mr Darracott: The Society’s review of the available evidence was done in large part by Dr Harrison. What that evidence concluded is that the evidence in this country is fairly sketchy. We collected together the evidence that was available from around the world on lots of diVerent sorts of systems, whether they were fixed charge systems, annual maximum systems or various forms of co-payments or coinsurance. There is evidence around but it is fairly fragmented and it may only look at a particular category of patient. There are some very interesting studies which suggest that the very vulnerable types of people and those who are a focus for government policy are the sorts who are inordinately aVected by this sort of work. For example, one of the stories we quoted was looking at some people with mental health problems in the US, where a cap on the amount of costs which could be allowed in any patient case actually led to an increase in hospitalization and the economic examination then suggested that the total excess costs were 17 times the cost saved by putting the cap on in the first place. The other thing that is very interesting and why this particular inquiry is very timely is that we have a live experiment going on at the moment in Wales and although we are only part-way through what is a stepped programme for the removal of charges to the people in Wales, we are now at £4 and we are going to go down to £3 in April, there is evidence now beginning to emerge on how that is aVecting the number of prescriptions that is actually coming through. There is evidence around and we have tried to summarise a lot of it, but in this country, apart from some other work done at Manchester, there is not a lot. Q142 Charlotte Atkins: The Committee will be taking evidence in Wales. I am interested in why there is not any evidence in this country. It is not as though we have not had prescription charges for quite a long time. Why is that? Has the work not been done or is it not easy to collect? What is the issue? Dr Harrison: There is evidence about the impact of charges on the uptake of prescriptions. Where we lack evidence is on what the further impact of that is. As Rob mentioned, a particular study done elsewhere suggested that the impact could be very considerable. Other studies have confirmed that hospital admissions may rise as a result of people not taking up prescriptions because of costs and they may find themselves going to their GP or doctor more frequently. Those overarching studies just have not been done in the UK. A few studies were done on the impact of charges over the years in the Sixties and so on. So we can be fairly confident that

charges do deter some people and, as Rob has already said, mainly it is people at the lower end of the income scale, although it is not those right at the bottom. Q143 Charlotte Atkins: The indication that there have not been any studies done implies to me that there is not a big issue here. Dr Harrison: Other people—and I think they will be giving evidence probably later on this morning— have collected evidence directly from individuals who say they cannot aVord three prescriptions at one and the same time, and Dr Schafheutle has done a lot of work on the way people and professionals react to the existence of charges. So that work has been done and it is strong enough to suggest that there is an issue. What we could do with are some more comprehensive and wide-ranging studies than we have ever had in this country which do trace the impact of charges through to what happens to those who do not take up their medicine, who do get a prescription in the first place and they spin out the prescriptions, ie making them last longer than they should and all those eVects. What is the consequence of that on health, hospital admissions and other use of services? That is what needs to be done. Q144 Charlotte Atkins: Maybe Dr Meldrum can help us here. Have you picked up if there is a regional dimension to the impact of charges? One might think that maybe in more prosperous regions there is not such an issue and in poorer areas there is. Have you picked anything up from your experience? Dr Meldrum: I recognise your anxiety about the lack of evidence. I think some of the reason for that is that so many who are close to it feel the whole system is so patently inappropriate, the anomalies within it, who is exempted and why they are exempted, so why spend a lot of money on getting evidence when something seems so obviously wrong. Q145 Charlotte Atkins: Some of us believe we should have evidence. Dr Meldrum: Absolutely, and as doctors we would go along with that too. In terms of eVects in diVerent areas, certainly within a practice one knows that there is a certain group of patients—not those right at the bottom end who are often on income support and therefore exempt from prescription charges— just on the threshold where there is a real impact on the uptake and the use of medicines. They are the ones who complain most about having prescriptions and also wanting prescriptions to be given for six months at a time so they only have to pay the prescription charges much less frequently and various other things. So doctors are often under quite a bit of pressure to try and play the system in order to reduce the financial impact on patients. Q146 Charlotte Atkins: What you are saying is that the group that is most aVected is those just on the edge, is it not?

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Dr Meldrum: Yes. Q147 Charlotte Atkins: If you were to look at the overall figures—and I am sure the Department of Health would say this—you would see that only a small fraction of the population pays for prescription charges. So is it a big issue? Dr Meldrum: Yes, 85% of prescriptions are exempt, but that does not mean to say 85% of people are exempt and for those who are not exempt it is a very big impact. Yes, we can argue that because all the young and all the elderly are exempt—and particularly in the elderly that is where the bulk of prescriptions are—that it is not a problem, but of course you are exempt whether you are elderly and a millionaire or a pauper. It is those in between who have to pay where the biggest impact is and often it is at a stage in their life when you can make quite a big impact on them if you treat them adequately. Q148 Charlotte Atkins: You pointed out it is the percentage of prescriptions we are talking about here. Is there any evidence about the percentage of people who are ill, who regularly take prescriptions and who are not exempt? Dr Meldrum: I cannot put a figure on it. Most of my evidence in that sense is anecdotal. In terms of the number of occasions when patients complain to me about the number of prescriptions which are necessary and whether they can have them for longer periods, that is a very frequent occurrence, and I have found from talking to colleagues that that happens very frequently. Q149 Charlotte Atkins: When you say frequently, do you mean at every surgery or once a week? Dr Meldrum: Once or twice a week. Q150 Charlotte Atkins: Is there any evidence that anyone else would like to bring in on this issue? Dr Schafheutle: I would like to pick up on the last point about patients talking to their GPs and raising the issue of aVordability. Based on the work that we have done at Manchester, it seems that a lot of people do not raise the problems they may have about aVordability with their GPs as they do not see it as a doctor’s job to address those issues. A lot of people who find the cost of prescription charges to be a problem do not speak to their GP, but they may speak a little bit more to their pharmacist because that is the point at which they have to hand over the money, although a lot of it just goes on without any awareness. The things that the GPs and the pharmacists see are probably an under-estimate of what goes on. Q151 Charlotte Atkins: Have there been any studies to tease this out? Dr Schafheutle: We have done some work to look at the non-dispensing at the point where people pick up their prescription in commuter pharmacies to see what the impact is and how much cost comes into this and how much other reasons play a part and it is quite clear from that that for those that have to pay cost is quite an important impact. There are

other factors that come into play in people not picking up their prescriptions. A large percentage of those that are cost related are where people can buy something over the counter. So there are quite a few cases where adequate substitution takes place because an over-the-counter product is cheaper than a prescription charge, but there are still a number of prescriptions that would be deemed as necessary or clinically important that people do not get dispensed because they cannot aVord the prescription charge. Q152 Dr Stoate: I think we can all agree from the initial answers to the questions that the current system is dog’s breakfast. It is a question of where we go from there. I would like to pick up one or two points about health policy. None of you seem to have had much enthusiasm for any advantage to health policy. Is it not part of government policy that we should be encouraging people to use pharmacies? Is there not some evidence that a prescription charge might encourage somebody to go to their pharmacist before going to their GP and getting something over the counter that they might otherwise queue in their GP’s surgery to get? Is that not at least a potential advantage in terms of policy? Mr Darracott: Yes, it is potentially. The figures that we uncovered showed that for every 1% increase in charges there is a 0.3% decrease in the number of items. You are absolutely right in that a number of strands of government policy are promoting that. Not only is there a visible encouragement of people to access pharmacies, but behind that sits a policy to examine particular medicines and to decide, for those that are safe and eVective, to move them from a prescription category and into a pharmacy category and therefore widening the range of products that is available in that way. Yes, that is an important part of it. We have had the system now that we have got 40 years with all its illogicalities. I do not think it has been teased out as to what the impact of that is on this specifically. Q153 Dr Stoate: At least potentially you could argue that there could be an advantage to government policy if more people saw the pharmacy as appropriate for them rather than waiting to have an appointment with their GP. Mr Darracott: Yes. There has been an encouragement of what is called the Minor Ailment Scheme in which people who are exempt from charges, who require advice on something that you put into that category can go directly to the pharmacy and yet will be treated in the normal charging regime and obtain the medicines they need without paying for it because they are automatically exempt. There are a number of strands of policy which are supporting that. Q154 Dr Stoate: Hamish, you have talked already about the inappropriate use of GPs’ surgeries. There may be inappropriate consultations for a number of reasons. You have already said you do not believe charges are a very good method of deterring

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inappropriate consultations. If we can agree that such consultations exist, how would you feel the best way of tackling them is? Dr Meldrum: How do you make sure that people use the health services most appropriately? That is mainly about education. At the moment it works both ways with prescription charges. I get people coming to me rather than going to the chemist when their child is sick because they can get free Calpol whereas they should really be going to the chemist when he has just got the sniZes or a cold. The prescription charges are a pretty blunt instrument in terms of trying to implement what I would think is cohesive and comprehensive health policy. I do not think I would be saying we should just abolish prescription charges and do nothing else. You would also have to look at the system, which would encourage people to make use of pharmacists and perhaps have voucher systems for those who would otherwise have to pay. We have talked about pharmacy prescribing. The BMA is actually supportive of pharmacy prescribing for minor ailments and such like. There are other ways to try to address this to avoid inappropriate use of various parts of the Health Service and I think it should be mainly done by education rather than by a rather crude tax, which is what the prescription charges are. Q155 Dr Stoate: Dr Schafheutle, has any research been done on whether costs elsewhere in the Health Service are increased purely by having charges in the system? If somebody has to pay and does not get their medication, have we any way of measuring what knock-on eVect that might have on other Health Service costs? Dr Schafheutle: Unfortunately not in the UK. That evidence is not available for a number of reasons. We have evidence from the United States and also from Canada where a very, very large scale study looked at the impact of co-payments on particularly vulnerable groups, which were the elderly and welfare recipients in that country, and they found they reduced their use of essential medication and that had a direct impact on their health services use. This was a cost-related impact and therefore it had an impact on the increased use of acute services, emergency department admissions, admissions to hospital and also increased mortality, which they linked directly back to an increase in co-payments in those vulnerable groups. Q156 Dr Stoate: Is it not rather important to know that figure? If it turned out the figure was £450 million a year it would rather wipe out the whole benefit of prescription charges in the first place. Is it not rather important we do that research? Dr Schafheutle: It is. The problem is the lack of evidence. In Canada and the United States it is generally much easier to access large datasets through their insurance schemes like Medicare and Medicaid who reimburse patients and they hold a lot of information about those patients and so they can relatively easily assess the compliance of people, how often they refill, what kind of conditions they have and draw conclusions from that. We do not have one

available dataset that we can access to set up that kind of study in the UK. In GPs’ surgeries and often in pharmacies we do not hold the information on whether somebody pays or not. Q157 Dr Stoate: That is remarkable. The GP dataset is probably the most comprehensive in the world in terms of the fact that every single prescription is logged on the computer now. Surely that data must be incredibly easy to access. Dr Schafheutle: That data is probably not so diYcult to access. It is linking it with whether somebody pays or not that is the diYculty. Q158 Dr Stoate: That cannot be rocket science, can it? It is very simple to work out if somebody pays. Dr Meldrum: It is simple in terms of the age ones, but there are many other exemption categories as you know. As a GP, I will not always know who pays certainly within the age group of 16 to 60. Q159 Mr Burstow: I want to ask about the research that you have done, Dr Schafheutle, and how that looks at the current system of exemptions and what eVects prescription charges are having on patients. What kind of things has the research revealed so far? Dr Schafheutle: Over the years we have been involved in a number of studies. It began with a European study that involved six countries all looking at the impact of the diVerent co-payment systems in their countries and obviously we were particularly involved with the UK side of things. We did focus groups with patients and that included people with hypertension, HRT, hay fever or dyspepsia, and then we developed a survey of people who had to pay for their prescriptions in the UK. Then we did a study on non-dispensing that I mentioned earlier. More recently, as part of my postdoctoral Fellowship, I have been doing interviews with people who have asthma or people who have coronary heart disease or who suVer from high blood pressure. From all of that research we found people do a number of things. If prescription charges are a problem—and we have shown that they are a problem—and if people are below the average income then they use a lot more strategies to cope with costs, whereas those that are on higher incomes do not need to use those strategies to cope with costs. First of all, it prevents people from going to their general practitioner because they assume it is going to end up in a prescription and that is going to cost them a lot of money. The next step is not to get a prescription dispensed. If somebody has a number of items on their prescription then that adds up—the current cost of one item is £6.50—to rather a lot of money for somebody on a relatively low income and so people try and prioritise. Some of them will ask their GP or their pharmacist about it or they will decide which one they need the most without that input. An example of that is asthma inhalers, where people take a preventer and a reliever and then choose the reliever at the expense of having their asthma controlled well. Some people may use a lower dose to make their medication stretch over a longer period of time and in some cases that may not

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be a problem, but if it is a problem they may borrow money from friends or family, they may use somebody else’s medicine or they will delay it until they have the money available. One mechanism that is available for people to use is the Pre-payment Certificate which they can buy either to cover their medication for four months or for 12 months. We have identified a number of problems with this and the Citizens Advice Bureau research has identified very similar issues for those people on low incomes, the ones that most need protection against aVordability issues, in that the lump sum payment of these Pre-payment Certificates can be a real problem. So paying out in advance over £30 for four months or over £90 for 12 months is actually a real issue. Something else we have identified is the predictability of certain conditions. After somebody has a heart attack, for example, they are normally on a lot of medication which is prescribed on a monthly basis, so it is very obvious to them that they will benefit from having a Pre-payment Certificate and it is very obvious to the GP and the pharmacist that would then recommend these certificates. On the other hand, there are conditions—and again I come back to asthma—where this is a lot less predictable. Very often for people who are feeling generally well and who pick up their inhalers every six weeks getting a Pre-payment Certificate is just not worth their while. They do not know when they are going to have an infection that may require antibiotics and when it is not clearing they may need another course of antibiotics or they may need a course of steroids. These individual charges add up very quickly. There is no way for them to go back and say, “Over the last four months I have paid out far more than this £30”. That is another thing that we have identified as a problem. Q160 Mr Burstow: I want to come back to the point about evidence and datasets and so on. You have described the focus group work, the qualitative work, the case study-type work that has been done which illuminates the issues. Do the datasets that would be necessary to do the work that has been done in Canada and the US exist in the UK and, if not, where are the gaps? Maybe that is something you can come back to us on if not now. Dr Schafheutle: I would probably need to come back to you on that. Q161 Mr Burstow: Dr Meldrum, your evidence suggests that the list of exempt items is out-of-date in terms of the burden of disease as it is now. I just wondered if you could say a bit about what changes you think are necessary and particularly what sort of criteria we need to use to make decisions about what conditions should be added to the list and what conditions should be taken oV the list. Dr Meldrum: Where do I start? There are so many anomalies both between diseases and even within diseases. Diabetes is a classic one. If you have diabetes but can control it by your diet you are not prescription exempt whereas if you need tablets or insulin you are, but even diabetics on the right diet nowadays should probably be on an ACE inhibitor,

a statin, on aspirin and other things. They are going to need a sizeable amount of medication but they do not get that exemption. If you happen to have an under-active thyroid at any time in your life and you are required to take thyroxine you are prescription exempt for everything. Somebody who happened to have an under-active thyroid at 20 and who turns out to be hypertensive in their 30s or 40s gets free medication. Somebody else who just becomes hypertensive and did not have the fortune to have an under-active thyroid does not, they pay. We have talked about conditions and my colleague mentioned asthma. Often that condition requires quite a large number of drugs now and if treated eVectively it can help reduce hospital admissions and improve the quality of life, but it is not exempt and it is often a condition aVecting the young and young adults. Increasingly now we are seeing hypertension, we are seeing heart problems, all of which there are good therapies for which will help prevent further complications in later life and these people are not exempt. Q162 Mr Burstow: Have you put these concerns about how the system works and arguably the diversities in the way the system works to the Government and, if so, what response have you had from the Government? Dr Meldrum: Frequently. Every government in the last 30 years has probably seen that. Q163 Mr Burstow: Has the response changed over those 30 years? Dr Meldrum: The response tends to be “We’re looking at it and we’ll get back to you”. That is why it is quite refreshing to see somebody like yourselves taking a real close look at this because I think we would feel that the response so far is that it’s just too complicated to touch and we do not really want to change things. Q164 Mr Burstow: In written answers the Department has said that the reason there has not been a change is because there is no consensus about what the change should be outside of the Department. Is that a fair characterisation of the position from your discussions with other organisations and certainly some of the others who are giving evidence to us today? Dr Meldrum: I think it would be fair to say that to try to achieve a consensus and get a system that was totally logical and that stood the test of time would be quite diYcult. There might be an argument for saying that rather than trying to look at conditions which should be exempt you should perhaps look at drugs which should be exempt. There might be more logic in that because it might be better for important drugs that were needed for certain conditions to be made exempt rather than conditions. I think part of the reason why, after a lot of looking at this issue, we felt that probably the simplest thing would be to get rid of prescription charges altogether is that whatever system of exemptions you have there are bound to be anomalies and unfairnesses within it.

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Q165 Mr Burstow: In designing an alternative system, can I ask if there are any criteria or factors that should be taken into account? This point about looking at exempting particular drugs is one way in which it might be approached. Are there any others that we should be considering? Dr Harrison: Obviously the simplest thing is to abolish charges for prescription drugs entirely and then everybody on the receiving end of that would be happy. If the Government then says “Yes, but we lose £450 million, what do we do to make that good?” I think the diYculties would arise in trying to get consensus on what the best way of replacing that lost revenue was. I could think of other systems of charges that would probably be more equitable and still raise some revenue. The point has been made about the fact that some people with substantial incomes are exempt. You can think of diVerent ways of capping the total sum people have to pay. People may not know how much a course of treatment is going to cost and so they do not take out the Prepayment Certificate. A simple way round that is to have a limit at a low level, for example let us say people pay up to £50 and then everything is free and a higher level where better oV people might pay £100 and within a given period everything is free. You could think of other ways of raising money from prescription drugs. I guess in any system of that kind some people are going to be losers. Obviously the people who are exempt now and who are well oV would be losers so they are not going to be very happy with it. I think that is where the trouble begins. Q166 Mr Burstow: Mr Darracott, have you anything to add in terms of what we should consider? Mr Darracott: I would support the idea that the method which seems to be used in lots of other places is either an income related single threshold or essentially everybody pays, but there is a safety net. There are ways of viewing that sort of income related idea which could be linked to some of the issues around the Pre-payment Certificate and the fact that they are not terribly well used. One of the issues in terms of the datasets is that they exist in various places but they are not joined together. There are datasets which are what doctors prescribe and there are then diVerent datasets of what has been supplied which the PPA may hold and it certainly exists on pharmacy computers, but they are not networked. Then there is the other dataset, which is the hardest of all to get to, which is whether any other medicine that has been not only prescribed but also supplied has ever been taken, and linking all those things together is quite complicated. I suppose one of the answers ought to be the long-awaited NHS super IT system which is going to connect everybody together and put everything on a particular card and then we might begin to make some progress. One of the things I ought to observe on that is that the Prepayment Certificate itself is a complicated process as indeed is the HC11 which my 18-year old has just been given a copy of. This is a 16-page document. Have you ever seen an 18-year old trying to fill in a document of that kind? It is a very complicated piece

of bureaucracy which has to be filled in. If we were to have a fully integrated IT system then an annual limit, presumably managed through that, as indeed the Norwegians manage, would be necessary and so when you get to your annual limit everything else is then free. All of the professionals in the system know it is free because they have an integrated IT system. Q167 Mr Burstow: So come back in 15 years and we might have an answer, is that what you are saying? Mr Darracott: Is that the current implementation date? Mr Burstow: I do not know. Q168 Dr Naysmith: I would like to return to an area that we touched on earlier and that is the question of how charges might aVect the behaviour and decision-making of professionals involved in the National Health Service. I think Dr Harrison has indicated that Dr Schafheutle had some evidence. Do you think there is any evidence that these professionals make decisions which could result in suboptimal outcomes for the patient; in other words they do not perform as well as they might with their patients because of charges? Dr Schafheutle: I am not sure if it is suboptimal outcomes because GPs will do their best to try to keep the cost as low as possible, but if the GP feels that a particular medication is required and they prescribe it then there is not an awful lot else they can do. If the patient cannot aVord it then I am afraid the problem is very much left with the patient. There are a number of things that GPs will do. One example is to prescribe a longer supply of medication. So rather than just writing a prescription on a monthly basis, a GP could issue that prescription for two or three months, which means the supply is given at the same charge for that longer period, which helps for that person to aVord their medication. The focus groups that we have done with GPs have shown that they may try and prescribe what they call “more eVectively”. So if there is a way of only prescribing two diVerent items rather than three, they will try and do that. There is only so much they can do. There is not a lot of flexibility within the system for GPs to adapt or other people to adapt their prescribing to bring the costs to zero or something. Q169 Dr Naysmith: It emerged earlier on that sometimes patients manipulate the system. If they know they cannot aVord a prescription they do not go and seek advice. Is that something that you think people need to be warned about? Do you think professionals need to be warned that there are such patients and they need to look out for them if they can? If nobody turns up at the surgery then the doctor will not know about them and they are often chronic patients. Dr Schafheutle: It is a good idea to alert and remind people that there may be people who have aVordability issues in paying for their prescriptions. As I said earlier, we know from some patients that they will not raise their problems with the GPs and yet the GPs tell us that they will try and help the

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people, but if the two do not talk to each other then that is not going to happen. So to encourage the professionals to raise the issue will be important. Q170 Dr Naysmith: Dr Meldrum, do you have anything to add? Dr Meldrum: I think on most occasions GPs will try and prescribe what they think is the appropriate prescription and unless the patient raises an objection or a problem they will assume that everything is all right. I do not think—and perhaps we should—we routinely ask people if they are going to be able to aVord the prescription, we tend to rely on the patients. It is maybe not the tip of the iceberg, but I am not getting feedback from all the patients who realise they cannot aVord it because in some ways they feel they do not want to oVend me by saying that and so they will either talk to the pharmacist or do something else. Q171 Dr Naysmith: Given what Howard was saying earlier on about the enhanced role of the pharmacist nowadays, maybe people would ask advice from a pharmacist as to which is the most important of the medicines. Mr Darracott: That is right and they do. The pinch point comes at the point when the money has to change hands. It is very easy to think £6.50 is not a lot, but if it is four items then it is £26. If you have just been to the doctor and it is late in the evening you might not have that. In preparing for coming here I had a very useful conversation with Gerald Alexander, our Vice President and he gave me three examples oV the top of his head of where that has happened very recently to him as a practicing pharmacist, where patients have asked his advice. Paradoxically, from the patient’s perspective, professionals are doing a great job because they are helping them make what are actually quite diYcult choices. One example that Gerald gave me was of a 19-year old, so someone literally just into the bracket where you start to pay charges. This was an asthma patient, it was a four item prescription, it was an acute episode requiring an antibiotic and a steroid as well as a preventative reliever and the question was, “I can only aVord two, which do you think I should have?” From the pharmacist’s perspective preventers are very important but that is not what gives the patient immediate relief. There is a kind of trade-oV there for the patient and the pharmacist is therefore helping the patient to make those decisions, so from their perspective it gives the professionals an opportunity to appear even more helpful. They are live choices and they happen on a very regular basis. Q172 Dr Naysmith: What do you think would happen to the workload of GPs and pharmacists if prescription charges were abolished? Dr Meldrum: One would not necessarily want to see the abolition of prescription charges and nothing else, I think it has to be part of a package. There needs to be better education about what is appropriate to go to the pharmacist or to the GP with. At the same time I would probably want to see

either a voucher system or a pharmacy prescribing system certainly for minor ailments so that people were not prevented from accessing appropriate medicine but that they would not necessarily come to see a doctor for. I think there is the potential for an increased workload. Perhaps only some of that increased workload would be inappropriate because there is plenty of evidence, as we said earlier, that people for whom it would be appropriate to attend the doctor are dissuaded from doing so because of the thought of charges. Although with one hat on I would not like the thought of that, in trying to provide the best service and treat people well I want people for whom it is appropriate to come to see me to come but, at the same time, I want to try to divert those who should more appropriately be seen by the pharmacist at the pharmacy and make sure people can access care there without additional expense. Dr Harrison: The experience in Wales should give us some clues as to what would happen in real life, but, leaving that aside, clearly if charges were abolished there would be some increase in the usage of pharmacy drugs, but that is a short-term impact. If we believe—and we have to be careful about this— that studies done in other countries can transfer to this healthcare system then the medium to long-term eVect might reverse that. There is no doubt there would be a short-term impact in terms of workload, but what we said in answer to the questions that we collectively tried to answer earlier on about the overall impact of charging was we could not know because the relevant studies had not been done for this country. If things worked out here as they have done elsewhere then the medium-term impact could be favourable. That is a big speculative question we cannot answer. Q173 Dr Naysmith: Finally, what do you think the eVect would be on the pharmaceutical industry if there was the abolition of prescription charges? Mr Darracott suggested in his written evidence that the Government has a dual interest in this because it is interested both in the health of the pharmaceutical industry and the health of the population. When we were doing our pharmaceutical industry report not all that long ago we recommended that it would be better to transfer the pharmaceutical industry to the Department of Trade and Industry rather than have it dealt with by the Department of Health, but the Government did not think that was a good idea and it is not going to adopt that. Do you have any further observations? Mr Darracott: I think it would be broadly neutral. I can think of a couple of issues that might be helped by this. One of the anomalies that is in the system— and it is a fairly minor anomaly but it takes some explaining to patients—is that as a means of improving compliance in certain conditions the industry will package sets of medicines together. So the patient to all intents and purposes receives one box but they may have to pay three charges. That is a very diYcult one to explain. So there may be an encouragement of more of that sort of activity needed because there is not an immediate disincentive, as perceived by the patient, to having

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what is eVectively better treatment all packaged together. I suppose if the overall numbers go up then the industry is likely to be broadly interested in that. As to the impact and whether they should research more things, I am not entirely sure there would be one. It seems to me largely neutral in that respect. Q174 Dr Taylor: You have given us a huge amount of information and it is really very helpful. Obviously the overall message is that prescription charges are a blunt instrument, inappropriate to government policy and aims and that you would really like to see them abolished. Is that fair? Dr Meldrum: Yes. Q175 Dr Taylor: You have already given us lots and lots of suggestions of changes that could be made to the system that is working at the moment. Can I pick up one or two of those specifically? We gather that in Scandinavia they are widely used, that they have lowered the prescription charge and got fewer exemptions. Have you any comments on that? If we cannot get rid of prescription charges, you have given us several suggestions of what we can do. What about a lower charge and fewer exemptions? Dr Schafheutle: In the interviews that I do with people at the moment in my work I asked them about that and I found that people are not totally against paying for their prescriptions. I should add that these people are all paying for their prescriptions at the moment. They are very much in favour of the NHS. They say, “If we abolish prescription charges, how is that going to aVect us?” They are willing to pay, but they are saying the problem really for them is the level of the charge, especially if you are looking at more than one item. Having a much lower charge would ease that. Q176 Dr Taylor: Do you get any feeling from the people who do not pay that there would be some willingness to pay? Dr Schafheutle: I am afraid I cannot say that because I have not spoken to those people as part of my study. Q177 Dr Taylor: There are tremendous anomalies amongst the people who do not pay. You mentioned the people with hypothyroidism. Has anybody ever asked them if they would pay for other things? Dr Meldrum: I do not think we have specifically. I am sure you would get a mixed response. I think some public-spirited ones would think it is not really fair. Some of the elderly who are very well oV would probably think it is not really fair. I am sure lower charges would be better than we have got at the moment, but to me it is almost a point of principle. We supposedly have an NHS free at the point of use, funded from taxation. You could say should we not have a £2 charge for people coming to see me? That might help raise some revenue, it might help to dissuade people inappropriately and yet I think the same arguments would apply that would apply to prescription charges and I am sure there would be all the exemptions too. It does seem a bit incongruous that we have this system where you have a charge

whereas the rest of the NHS—I know we are not talking about dental and sight charges at the moment—is virtually free. Fewer exemptions is a marginal improvement but I do not think it is really solving the problem. Q178 Dr Taylor: One of you has mentioned the work in Wales. Are they going down as low as £1 a time? Mr Darracott: They are going down to £3 in April and then the plan is that they go to zero in 2007. Q179 Dr Taylor: That is going to be well worth watching. Would there be huge administrative costs if we had a flat rate of £1 for every prescription or would that cut down the administrative costs? Dr Harrison: It would be a very expensive way of raising revenue, would it not? Q180 Dr Taylor: It would. Ellen, you mentioned the work in the US and Canada. You have given us a huge list of references in your evidence. Are the references to that work listed there? Dr Schafheutle: I can check if it is in the list of references. Q181 Dr Taylor: It would be extremely useful if you could let us have the references to that. If the ingredients are mixed, for example hypertensives and statins, in the same pill then presumably that only has one prescription cost. Mr Darracott: Yes. Q182 Chairman: Ellen, you talk to patients who find it a burden having to pay. What do they say about the threshold, which is eVectively not tapered at all, it is on income and you are either over it or not? Beside the pre-payment thing, do they say that there is something wrong there? Dr Schafheutle: Those that are aware of it very commonly say it is important that we protect those people that are on a low income. They are not necessarily aware of what the exact threshold is unless I speak to somebody that really is just above that income level. Q183 Chairman: So nobody says to you that this threshold is harsh in as much as it is not tapered, you either go under it or you go above it? Does anybody ever say that to you? Dr Schafheutle: Sorry? Q184 Chairman: The threshold for paying is you meet a set level and then you have to pay all of that, there is no taper on that level at all. Does anybody ever say that that is unfair? Many other things we get from the state do have a taper. Dr Schafheutle: I am afraid that most people do not know exactly how the prescription charge system works. Even though I may spend my life thinking about it, most people do not, so they are not aware exactly of where the level is and they do not comment in that detail.

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Q185 Anne Milton: The level of the charge is set and the exemptions, etcetera, is really diYcult to look at until we know how much it costs to the system because there is a point at which the system is costing more to administer than the money you are collecting. You were saying it is almost impossible to find that out, were you not? Dr Schafheutle: Yes. Q186 Anne Milton: Nobody has any idea because the administration of the system is crucial to the costs, is it not? Dr Meldrum: Yes. Q187 Anne Milton: So it is all a bit irrelevant otherwise. Just moving on to Dr Harrison, your evidence concludes that, “co-payments are generally an ineYcient way of achieving objectives which could be obtained more easily and with fewer undesirable consequences by other means”. I wonder if you could expand on “other means”. Dr Harrison: I think we are just referring there to the simple point that if you want to raise income, general taxation is a better means of doing it with a very specific, focused charge-cum-tax and that is the point we had in mind, I think. Q188 Anne Milton: Better ways of doing it with regard to prescriptions or just generally? Dr Harrison: Generally. Q189 Anne Milton: So raise the money from elsewhere, just from general taxation. Nobody else has anything to add to that, have they? Dr Meldrum: Only to say that the BMA did a very big review of how to pay for the NHS and looked at all the various things, whether they be insurance schemes or whatever, and decided that the favoured and most eVective way was to raise the money from taxation. Q190 Anne Milton: And, therefore, could cut out all sorts of charging? Dr Meldrum: Yes. Q191 Anne Milton: Is that without exception? Would you all want to scrap charging? Is it just the inconsistencies that bother you or is it the charging in itself and, going back to what Dr Meldrum said, would you rather the revenue came from general taxation? Dr Meldrum: My own view, and there are two things, yes, on a point of principle, and we keep going on about an NHS which is free at the point of use and this is an example of where it is not, so there is an issue of principle there, but I think, for a lot of practical reasons as well which we have tried to outline, this system is obviously full of anomalies and I suspect that any alternative system might not have as many anomalies, but would still have several and, therefore, I think would be seen as not being entirely fair. Dr Harrison: Perhaps I could make a slightly diVerent point from that. The Government is spending a lot of policy eVort and a lot of money on

promoting access and the latest White Paper is a good example of that. In and of themselves, most of these initiatives look good and attractive, but they do cost money. One way of rephrasing this discussion is to say that improving access is a good policy objective and here we are actually reducing access for albeit a small section of the population, or a lot in terms of people, but only a small section of the pharmaceutical bill, so is it consistent to open up GP facilities in railway stations, walk-in centres, high streets and so on which are free while imposing, as it were, the entry fee for some people to pharmaceuticals? Prima facie that is not consistent, so if the policy is to promote access, why are we restraining access here? It is not easy to see an argument for it. More specifically, the Government has quite rightly begun to focus on long-term conditions and I think in itself everybody would say that was a good move as well, so it is a bit ironic to create a barrier for some of those people with longterm conditions to access the medicine they need. Again there is a big inconsistency between the policy objective and the charging system that we have. Q192 Anne Milton: Mr Darracott, I would be interested in your views. Mr Darracott: I think, broadly speaking, that is right. Our paper, I think, says we support a move towards abolition, that our long-standing policy is that there should not be a financial barrier for access, but also we would be in favour of a major reform of the system in a way that can be shown to have little or no deterrent eVect on use, particularly focused on this segment of people that tend to be very vulnerable where they are just into the charging bracket and yet they are people who are faced with these decisions. Q193 Anne Milton: So, just to sum up, discussions about the anomalies are really a bit irrelevant to all of you and we should look at just forgetting the charging there and to raise the money elsewhere, correct? Dr Meldrum: Correct. Q194 Anne Milton: I am looking for you, Ellen, to shake your head one way or the other. Dr Schafheutle: I think the important thing is that the vulnerable groups are protected, those on chronic medication. As a researcher, I like to make my statements based on the evidence I have available, for me to say that I think you are going to solve all problems by abolishing— Q195 Anne Milton: No, I was not suggesting that. Dr Schafheutle: I think the important thing, and everybody has said it, is that the current system is inequitable and the important thing is that those people that are actually deterred from accessing necessary, essential medication are protected. Q196 Anne Milton: I just go back to the final point, that until we know what it costs to collect the money, it is all a bit daft really, utterly daft.

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Mr Darracott: Just on that point, I am sure within the reports of the PPA, the actual administrative cost of the system must be logged there somewhere. Q197 Anne Milton: Well, I do not know. Mr Darracott: I guess the counterpart to that is that the system of charges now is currently administered largely by people who collect it as part of their job and the actual transfer of the money into the revenue is an automatic one because it is taken oV the reimbursement back to those people who work for the NHS, so, from that perspective, it is actually quite an eYcient way of collecting money because it is being administered in the high street and it comes straight out and is top-sliced oV the remuneration and reimbursement that is going back. Dr Meldrum: You are only indirectly paying the tax collector, whether it be the pharmacist or the dispensing doctor. Dr Schafheutle: It is probably the administrative costs of administering the exemptions. Anne Milton: Precisely, it is all the rest of it, yes. Q198 Chairman: Dr Meldrum, do any of your patients ever get discharged from hospital with a months’ supply of eVectively a prescription drug that they would normally pay for? Dr Meldrum: Sometimes they do. I am afraid, more often they get discharged with seven days’ supply and then come knocking on my door, wanting a month’s supply to follow on. Q199 Chairman: I just wondered if you thought it was inequitable that that can happen. Dr Meldrum: Yes, and of course the reverse happens too, that they will go to hospital and take their tablets in with them which they have paid for and find that they disappear somewhere into the system, which some people might view as actual theft, but never mind. Chairman: It is a give-and-take situation, is it? I am not familiar with that! Q200 Mr Burstow: This question follows on from that point. With the direction of travel of policy which says more is going out of hospital in the first place, will there be more instances where there will be drugs which hitherto you would have got free and in future will be paid prescription items? Dr Meldrum: It is possible. You are really only talking about the cost of medication while somebody is in hospital or for that immediate period when they come out in terms of what they do not pay for. I think the other thing I often get when people come out of hospital on half a dozen diVerent drugs is that they say, “I don’t really need to keep taking all of these, do I? Which ones can I cut out?” Sometimes there are good clinical reasons for cutting them down, but often there are economic pressures for patients to do that as well. I am not sure that necessarily the shift to more out-of-hospital care will have a huge impact in that direction.

Q201 Dr Stoate: As a GP, one of the things that always surprises me is the number of people who do not actually know that there is a Pre-payment Certificate or certainly do not know how the scheme works. I wanted to ask Rob, if it were more widely publicised, do you think that would have a beneficial eVect on the system? Mr Darracott: I think it would. I am not sure how it is publicised at the moment. The publicity which I am familiar with is this card which you will find normally situated in a pharmacy somewhere. This is actually produced by pharmacists. This is their contribution to getting over this issue because it is a live issue, but it is produced by pharmacists, not the NHS, to explain to patients. I happen to think, and you have asked a question, that we probably do not make as much of Pre-payment Certificates as we ought to on this card, but we are concentrating on the headline figure, the PST produces this card, concentrating on the headline figure. I think, in short, more publicity would be helpful because at the moment the profession itself is producing this card to tell patients about what the charges are. Q202 Dr Stoate: So certainly if we were, for example, to recommend the Government put much more eVort into publicising it, you think that would be helpful to the system? Mr Darracott: Yes. Q203 Dr Stoate: Another quick question on the same line—do you think there should be a monthly version of the Pre-payment Certificate? For example, you pay for a television licence on a direct debit monthly, so do you think the same should apply with the Pre-Payment Certificate and would that be helpful? Mr Darracott: I think it would be helpful. Intuitively that just feels right, does it not, that, if you make it more available and there are more ways to pay, as there are so many ways of paying the Congestion Charge, having more ways to pay just seems intuitively to be right. There is this issue that it is a big slug of money. For some people £30-odd is a lot of money when they are faced with it in the pharmacy right now. “I have got three items. Might I use five or six over the course of the next four months? I do not know. Do I want to pay for three now or shall I find money for six now?” For some people, that is a lot of money, and the £90 is certainly a lot. Q204 Jim Dowd: Just briefly on that point, is the pharmacist really in a key position to promote this because most people, I imagine, get their prescriptions from the same pharmacy? The pharmacist has the records and over time must be able to see who is going to benefit from the certificate and those who will not. Mr Darracott: Yes, I am glad you have asked me that question because I think that is absolutely right. Pharmacists do help people and point them in the direction of the Pre-payment Certificate where that seems to be an option. I think there is another point which leads on from that, that there is a new strand

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of policy, if you like, within the new contract for pharmacists in England and Wales which is about promoting a new service which is where pharmacists will review medicines that patients are taking where, generally, people are taking several groups of medicines. Now, it would seem to be entirely consistent with that policy that people are encouraged to use the same pharmacy over and over again because that is the way the relationship builds up. We have a system, unlike the GP system, where patients can have free choice and they can go to diVerent pharmacies at diVerent times. In the Norwegian model, the annual cap is pharmacyrelated, so if you are, for want of a better word, promiscuous with your prescriptions and you go to lots of pharmacies, you might never get to the point where you trigger the annual cap, so there is a thing built in there where patients, whilst they have a free choice, are encouraged to use the same provider of services over and over again and we would see that as being a good thing because that is how the relationship builds up and that is how the health professional can help people. Q205 Anne Milton: We get suggested questions and I am slightly bemused by the beginning of this question actually which says, “If the NHS enters a time of fiscal stringency . . .” but when has it ever not been in a time of fiscal stringency? You might find it diYcult to answer, but how would you rate the abolition of prescription charges against other calls on NHS funding? How important do you think it is? Dr Meldrum: At the moment, and we have argued about the costs of collection and such like, if you take the actual revenue of £450 million, whatever, it is less than 1% of the NHS budget, significantly less now, particularly with the budget having increased. It is obviously going to have an impact, one cannot deny that, but it is probably less than the appropriate accumulative deficit from certain trusts at the moment and, therefore, it may be that there are ways that one could actually compensate for that. Yes, I think I recognise that if you are going to get rid of prescription charges, the money has to come from elsewhere and, as I have said, it will have to come from central taxation. In the long run, that could mean a fractional rise in income tax, I suppose, but it would be very small. Jim Dowd: Or a reduction in GP contracts! Q206 Anne Milton: I was not going to be as harsh as that, but say that it would be an opportunity to encourage GPs to prescribe better. Do you prescribe painkillers or physio for a bad back? Dr Meldrum: I think I am always anxious to find ways to make sure that we prescribe appropriately and there have been lots of measures done to do that. Having said all that, the UK’s drug bill proportionately is still significantly less than many of our Western counterparts. We are not particularly high medicine prescribers if you compare us to places like France and Germany and, therefore, I would slightly refute the inference that we are sort of frivolous prescribers.

Q207 Anne Milton: No, I did not say that. Dr Meldrum: I know you did not. Q208 Anne Milton: There are maybe not always well-educated prescribers actually. I think that is an issue. Dr Meldrum: Yes, and you mentioned physiotherapy for a bad back, but unfortunately the sort of wait I have locally for physiotherapy is about 14 weeks and, therefore, there is not much option but to prescribe painkillers, at least for those 14 weeks. Q209 Anne Milton: Do any of the rest of the panel have a view? Mr Darracott: I would just support that. I think a lot of the levers around prescribing have already been pulled in the UK. In fact if you look at the long-run prescription growth, you can see when those levers have been pulled and how eVective they have been. We have the highest generic prescribing rates in Europe, we have got lower costs, as has been mentioned already today, comparing like with like, so a lot of those levers have been pulled. In fact some of the other countries do use a charging system as a mechanism to pull those levers, so you will find diVerential rates of charging or co-payment related to the supply of a brand versus a generic, for instance. Well, we have very high generic prescribing rates in this country already and that lever was pulled 10 or 15 years ago. Dr Schafheutle: Also it is worth considering that, if some of the US and Canadian findings that we talked about earlier may apply in this country, the loss in revenue may actually be oVset by saving people through not using their medication due to the access problem of cost, being admitted to hospital and actually using much higher-cost services than the prescription charge that is saved at the outset. Q210 Anne Milton: And we are not very longtermist, are we, in the NHS? Dr Schafheutle: I think it would be quite diYcult to put a figure on it as well, so you have got a loss, a clear figure of £450 million, but how it would then translate into the improved use of resources would be probably diYcult, but it is worth considering that because it may well be oVset. Dr Harrison: This is the point we were on some time ago, that we do not know the answer to that crucial question, so, if one is saying, “What should happen now?”, I do not think I would say that we should abolish it tomorrow, but I would say, “Let’s get that work done and really prove, or otherwise, that the system is ineYcient in its own terms”, so prepare for that position, if you like. There is perhaps a wider point that stems from your question which is that, if we assume that the NHS will be in a worse financial crisis in two years than it is now, we might raise the question, “What role should charges have in that context in financing it?” If one raised that question, one could look across all services and I doubt whether one would come back and say, “Well, the best way of doing it is prescription charges”, as we have it now, so I think this could be part of a much

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wider discussion of the general role of charges and, if one did look at that, one would be trying to identify areas where charges did the least damage to health because people could aVord them or one was unaVected by them. Q211 Chairman: Dr Harrison and maybe Dr Meldrum as well, there is an argument that the country cannot aVord the rise in drug costs at the moment and we are seeing the reaction of the Health Service, particularly PCTs, to the issue of Herceptin just in recent weeks. We are told in the media that there are many other drugs like that, probably as expensive, waiting in the line, waiting to come on to the market for the treatment obviously of serious conditions. Do you think there is an argument that really needs to be put forward, that, unless users pay more for drugs, it is a very small proportion of the actual drug costs, what users do actually pay at the moment? Dr Harrison, you are suggesting that not unless someone is having an operation does someone pay a little bit as well. Dr Harrison: What I am saying is that, if the situation is deemed to be so financially tight that you need income from the charges, you should ask the question, “Which is the best area to raise them from?” Just because drug costs are rising for the reasons that you mentioned, there is no reason to necessarily focus on that area. That is all I would say. Although it is obviously relevant and sensible to focus today on this particular set of charges, if you set it against the wider financing context, then I think you should look, or not you, but the Government should, at the appropriate time right across the board and decide where charges would impose the least damage.

Q212 Chairman: And not user-specific as that argument would— Dr Harrison: That is right. I do not see that one needs to make that connection. Q213 Chairman: Dr Meldrum, what do you think? Dr Meldrum: I think you are really getting into quite complex arguments of health economics. If you are talking about Herceptin and these very expensive drugs for a few, but very seriously ill, patients, then I think there is not much link there with the argument about prescription charges. I think you are then talking about the overall costs of delivering a health service and what is the best, fairest and most eVective way of raising the revenue to pay for that. I think our argument would be that prescription charges are not the most eVective way of doing that. We will always have to look at priorities, what you can aVord and what you cannot aVord and that should be done on good evidence and the value for money that you are going to get in actually using any particular drug. Let’s just take an example of drugs like statins where, yes, there is a very large, very significant immediate cost, but you have got to look at the longterm benefits and the potential savings, not just in actual cost to the NHS, but in actually improving the quality of life for people. It is these sorts of arguments you have got to look at when you are deciding priorities and then decide how you are going to raise the appropriate revenue. I think all we are saying from the BMA is that we do not think that really part of that equation or a very logical part of that equation is to raise a small fraction of that revenue from prescription charges. Chairman: Thanks very much for that. Could I thank you all very much indeed.

Witnesses: Ms Pauline Thompson, Policy Adviser, Age Concern; Ms Liz Phelps, Social Policy OYcer, Citizens Advice; and Mr Martin Rathfelder, Director, Socialist Health Association, gave evidence. Q214 Chairman: Could I welcome you all and I wonder if you could just give us your names and the organisations you represent. Mr Rathfelder: I am Martin Rathfelder and I am Director of the Socialist Health Association which is aYliated to the Labour Party in the same way as the Fabians. Ms Phelps: I am Liz Phelps, Social Policy OYcer from Citizens Advice. Ms Thompson: I am Pauline Thompson, a Policy Adviser at Age Concern England. Q215 Chairman: I think, Mr Rathfelder, we should have had you here last week, so I hope you have not been on the train all week and it was just a delay last Thursday! Mr Rathfelder: Thank you very much for letting me have another bite of the cherry. Q216 Chairman: Can I ask you, starting with you, Mr Rathfelder, in your written submission you recommend the abolition of all charges, so why is that?

Mr Rathfelder: We are essentially concerned with the issue of health inequalities and we see charges as deterring particularly the lower middle classes actually. We have a bizarre system where people with lower incomes and of middle age have to pay and other people get them free and that does not seem to us to make any sense whatsoever. The Government has made quite a lot of commitments to the idea of reducing health inequality, but the Department of Health does not appear to have taken that on board because clearly, if you make a charge on something, be it prescriptions or windows, then the consumption of those items is likely to reduce amongst the population least able to aVord them. If we are serious about encouraging people less able to pay to use the Health Service, then forcing them to come up with £6.50 every time they have a prescription seems counterproductive. I would also like to say a bit perhaps later about the Hospital Travel Costs Scheme because that is also part of the same— Q217 Chairman: We will move on to that.

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Mr Rathfelder:—and other things that the Department of Health seem to have forgotten about, like wigs and trusses. I came into this because I used to work as a welfare rights oYcer in a teaching hospital and I was next door to the orthopaedic department. People who have to have a surgical truss have to pay for it, unless they come within the scope of the Low Income Scheme. Similarly, if they need a wig for surgical reasons, they have to pay a charge for a rather inferior item. These are forgotten areas of the National Health Service and I found myself advising doctors, pharmacists, all sorts of people, who had no idea about the Byzantine nature of the system of charging, exemptions and reductions in charges. A system of rationing which works essentially on ignorance seems to be the worst possible method of rationing. Q218 Chairman: Could you expand on your comments about the question of charges deterring patients from seeking help? Do you know which groups are particularly unlikely to seek help? You have said obviously the issue of income which is something we touched on in the earlier session and indeed we did last week, but are there other groups beyond this question of income? Ms Phelps: I think from our point of view it is a combination of people’s chronic health problems and low income. It is when those two things butt up against each other, that is the client group that we find most often has problems with prescription charges. As was mentioned earlier, the PPC actually really misses out here on this highly vulnerable group because, if they cannot aVord the individual charge, they cannot aVord the PPC. Particularly, I think, when you come down to people on Incapacity Benefit, that is where it really hits hardest because a lot of this client group were on Income Support and they got free prescriptions, but then they got sick and, for whatever reason, got moved on to Incapacity Benefit at a slightly higher level and now, thanks to a slight change in the rules in April 2004, there is help with the short-term lower rate, but once they get on to the long-term rate, which is slightly higher, they lose out. You might think that Incapacity Benefit is paid at a higher rate, so they can aVord it, but the point is the way Housing Benefit and Council Tax Benefit impact on ICB which is that they pull back 80% of any income above Income Support. I am not sure that Department of Health oYcials and ministers suYciently recognise that. What that leaves is a huge poverty trap and, if you are trying to tackle health inequalities, you are missing the boat. From our point of view, we were very disappointed that this is the one area in the whole NHS where money is changing hands between patients and the Health Service and yet, in the context of the whole health inequalities agenda, it has not been looked at. Ms Thompson: Obviously for older people prescriptions is not an issue, but, where we do have problems, if you go to any Age Concern in the country, they would say they are really concerned about older people with dental charges and optical charges, and the amount of time they actually have

to spend describing the Low Income Scheme. I think, when we are looking at costing things, you are not just costing what it costs the NHS to collect the money, but it is really costing all of those services that are spending hours and hours trying to help people and encourage people to go and to see the dentist when they are really quite scared to because they are so worried about the cost. We would, therefore, say exactly the same thing, that it really does impinge and we are very concerned about the way it does put people oV. When you have got a government which has just issued a White Paper that mentions the word “well-being” 179 times and you are trying to look at the same time at charging to actually try and achieve that well-being, it just seems very strange. Mr Rathfelder: Just to follow up on what Pauline has said, because there is an age angle to this, it is not widely known that the Income Support system is age-biased. People under the age of 25 are given less money to live on and that is reflected in the way the National Health Service Low Income Scheme works, so for people under 25, they are expected to live on £44.50 a week, and that is not really a great deal and, if that is all they get, they get free prescriptions, but, if they have Incapacity Benefit or some other benefit or they work, the marginal amount above £44.50 is expected to pay part of their rent, their food, their heating, the costs of all their prescriptions. If they have to have any dental treatment or an eye test or anything else, they are in severe financial diYculty. One other point I would like to put to you is that, if we are going to continue with some sort of means-tested system, why are we still attached to the Income Support system which was designed with entirely diVerent considerations in mind? The point of the lower amount for people under 25 is that it is expected that those people will live with their parents, so they do not have as many costs, which may or may not be true, but I do not see that it is the scope of the Low Income Scheme to encourage young people to stay with their parents because that is the only way they can aVord their prescriptions, nor does it make much sense for older people when they get an Income Support amount of £109 a week now. Why do we do that? If old people need £109 to live a tolerable standard of life, why should young people only have half of that? The argument for that is about incentives for work. Chairman: That might be for a diVerent select committee. I have some sympathy with what you are saying, but not today. Q219 Dr Taylor: Going back to Ms Thompson, prescription charges are free, whereas dental and optical are not. Are there any others that are free for the elderly and for co-payment? Ms Thompson: Prescriptions is the one that is the free one. Older people get free optical checks, but not free dental checks, so why? Teeth are incredibly important to older people. Malnutrition, well-being, yet they can have free optical checks, but not free dental checks.

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Q220 Dr Taylor: Is there an argument that the very rich who are elderly should not get these exemptions? Ms Thompson: The problem is then that you are going to bring in means-testing and, as soon as you start bringing in means-testing, you get the whole problem of people who are entitled but not applying because they do not understand the system. You have already said that it is a labyrinthine system of means-testing for healthcare costs. Quite often it is a means-test for a one-oV cost, so people think, “Oh well, I can’t face filling in this 16-page form for a possible, very small charge”, but of course the other thing that is not looked at and has not been looked at so far this morning is that actually people do not just have one-oV costs. Overall, older people with multiple needs will have to travel to hospital, they will have their dental appointment, they will probably wear glasses, they might need a hearing aid, so, by the time you have added it all up, you are into quite large costs, but on each individual occasion with the problem of actually working through the system, then quite often you have to pay and get a refund, and that is another complication. Q221 Dr Taylor: We are coming on to the other bits, but would you agree with the previous witnesses, I think it was the witness from the King’s Fund, who said that really the only way to increase the amount of money is from general taxation as being the only fair way? Ms Thompson: Well, we have got a free National Health Service, so you can either do that through taxation or rejigging, the Government deciding how one is spending the money and whether or not more should go into the NHS, so there are two issues there. Q222 Dr Stoate: Let’s talk about the travel scheme for people who are able to claim travel costs back. At the moment, we have found out, only people attending hospital are entitled to claim on the scheme, but, with the Government’s latest policy to move more care out into the community, does that not seem wrong and is there any way of improving it? Ms Thompson: Paragraph 6.67 of the White Paper sort of points in slightly the right direction because it does actually say that they are going to extend the patient transport service to where it was traditionally provided in hospital and they are also going to extend the eligibility for the Hospital Travel Costs Scheme to include people who are referred by a healthcare professional for treatment in a primary care setting. Now, I noticed in the last set of evidence that there was quite a lot of discussion about the Travel Costs Scheme and how very complicated it is and I think this will need quite a lot of unravelling as to exactly how good or bad it will actually be. Who is the healthcare professional who is referring for treatment in a primary care setting? People selfselect to go and see their GP, so does that mean to say they would not get the Travel Costs Scheme for their first, initial appointment and it would only be after the doctor says, “I’ll need to see you back here in four weeks’ time”? There are going to be all sorts

of issues around that which I have not had time to look at, but I would just say that this is on the cards, but how limited it will be and how much it will actually meet what is needed is another matter. Ms Phelps: I think there are two other aspects of that which really are important. One is what we have been raising in relation to access to dentistry which is a huge issue and, whilst we keep our fingers crossed that everything will be rosy after 1 April, I think in the real world we do not expect that to happen. We have long been arguing that, if the PCTs cannot deliver dentistry in the local community, then at least there should be help through the Travel Costs Scheme for people on low incomes who actually have to make journeys of 30 or 50 miles because our evidence shows that that is one of the main reasons people have not been taking up any dentistry that they can get hold of from the NHS, that they cannot aVord to get there, so there is that issue. Also completely forgotten is the issue of the costs for visitors to hospitals which is completely outside the scheme and the only help that is available is through the Social Fund. Again if you compare that with the Assisted Visitors Scheme for prisoners under the Low Income Scheme, they can get help every two weeks for a visit, yet you might have an elderly person who is long-term in hospital and her health is very much aVected by the fact that she cannot get visits from her spouse because he cannot aVord it. Those are exactly the kind of cases we are getting in bureaux which are really heart-rending and they cannot be right. Ms Thompson: I think there is another issue and that is that we have not talked about people who are getting continuing NHS care in nursing homes, yet they cannot actually access the hospital transport scheme for patients to be visited in those situations. Q223 Dr Stoate: Is it the case at the moment that, if someone is sent by their GP to hospital for an X-ray or a blood test, they are eligible for the scheme at the current time? Mr Rathfelder: No, because that is not care under the care of the consultant. Q224 Dr Stoate: That is what I want to clarify. Mr Rathfelder: If I can amplify that point, I think what we do not want is for people to come and see you in your surgery simply so you can authorise transport at the cost of £4 or whatever it might be in your locality. That does not seem a very good use of a clinician’s time. The Social Exclusion Unit report on transport, I thought, was very good, but the Department of Health do not seem to be in the least bit interested in implementing it. Q225 Dr Stoate: So you would recommend a thorough review of the system? Mr Rathfelder: Yes, because it has got to take into account the money that is spent on the patient transport service at the same time which at present is oYcially regarded as providing transport for people for whom it is clinically necessary, but that does not convey any real meaning to me. If you are sending your patient to hospital, it is clinically necessary, I

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imagine, in your judgment that they should go there. If they cannot aVord it, then are they entitled to the patient transport system? It is not an ambulance service. Q226 Jim Dowd: But that is not it. It is for people who are deemed to have a medical condition which makes public transport unsuitable. Mr Rathfelder: Well, most of them do go by the patient transport system simply because they are old and frail actually. Why is public transport unsuitable for old, frail people? Q227 Jim Dowd: For the same reason you get oV the Congestion Charge if you want to go to St Thomas’s, for example. If the clinician says that you are unfit to use public transport, you are— Mr Rathfelder: So we all have to go and see our doctor so that he can certify us as being incapable of going on a bus? Q228 Dr Stoate: Does it have any eVect, negative or positive, on people who are housebound? Are they in any way disadvantaged or advantaged by the current scheme? Ms Thompson: One of the problems we come across is where people who are housebound, and I am not only talking about the Hospital Travel Costs Scheme here, but the patient transport service, and, because they are housebound, they need to have the patient transport service and it, therefore, makes appointments very, very long in hospital. You are talking about pretty ill people and, because the ambulance will come and pick them up at whatever time it suits the ambulance, quite often that is two or three hours earlier than the actual appointment, so the person is then sitting in a waiting room for that length of time to actually get seen and then quite often they have to wait another hour, so it is a day trip basically if you are using the ambulances. Q229 Anne Milton: Pauline, hospital car parking charges for the elderly, how great a burden do you think they are? Ms Thompson: We are getting increasing numbers of phone calls from our local Age Concerns about it and from people directly. It is probably not to the same level as perhaps the Macmillan evidence will be, but people do often have more than one condition, so they go into hospital for one condition one day and within the same week they can go to hospital to see another person, so overall it does actually start to mount up. Because many people cannot use public transport, then they are using their cars to drive themselves, but more often than not relying on friends and family to drive them, so then that person has to park in the car park. We are beginning to find that the charges really are going up and it does seem to be a revenue-raising system for hospitals. Also, the more ineYcient the hospital is, the more you are likely to be charged because, if you are there and your outpatients appointment is at such-and-such a time, but you actually wait two hours, you are then paying extra for the hospital’s ineYciency which obviously does not go down very

well, so it is actually much more of a problem and we have been getting more and more phone calls about it over the last few years. Q230 Anne Milton: I think the diYculty with saying that people can or cannot use public transport, probably the truth is that everybody can, but it is just that it will be deeply unpleasant and unacceptable. That would be my feeling. At what point can you not use public transport? Ms Thompson: Many people cannot use public transport. They might have a back problem, so they cannot actually go and stand at the bus stop. They might have diYculty in getting on the bus. The buses do not always go to where you want and you might have to have several changes on the bus, so you might actually be talking of making a journey which by car would be about 10/15/20 minutes into a journey of an hour or an hour and a half. That in itself for older people, who might not have a huge amount of energy and who are, by nature, ill because they are going to hospital, I think it is quite impractical for some of them to use buses and probably the majority. Q231 Anne Milton: I am not actually disagreeing with you. I am saying it is a bit of a nonsense to talk about it because it is terribly area-dependent. A bus in a rural area is a completely diVerent prospect from a bus in the middle of London. Ms Thompson: Yes, but some people would just have absolute diYculty in using a bus. Mr Rathfelder: There are particular problems for people with sick children where of course the patient is not the person who is paying the costs. People who have a number of children who may not have anywhere to leave those other children may have to take the entire family to hospital. People with severely disabled children, certainly in Manchester when I was working there, had consultants often in six diVerent hospitals and would spend their entire lives trekking from one place to another to see Mr So-and-so for one organ and Mr So-and-so for a diVerent organ. I had a terrible case of a Somali man with a child with dislocated hips and he was expected to take this child in plaster on a bus, then change in the middle of Manchester, walk across the middle of Manchester from one bus station to another bus station and the hospital would not pay for a taxi for him and, although they accepted that he was eligible for the Hospital Costs Travel Scheme, they would only pay his bus fare. I thought that was cruel and inhumane. Q232 Anne Milton: Should we pay the childcare costs then, do you think? Mr Rathfelder: Well, it would be more sensible than dragging all these other children into the hospital. Q233 Anne Milton: Pauline, do you think we should be building car parks at hospitals to help with transport and letting people have it free? Ms Thompson: Quite a few hospitals do actually have them and I know in London it is diVerent, but a lot of hospitals do have fairly large car parks, though

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there is always a problem about how many disabled parking places there are. Certainly I think that hospitals need to take cognisance of the fact that many patients are old and are not going to easily be able to get there, so you, therefore, do have to think of it in the round. Again in the White Paper it does very specifically look at local transport in general which is welcome to actually get some joined-up thinking between local transport and the Department of Health, but I do not see how you can avoid car parking in the current system. Okay, I think we are going to raise some new issues when we go to the idea of more surgery care and again I think they are going to need to address that issue because quite often surgeries will not necessarily have adequate parking nearby, so it actually in some way could compound the problems initially while people think about how they are going to access the surgery if they need to come by car. Q234 Anne Milton: And there are issues with community hospitals which are very good and local, but you have clearly read the White Paper in a great deal more detail than I have at this stage, but I think they are talking about populations of 100,000 which in rural areas is a huge geographical spread probably. Ms Thompson: Yes. Q235 Mr Campbell: The Low Income Scheme which was mentioned before, what are its weaknesses and does it benefit those it has got to benefit? Does it benefit the people it is supposed to? Ms Phelps: What we do not know is how much nontake-up of it there is, but our evidence would suggest that that is a lot. It is highly complex and it is divorced from the DWP benefits, so it does not benefit from being piggy-backed in any way when you are making claims for other benefits. It is not well advertised. Amazingly, health providers are not required to publicise in the GP surgeries, in pharmacies, in opticians and dentists, they are not required to display any information about it, so it seems to me that was a missed opportunity with the new contracts which could require that, but they do not. Then it is very complicated and, as has been said, the leaflet runs to 70-odd pages and the claim form runs to 16 pages, so it is very deterring. Our evidence certainly shows that it does not work insofar as a lot of people who should be getting help through it are not. Perhaps the worst thing that is coming and the one thing that we did not pick up in our 2001 report because it happened since is this system of penalty charges which has now come into force. That is a very harsh system. You can understand you have got to police any system once you have built it and it is another admin cost. But now if you so-called fraudulently claim for a free prescription and you get caught, you are subject to five times the prescription charge and, if you do not pay it, it doubles in 28 days. We are finding a lot of clients caught in that system who actually could have got free prescriptions under the Low Income Scheme, but nobody told them or actually in some

cases pharmacists and health professionals told them wrongly. They said, “Are you on benefits? In that case, tick that box”. Q236 Mr Campbell: That was going to be my next question. Is there anything in the information line that is put out to get this across? Ms Phelps: The Department of Health does produce publicity, there are leaflets and things, but I would like to see all health professionals required to display this and required to be more proactive, particularly at the point of the pharmacy, at the point of dispensing, to pick up whether or not people should be entitled and to help direct them towards that. There is a lot more that could be done, but, having said that, the system is burdensome, it is complex. Q237 Mr Campbell: It is not very good. Mr Rathfelder: If it was not a system based on the social security system but something with a simple line which said, for example, that if your income is under £100 a week, then you qualify, because the key information that people need to know is whether they are poor enough to qualify, On the Department of Health’s website, there is a Frequently Asked Question, “What is the maximum income I can receive that would still enable me to qualify for full help?” and what is the answer? “Each claim is assessed individually based on the information contained in the HC1 claim form. There is no maximum amount as it depends entirely upon the circumstances of the individual or family”, which is of course just the information we were looking for, is it not? Ms Phelps: It is interesting, looking again at who is entitled to free prescriptions from that point of view with the new Tax Credits system. It has become really bizarre that, if you are entitled through that, if you are in receipt of Working Tax Credit with a disability element and/or Child Tax Credit, then you get free prescriptions up to an annual income of £15,050 which is about £289 a week, but, if you happen to be a single, unemployed person who is sick and on Incapacity Benefit, then it is IS plus half the prescription charge, which is £59.45 a week. Now, there are just huge diVerences and it shows how the system has grown piecemeal and there is no coherence to it. Q238 Mr Campbell: You have suggested tapering assistance to reduce the impact of the purchase of the Pre-payment Certificate, which is another promising idea as well, as well as greater passporting to treat benefits. Can you expand on that? Ms Phelps: One thing you could do is say, “If you are entitled to a means-tested benefit, then you get your free prescriptions”, so you piggy-back on to that and do not have two tapers for in particular, Housing Benefit and Council Tax Benefit, which run well above Income Support levels, and that would simplify it for a lot of people. The thing we have said about the Pre-payment Certificate, I do not think it would complicate it more, but it would just be to say that you bring it into the Low Income Scheme. You would leave the system as it is, but, if you are on a

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low income, your HC3 Certificate telling you how much help you get with dentists, how much with optical charges, et cetera, could also say, “You can get a Prescription Pre-payment Certificate for £5, £10, £15 or whatever”. I think that is, to our mind, a much better way than saying that you can pay for it on a monthly basis because then you are still saying that people on low incomes have got to pay £90-something over the year, whereas, if you actually tapered the costs of the PPC, you would be giving people on low incomes the same advantage that people on higher incomes have who can aVord to cap their costs. Q239 Mr Campbell: That would be good, I think, if that could happen. If we cannot get the charges abolished with this Government, then obviously I think that which you have mentioned is a better plan hopefully. You have mentioned the voucher system just before for low-income groups. What are the pros and cons of this voucher system? Ms Phelps: The optical voucher? Q240 Mr Campbell: Yes. Ms Phelps: I think it is the bit that confuses people most partly because it sort of works the other way round. Instead of telling you how much you have to pay, it tells you how much help you get, so people get very confused about it in the first place, but the real problem with it is that there is no guarantee that you can actually get glasses within the cost of that voucher. It seems that in one part of the world the Department of Health fixes the cost of the voucher, and this is for people on Income Support on the lowest incomes, and in another part of the world opticians are deciding what the cost of glasses is and it is never road-tested properly. So particularly if you are living in a rural area where you cannot shop around so easily, you could well find that your local optician just does not provide them within the voucher value and you have got to find the diVerence which then immediately brings you below the Income Support level. You may then decide maybe, “I can’t aVord to go to the optician’s at all” and this leads to all the other health inequalities we have seen. We have suggested that that has to be joined up better and that, if opticians are dispensing through the NHS system, they should be under an obligation to provide glasses within the cost of vouchers. Q241 Mr Burstow: That has partly answered a question I was going to ask about the voucher system and how we can set the value in a way which is more sensible, and joining up the two parts of the system would make some sense. Are there any other points you would like to make to us about how we can set the appropriate principles when it comes to setting the value for spectacles and vouchers? Ms Phelps: I know the Department of Health does sit down and talk about this with the optical profession, but so often when you get these semiprivatised systems, what you end up with is a shortfall because the market does not actually deliver what perhaps was the initial intention, so we have to find a way of joining that up. The other thing

we were considering is that maybe NHS Direct should, in the same way as it can now direct you, in theory, to your nearest local dentist, also be able to direct you to the optician who can provide glasses within the voucher value. It would also make the Department of Health much more aware of exactly where those were. Q242 Mr Burstow: That sounds like a useful suggestion. Pauline, do you have anything else to add on this particular point? Ms Thompson: I was just thinking, and this is just oV the cuV, about the use of NHS Direct because one of the big problems we have with the Low Income Scheme in general is the amount of time it takes to fill the forms in and how complicated it is, so when you are actually looking at the costs of running the scheme, it falls very much on social services and any sort of organisation that oVers welfare rights advice, so Age Concern, all the voluntary organisations, are spending a lot of time helping people fill these forms in when really they could be doing better things. If the Department of Health is going to continue having these charges, should they not have responsibility also to take on the costs of actually helping people fill in the forms and perhaps do this over the phone, although that will not work for everybody. It does seem quite strange, and again it is partly mentioned in the White Paper, that more and more GP practices are being encouraged to get welfare benefits advisers in. In fact there has been some research done by Liverpool University and the CAB about how getting benefits advice and an increase in income did actually improve people’s mental health and well-being and they have done a longitudinal study looking 12 months later at the people who actually did benefit from the benefits advice. Therefore, you have one arm suggesting that you need more and more people to give benefits advice to the well-being agenda and then, on the other arm, charging. Q243 Mr Burstow: So, as a sort of general conclusion from what we have heard so far today, would it be fair to say that there are some issues here about how Department of Health objectives and DWP objectives are met and whether they are actually properly aligned? Ms Phelps: Yes, and I think the DWP is moving very much towards the kind of idea of not having to claim for each benefit separately, but pulling those together. If you look at HC1, a lot of the questions, they exactly mirror those of other means-tested benefits, so you should not require people to go through that whole thing. Ms Thompson: It should be a single assessment process as well. Ms Phelps: Exactly, it should be brought into that, but that means more joining up between the Department of Health and the DWP. Mr Rathfelder: But the DWP makes assessments of the take-up of the various benefits and regards getting people to take up what they are supposedly entitled to as valuable. I have not seen all your evidence, but I have not seen any sign that the

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Department of Health has made any estimate of the take-up of the Low Income Scheme and how many of the people who are supposedly entitled to it either know it, know anything about it or take advantage of it. Q244 Mr Burstow: Well, we will have the Minister before us at some point and you may have helped us tip them oV that we might want to ask that question. Ms Phelps: What we find particularly hard in that context is that then you can be penalised in the context of not actually having maximised take-up. Q245 Mr Burstow: I think that point has been very clearly made to us today and certainly it is something I think we would want to come back to with other witnesses later. Can I come on to some specific services because really in a way that is the best way to understand how the system is working and how it might not work in the future. In the evidence we have had from Age Concern, there was a reference to the new structure of dental charges and how that will be inequitable for older people. I wondered, Pauline Thompson, if you could say a bit more about how that actually is so. Ms Thompson: We are obviously very concerned about dental charges because we have got loads of evidence about the problems that older people have with their oral health, and again it is all part of the Well-being Agenda, that it is really important. The fact that people do actually have to pay for their dental check-ups and then, once they have had their dental check-ups, I know we have got new charges and some of the worries have been slightly alleviated by the fact that the cost of replacement of lost or damaged dentures, they are making it slightly lower, but we do still have the question of what is going to happen to the people who just have wear and tear on their dentures and whether they are going to be expected to find £189 for this. I think really our big problem is that there are real problems with dental health, we know that dental health can actually aVect people very severely, even to the extent of malnutrition, yet we are still not looking at whether or not we are putting barriers, well, we are putting barriers to people having good oral health. Q246 Mr Burstow: On this point about wellbeing and malnutrition being potential consequences of this particular policy, how well grounded is that in terms of evidence? Are we talking anecdotes here or actual research? Ms Thompson: No. There has been quite a lot of research on gerontology, meeting the challenges of oral health for older people.13 Q247 Mr Burstow: Perhaps references could be passed on to us so we can look at that. Can I ask Ms Phelps from Citizens Advice, last week I asked a question about dentures of Rosie Winterton, the minister responsible, about this apparent anomaly that 30% of the highest band will be charged where 13

Note by witness: For example, Gerondontology, vol 22 supplement December 2005, Meeting the Challenges of Oral Health for Older People, A Strategic Review.

they have lost or damaged their dentures but they pay the full whack of £189 if they just happen to have had their dentures for a very long time and it is wear and tear. The Minister said there had been no change to the system. Has there been a change to the system in terms of how much people are paying and could you say a bit more about that? Ms Phelps: Yes. For my sins, I was on the Harry Cayton group that looked at this. To start oV with, given the health inequalities agenda it is very sad that the Government did set in the terms of reference of that group that they had to create the same amount of charged revenue as under the existing scheme, although compared to other European countries it is very high with people having to pay 80% of the cost, so a huge percentage of the charges. The new system has to deliver the same. There seems to have been a slight change in the language over time because the brief of the group was to develop a system which would deliver the same level of charges. We assumed that meant—working on 2003–04 figures—with inflation only up to what would happen in April, but in reality what appears to have happened is the new dental contract has proved to be much more expensive than under the old system and the Department has decided it wants to raise the same percentage of take from charges as under the previous scheme. In fact, we are going to see a very significant increase in the amount of revenue that comes from charges post-April, which I think is another example of where policy is not being led by trying to tackle health inequalities, it is being led somewhere else in the agenda. What has happened in the end is bands two and three are significantly higher than the Cayton group hoped would have happened, particularly band three at £189. If you look at the cost now of a partial denture, there has always been help with replacement, if you break it or lose and that has not changed. But if you are an older person who has had your dentures for a long time and they are not working properly any more, I am told that currently that will cost about £100 to get a new partial denture and under the new scheme that is going to be £189. Q248 Mr Burstow: So there is a change, they are going to be paying more. Ms Phelps: We knew that moving from however many it was to three bands would mean that there will be some gainers and some losers but what we do not know is where some of those big losers will be. It is a question of guessing, the Department has not been clear for which groups or in which situations it will cause the biggest losses. It struck me straight away that the partial denture was one concern. Q249 Mr Burstow: Maybe we need to return to that again when we have the Minister. Can I ask Age Concern about free eyesight tests for the over-60s. What is the evidence for an improvement in people’s health as a result of that? Is there any evidence? Ms Thompson: I cannot honestly say. One would sincerely hope that by having a free test you are encouraging people to go along and are not putting a barrier to them having a test where other conditions

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might well be picked up. I think that there is that problem and across the board it is really important, it is part of health. You have chosen some things that you are charged for and some where it is free. Q250 Dr Naysmith: Can we move to another service that is regarded sometimes as a bit of a Cinderella in the National Health Service, and that is chiropody, which is mentioned in the Age Concern evidence they submitted to us. Particularly you talked about the service being free in theory but patients are charged by default for these services. Could you expand on what you mean by that? Ms Thompson: There is some evidence which we have just picked up, a report, and some government figures. Initial contacts with chiropodists have fallen from over 960,000 in 1996–97 to 769,000 in 2003–04, so that is nearly 200,000 less people who are being seen by chiropodists at a time when we have got more older people. It is because chiropody services have largely been withdrawn and their eligibility criteria are becoming much higher. We have got evidence from some of our local Age Concerns that even people with really severe arthritis who are blind cannot access chiropody services, they have to go and have their toenails cut and feet looked at either by a private chiropodist or local Age Concerns who in some areas are picking up the lower end, the toenail cutting service but, again, it is a cost to us to provide this service and sometimes we have to pass it on to the individuals. It is really charging by any other name. Basically, how much is chiropody part of the Health Service and how much is it health, how much is it social care. It is back to the old bath syndrome: when is toenail cutting a health service or a social service? One of our Age Concerns has been very concerned because they have done a huge tightening of the criteria and they feel that older people should not be put in the undignified position of having to plead for basic foot care. They had a case where somebody could not aVord to go to a chiropodist and they ended up pleading with the health authority to go to the NHS chiropodist. They also, quite rightly I think, say it is a short-sighted policy because money might be saved initially but not in the long-term. We did a document some years ago called On your Feet but I think we would have to call it OV your Feet now because things have got so much worse. In her letter she ended up saying: “If the people who make decisions could come face-toface with some of the toenails we have seen they might change their mind”. It is really charging by stealth. Q251 Dr Naysmith: Certainly it is something where I imagine most MPs around this table have had a similar experience to me where you get people coming and saying, “We used to have our toenails clipped and now we do not”. In my constituency, which spans two diVerent primary care trusts and two diVerent local authorities, there are a number of ways of dealing with that situation. You are right. I had a case two years ago where the health authority, after exchanging letters, said, “Has the person concerned asked her neighbour if he will cut her

nails?” Within the area people recognise what you have just said, that you can prevent much more serious illness by clipping nails and doing minor foot care. Ms Thompson: A bit of help at the right time. We are always saying it. Dr Naysmith: So that is a hidden charge that we have identified. Q252 Jim Dowd: I want to return to Paul’s question about the eVect of removing the cost of eye tests. All of you individually have cited the deterrent eVect of charges generally. Why is it possible to calculate that but not the beneficial eVect of the removal of charges? Ms Phelps: Certainly from our point of view we see people come in the door who say, “I did not get my prescription” and the MORI work we did showed 750,000 people had not got their prescriptions dispensed in the previous year. We see that bit of it. We see other people driven to below poverty level paying them. The health impact, certainly in terms of prescriptions, is I would assume it is a given that if a health professional has decided that person needs that drug and they do not take it, to my mind that is enough, is it not? Q253 Jim Dowd: I am asking you . Ms Phelps: To measure the health outcome would not be something that we would be able to do around this table, you would have to do it further down the line. As Pauline said, the nearest bit is the evidence we got on the impact of just having CAB advice in GPs’ surgeries and how that led to a reduction in prescriptions. Yes, it is possible. Mr Rathfelder: Does this not take us further towards what is the essential point of charging? When charges were first introduced they were clearly designed to reduce the consumption of medication but that no longer seems to be an objective of the present Government. Certainly in Manchester they are encouraging GPs to prescribe more in order to reduce other costs. It makes no sense to continue with charges. What may make sense is a more refined argument about what the National Health Service ought to be providing. The decision should not be made by individual patients who can or cannot aVord £6.25 or whatever it is to have their teeth, toenails or whatever other part of the body is not included looked after. We have a system now for evaluating the cost-eVectiveness of interventions and that was not in existence in 1950 or in 1968 when we had charges. We should have NICE investigating the cost-eVectiveness of chiropody, eye tests, dental tests and deciding whether they are worth doing, not rationing them by paying for them. Chairman: I think you have answered Richard’s next question. Q254 Dr Taylor: That is a very interesting point as to what the NHS ought to be providing because it raises the whole question of healthcare rationing which is something that I personally feel we should be facing up to. My question is the really huge question: if each one of you started with a blank

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piece of paper what would you have on it as ways of raising the money that has got to be raised other than these charges that we have been talking about? Everybody wants to abolish prescription charges but we have got to raise the £450 million they make. We want to abolish the other charges but where is the money going to come from? Mr Rathfelder: Either we put the money on higher rates of tax—I do not understand why people who earn more than £100,000 should pay less per pound than poor people do on their income—or we work out something that we want to deter. I would put a tax on hydrogenated vegetable oil personally. Q255 Dr Taylor: So we increase specific taxes on certain things. Anything else? Mr Rathfelder: No, I think that is enough. I do not see that there is any point in trying to raise money through the National Health Service, that is not the point. The whole point about the National Health Service is that it is supposed to be free at the point of need. We can have discussions about what it ought to be providing. Personally I have no qualms with some things you can pay for as an optional extra, although I do not know whether my colleagues in the Socialist Health Association would agree with that. Q256 Dr Stoate: I certainly would not and I am a member of it. Mr Rathfelder: If you are admitted to hospital and they say, “You can have wine with your meals but you have got to pay for it, but you can have tea for free”, that does not seem to me to be— Dr Stoate: I think that is important because that is a slippery slope argument. Queen Charlotte’s Hospital, which we have been looking at this morning in terms of an article, are saying you can have a decent midwife if you pay four thousand quid or you can have an NHS one if you do not and— Anne Milton: No, it was not saying that. Dr Stoate: It was not quite saying that. Chairman: Can we leave that point until we see the actual papers and then we will come back to that with another set of witnesses. Anne Milton: That needs to be challenged. It did not say “decent”. Dr Taylor: Can we go to the other two to get answers. Anne Milton: That is very derogatory. Q257 Chairman: Where does the money come from if it is not charges? Ms Phelps: I have to agree, I think it has to come through general taxation. The reason for that is I think all of us would rather pay over our lifespan according to our means rather than face sudden large sums at a point when we are ill when that means our income has dropped for those very reasons. It is not the best way to do it. If you took it through the income tax system then you could

instantly make a positive contribution to tackling poverty and ill-heath because those on lower incomes would pay less. We know that they are likely to be in higher health need so currently they are likely to pay more. It supports the prevention agenda and you cut those admin costs and penalty charges. Ms Thompson: I can only say I would agree with what has been said. Q258 Mr Amess: I just want Mr Rathfelder to clarify something. The Socialist Health Association is aYliated to the Labour Party, so you support Labour. I have been listening very carefully to what you have been saying. How successful are you and have you been in influencing the Government’s health policy? Mr Rathfelder: This one or its predecessors? We like to claim some credit for the establishment of the National Health Service in 1945. More recently I think this Committee has been doing a better job than we have. Jim Dowd: So the answer is nothing. Chairman: The answer is no comment on that. Q259 Mr Burstow: This comes back to the question of drawing the line between what is free and what is not free. Last week in the High Court a judicial review decision in the Grogan case decided that the guidance issued by the Department in respect of NHS continuing care was flawed. Pauline Thompson, do you think that the framework that is long awaited, that is being put forward as the next step to try and deal with problems of NHS continuing care, is an answer to the criticisms that the court made last week? Ms Thompson: I think the judge did say it was the local criteria that was fatally flawed but he certainly had lots of criticisms about the Department of Health guidance as well. It is going to be a step—it is only a step—in that if you have one national set of criteria you have still got lots of diVerent people applying it and it depends how the assessment tools are sorted out. All I can say is it really depends. I still feel very strongly that unless we have sorted out the registered nurse care bands and what is considered to be incidental and ancillary nursing care then I do not think we are going to be very much further forward. It will be very interesting to see whether or not there is an application to appeal the case and what happens after that. Chairman: Can I thank you very much indeed. Can I just say one thing: if any of you know of any study that has been done in recent years about the actual eVects on charges due to the changes in benefits, Family Tax Credits and things like that, I would be very appreciative if you could direct it to us. It would be interesting to see exactly how quick or not the Department of Health reacts to these changes in the state benefit system. Thank you all very much indeed. I am sorry it has gone on so long.

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Witnesses: Mr Peter Cardy, Chief Executive, Macmillan Cancer Relief; Mr Robert Meadowcroft, Director, Campaigns, Policy and Information, Parkinson’s Society; Mrs Rosie Barnes, Chief Executive, and Ms Lynsey Beswick, CF Trust Expert Patient Advisor and CF Patient, Cystic Fibrosis Trust; and Dr Moira Fraser, Policy OYcer, Mind, gave evidence. Q260 Chairman: I have to now say good afternoon, it should have been good morning. I am sorry for the further delay we have had in this morning’s session. I wonder if you could introduce yourselves for the record. Dr Fraser: I am Moira Fraser. I am Policy OYcer at Mind. Ms Beswick: Lynsey Beswick, I am an Expert Patient Advisor and also a cystic fibrosis patient working for the Cystic Fibrosis Trust. Mrs Barnes: Rosie Barnes, Chief Executive of the Cystic Fibrosis Trust. Mr Meadowcroft: I am Robert Meadowcroft of the Parkinson’s disease Society. Mr Cardy: Peter Cardy, Chief Executive of Macmillan Cancer Relief. Q261 Chairman: Thank you very much. Could I ask a general question to all of you. Which groups of patients are most disadvantaged by charges? Is it mainly a question of poor take-up of services or of hardship by those who actually pay for treatment? Mr Cardy: I can certainly illustrate for you the impact of charges on people with cancer. If we take a typical cancer career of perhaps nine months or so, from suspicion of cancer to referral for investigations to eventual admission for surgery perhaps and then repeat treatments, radiotherapy or chemotherapy, which would be the norm, we would see the costs to the patient piling up during the course of that time. In the course of hospitalisation they will be paying charges in hospital, they will be paying travel costs, which because of the concentration of specialities in cancer centres, which is a perfectly proper and desirable move, means that people are often travelling long distances, sometimes very long distances, for treatment, and they will be paying car parking charges. When discharged from hospital they will be paying prescription charges. So costs, each of which is modest in itself, will be piling up very considerably for people who have this quite typical trajectory. That often results in very considerable hardship. We have quite a lot of survey data, which you have seen in our submission, but we also have the surrogate data that comes from our own grants. Last year we gave small grants to over 20,000 people in financial distress because of cancer. That is a very small proportion of those who will find themselves in financial diYculty. Quite a large proportion of those grants were for travel costs and associated matters. Costs for people with cancer mount up, they become very considerable and very burdensome. We have evidence of people having to make a choice between eating and being treated, which seems a shameful state of aVairs to us. Q262 Charlotte Atkins: Do you think this is the sort of thing the NHS should be dealing with, these sorts of costs? It opens up a whole range of things. What happens if someone needs a hotel stay, maybe the NHS should pay for that too?

Mr Cardy: The eVect of the change in the pattern of cancer treatment, which is wholly desirable, that people spend their time principally at home rather than in hospital has been to shift costs on to patients. Previously the Health Service would have paid hotel costs which now would run at about £200 a night per patient but those costs are met by patients and they are met in the form of travel, transport and parking costs. Q263 Charlotte Atkins: If we could just expand on that. You are saying that previously the NHS would have paid for an hotel? Mr Cardy: I mean the hotel costs of hospitalisation because that is where cancer treatment is carried out. Q264 Charlotte Atkins: You are not just talking about the patient, you are also talking about the family and friends as well when you are talking about severe treatment over a period of time. What I am asking you is do you think that the NHS should be paying for things like car parking, hotel costs? If we are talking about the regionalisation of a health service we could well be talking about patients having to stay overnight in an hotel rather than in the hospital. Do you think these are the sorts of things that should be paid for by the state? Mr Cardy: In Scotland, because of travel distances involved, it is by no means uncommon for hostel accommodation to be provided for people who have to travel long distances. Q265 Charlotte Atkins: What you do you mean? Mr Cardy: Provided and subsidised. Q266 Charlotte Atkins: Provided by? Mr Cardy: The NHS. Q267 Charlotte Atkins: What you are saying is that they provide hotel accommodation or they pay for it in the private sector? Mr Cardy: Provide hostel accommodation. If I can take up your other point, the thrust of health policy for the last 10 years since the publication of the Calman-Hine report, which has had a very high level of support from Government and from all parties, has been to address the rather dire situation we were in with cancer treatment and cancer survival. The direction of travel has been to increase the number of people surviving cancer, which has been successfully done, to shorten the waiting times, to extend the number of people who are able to stay at home, to extend oral therapy so that people are able to take those at home. The goal of health policy as far as cancer is concerned and the direction of travel is very clear but these additional costs, which are borne by patients and, indeed, their families, work against the direction of this policy.

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Q268 Charlotte Atkins: Does one not even out the other? You are saying there are some developments which mean that people can be treated at home, therefore there are less travel costs, less car parking charges and no need for an hotel. Mr Cardy: If you are treated at home with, say, hormonal treatments, and a lot of older men who develop prostate cancer will be treated with hormonal treatments, and women increasingly can be treated with oral therapies at home, you will be paying prescription costs for those drugs. The drugs that manage side-eVects are extremely important, anti-nausea drugs for example, painkillers, drugs to manage things like damage to salivary glands and tear ducts and so forth. All of those will have to be met by patients as prescription charges at home. Had they been treated in hospital they would not have been paying those costs. Q269 Charlotte Atkins: Until they got out of hospital? Mr Cardy: Until they got out of hospital. Q270 Charlotte Atkins: Obviously if they take the certificate there will be a maximum for the year. Mr Cardy: Yes, of course. Q271 Chairman: Back to the general question. Mr Meadowcroft? Mr Meadowcroft: Parkinson’s disease is a long-term neurological condition for which there is no cure. The main form of treatment is drug therapies and drug treatment is the mainstay of treatment. The average age of diagnosis is around 60–62, so most people with Parkinson’s will be turned 60 and will be exempt. It is the substantial number of younger people for whom the prescription charges are a problem. How many people are aVected by this, about 8,000 below the age of 60 with Parkinson’s disease. Although they are a small group, at times they are facing real hardship. We consult our members each year on what their major priorities are for changes in health and social care and this issue of prescription charges and what is seen as being unfair since the 1968 list of exempt conditions always comes up in the top four or five and it is there now as a major priority for younger people with Parkinson’s. Because the 1968 list was drawn up when it was most drug treatments for Parkinson’s have been introduced since then and there are more recent treatments with more drugs coming through. Most people take several drugs at once, four or five is quite normal, and the costs are quite excessive. That is where the real pressure for change is coming from from our membership who wish to see this iniquitous system changed. Q272 Chairman: Rosie, in general terms which groups of patients are most disadvantaged by charges? Mrs Barnes: In the case of cystic fibrosis it tends to be very young adults, late teenagers and early twenties. Of the 3,500 or so adults with cystic fibrosis, it is estimated that roughly a third are still

in full-time education and a third are too ill to work and are on Income Support and are exempt. It is the remaining 1,000–1,500 we are very concerned about. These are people who have had poor health since birth and tend to be on very low income jobs because their education has been disrupted by health problems. However, they are young and they know they are not likely to live all that long and live life in the fast lane. They have a high cost of living because they have to eat far more than most of us eat even to retain a very low body mass index. They are very slender people because they find it diYcult to absorb food, which is part of the condition. Also, they have deteriorating lung function so they tend to rely on cars and taxis more than the average simply because they cannot walk, they get very breathless. Although, of course, they can pay the annual cost which would be cheaper than paying by item, because these are youngsters and they want to pack what they can into their short lives they do not have very much money and £100 at that time seems a great deal so many of them do not pay it and then we do have the problem of knowing they are being prescribed drugs, particularly after a period in hospital. They take dozens of drugs. Lynsey, who is with me today, has brought an example of the sorts of things she would take on an everyday basis. If she brought all of her equipment and all her drugs she would need a suitcase and people would think that is a year’s supply but that may be a week’s or a fortnight’s supply. It is those people who we feel are very disadvantaged by the current system. Q273 Chairman: Moira, do you have anything to add? Dr Fraser: From a mental health point of view, the people who are most significantly disadvantaged are the people on low incomes who do not meet the exemption criteria either because they are on Incapacity Benefit which brings them over the limit or because they are in low paid employment or parttime employment. I think that is quite significant currently with the push towards moving people back into employment. We are going to see a rising number of people who are on the peripheral edges of employment who no longer qualify for free prescriptions and who are also liable now for things like council tax and full rents on their accommodation, et cetera, and this can be quite a burden and can result in people having to make invidious choices: do I cash in my prescription or do I not? Also, people with mental health problems tend to have physical health conditions more commonly than the general population, so it is not uncommon for somebody to be on four or five diVerent kinds of medication, which is often prescribed monthly but in mental health sometimes things are prescribed weekly, typically antidepressants but also other things, tranquilizers, for example, or sleeping tablets. If you are on a low income and are being prescribed a drug weekly you are talking about £30 a month for one drug. If you multiply that with the other prescriptions it becomes out of the range of many people.

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Q274 Chairman: Could I ask you a specific question, Lynsey, in your unique role in a sense as a witness today. Could you give us an illustration of the eVects on household budgets of paying for medicines to manage cystic fibrosis. Particularly, does this have an impact in terms of people seeking employment or pursuing education or training? Ms Beswick: Firstly, I would just like to point out that this is how many tablets I have. There are about 85 tablets, plus nebulisers three times a day. 85 tablets are what I have to take daily. I am surprised I do not rattle really. The basic costs that we incur every day are everyday things that most young people face, apart from the fact that because of our health we are sometimes limited as to the career pathways that we can choose which may have an eVect on our jobs which may mean that we have quite low incomes. I am on lower support DLA but that barely covers my dietary requirements. I have to have a high fat, high calorie diet. I have parking fees, parking charges, travelling to and from specialised clinics, along with all the regular things that people my age have, such as a student loan and on top of that maybe setting up a house, rent or mortgage, and other costs, just generally going out and having a good time. If you add to that that you have to pay for a pre-prescription certificate every year, and it is guaranteed every year for life, for this vast amount of pills that I did not even want to take, there is not any incentive. Obviously if I do not take these pills it will have a detrimental eVect on my health and also decrease my life expectancy overall. I do feel that it is such a shame that I have to pay for something where I have a life threatening illness and this medicine is keeping me alive but I have to pay for it and I have got to make allowances in my yearly budget for that. Q275 Chairman: Presumably you must do in terms of the actual amount as far as the medicines are concerned. You have mentioned travel, travelling to and from specialised clinics. What is your travel pattern in any one week or month? Ms Beswick: It varies from patient to patient. Q276 Chairman: I realise that. Ms Beswick: Personally, I travel to my specialised clinic. I live in York and that is in Leeds. Typically I will travel every six weeks to two months to my local centre for specialist care and on top of that maybe every few weeks to my GP to pick up my prescriptions and so forth. Q277 Mr Amess: Rosie, your colleague is certainly giving powerful evidence to the Committee. It still seems strange to see you that side and not on those green benches next to David Owen, those glorious days. If I can put my question to Mind because obviously everything the Committee has heard in the last couple of hours is saying that all is not well with charging but we have got to try to come up with some solutions. There is probably no more diYcult area in terms of charging than for those people with mental health problems. Can you tell the Committee

how the charges work, where the problems are, what the disincentives are and, most importantly of all, any solutions? Dr Fraser: In relation to prescription charging— there are a number of other areas of charging which are also problematic—the particular problems are that it is very easy to go over the threshold and, therefore, no longer be eligible for free prescriptions. If someone is unable to purchase their prescriptions obviously this can have an eVect on their mental health. I have a letter with me that was sent to me by one of our local Mind associations because they were being asked by social services if they could help. A young man they were in contact with, who has a diagnosis of schizophrenia, had been hospitalised for a number of months and was now in the community being supported by a community psychiatric nurse. He was in employment but very low paid employment and had periods oV sick unpaid and could not aVord his anti-psychotic medication and, in fact, had only filled three of his monthly prescriptions in the last year. They were asking a local Mind association, a charitable fund, for money from the crisis fund to pay for these, which they did. When we are moving towards a system where Government has indicated its intention to try and potentially force people to take medication in the community, here is a man who is quite happy to take his medication but cannot aVord it because he falls over the threshold. That seems to me exactly the type of situation that just should not happen. There must be a more robust system which can be in place which can support people who are willing to take drugs that the doctor prescribes for them, not just for mental health conditions but also for their physical health, but cannot aVord to do so. It seems to me it is entirely counterproductive. The ultimate consequence of that presumably is that he may well end up back in hospital if he does not have his medication. Medication is not the only thing which supports somebody with a mental health problem but for some people it helps. The cost of maintaining somebody in an inpatient hospital is enormous. For the cost of paying for his medication, a small cost, we could well have prevented it from leading to him needing hospitalisation. That is the kind of situation we need to start looking at. It is not only people with things like schizophrenia, I am particularly concerned about people with chronic depression and anxiety, for example, who are likely to be on low income, who are likely to be on the margins of employment or Incapacity Benefit and who may well have poor physical health. For them, getting access to help when they need it, by which I mean the drugs which will help them stay well, be those for mental health or physical health, is very important. If we do not provide those people with those drugs they are likely to become more unwell and require more care and treatment at great cost to themselves personally as well. That is the situation on prescription charging. There are also people who have been detained under the Mental Health Act who should receive care and treatment under section 117 after discharge from section 3 of the Mental

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Health Act but that system is very poorly understood. There is no failsafe means of enabling people to access that meaning that unless they fall into the low income bracket people do not get their medication free. Also, with the possibility of moving to a future situation where people could be compelled to take medication, we very much hope that situation will be looked at because surely you cannot compel people to take medication and then charge them for it. On the other side of the charging issue, there are many people who need to use services which are a long way from home, not only the high secure services, the high secure hospitals and medium secure hospitals. I was recently at a mother and baby unit in Welwyn Garden City, a fantastic unit and a much needed service. These services keep families together. They have families there who have come from as far away as Ipswich, which is a long way away, and it is absolutely vital for dads to come and visit regularly but it is too far to come on the bus, you cannot really get there unless you have a car, and you need to stay overnight. If you are on a low income it becomes very diYcult. Without the family being able to spend time together it completely defeats the purpose of the whole service. The Social Inclusion and Mental Health report from last year laid out these issues very clearly. Social inclusion in mental health is absolutely vital to recovery. You need people to be involved in their communities and to continue to engage with family members whilst they are away from home in hospital. We need to support people to do that where they do not otherwise have the income to do so otherwise there is no point in spending a lot of money on inpatient services if the things are not there to support them when they are discharged from services. Q278 Mr Amess: Thank you for that. To summarise: not much commonsense in the way the charges operate in your particular field and for short-term gain long-term needs are really suVering in that there are all sorts of extra costs. Dr Fraser: Exactly. Q279 Mr Campbell: To what extent is there evidence of patients paying for treatment recommended by their local doctor, such as counselling? Dr Fraser: I have got anecdotal evidence as long as my arm. Every day I get calls in saying, “my doctor has said I should be able to get cognitive behavioural therapy, counselling psychotherapy, but the list is too long”, or “they are not even going to put me on the list because the list is too long”. There is evidence of services closing the list at a six month deadline, so if the list is more than six months long they just close the list and do not take any more referrals so that they can say their list is six months long. Q280 Mr Campbell: So those who cannot aVord to pay further down the line may cost the National Health Service more money? Dr Fraser: That person then has to choose. They can either wait in the hope that they might get on the waiting list or they can pay privately or not have

anything at all. For some people not having anything at all is not really an option because in order to continue to function and keep their job and do all the things we do in life, bring up your kids, they have to function so they make really diYcult choices about what to pay for. We did a survey two years ago on what people were paying for and we found that 45% of the group said they were paying for some aspect of their care and treatment and of those more than 20%, so in total more than 10% of the group, were paying for talking treatments which their doctor had recommended but were not accessible through the NHS. Given that the NICE guidelines say that for mild to moderate depression/ anxiety talking treatments should be the first line it is fairly shocking that those are not available and people have to pay for those. Q281 Mr Campbell: It is costing more at the end of the day. Dr Fraser: Absolutely. If people do not get the help they need at primary care level we will end up with people much further down the line needing much greater intervention. Q282 Mr Campbell: Do you have any figures of such patients that you could give to the Committee, a rundown of how many patients fall under this net? Dr Fraser: I can give you copies of the research we did. I am not sure we have anything on how many people could have been helped at primary care level and ended up in secondary care because that is probably everybody. Everybody in secondary care could probably have had more help in primary care and it might have helped. For some people it might not have helped, it is very hard to tell. We are told very, very frequently, “I asked for help early, I was given nothing”. What happens is that people are given nothing and they end up going oV sick at work and from there on it is a vicious circle and after you are oV work for more than six months there is a very small chance of ever being back in permanent work. The trick is to provide support at primary care level so that people can be supported and get the help that they need then before they get into the situation of needing to be oV work, having problems with money, et cetera, et cetera. There just is not the resource there to provide the talking treatments that people need and it is one of the things where we really need much more investment in resource. Mr Campbell: That is certainly a point that needs taking up. Thank you very much. Q283 Chairman: Moira, can I ask you one brief question. You have talked about people in the primary sector having to go to the acute sector, or avoiding it. Give us your view on what is happening now on the non-residential treatment orders where people will be asked (a) to stay in the community under certain orders and (b) directed to take prescriptions and will have to pay for them. What do you think about that? Presumably if it was residential it would be free.

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Dr Fraser: Yes. It is something which has been indicated in the draft Mental Health Bill that that is what the Government’s intention is. We have yet to see what that would look like. Mind is opposed to non-resident treatment orders entirely, full stop. However, if they were introduced it seems to me completely counter to natural justice that you should require someone to pay for something on which their freedom depends. We have no indication of how the system would work. We have no indication of whether it would only be certain drugs that would be laid out by the Mental Health Tribunal that would be exempt because it is the Mental Health Tribunal who will set the care plan for that person. Would the Tribunal say, “These particular drugs at these particular dosages are the ones that are to be exempt”? That is all very well but medication changes very frequently and you are not going to be able to go back to the Tribunal. How are we to know which are to be exempt? As I said before, people have physical health problems as well, so are we to be in a situation where some drugs are exempt and some are not? In that situation, if it were to come in, which I hope it does not, the only thing would be to make those people exempt from all prescription charges because by nature they are a very vulnerable group and their health is compromised as it is so it would seem to be sensible to make them completely exempt. Chairman: Thank you for that. Q284 Dr Taylor: Mr Cardy, in your written evidence in the summary you have got this sentence: “The Disability Living Allowance and Attendance Allowance hospital down-rating rules should be relaxed in recognition of the additional costs, including phone and TV charges incurred by hospital inpatients”. Can you expand on that and explain that a little bit more to us? Mr Cardy: I am not an expert on the benefit system but let me do my best. The down-rating rule means that people who spend 28 days in hospital, either as a single period or over a period, will have their benefit withdrawn. We think this is quite wrong because costs do not cease, the costs of being in hospital continue, and we draw particular attention to telephone costs and so forth. We have given you evidence in our submission of the sort of scale of those costs. People in eVect suVer double jeopardy. The onus of having a series of visits to hospital to report that they have had 28 days in hospital falls upon the patient and their benefit will be stopped and an overpayment will be reclaimed if they are discovered to have inadvertently not let them know. Q285 Dr Taylor: It is cumulative, is it, if you spend four separate weeks? Mr Cardy: If you spend 28 days, each of which is not separated by more than 28 days from the next then it mounts up. It may be over a short period with several long spells in hospital, it may be over a long period with many short spells in hospital.

Q286 Dr Taylor: Have you any idea how many people are aVected? Mr Cardy: In the sense of? Q287 Dr Taylor: In that they are caught in this trap. Mr Cardy: I do not think we can tell you the answer to what. What we are clear about is that Disability Living Allowance and Attendance Allowance are critical benefits for people with cancer who very frequently develop disabilities that make them eligible for these benefits which are compensation for some of the costs of disability. Q288 Dr Taylor: So how should we deal with the problem? Mr Cardy: Quite simply by removing the downrating requirement. It works very, very adversely to people with cancer in particular who have these patterns of treatment. The down-rating was removed from all other benefits in last March’s Budget and takes eVect this April. I am sure somebody knows why it has not been applied to DLA and AA but it seems frankly bizarre to us. Dr Taylor: Another peculiarity. Thank you very much. Q289 Dr Naysmith: I have got a couple of slightly unrelated points to make and questions to ask from them. How do you see this situation developing in the future and are there new problems which might emerge with charges which can impact on patients? Moira has just referred to one under the Mental Health Act that might come in and produce a new situation. I wonder if I could ask Rosie first of all. The last time we met was when you were at the oYcial opening of the cystic fibrosis unit at BRI in Bristol and we are very grateful to the Cystic Fibrosis Trust for all that happened there. Do you see anything happening in the future? Mrs Barnes: A bit like cancer, cystic fibrosis is a victim of its own success in its ability to treat patients at home. Because those with cystic fibrosis are primarily children, adolescents and young adults there did not seem any point in the extensive treatment regimes to keep them alive if they had to be in hospital all that time. We have worked very hard to ensure that with very expert support patients can stay at home most of the time. They will do their own physiotherapy, they will take their own nebulisers, and they will do their own intravenous antibiotics. We do suVer from a situation where what people get depends on where they live in terms of extra support. We do see that the treatment regime we have introduced which is keeping them alive will continue and will continue to make improvements until such time as we find a cure. The problem we have is that, as Lynsey has explained, it is a costly disease to live with. They have to eat a lot of food, they need a lot of transport help. Unless some of the hidden costs as well as the direct costs of prescription charges are dealt with people will not take the treatment that they need and it will shorten their length of life and reduce their quality of life.

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Q290 Dr Naysmith: Anybody else? Mr Cardy: Yes. In our submission we indicated that the demography and epidemiology of cancer has changed and the patterns of treatment have changed very much. Four out of five people now receive radiotherapy as outpatients rather than as inpatients, similarly with chemotherapy. The five year survival rates—five years is normally regarded as the test for survival of cancer—have risen considerably, happily, so 80% of women who develop breast cancer can now expect to live five years or more whereas 30 years ago it was only 50%. These trends are going to continue. This is all very good news. The eVect of the way in which costs are incurred mean that these are being transferred, so patients have to incur large and increasing costs in order to undertake life saving treatment, which to us seems morally wrong that that should be the case. Mr Meadowcroft: I think in the future much the same will apply to Parkinson’s disease. We are looking at new drug therapies coming on stream to deal with the symptoms today. There is a huge research push for breakthrough therapies. There is cell therapy, stem cell research at places like Frenchay and other places, or in neuro protection, trying to identify those most at risk and to find a medication that will stop the disease progressing. There are real problems today living with the condition below the age of 60 but longer term the new treatments, and there will be breakthroughs, will have a cost to them as well, inevitably so.

exempt list based on severity of condition and need for medication there is absolutely no reason for cystic fibrosis not to be on it. As you will have gathered, the only reason it is not on it is that when it was drawn up most people with cystic fibrosis did not live until adulthood so they were covered by the fact that they were a child. The considerable illfeeling that those with cystic fibrosis bear on this matter is the fact that they were promised that this would be reviewed—it was cited as an example—and it seems a huge injustice compared with the conditions that are on the list.

Q291 Dr Naysmith: The other point I want to check on is we will obviously be looking at the list of conditions where there will be exemptions because of the fact that it is a bit of a muddle at the moment. We want to get an idea of what the likely costs of any changes would be. Can you estimate what it might cost the NHS to add the conditions that your organisations deal with in these four rather diverse areas of disability and disease? What would the costs be if you came along and said, “We want exemptions for some of our people” and how many people would be involved now? Mr Meadowcroft: I cannot give you a precise figure but I can give you a ballpark figure. There are around 8,000 people with Parkinson’s disease below the age of 60 aVected by this, some would have an exemption anyway if they receive Income Support. If we take the assumption that most of those would benefit, we would have a figure of around £1 million a year. That is the best figure I can give you. It is not robust but it is about £1 million a year, I think. Mrs Barnes: For cystic fibrosis not much over £100,000 calculating it at the annual rate which people are paying currently if they are on the annual rate. It seems ludicrous to have caused so much illfeeling for a cost of around £100,000 on a drug budget which is over £6 billion. It seems ludicrous that the exempt list has not been reviewed. I think the Cystic Fibrosis Trust and those aVected by cystic fibrosis would accept the situation if it was decided to abolish the exempt list and treat the whole situation diVerently, but if there is going to be an

Q296 Jim Dowd: Since? Mrs Barnes: 1968. The only reason I can possibly put forward as to why it has not been changed is that there are conditions on it which perhaps aVect a great many more people than cystic fibrosis who should no longer be on it and they would all be terribly aggrieved if they were taken oV. If you opened the list there would be a queue of conditions wanting to go on it and there may be some that were eligible in 1968 but for which treatment has improved so dramatically they no longer need to be on it. Of course, once you are on it you get everything free, it does not matter whether you have got bunions, the flu or whatever it is, whereas cystic fibrosis patients, who have to have this huge quantity of daily medication, are not on the list. It does cause them a disproportionate amount of anger. They are always sending me petitions and writing letters and wanting to come and march on Downing Street.

Q292 Dr Naysmith: Have you put it to the Government and asked them why it is not on the list? Mrs Barnes: Repeatedly. Q293 Dr Naysmith: I have done it as well and I get the same answer. They are constantly reviewing it. Mrs Barnes: I have asked them have they ever been given any medical evidence by any authoritative body which says that cystic fibrosis does not meet the criteria to go on the exempt list and they have not answered that question. Q294 Jim Dowd: I am sure it is here somewhere, but has the list changed much over time? Mrs Barnes: It has not changed. Q295 Jim Dowd: At all? Mrs Barnes: They have not reviewed it.

Q297 Jim Dowd: Let us ask Lynsey what she thinks about it. Ms Beswick: There are other illnesses that are related to cystic fibrosis. For instance, I suVer from arthritis which is related to my cystic fibrosis and that requires extra medication and extra hospitalisation time due to my cystic fibrosis and that is an extra cost caused by cystic fibrosis that I have to pick up the tab for. I do think it is a crying shame that we cannot get our prescriptions free when we are having all this medication every day.

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We do not want to take it, we did not ask to be born with cystic fibrosis. I think it should be reviewed, it is ludicrous that it has not been before now. Mrs Barnes: As well, 15% of adults with cystic fibrosis develop diabetes which is another sting in the tail and another horrible thing to have to deal with, but that is on the list. The minute they get diabetes they then get all the rest of their cystic fibrosis drugs free. The doctor breaking the news says, “You have now got cystic fibrosis related diabetes. That is the bad news. The good news is you do not have to pay for your prescriptions any more”. Some nurses and doctors who are a bit more imaginative tell them to tick the box to say they have got a fistula. There are people here who probably know better than I do what a medical fistula is. Many people with cystic fibrosis have something called a portacath which is a device implanted into the chest to access the veins more easily for intravenous antibiotics or they will have PEG feeding whereby they have a permanent tube fixed into their stomach so they can be fed overnight to maintain a more reasonable bodyweight. The more imaginative nurses will say, “As far as I am concerned that is a fistula”. I do not think it is actually but the pharmacists do not get into the nitty-gritty. The doctors and nurses do try and help them because they are so young and they know there is a danger to them if they do not take what they are prescribed. Dr Fraser: In terms of the cost, obviously mental health is of a diVerent scale from the two kinds of conditions you have heard about. One in four of the population experience mental distress at some point in their lives. Not all of those end up being a diagnosable mental health problem that is ongoing. You are talking about a significant number of people. I think we have got to look at it in the round. What is it that we are trying to achieve with the National Health Service? Are we just patching people up who have got to a critical stage in their lives, who have got to the point of being on a low income or are chronically unwell, or are we trying to support people’s health and wellbeing and support people who are potentially very vulnerable to stop them from getting more unwell in the future? I know it does not come from the same budget and it is not easy to count but the costs of prevention far outweigh the costs of things like hospitalisation later on. Whilst the cost in terms of revenue that is not clawed back from people may be relatively high, the saved cost is much, much higher, not only in terms of hospitalisation but in terms of benefit levels, in terms of contribution to the community and all the other factors that we know about. Mr Cardy: As far as prescription charges for people with cancer are concerned, the DH tells us that it does not keep that data but it has recently estimated that exempting terminally ill people from prescription charges would cost about £2 million which in terms of the overall cost of cancer treatment and care is a very modest amount indeed. Perhaps I could just allude to a couple of things that we have not mentioned yet. One is the cost of car parking. We

have the strange situation where this is one of the freedoms that hospital trusts have to fix car parking charges and some of them use it as an important revenue stream at the expense of patients and, as we point out, at the considerable expense of cancer patients. The other is the Hospital Travel Costs Scheme. The cost of parking is very often well publicised in hospitals but the existence of the Hospital Travel Costs Scheme is not. In many hospitals there is no enthusiasm for making people aware that the scheme is available and it is very, very tightly means-tested. Our view is that eligibility for the scheme should be liberalised and that it should be much more widely available to people aVected by cancer. Q298 Charlotte Atkins: You have all argued for exemptions in various forms, how would you raise money without charges? Mr Cardy: Perhaps I could respond to that by saying that I think the decision making is not joined-up. With the change in the pattern of cancer treatment that I have described, that others have related to the conditions with which they are concerned too, it is clear that it is part of the policy and practice of hospital trusts to save money by delivering treatment outpatient rather than inpatient. There is really no connection made between that saving and the cost that is transferred to patients. I do not believe in the end that there is any other place to go other than general taxation, except I would say this: in the course of last year Macmillan Cancer Relief put about £70 million into the development of NHS cancer services, so we do feel that we have made a contribution. Mr Meadowcroft: I think I would make the same case too from the Parkinson’s Disease Society’s point of view. We have funded nurse specialists in Parkinson’s to the tune of £4.5 million over five years, so we do input. In terms of an equitable approach I think it should be through general taxation that would avoid means-testing and it would reach more people. We would support that. Mrs Barnes: The Cystic Fibrosis Trust has not argued for prescription charges to be abolished altogether simply based on our own experience. We provide a lot of free services for those with cystic fibrosis, including conferences. If we have a conference and we ask people if they would like to come, we might get a list of 300 or 400 and we organise the day and pay for their food for the day and only 200 turn up perhaps and we have paid for 300 lunches and people have not come. If we charge them £5, which is only a token amount, we get a much more realistic list. We have viewed prescription charges in very much the same way. For routine and occasional matters people should be able to pay and it makes sense in feeling you are getting something of value, you are not taking it frivolously, you are taking it seriously. In terms of reducing the costs for those with cystic fibrosis, if they were exempt from prescription charges it would probably have the eVect of keeping many of them out of hospital for longer because those with cystic

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fibrosis get very ill, they throw themselves on the mercy of their CF team who immediately admit them for a week or two to look after them properly and that will mean giving them all the drugs and medication they need, giving them in-hospital physiotherapy twice a day and ensuring that they get a high calorie diet. Many hospitals go to a lot of trouble to make sure that those with CF can eat properly. They tend to eat later in the day than most people, partly reflecting the fact that they are so young but partly reflecting their condition. For example, in the Bristol Royal Infirmary all cystic fibrosis patients are allowed to go to the doctors and nurses’ dining room if they want to during the night to eat. There is never many of them but it gives them an opportunity to be fed. If you think of hospitals taking patients in for a week or two at considerable cost, £1,000 for the hotel and catering aspect of it never mind for the drugs, to look after them better at home would save the NHS money in the fullness of time. Dr Fraser: One of the things we can do is look better at the pre-payment system. We would argue for free prescriptions for all but in the absence of that, as we

have heard from other people today, the amount that people are required to come up with to get that Pre-payment Certificate is prohibitive. A scheme which would make that easier would help. There is an example I know of, somebody pays £2 a week to a local Mind group and at the end of the year they give them a cheque to pay for their annual Prepayment Certificate. £2 a week might be manageable but even £10 a month might be too much to come up with at once. If you are on a very low income these are considerable amounts of money. I think we need a tapered approach so it is not all or nothing. At the moment we have got a “you are either in or you are out” approach and for those people who are on the margins that is very inequitable. Having some kind of tapered approach where you can pay a little bit but not the full lot might be better than the system that we have now. Chairman: Could I thank you all very much indeed and apologise for the lateness of the ending of this session. It has been a very good session. Thank you for bringing your experience to us, I hope it will be well-used in the next few weeks. Thank you.

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Thursday 9 February 2006 Members present: Mr Kevin Barron, in the Chair Mr David Amess Charlotte Atkins Mr Ronnie Campbell Jim Dowd

Anne Milton Mike Penning Dr Howard Stoate Dr Richard Taylor

Witnesses: Dr Lester Ellman, Chairman of the General Dental Practice Committee, British Dental Association, Dr Maureen Baker, Honorary Secretary of Council, Royal College of General Practitioners, Mrs Lynn Hansford, Chairman, Association of Optometrists, and Mr David Cartwright, President of the College of Optometrists and Director of Professional Services for Boots, gave evidence. Q299 Chairman: Good morning, ladies and gentlemen. May I welcome you to what is now our third evidence session in relation to the inquiry we are doing on NHS charges. I wonder if I could ask you to introduce yourselves for the record and say what organisation you represent. Dr Baker: I am Maureen Baker. I am the Honorary Secretary of the Royal College of GPs. Dr Ellman: I am Lester Ellman. I am the Chair of the General Dental Practice Committee of the BDA. Mr Cartwright: Good morning. I am David Cartwright, an optometrist with Boots Opticians and also President of the College of Optometrists. Mrs Hansford: I am Lynn Hansford. I am an independent optometrist and I am the Chairman of the Association of Optometrists.

Q300 Chairman: I want to ask a general question to all of you about NHS charges. Do you think charges deter patients from seeking the services that you provide? We had evidence last week from the CAB saying that they believe people do make choices on occasions about what they can and cannot aVord if they have more than one prescription to pay for. Do you think that is the case? Dr Baker: Yes, I do think that is the case. We have heard, particularly from pharmacist colleagues, of patients bringing in a prescription and saying, “I’ll have that one but I’ll not have that one”, or, “I’ll come back next week and get that one”. I am sure that it does happen, yes. Dr Ellman: Certainly in dentistry the patient’s choice range is now huge and a lot of them do opt to take choices that are not within the standard framework of the NHS. That is because there are a lot of things out there which are not covered by the NHS. Mr Cartwright: I think in optical services it is slightly diVerent in that we do not have charges, so a patient does not come in and pay something. What happens is if they are eligible for an eye examination they have a voucher which should cover the cost of spectacles. I think the issue is that people are not deterred by the charges, but perhaps they are not adequately aware of what is on oVer. Mrs Hansford: I would agree with David.

Q301 Chairman: I think in general terms we are saying it is probably the prescription charges that may deter people from taking them up. Is there any particular area of concern in relation to that or do you think it is across the board? People on low incomes are exempt from prescription charges so why do we have this type of problem? Dr Baker: If someone has an acute illness and they have not been on regular prescriptions and so they have not paid their “season ticket”, so they have to pay for each item, and they come along and they are prescribed a number of items that relate to that particular acute illness, then three or four prescriptions soon mount up. Yes, people on low incomes are exempt, but if you are just over the threshold then it can be quite a hit if you are not expecting it and so it can have an eVect. Q302 Chairman: Has the Royal College ever done any studies of this as opposed to the anecdotal things we hear about of people not being able to aVord four prescriptions? Dr Baker: Not to my knowledge. Q303 Chairman: So we have no evidence base for this? Dr Baker: No. Q304 Chairman: We just think that it happens and pharmacists say that it does. Dr Baker: That is right. Q305 Chairman: Dr Ellman, in your evidence you talk about the widening gap in the dental health of the population. Why is this? Dr Ellman: It is very diYcult to answer directly and say we have got absolute evidence of why it is. There is no doubt that some socio-economic groups particularly are more at risk and that some priorities are given in diVerent directions by diVerent people, and there are some cultural diVerences too. If you have not grown up in a culture of looking after your teeth and regarding that aspect of your healthcare as being particularly important then it tends to lapse to some extent and you only seek emergency care when there is some problem. So there is that widening gap. A tiny bit is related to the people who are not in the supported group but who are on the threshold of being who may find charges inhibitive to them. I

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have no evidence for that. I worked in inner-city Manchester for 30 years and I ran a practice there and we have certainly got some of that, but I cannot identify it entirely. Q306 Chairman: Is there any conclusive evidence that suggests that those who do not consult dentists early on for check-ups can end up costing the NHS more in the long run as it were? Dr Ellman: That must be so. I am not sure that we have done any studies on it directly. If you take the simple evidence that if you can get to the problem that the patient has before it becomes a major problem and moves on—because dental disease is progressive—then obviously it has got to be less expensive in the long run. I am not sure it is entirely as simple as that, but that is a fair estimate. Q307 Chairman: Has your Association argued with government that that is what you ought to be doing when you have been looking at issues around a new contract and things like that? Dr Ellman: We have talked in terms of prevention as being something that we would very much like to see heavily espoused by the new contract. Q308 Chairman: Is the same true for patients who delay or avoid having sight tests, that in the end it could be that there would be increased costs because of that delay to the National Health Service? Mr Cartwright: Yes, it is. If you take many of the common eye conditions, if they are diagnosed early and are treated they will not lead to visual loss in the future. For instance, glaucoma would be a good example where the patient is not immediately aware that their vision or the visual field might be getting worse until it is often too late to treat. So it is essential to diagnose that early and treat it early and that would lead to savings later on in the ongoing care of that patient. There is some evidence from the University of York to say that about 10% of falls in the elderly are due to visual disability, much of which is preventable and that costs about £250 million a year. Q309 Chairman: The elderly are not charged for sight tests any longer, are they? Mr Cartwright: That is correct. Q310 Chairman: It is the deterrence of the NHS charges that we would like to look at, where that shows that because of these charges people do not go along for eye tests and consequently it costs more money in the long run. Do you think York may have looked at that? Mrs Hansford: There is no evidence that the cost of eye care does put people oV going. When free eye examinations were introduced for the over-60s there was not a huge increase in the uptake of eye examinations; it stayed pretty stable. That would indicate that it is not a deterrent for people to come and have their eyes tested. What it is is they do not understand because there is not enough publicity

about the importance of good vision and how good vision can maintain your independence and make sure that you function properly through your life. Q311 Anne Milton: The evidence about elderly people falling over because they do not see well I have heard before. Dr Ellman, could you give me an example in dentistry of what will cost more if you do not get it treated early? Dr Ellman: If you leave a tooth which has decayed it may well progress into requiring more extensive treatment like root canal therapy which is a lot more expensive than a simple filling restoration, and that is not uncommon. If it does not particularly hurt at the beginning and they do not seek help, although they may know it is there, then it may well progress and become a much larger problem and the restoration may be much more diYcult. Q312 Anne Milton: I am no expert, but it feels as though if dentistry does not treat you early then you just end up having your teeth out. Do you see what I mean? Dr Ellman: I do not, sorry. Q313 Anne Milton: By not treating a dental problem early there is a limit to how much it can cost you in the long run. In your example about root canal work, if you take the tooth out it costs money— Dr Ellman: Under the current system there is a limit to what the patient can pay, but that does not limit what the NHS will have to pay, it is merely a limit to the patient charge. Similarly, even in the new system which the Government is introducing in April, although there will be a capped ceiling on what the patient’s charge would be, in fact it will cost the NHS more because it will take the dentist’s time away from being able to treat other patients just because it is a more expensive and time-consuming procedure. Q314 Dr Stoate: I think what Anne is trying to say is that if you do not get an optical test done you can go blind and that can have huge consequences. If you do not get your teeth fixed the worst that can happen is you lose your teeth. Are we saying there is more that can happen to you than losing your teeth and, if so, what? Dr Ellman: Obviously losing your teeth is now a social stigma in this country to a large extent. Q315 Dr Stoate: What is the big deal with losing your teeth? Dr Ellman: You have got to have dentures replaced regularly. Q316 Dr Stoate: Are there chronic long-term health implications apart from losing your teeth? Dr Ellman: Not once they have been taken out! Q317 Chairman: I want to ask the optometrists about young children. When I was at school I used to have eye tests. They may not have been that scientific, but I do remember having an eye test at school. That has stopped now. Do you think that is a disadvantage?

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Mr Cartwright: Certainly in my view there should be a more universal screening programme for children before the age of eight because if you catch something before the age of eight you have a chance of treating it, but if it is after the age of eight you cannot. Children under-19 in full-time education are eligible for an NHS examination. Q318 Chairman: How many of them take it up? Mr Cartwright: Out of 11.7 million NHS examinations, around 25% are children so around 2.5 million would be children. Chairman: We do not know what the population of under-16s is at any one time. Q319 Mike Penning: Perhaps you could let us now. Mrs Hansford: In an ideal world all children should have their eyes examined before they start school because the formative years, as David said, are up to age eight, so you need to detect any developmental problems before that time and the earlier the better because the earlier you pick it up the more easily you can deal with it and the better the outcome at the end. You wear spectacles and so you understand that if you cannot see properly you do not perform properly. It really is important that all children, in order to reach their educational potential, ought to be able to see properly at all times. So we would really feel that that would be a major health benefit. Chairman: A member of my family has just found out at 14-years old that they have got a sight deficiency. I think that may have been picked up earlier if it had happened to me as a child. Q320 Dr Stoate: I am surprised that you are so benign about your age of eight because in my experience as a GP, if you do not diagnose strabismus before the age of 18 months you are never going to get binocular vision and that in itself is quite a handicap. Eight is far too late if you are going to diagnose a squint. Mrs Hansford: I would agree with you. Eight is the cut-oV time. Q321 Dr Stoate: It is much too late by eight. Mrs Hansford: You could pick them up at four. Q322 Dr Stoate: Four is too late. Mrs Hansford: It is too late. A child with a strabismus like you are speaking of most parents would be aware of. Q323 Dr Stoate: I would like to put on the record that I am a Fellow of the Royal College of GPs and a former College examiner. Dr Baker, we have had a lot of anecdotal evidence that prescription charges put patients oV receiving treatment. Is there any concrete evidence that prescription charges aVect the way that GPs treat their patients? Dr Baker: I am not aware of any literature that would provide that evidence, but that is not to say it is not there. I try to keep up particularly with the health inequalities issues. We can certainly ask our Information Services Department to see if there is

anything that relates to that question. I personally am not aware of any studies that have looked at that specifically. Q324 Dr Stoate: If your Information Services Department does have any evidence, I would be very grateful if you would submit it to us because we need to have a good evidence base if we are going to make a sensible report to Government. Dr Baker: We did have a publication by our health inequalities group called “Hard Lives” which is an overall look at some health inequalities issues. I would certainly be happy to send that on and I can make a specific request around the literature regarding charging and deterring people from treatment. Q325 Dr Stoate: Obviously everyone resents paying charges. What we need to know is how much of people’s reluctance to pay is just simply resentment at having to pay for what ought to be a free service and how much of it is because they are having a genuine hardship eVect. We need to have some evidence for that if possible. Dr Baker: The evidence we will find for you if it is there. In my own experience as a GP, I have people say to me, “Don’t prescribe me this and this because I cannot aVord it”. Q326 Dr Stoate: I am sure that happens. What we need to try and gauge is a measure of how prevalent that is. I want to move on to non-emergency transport. Do you think that the cost of transport for people to get to hospitals and to clinics can aVect the way they access the service? Dr Baker: Yes, I do. In fact, the Royal College of GPs is currently writing a paper with colleagues in the Royal College of Physicians and we are looking at the best way in which generalists and specialists can work together so that patients can get the best access to treatment. That is one of the issues that have come up. We have been hearing of cases where people may have a number of chronic conditions and they attend outpatient clinics for that, but because of a number of factors, ie they are more ill, they are poor and they either rely on public transport or it is a question of can they drive, can they park, do they pay parking charges, people default from ongoing treatment for those chronic conditions and that leads to poorer outcomes for important chronic conditions. Q327 Dr Stoate: Do you have any evidence you could submit on exactly how prevalent that is? Dr Baker: Again, I am not aware of any evidence. We are looking to see what there is in terms of referencing this paper. If we find specific references we can send that to you and I would be also be very happy to send the paper to the Committee once that has been launched. Dr Stoate: Thank you very much.

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Q328 Charlotte Atkins: Dr Ellman, what are your main criticisms of the new system of dental charges and what do you think will be the impact on the uptake of treatment? Dr Ellman: The impact on patient behaviour is absolutely unknown. This is one of the biggest problems we have. The problem that arises from that is you cannot then model the system to make sure that it brings in the appropriate amount of money. The remit of the Cayton committee14 that looked at it was that it should bring in the same proportion of money as the current system does. The current system brings in about £487 million out of a total spend of £1.8 billion, so it is about 28%. What we do not know is when you change charging regimes as drastically and dramatically as this particular change is happening what that will do to patient attendance and patterns and nobody else can tell you. The bits that we do not like about the charging are the massive steps which are diYcult for patients to get their heads round. For one simple filling they move from a band of £15.50 to £42.40. I do not know what the patient is going to say about that. They may opt to get additional treatment done or they may save it for some time. Q329 Charlotte Atkins: What you are saying is that patients may wait until they have more than one pain in their mouth to ensure that they fit nicely into the middle band as opposed to just missing the first band, is it not? Dr Ellman: It is a possibility. I have no handle on this. I have no way of knowing what patients will actually do. Some will progress as they have always progressed but many will be unsure. Q330 Charlotte Atkins: Is the new contract going to be profitable for dentists or are a lot of dentists going to go down the completely private route? Dr Ellman: There is some evidence from the plan providers particularly, because they are the people who have people signed up, that quite a number of dentists are moving outside the NHS because they do not see the reforms being satisfactory for their particular practice. How workable it is remains to be seen. I know that the Department of Health is fairly confident that they think they have got it right, but a lot of my colleagues are confident they have not. The one really big item that is missing is the drive towards prevention. I think the drive towards prevention is the one that I would really like to have seen in place. That is there as a token more than as a positive driver. Q331 Charlotte Atkins: So by going private they think they could do more preventative work, do they? 14

Note by witness: In 2003, Harry Cayton, the Director for Patient Involvement at the Department of Health, established a working group to review patient charges. He submitted the group’s report to Ministers on 31 March 2004. The report was published on 7 July 2005. The BDA were present on the committee as expert advisors and concentrated on two key issues for dentists of bad debt and missed appointments.

Dr Ellman: Most dentists who go private do not go private just for the income. They go private to allow them to spend time to produce the quality of dentistry they think they want to produce and they feel patients deserve. The two things do go together. The new system does not really provide them with that time and it does not provide them with a generation towards a quality of service and a quality of outcome which we all want. The intangible factor is that of job satisfaction and that is one that dentists do not get when they are pushed really hard in terms of a lack of time to deal with patients. So when you get the average dentist out there working on the NHS seeing 40 patients a day, they do not feel that they can form a good working relationship with those patients, they have not got the time to encourage prevention to take place and that is a continual reinforcement process. Q332 Charlotte Atkins: If they want to get oV the drill-and-fill treadmill, would not the best way of doing that be by increasing the input of fluoridation in terms of particularly young people’s health? Dr Ellman: The scientific evidence is that fluoridation makes a massive impact particularly on young people’s dental health, yes, but this has issues that you know a lot more about in this House than I know about it to do with the resistance to it. That is not in my gift but it is there. Q333 Charlotte Atkins: What is your view about the issue of dentists who are requiring parents to go private while they treat their children on the NHS? I understand under the new contract that will not be acceptable. Dr Ellman: I have no evidence that this actually happens. I am not denying that it does. Q334 Charlotte Atkins: You should see my postbag in that case because I can assure you it does. Dr Ellman: I will take your evidence. I think it is wrong that patients are treated in that way. It is not something we do in our own practice. You could say we only treat adults privately and we will happily take your children on the NHS, but I do not think one should be a condition of the other. I find that unacceptable. Q335 Charlotte Atkins: Is it not diYcult to separate that? You could have a dentist saying, “I don’t make it conditional”, but we know some say on a nod and a wink, “I will not take your children unless you go on Denplan”, or some other private system and it is very diYcult to prove one way or the other, is it not? Dr Ellman: I would imagine it is. Q336 Charlotte Atkins: If you heard that some of your members were going down this route you would condemn them for that, would you? Dr Ellman: I think we would want to advise them not to do so.

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Q337 Charlotte Atkins: Mr Cartwright, based on what I hear and see from your own evidence, you are concerned about the cross-subsidy to sight test fees from people who require spectacles, is that right? Mr Cartwright: That is correct, yes. Q338 Charlotte Atkins: Is that because you think that the present sight fee does not cover the extensive sight test that most optometrists embark on? Mr Cartwright: The current sight test paid for by the NHS, which is £18.39, does not cover the real cost of providing that examination, which is around £37. There is this cross-subsidy from the sale of spectacles and contact lenses which in eVect is a tax in some ways on the wearer of spectacles who is then paying for part of that examination. Q339 Charlotte Atkins: Just because you have a sight test at one particular practice does not mean you cannot take that sight test oV and go and buy your spectacles somewhere else, is that right? Mr Cartwright: That is correct. Q340 Charlotte Atkins: In the future you could have a basic sight test, a medium one and one that is far more expensive. Could you have a diVerent level of sight test and follow-on care in the future? Mr Cartwright: Absolutely. The optical profession has published its view of what could be done in the future where there was a much wider role for optometrists in providing that essential eye examination. The role of the optometrist could be expanded within that to some extent, but then we would also have an additional service where the optometrist is eVectively the first port of call for anybody who has a problem with their eyes. So if it is a red eye conjunctivitis then that would go to the optometrist and the vast majority of cases the optometrist would be able to treat. We could also have glaucoma monitoring and diabetic monitoring where the optometrist should be fully engaged as well. If optometry was doing that those services should be remunerated at a realistic level. Q341 Charlotte Atkins: Would it make sense to oVer a diVerential service to diVerent people depending on age and general health? At the moment you have a standard sight test that everybody who comes through the door has, although I have been very impressed by some of the sight tests I have been oVered because they seem incredibly extensive. In fact, they normally convince you you are blind and you are so relieved by the end of it that you are not that you are willing to accept anything! Mr Cartwright: Over the last 10 years the diagnostic tests that are available have expanded quite markedly and optometrists are involved in that. At the moment there is this cross-subsidy and actually it would be something that the Government is missing out on in not taking advantage of that resource that is available to free up resource elsewhere.

Q342 Charlotte Atkins: What do you think the future for the sight test should be? What would you recommend? Mr Cartwright: We would recommend that we should have an expanded eye examination as an essential service that is available in all areas. Q343 Charlotte Atkins: So that you are pulling in youngsters who at the moment are not getting that full cover? Mr Cartwright: Certainly there should be a much greater awareness of the importance of eye examinations and eye health and preventative eye care. There would then be optometrists being in eVect the GP for eye services. So any eye condition would initially come to the optometrist for diagnosis and monitoring to decide what it is and to potentially treat and then we would also be engaged locally in glaucoma schemes, diabetic retinopathy monitoring schemes, the treatment of age related macular degeneration or the diagnosis of age related macular degeneration and advice and guidance there. Q344 Charlotte Atkins: The Department does not seem to think that the sight fee itself really matters because it is negotiated in a competitive framework. What is your view about that? Mr Cartwright: Absolutely not. The cross-subsidy is not a good example where the one who wears spectacles then has to pay for part of the eye examination for somebody who potentially has not got to wear spectacles, so there is a hidden cost to a third party. Q345 Charlotte Atkins: The other issue is to do with the NHS voucher and the fact that many practices do not seem to stock spectacles which are fully covered by an NHS voucher. Does that mean that a number of people either do not come for a sight test or they decide that they will not buy a pair of spectacles simply because they cannot aVord the gap between the voucher and the cost of the spectacles? Mr Cartwright: Two-thirds of optical practices do supply spectacles like single vision or bifocals or two pairs covered by the cost of the voucher. There is not any evidence—that does not mean to say that it definitely does not happen—to say that people are deterred from an eye examination or from coming along to an optical practice because of the cost of spectacles. There needs to be greater awareness of the fact that people can come along that are eligible for an eye examination and that it is an important part of monitoring for eye conditions which if found early can be treated, but in two-thirds of practices the voucher will cover the cost of the spectacles. Q346 Mike Penning: Dr Ellman, I was astonished to hear you were not aware of this blackmailing which is going on within dentists about how you cannot keep your children on the NHS unless you go private yourself. Not only is that an issue for my constituents, but my dentist wrote to me (obviously he does not realise I sit on this Committee) saying

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that if I wanted to stay with him I had to go private and my children would get NHS services if I stayed. Are you saying you have never heard of this before? Dr Ellman: I said I have no evidence that that is happening. You are giving me some. Can I just correct the position that your dentist seems to have taken which says he will happily treat your children on the NHS but you must go private? He did not use that as a lever. Q347 Mike Penning: He did. He said he would remove me from his list as an NHS patient unless I went private. Dr Ellman: He did not say he would not treat your children on the NHS unless you go private. Q348 Mike Penning: Yes, he did. Dr Ellman: In that case, I am sorry, I would not agree with that. Q349 Mike Penning: I will supply you with that letter. Are you for the contract? Are you happy with it? Are you going to sign the contract that is being oVered to you or are you going to reject it? Dr Ellman: I do not have powers to reject on behalf of the dentists. Q350 Mike Penning: But you are going to advise them on whether it is good or bad for them. Dr Ellman: Yes, we do advise them. We have just said that at the present time this contract is an absolute mess. That was in our press release the other day. The contract needs to be looked at in a much more serious manner than it has been looked at because there are serious flaws in it. Q351 Mike Penning: If they do not change the flaws you are going to advise your members not— Dr Ellman: They will probably have to live with it because quite a lot of our practitioners on two grounds want to remain within the NHS. One is that they are in areas where to move outside the NHS would be inappropriate and the other is that a lot of dentists are actually wedded to the concept of the NHS; that is what they want to do. Those who move away rarely do it on grounds of the economics of the situation, but rather the fact that job satisfaction of spending longer with patients, has been removed.15 Q352 Mike Penning: NHS dentistry could not survive without your members being fully involved in that. If your members said “No, we’re not happy with his contract” the Government would have to look again, would they not? 15

Note by witness: An independent survey carried out for Doctors’ and Dentists’ Remuneration Review Body in 2002 looked at the reasons why dentists were turning away from NHS dentistry: about 70% said they felt rushed when treating NHS patients; around 60% said that their workload did not allow them to provide the professional standard of care with which they were comfortable; while at present 60% of dentists spend at least 90% or more of their time working in the General Dental Services, only about 16% expected to be so committed in five years’ time.

Dr Ellman: They would, you are quite right. Unfortunately dentists do not work that way. They are independent contractors and the word independent comes to the fore. Q353 Chairman: Do dentists take a collective view through your Association on issues like new contracts? Do they have a vote? Dr Ellman: No. We do not do that because we did not negotiate the contract; it was imposed on us.16 It is a Department of Health contract that has been pushed forward. All we have done is talk about it, advise them and chip away at some of the things that are wrong. Some of the things that are still wrong make it a very disadvantageous contract in some respects. Q354 Chairman: As an Association representing dentists you have not negotiated the new contract with the Department like the BMA negotiated with the new GP contract, have you? Dr Ellman: That is correct. Q355 Chairman: You have not done that and therefore you do not have a collective view on whether it is good or not. Dr Ellman: It may have been done previously but it has not been done on this occasion. Chairman: I hope my two colleagues will be able to send you information about this other issue and then you can respond to that.17 I am sure we would appreciate that during the course of our inquiry. We are going to move back now to vouchers for glasses. Q356 Mr Campbell: Citizens Advice told us that they had evidence that a lot of people who go for an eye test cannot aVord to pay the diVerence between the voucher and the price of the glasses. What is your take on that? Is the voucher system wrong? Do they need to increase that or take it away altogether? Mrs Hansford: As David said, two-thirds of optical practices in the UK oVer spectacles within the voucher value. I think you will always be able to find people who fall outside that or who perhaps have not understood it. When I read that I did feel that perhaps we need to work with Age Concern and the CAB to see if we cannot resolve that. It sounds like it is small pockets of a problem. What you have to understand is there is no such thing as an NHS pair of glasses anymore. What happens is that all 16

17

Note by witness: As a result of primary legislation—the Health and Social Care (Community Health and Standards) Act 2003—the new General Dental Services contract was outlined in this Act. The Act was an enabling act for the Department of Health to implement the contract. It was not designed as a negotiated contract between the Government and the profession. The BDA were privy to discussions with the dentistry Minister, Rosie Winterton MP and her departmental oYcials about the contract. The BDA constructively inputted into these discussions, but the final details of the contract lie with the Department of Health. Debate about the precise details of the contract came through secondary legislation—the National Health Service (General Dental Services contract) Regulations 2005 See Ev 137. The BDA has also written to Charlotte Atkins MP and Mike Penning MP to help clarify their constituency cases.

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spectacles are provided as a private contract and the Department of Health provide a voucher to help people who are on low incomes towards the cost of a private pair of spectacles. It is up to the patient to decide what spectacles they want to buy, whether they want to buy a budget pair or a more expensive pair. Maybe there are misunderstandings about whether there are cheaper pairs available, I would not know and it is diYcult to talk about specific cases. There is plenty of opportunity to buy spectacles within the voucher value. Q357 Mr Campbell: There must be a big diVerence between the worth of the voucher and the price of the glasses. Mrs Hansford: There can be. If you buy a pair of spectacles like I am wearing there will be a huge diVerence between the voucher value and the spectacles. You would expect me to be wearing top of the range spectacles, would you not? If I had a voucher it would make a very small dent in the cost of this pair of glasses, but I did not have to choose this pair of glasses, I could have chosen a budget pair and I could have had a pair of bifocals instead of a pair of varifocals, but that is my choice. One of the strengths of the optical market is that it has complete and utter patient choice. There are no restrictions to the optical market whatsoever. You can have 10 optical practices in a row in a street. Whilst that is very uncomfortable for us sometimes as business people, it is a driver for excellence. If you have got lots of competition you have to be good to make sure that you keep your head above water and that your business is a success. Q358 Mr Campbell: Would it not be better to do away with the voucher system and have an income cut-oV rather than a voucher system and give them a good pair of glasses? Mrs Hansford: I do not understand what you mean.

Mr Cartwright: It is a fact that two-thirds of practices will provide spectacles of the voucher value, so at no extra cost at all and with a range of spectacles. We are not going back to the old NHS days of brown or black glasses where there was a badge of poverty— Mr Campbell: There is not a great choice. I have looked at them when I have been in there. For the best glasses there are three or four cases. Q362 Jim Dowd: Go to another optician, Ronnie! Mr Cartwright: I beg to diVer because it is a very competitive market and there is choice, so people will be able to go in and there will be a number of frames that are available for that person. Q363 Mr Campbell: I have not got a problem with that. My point is about the diVerence between the voucher they get and the price of the good glasses. I am talking about poor people on Income Support getting a good pair of glasses. Mr Cartwright: These would still be good glasses, they would be good lenses and they would still be backed by that professional service. There is no diVerence in the oVering to the patient. Anne Milton: My child has worn glasses since he was 18-months old and I have never paid for them. The choice has been fantastic. I live in Surrey and if there was any way of going to the opticians where you did not have to pay for glasses it would be there, but in fact every optician has distributed them. They are fantastic glasses. You are using the words good and bad prejudicially and it is not fair. If you want a Giorgio Armani pair of glasses you are going to have to pay for it like you would a suit. Mr Campbell: The voucher system only applies to some frames. Anne Milton: And they are absolutely fine. Mr Campbell: They should go beyond that.

Q360 Mr Campbell: A lot of people would not wear a budget pair. They may say, “I’m not going to pay the diVerence just for a budget pair of glasses, but if I had a bit more money I would go for a good pair”. Even the poor want to have glasses like my own. Mrs Hansford: There is plenty of selection in spectacles.

Q364 Chairman: Maybe you should have that debate in a private session. Would the issue of the value of the voucher be the diVerence in this debate? Mrs Hansford: There is not any such thing as free glasses and then the next pair of glasses cost you £200. You might pay £5, £10 or £15 to have something a little bit better. We are not talking about huge amounts of money to have a bigger choice. You can spend a lot of money on spectacles just the same as you can spend a lot money on a suit, but you can also get an oV-the-peg suit that is perfectly reasonable, that can be thrown in the washing machine and look good for years that you do not pay a lot of money for, and you can have a pair of glasses that you do not pay a lot of money for that look perfectly good and do the job. Mr Campbell: A good pair of glasses costs about £100. Chairman: This is a very interesting but anecdotal debate in many ways. I would like to move on now.

Q361 Mr Campbell: I do not know about that. I go to my optician’s and I look at the little case with the budget pairs and there are only about 12 pairs in there.

Q365 Mr Amess: Chairman, just for a moment I want to join in the free-for-all and go completely oV the script. About 45 minutes ago we had this interesting exchange between Dr Ellman and my two

Q359 Mr Campbell: So instead of having a voucher system they would have to declare if they are on Income Support or low wages. Would that not be a better system, where the Government would give them a good pair of glasses rather than the budget pair? Mrs Hansford: But a budget pair does not mean it is a bad pair of glasses, it just means that it is not a designer pair of glasses.

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colleagues about what happens when you neglect your teeth, what is the ultimate eVect of it and all the rest of it. Surely you end up with dentures. Not everyone is successful in wearing dentures. You need teeth to eat and chew your food. You cannot just sit there sucking boiled sweets all day. I would have thought you could even die through it. Never mind your remark about the aesthetic result, I would have thought it was very, very important that you keep your own teeth. Dr Ellman: There is no doubt whatsoever that in today’s world more and more and more people wish to retain their teeth for as long as they live and that is where the additional expenditure will come in. If their teeth are taken out and they wear dentures then that will reduce that eVect to some extent. Q366 Mr Amess: Believe it or not, I am trying to help you with the answers. Dentists no longer pull out teeth unnecessarily. They do everything they can to save them. Let us come on to the opticians and the national service framework. Mrs Hansford: We never pull out eyes! Q367 Mr Amess: In your written evidence you say that General Optical Services are “not underpinned by a national service framework for improving health in the optical field”. Obviously you feel that this is a big issue. Given that it is a big issue and given that there are all these diVerent contractors, there is certainly some resistance as a result of the charges. Why is it so important, and how could you achieve this national service framework in practice? Mrs Hansford: That is all laid out in this document that I waved around when David was talking. We did present this document to Rosie Winterton in the autumn of last year and it does lay out our vision of the future for primary eye care and David did explain it in quite a lot of detail, ie the essential service, the additional services and the enhanced service. It is pretty much the same as we have in Wales. My practice is in Wales. You are probably aware that we have enhanced primary eye care in Wales where we provide an acute referral scheme which is in eVect a triaging system and where patients with eye problems can come to the optometrist. About two-thirds of the practitioners in Wales are accredited to deliver those charges. There is the Low Vision Scheme and other things like that. We feel quite strongly that there ought to be a national service framework and a publicity campaign so that everybody understands the importance of vision. If you speak to anybody about the importance of vision and they think about it for more than 10 seconds, it is obvious that you cannot function unless you can see properly, but it is never a thought that is prominent in people’s mind. The children’s NSF does not mention eye care for children and the older people’s NSF does not mention eye care for older people and yet when I say that you think that is mad. If we had an NSF for vision so that everybody understood the importance of vision, the importance of eye care, seeing well and

detecting eye disease early, then I think that would be a huge health gain for patients and for the NHS as a whole. Q368 Mr Amess: If this were to be eVective you would systematically have to monitor the situation. How would you get the information across to the public and private sector? What would be the mechanism to make this national service framework a reality? Mr Cartwright: We are currently about to embark on negotiating the new GOS contract and we would propose that the essential services, the additional and enhanced services within that and they should be properly funded. Much of this information would go through the Department of Health. We would have payments and all that sort of information would be there. Is that the sort of things you are thinking of? Q369 Mr Amess: Given that there is public and private provision, how would you collect it all? How would you get everyone to agree? You are suggesting that the Department controls the thing overall. There seems to be a bit of a contradiction. Mr Cartwright: If we were thinking about awareness and if we had a framework—and they do exist in some areas of the country and Wales is a good example—where a patient who has an eye problem is going to their GP but then they no longer go to their GP but to an optometrist locally. That actually would raise awareness very quickly that if I have got a problem with my eyes I will go to my optometrist. At a GP’s surgery you would be told to go to see the optometrist. When you ring up for an appointment and they ask you what it is about, you would say it is to do with your eyes and you would be referred to the optometrist. We do not need to talk to every GP, although that might be a useful thing to do, but if that was a nationally set framework which was set centrally and then PCTs were picking that up then that would happen naturally. Mr Amess: The Committee will reflect on your evidence. I think Boots is splendid! Q370 Jim Dowd: It is a German company that has just bought them! Mr Cartwright: It is Italian. Q371 Jim Dowd: I want to raise the comparatively recent development of people being able to buy glasses oV the rack from supermarkets. I just wondered what your view of that was. Mr Cartwright: Supermarkets have entered the market and it is very competitive. In the supermarkets it is a registered practice so you will have an optometrist or a professionally qualified person there to help. Q372 Jim Dowd: I am not talking about that, I am talking about the fact they are on the shelves alongside any other product. What is the percentage of people buying glasses without professional guidance?

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Mr Cartwright: This has been there for 20 years and I think at the time the profession thought it was appropriate. There is also unregistered spectacle dispensing. Both of those have regulation behind them. If it is a readymade pair of readers and it is to correct presbyopia, that is glasses for near work, you should not be able to go in and buy them for driving for instance. There is an age limit set so that children cannot go and buy these to correct their distance vision. It is acceptable if there is background regulation. Also, for unregistered dispensing, so somebody can set up without the professional service, the regulation says that there has got to be a prescription dated within two years. There has got to be measurements taken. I think it is acceptable if there is some background to it. Q373 Jim Dowd: But there is not. They are just on racks. People go in and pick up a pair and they go to the cashier and that is it. Mrs Hansford: That is why we need the national service framework. Q374 Jim Dowd: I was asking your view about that as a practice. Mr Cartwright: It certainly has its dangers but in a lot of places there will be responsible promotional material with it saying an eye examination is important and you should do that every two years, so that would be a responsible way of doing it. There are some places where you can just go and buy them. You can imagine that for somebody whose sight is failing they may think, “I’ll just go and get myself a slightly stronger pair of glasses”, and actually they have got a medical problem and they should be going to have their eyes examined to correct that. Q375 Jim Dowd: So the supermarkets should adopt a more responsible and active role, is that what you are saying? Mr Cartwright: It would be unfair to pick on supermarkets. There are some places where you can just go and buy readymade reading spectacles. The important point is to raise awareness so that people think, “Okay, I can get these, but I need to make sure they are right for me and I need to back that up with an eye examination”. Mrs Hansford: There is a lot of evidence to show that people who buy “ready readers” are quite often buying them as a backup pair to their prescription pair. So they have had their eyes examined and they have bought their prescription specs. That may not be every case. Q376 Mike Penning: When you are in the opticians having your eye test they give you the prescription and they try and sell you glasses while you are there, but if you get out the door like I did you can buy them elsewhere for £10. Mrs Hansford: As long as you have had your eye examination and as long as you are buying a pair of reading glasses that suit you that is not a problem.

Q377 Jim Dowd: I bought a pair in Sainsbury’s largely because I could not read the label on something I was going to buy and thought they would help. Mrs Hansford: As long as you went and had your eyes examined by the optometrist the next day that would not be a problem. Q378 Jim Dowd: I have not. Mrs Hansford: Well, you need to. How do you know you have not got glaucoma? Jim Dowd: You are right. Q379 Dr Taylor: I am going to follow the rather rumbustious precedent of not sticking to the script certainly for the moment. I am really quite staggered to hear that the BDA has not expressed a collective view about the contract because I really thought it had.18 Are local dental committees aYliated to you? They are part of you, are they not? Dr Ellman: No, they are not. They are statutory bodies that represent the profession locally and present the views and they are there to assist primary care trusts and the like in formulating policy and dealing with things on the ground. They are not dissociated from us but they are not part of the British Dental Association. Q380 Dr Taylor: The Birmingham Local Dental Committee is convinced that the BDA has really given up and is really trying to persuade local dental committees to make the best of a bad job, even actively advising members to convert to private dentistry. Does that accord with what you have heard? Dr Ellman: Yes, indeed. I am aware of what Birmingham LDC has done. Q381 Dr Taylor: We went to Wales yesterday and we were told by the minister that they had made distinct changes to the dental contract in Wales which made it more acceptable to the Welsh dentists. Do you know about that? Dr Ellman: I am not familiar with the details of the changes in Wales. I am aware that they are making diVerences between England and Wales, but I am not entirely sure that I understand all the nuances of it so I cannot comment.19 Q382 Dr Taylor: Let us come on now to help and information that is available to patients. Firstly, Dr Ellman, in your written evidence you have said, “as with many co-payments in the NHS exemptions are absolute. Consequently there will be a large proportion of the population on the cusp of exemption criteria.” Have you any idea what could be done to help these sorts of people? Dr Ellman: It is really a matter for government. It is possible to work on the basis of a partial subsidy in relation to the income level that is there and therefore in a way means tested. You could support it in stages. 18 19

See Ev 137 See Ev 137.

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Q383 Dr Taylor: Would you like us to put that sort of suggestion forward? Dr Ellman: I have no reason not to. It would be very helpful for many who are on the lower economic scale but not supported by benefits of any sort. Q384 Dr Taylor: Can I just clarify some detail about the actual charging. Have I got it right that you pay £42 for one filling and, if you have 10 fillings, you pay exactly the same? Dr Ellman: Yes, £42.40 is the current— Q385 Dr Taylor: So one filling is exactly the same? Dr Ellman: Yes, it will be. That is exactly how it works. Q386 Dr Taylor: Surely, if patients know about that, as we have rather been hinting before, they are going to delay and have a few fillings to get their money’s worth rather than just pay the 42 quid for one and then go back and pay another 42 quid for another? Dr Ellman: Yes, that is a possibility. I have no idea. I suppose, to some extent, it depends on how diYcult the problem is. If it is causing you acute distress, then you are obviously going to seek help straightaway. Q387 Dr Taylor: Before I come to the others, how are you setting about letting people know, and really it is supposed to be a simple banding system, but, if one crown costs you the same as several crowns, one tooth on a denture the same as a whole denture, how are you setting about explaining it to people? Is it your job to explain to the person in the chair how much it is going to cost? How do you set about that? Dr Ellman: We put out some advice leaflets for dentists to help them explain the charges and the changes to the patients, so we have gone in that direction. That has only recently been published and it is actually on the BDA’s website now, together with a poster that they can download and put in the waiting room, which explains as simply as we can what the changes will mean for patients, so we have done that. Dentists are aware of what is going on and most of them do explain to their patients what is involved.20 Q388 Dr Taylor: Again, in your evidence, you draw attention to the document Help With Health Costs, and, as other people have told us, and I forget how many pages it is, but it is terribly complex. Dr Ellman: Yes. Q389 Dr Taylor: You say here that you want to go out with your own paper. Is this what you have actually done already? Dr Ellman: No, we are not allowed to. Sorry, are you referring to that form that you can claim on?21 20

21

Note by witness: As part of the National Health Service (General Dental Services contract) Regulations 2005, dentists must display an NHS-sponsored poster in their waiting rooms explaining the new dental charges regime. Note by witness: The BDA has produced leaflets and posters for dentists to display in their surgeries explaining the new dental charging regime and which patients are exempt from dental charges. The Department of Health have produced their own patients leaflets which build on the HC11 form.

Q390 Dr Taylor: I am referring to HC11, Help With Health Costs. Dr Ellman: That is a big form that is published by the Department of Health, I think, which means that, if you are on a low income, but not on Jobseekers Allowance or one of these benefits, it will allow you to claim the money or the support from the relevant authority. That is a big, complex document, as you rightly say. We would like that simplified because it makes it very diYcult for patients to deal with and some, I am sure, are deterred by the fact that it is a big jargony form. Q391 Dr Taylor: So, and this is really to everybody, should we be suggesting that that document is sort of fragmented into separate documents for each particular service? Obviously the dentists would say yes. Dr Ellman: I think it is the same document for every service, is it not, that applies? I am not sure. Q392 Dr Taylor: I rather imagined, although, I have to admit, I have not seen it, that it actually explained details of the charges. Dr Ellman: No, it does not. It is a form that is used for you to claim repayments or payments of the dental charges in this particular instance. Q393 Dr Taylor: So how are you and the others trying to draw patients’ attention to the range of costs? Is it your job to tell them what it is going to cost? Mr Cartwright: If I could pick this up for optics, many practices have this sort of leaflet which is a guide to NHS entitlements because we are slightly diVerent in that we do not have charges, we have entitlements. Practices would also have posters, saying what the entitlements are and on the PCT, primary care trust, visit, the ophthalmic advisor will pick that up if there is not one there and say, “Well, you should have one. You should have leaflets”, and staV would be aware of that as well. Q394 Dr Taylor: So you would accept that it is a part of your role to hand out the information? Mr Cartwright: Certainly, and we do so, yes. Dr Ellman: We do likewise. Dr Baker: Anyone who has been to a GP surgery will know there are racks and racks of leaflets and there are normally leaflets explaining prescription charges available for people to pick up. Q395 Mr Campbell: Back to the opticians again, I have a thing about opticians! Scotland and Wales have introduced a new eye test examination. Basically can it come here? Can it come to England and how much will it cost? Mr Cartwright: We would certainly be delighted if it were to come here or a very similar sort of system and I think it can come here. That would be part of what the general ophthalmic services review should be about. We would need to look at the cost and I think certainly it would cost more, but I think, if that

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was looked at in terms of the value of the longerterm savings, that would clearly make the case for that sort of system coming here. Mrs Hansford: Someone has just whispered in my ear that, if the Scottish scheme were introduced in England, it would cost £92 million according to the Department of Health. Q396 Mr Campbell: So that is a lot of money. Mrs Hansford: In NHS terms, it is a drop in the ocean. Q397 Mr Campbell: A drop in the ocean of course, yes. Mr Cartwright: If we were saying that the current expenditure is £350 million and that includes vouchers and eye examinations, and I think we had a figure of nearly £2 billion earlier, you can replace teeth, but not eyes. Q398 Mr Campbell: Are you getting more money for better tests? Mr Cartwright: There is a wider range of services, yes. Q399 Mr Campbell: And of course available to all? Mr Cartwright: Yes. Mrs Hansford: I wanted to interject when we were talking about patients travelling to hospital and paying car parking fees. Of course the beauty of an optometrist delivering services in the community is that there are no car parking fees, there are no hospital trips, there is no transport because they can get on the bus, they can walk round the corner and the optometrist is there. That is one of the benefits of delivering more optometric services in optometric practices. It is an under-used resource. Mr Campbell: I will have to get on my bike then! Q400 Chairman: I have just one more question to you about the issue of domiciliary eye tests when we were talking earlier about elderly people falling and everything else and sort of the added cost to the NHS for that. What is the current position with domiciliary eye tests? Mr Cartwright: Domiciliary eye examinations are available, and there are many practices who do them and some companies which specialise in domiciliary eye care. I believe that one of the issues there is that there is a fee for the first patient and then a lower fee for subsequent patients. There should be a higher fee for the first and second patients and then perhaps a tail-oV, whereas it happens at the moment after just one patient. Q401 Chairman: If you had this National Service Framework which was mentioned earlier, obviously issues like that would be in there and hopefully would be accepted throughout the UK. Could I move on to Dr Ellman. You advocate an automatic, free oral health risk assessment programme which I would have thought, in terms of last week’s White Paper, was something that the Government would

be interested in looking at. What are actually the costs and benefits of such an initiative like that? Has it been costed in any way? Dr Ellman: Not as far as I am aware, but it has not been developed properly yet either.22 There is an outline being developed, but there is no IT system to support it currently. A full oral health assessment has been used by other people in private plans, for instance, to give guidance to get a full picture of somebody’s oral health, not just the fillings, but the whole picture. That would be beneficial because you could see and again you could do the one thing we have never really done much of in dentistry and that is to measure the health gain, the eVects in terms of what we do. We know what the immediate eVects are, but we do not know the long-term eVects. It would also enable patients to be encouraged along the prevention route by doing oral health scores, so you would know exactly where you were in terms of relationship. This has been trialled outside the NHS by Denplan actually who did it as part of one of their schemes with a fair degree of success, so I think we are not reinventing the wheel from that viewpoint. Q402 Chairman: Have you got reports from Denplan on that which perhaps the Committee could look at? Dr Ellman: I can try and ask them if they could supply us with some for you. I have not any. Q403 Chairman: The other thing I would just like to ask you, Dr Ellman, was not really about NHS charges, but it does come into what you have just said there to some extent. It is this issue of fluoridation of the public water supply. What is the BDA’s position on that? Dr Ellman: Absolutely solidly in favour. We ran a massive campaign here at Parliament for that some 18 months ago and that was very successful. The BDA is very much in favour of that and the science is very much in favour of that. There are entrenched views in the diVerent directions, but there we are.23 Q404 Chairman: We have heard them over the years, but, with our new regulations in situ now, we do not know when or who is going to operate them. Could I just move back to the opticians. How do you see the new general ophthalmic services contract developing in the future, not in terms of you would like it set in the National Service Framework and everything else, as I am sure you would, but in terms of charges? Do you think there is going to be any great change? 22

23

In 2003, the BDA produced a report, Oral Healthcare for Older People: 2020 Vision, which made a number of recommendations in this area. See Ev 137. Note by witness: Water fluoridation is the most eVective public health measure in reducing dental decay and for tackling oral health inequalities. Tooth decay is a significant problem in the UK and the dental health inequalities are widening. In socially deprived communities as many as one in three children under the age of five will have one or more decayed teeth extracted. As part of the Water Act 2004, MPs voted in favour of local communities being oVered the change to decide whether they wanted targeted water fluoridation schemes in their locality.

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Mr Cartwright: I think, in the ideal situation, there would be eligibility, so an eye examination would be something that everybody could access. I think we have to be realistic and say that there are certain groups that are more at risk than others, such as children, elderly people, suVerers of medical conditions and those on low income, so that is absolutely right. Personally, I would then put more eVort into extending the role of the optometrist to be able to deal with specific situations that would free up resource elsewhere. We have talked about where, if somebody has red eye or conjunctivitis, that would go into the optometric practice and, perhaps rather than extend eye examination eligibility to absolutely everybody, I would put some money into that side.

Q405 Chairman: Well, could I thank all of you for coming along this morning. It has been quite an enjoyable session with the little bit of entertainment in the middle of it all! Thank you very much indeed and hopefully it will not be too long before we are actually reporting to Parliament in relation to this. Any further papers you have on these issues we will be more than happy to look at before we come to any firm conclusions. Mrs Hansford: Would you like us to send copies of these documents to the Committee? Chairman: Yes, indeed we would. I think David would in particular. Thank you.

Witnesses: Mr Derek Lewis, Chairman, Patientline, Dame Gill Morgan, Chief Executive, NHS Confederation; and Ms Maggie Elliot, President, Royal College of Midwives, and Head, Midwifery and Women’s Services, Queen Charlotte’s and Chelsea Hospital, gave evidence. Q406 Chairman: Good morning. Could I welcome you to the Committee and thank you for coming along to help us with our third evidence session in looking at the issue of NHS charges. I wonder if I could just ask you to introduce yourselves and what organisations you represent. Ms Elliot: I am Maggie Elliot. I am representing the Hammersmith Hospitals NHS Trust. Dame Gill Morgan: I am Gill Morgan and I represent the NHS Confederation. Mr Lewis: Derek Lewis and I am the Chairman of Patientline.

Q409 Anne Milton: So what you are suggesting is that, if you cannot aVord to pay for it, you do not get the reassurance in the middle of the night? Ms Elliot: Yes, you do, but you do not get the same person to do that. Of course the relationship builds up with that one midwife, so, as soon as the woman calls her, she knows immediately who it is, what her issues are and provides very reassuring advice or tells her to come into the hospital or whatever. Yes, other women are able to call the hospital, but they speak to either a midwife on the delivery suite or they speak to a community midwife basically.

Q407 Anne Milton: My first question really is addressed to Maggie. Perhaps you could tell us a bit more about the scheme in place at Queen Charlotte’s Hospital where expectant mothers can pay for NHS care. Maybe you can expand on that and tell us a little bit about why it was developed in the first place. Ms Elliot: First of all, the mothers do not pay for NHS care and we are quite clear about that. The mothers actually book in to the hospital normally first, so they actually are entitled to, and absolutely would receive, NHS care if they themselves did not choose to go private. The scheme started about two years ago or the concept was two years ago, but the actual commencement of the scheme was about 18 months ago. One particular midwife came to me very, very keen to provide 24-hour on-call service to reassure women that everything is all right and that sort of thing, so it was started as a result of that conversation. She had also been aware of a very similar, but not the same, scheme in another trust. There was a demand from women, so we looked into it fully and started.

Q410 Anne Milton: There has been evidence around for years and years and years about the outcomes for women in pregnancy if they have a named midwife and certainly organisations like the NCT have been calling for that for years, so in fact your access to somebody you know is quite important when you are pregnant? Ms Elliot: It absolutely is and we would move towards that for everybody, particularly if it is part of the NSF, so it is planned for the future, but currently we do not provide the absolute midwife for that woman. The other thing of course is that the scheme has allowed us to provide this service for women with a clinical need, so, as well as this midwife and now another one and a half actually providing that service for the women who pay for it, we actually now can provide it for women with severe clinical need, and she takes on women free of charge which we would not have been able to have done if we had not actually started this scheme.

Q408 Anne Milton: So, just for the record, mothers pay for that? Ms Elliot: Mothers pay for the 24-hour on-call service that this midwife and now, since then, one and a half others actually provide which is not available to other women basically.

Q411 Anne Milton: What would be the clinical need? Ms Elliot: It is people who may have had a very traumatic experience with their first birth, so they would come to me and I would have a conversation with them on the telephone and then I would refer them on to the Jentle Midwifery Scheme because they basically need the reassurance of one, single midwife.

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Q412 Anne Milton: You talk about diYcult socioeconomic circumstances as well. What do you mean by that? Ms Elliot: Well, that could be somebody who had a history of domestic violence. Basically anybody who needs the reassurance of a midwife who absolutely knows their history from start to finish are the people who are referred to this scheme. Q413 Anne Milton: So clinical or socio-economic, people whose pregnancy is flagged up as maybe being complicated for a number of reasons? Ms Elliot: Yes. To put this into context, because it is a pregnancy from start to finish, this is called a “caseload”, so the Jentle Midwifery Scheme have actually taken 51 women who have actually delivered with them who have actually paid. Additional to that, they have taken on an extra 25 who have not paid, and they were able to expand that number as well, but they also provide reassurance and care to other women as well. Q414 Anne Milton: Are you comfortable with it? Ms Elliot: Absolutely, yes. Q415 Anne Milton: I need to ask you that because it could be seen very much as a two-tier system. Ms Elliot: It is not a two-tier system because all women at Queen Charlotte’s, I hope, have a high quality of care. These women do not actually receive a better quality of care, but they simply pay for the reassurance of one midwife and nobody else will get that. Q416 Anne Milton: You are subsidising, richer people are subsidising the needs of a group of people you have flagged up as having exceptional needs during their pregnancy? Yes? Ms Elliot: We are able to reinvest the money back into the NHS, yes. Q417 Anne Milton: Quite. Just moving on to Gill, do you think this kind of scheme will be introduced elsewhere? Dame Gill Morgan: I think the challenge for schemes like this is that they are right on the cusp between the private sector and the NHS which makes it, I think as you have been exploring, really quite diYcult to know how far people will take them. We are not aware of a large number of schemes of people trying these sorts of things, but we are aware of individual organisations trying them. This is really quite diVerent, I think, from the other one which has had a lot of publicity recently which is the dermatology clinic which is quite clearly a private service run in NHS hospitals. We have always been able to run private services in NHS hospitals and we have always been able to oVer extra amenity in terms of beds and hotels right back to 1948. This is really exploring a new territory and I think we are not going to know, and this is one of the problems for organisations, quite how acceptable it is until at some point it gets tested in law because it is right at the boundary, I think, in terms of position. You will have tested it before you actually set it up, but it will

be the test of whether anybody challenges it in court which will finally encourage organisations to do it. I think people will be looking at this, but not necessarily intending to go down the route at the moment. Q418 Anne Milton: Just to come back to you, Maggie, do you have any figures of the people who pay for this, how many of them have the sort of need that you would have identified? Ms Elliot: Well, first of all, anyone who had a need would have had our one-to-one midwifery service anyway, so it is actually a want absolutely rather than a need. They pay for something they want. Q419 Anne Milton: So they are paying for something they want, not something that they need? Ms Elliot: That is right. Q420 Anne Milton: And, in doing so, they crosssubsidise the service for the people who need it? Ms Elliot: Yes. Dame Gill Morgan: I suppose the other thing we should point out is that these sorts of services have been available by independent midwifery practices for a long time. What is unusual about it is oVering that sort of independent service within an NHS hospital and, therefore, using the money to crosssubsidise, and that is unusual. Q421 Anne Milton: Are you comfortable with it, Gill? You look wary. I can see wariness on your face. Dame Gill Morgan: I think this is right at the cusp of some real challenge and I am not really sure how comfortable I feel about it because I feel, I think, a little bit like you. There is a real benefit if you get additional resources in to boost the services which is why I feel comfortable about private services provided within the NHS because that money has always gone back into the NHS and I suspect, if this had been presented as a private service, I would have had no diYculty whatsoever. In one way, you could present it as a private service if you are quite comfortable about it, but I think the way that it is presented leaves me personally feeling slightly uneasy, but that is a personal view, not an organisational view. Q422 Chairman: Could you just answer this: how diVerent is this payment in principle from a payment for a prescription charge? Dame Gill Morgan: I think the thing that is diVerent about this is partly the scale, but I also think this is about the choices individual people can make to have something which, as I say, could have been presented as private and I would see it as fundamentally diVerent from a prescription charge. I think part of this and the discomfort is just the presentational issues for someone who is used to the way the NHS has traditionally worked. The prescription charge is diVerent. That is a payment that everybody contributes to, so it is a diVerent sort of thing for me. Briefly, while we are on prescriptions because I know that is not the purpose of today, but I know you have been wrestling with what evidence

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there is about how many people fail to use prescription charges, I have brought with me a paper from a Commonwealth survey which compared the UK with five countries which gives some answers around prescription and dentistry. I will leave that for you. Q423 Chairman: You do not then see a prescription charge as being a part-payment for getting a service from the NHS? Is that what you are saying? Dame Gill Morgan: It is a co-payment, but it is a diVerent co-payment because it is really focused the other way round and it has so many exclusions to it. My personal view again about prescription charges is that we are not very sophisticated about how we apply them, so we do not think about what we are trying to achieve as a policy context and I do not think we have fundamentally thought about the challenge of where we are today with expensive drugs. One of the things we have been thinking about internally which we have not sort of launched for a wider public is what I have seen in other countries which is that, if you want to make drugs available to everybody on an equity basis, but you also want to oVer some choice for people, what other countries do is make generic drugs free and then only charge a co-payment if somebody wants a branded drug. For example, if you take a drug used to make you pass water, the generic name is furosemide which would be free with no prescription charge, but some people, however, like the branded name, Lasix, because it comes in a green colour and they like that, so you are charged for the branded name and, in that way, you drive two policies, one being equity and the other being the issue that we want more generics prescribed. Q424 Dr Stoate: I have a couple of very serious points I want to raise. You say it is not a two-tier service and you also say you are just giving reassurance, yet, according to the newspapers, and I have given the articles to the Clerk to look at, they are not just getting reassurance, but what they are getting is one-to-one ante-natal classes and they are getting practice birthing sessions on a one-to-one basis. That is not about just giving reassurance over the phone 24 hours a day; that is about a completely separate type of service which is not available, except to the 25 people who have got clinical need, unless you have got 4,000 quid. That is the reality surely. Ms Elliot: First of all, I cannot comment on what the newspapers have said. Q425 Dr Stoate: They are wrong, are they, the newspapers? The £4,000 does not include the birthing classes, the practice sessions and the one-toone ante-natal sessions? That is not what is happening? Ms Elliot: First of all, other women that we actually give care to do actually receive that type of care throughout the one-to-one midwifery service, so we do have a service that actually gives exactly the same type of care, the only diVerence being that they do not get one named midwife throughout the whole of their care.

Q426 Dr Stoate: Well, that is not what is being said in the papers. It is specific women being interviewed and I want to know whether these newspaper stories in fact are true. The women being interviewed are saying, “It’s marvellous. I get ante-natal classes with one or two couples only, instead of the 30 I would get otherwise, and I have got this practice birthing session where the whole thing is done in practice on a one-to-one basis”. Is that not happening? Ms Elliot: That happens within the Jentle Midwifery Scheme absolutely. Q427 Dr Stoate: Right, so that is what they are getting for their £4,000 and not just reassurance over the phone. Ms Elliot: Yes, but that actually goes back to the fact that that is a want and not a need and that is what they are paying for. Q428 Dr Stoate: But what I am trying to say is that that is a two-tier service. They are getting something which is completely unavailable to women who are not paying £4,000. Ms Elliot: It is unavailable to those women, but the women that are not paying £4,000 receive an absolute high level of care that is acceptable and within the NHS. Q429 Dr Stoate: But not within the NSF. The NSF standards only reach those people who pay. Ms Elliot: Yes, but then you could go on then and add on separate things which women actually pay for that are not available within the NHS. Q430 Dr Stoate: What I am trying to get at very simply is that they are paying for a service which they cannot get on the NHS if they have not got the money. Ms Elliot: Yes, but then nobody gets those services on the NHS. It is not something that is available. There is not another scheme that provides one midwife total care within the NHS. That is not available. Q431 Dr Stoate: You are right, but it is an NHS service which is only available to those who have got £4,000 over and above the ordinary NHS standard. Ms Elliot: It is not an NHS service. Q432 Dr Stoate: Well, you have just said that it is part of the NHS. Ms Elliot: No, the women who are in our one-to-one midwifery service actually receive a very similar service, but these women pay for extra things which are not clinical need. They are things that they want, not things that they need. Q433 Dr Stoate: Okay, I will leave it there. You have said that you seem to support or seem to have some sympathy for a scheme whereby, if you want a generic drug, you get it for free, but not if you want the branded drug. What is the diVerence then if I were to say to a schizophrenic, “You can have largactyl or Chlorpromazine for free, but, if you

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want Olanzapine, one of the typical anti-psychotics, it is going to cost you 50 quid”? Would that not be the same thing? Dame Gill Morgan: No, I do not think it would because there you are not comparing like with like because the more modern anti-psychotics are clinically more eVective and they have been shown by NICE to be. It is not like for like and that, to me, is fundamentally diVerent.

when you add up all the charges that come into the NHS, it is a significant contribution to the running costs of the NHS, but we could be doing it in a way which does not actually compromise equity and which does not actually compromise another policy which is to get actually more generics prescribed. It is a suggestion that we need to begin to think diVerently about it rather than the way we have always thought about it.

Q434 Dr Stoate: Why is that fundamentally diVerent? What is the diVerence between saying that the basic NHS midwifery service is okay, but not up the NSF standards, whereas, if you are going to pay £4,000, you can have the NSF standard because that is not like for like either? Dame Gill Morgan: Well, that is where you go back to where I think, if this is presented as a completely private scheme, which is what the NHS has already been allowed to do, it would not be causing some of this heartache as it does sit right in this middle bit and the NHS has been allowed, even in Barbara Castle’s day, to provide some private practice. I think part of the issue here, which is why there is so much interest in it, is that it is stirring up this question of how far you mix private work with public work on the same ward and you get the benefits accruing to the NHS, and that is very diYcult.

Q436 Dr Taylor: We are coming back to prescription charges later, but I am afraid I wanted to talk to Maggie a little bit more because, when we did an inquiry on midwifery in the last session, it came absolutely clearly out that why mums like midwifeled birth centres is because they have a very high chance of having one-to-one care from the same midwife throughout. Now, I have to say that I think it is entirely wrong, and I hope the Committee will say it is entirely wrong, to do it the way you are doing it because these people are in fact getting private care at half price. What does it cost to have a baby privately, to have the whole shooting match privately? How much does it cost? Ms Elliot: Well, between £4,000 and £5,000 with a private obstetrician, depending on the service they have, whether they have a caesarean section or not, whether—

Q435 Dr Stoate: Are we not just going straight down a slippery slope? Okay, you could argue that the new anti-psychotics are clinically diVerent from the old anti-psychotics, though other people might not necessarily agree with that, and maybe the antipsychotics are not a very good example, but maybe we could come up with many other examples, and I am sure it would not take me long to come up with other examples, where a drug might be okay, but actually there is a “rather better one” and NICE might think it is a rather more sophisticated drug, and it does not make that much diVerence, but you can have that if you pay for it. Is that not the same thing and how far would you take it? Dame Gill Morgan: Some countries have done that of course. If you go to New Zealand, that is the way they have handled their prescribing costs. I am not advocating that because I think there is a duty to use the best, and most appropriate, drug and that is what NICE gives us. It gives us a view about what is the best drug to use at a particular time. However, within that, there is a great diVerence between the generic version of the drug and the branded version of the drug when things come oV patent and the cost diVerence can be absolutely phenomenal. Now, it seems to me that that is not the same because you would not be withdrawing a service from people, you would actually be putting in a top-up for people who wanted a particular branded version rather than the generic. Now, I have not done any modelling and I am not presenting this as a hypothesis of what we should do, but what I am trying to suggest is that we could be looking at some of these charges in diVerent ways and then maybe both ways of bringing some resource in because,

Q437 Dr Taylor: So they can have a baby privately for £4,000 or £5,000 and they can come into the NHS unit and pay £4,000? Ms Elliot: Actually I need to take advice on that. Q438 Dr Taylor: It strikes me that this is cut-price private medicine. Ms Elliot: Sorry, depending on the actual service, it is £7,000 to £8,000. Q439 Dr Taylor: In a hospital like Queen Charlotte’s, your delivery will be high-class, so you do not need to pay to make sure that you get the right obstetrician to do it. What you do need to pay for is the superb comfort of having the same midwife all the time, so here you are giving people who can aVord it a better class of care, and I hope the Committee will come out and say that it is entirely wrong without somebody having to take it to court to prove that it is wrong. Ms Elliot: It is not— Q440 Dr Taylor: Do not try and defend it! Ms Elliot: It is not a better level of care than the women on the NHS receive. Dr Taylor: Of course it is. What they want is the same midwife— Q441 Chairman: Let her answer the question. Ms Elliot: We do have a one-to-one midwifery scheme and that does provide a named midwife, but that midwife cannot be guaranteed, because of annual leave and because of other reasons, to provide that level of care. This midwife and now the two whole-time midwives give that guarantee to them that it will be them that actually will deliver

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that baby because they arrange their annual leave around those women, so they will not go on annual leave when they have got women booked, so it is a guaranteed service. The women actually want that. They want the reassurance of a midwife and it truly is not a better level than women with clinical need actually get. Dr Taylor: I think you have dug the hole deep enough. Thank you. Q442 Chairman: Obviously the individual concerned can arrange holidays in terms of days of the week, but the actual day, as I understand it, can be quite a long process in terms of hours and everything else. Ms Elliot: Yes. Q443 Chairman: Indeed on a couple of occasions I have sat through those long hours, waiting! Obviously it will disrupt that day, particularly the day of birth, for these individuals in terms of going back perhaps to their families and everything else at the times they would normally have been able to, so is there any personal gain in those individuals’ income, as it were? Ms Elliot: For the midwives? Q444 Chairman: Yes. Ms Elliot: No, they receive the NHS salary. Q445 Chairman: And that is it? Ms Elliot: Yes, and of course including all of the oncall allowances that the NHS provides as well. Q446 Chairman: So they will get that whether it was somebody who had £4,000 sitting alongside them or not? That would be the same? Ms Elliot: Yes, so, whether the women are either paying for the extra services or not, the midwifes would receive exactly the same salary. Q447 Anne Milton: I would just make a comment really about when you were talking about prescribing, Gill. I think one of the issues, and where it gets very complicated, is that compliance is a big issue, so, even if there is no diVerence in the tablet, but I would like Lasix and I do not like that ghastly furosemide, that comes into it, and also there is the placebo eVect of drugs where, if somebody perceives that Lasix will be better for them, then they are more likely to get better if they take the Lasix actually? Dame Gill Morgan: Sure. Q448 Anne Milton: But just to come back to Maggie, and I think you were given a particularly hard time by Dr Taylor actually, what these women are paying for is a guaranteed person? Ms Elliot: That is right. Q449 Anne Milton: If you believe, therefore, that they are not getting anything that they need, but it is something that they want, and I am sorry to be controversial, it is going to be said, therefore, that you are exploiting women at a very vulnerable time in their lives.

Ms Elliot: There is a huge demand for this and we are turning people away all the time. Q450 Anne Milton: But I can say that it is exploiting them and encouraging them to believe, because they will believe, I would guess, that they need this. Ms Elliot: We absolutely do not advertise it in any shape, form or description. It is the women that ask for it and for a long time they have always said that they cannot provide it, but this midwife had actually had experience of a very similar scheme and knew that it worked very well, so we were asked for it. She came to me with the proposal and, I have to say, the women that actually go on to the scheme actually have to be booked with us first, so, because we are in London and there are capacity issues, we cannot take women from Timbuktu, but they actually have to be booked with us and live within our local area in order for us to accept them on to the scheme. We are currently turning a lot of women away from it because we just cannot provide the demand. Q451 Chairman: Gill, can I just ask you about this issue of purchasing beyond a generic prescription. It is a form of choice, is it not? Dame Gill Morgan: Yes. Q452 Chairman: “Choice” is the sort of buzzword now certainly in terms of patients, though I am not sure about the people who are providers who work in the Health Service. I know this is not a confederation view, but just your personal view— Dame Gill Morgan: This is just a discussion, yes. Q453 Chairman: Do you see choice, which has eVectively a co-payment in that respect, as being something that is consistent with the NHS as it has been in the past or indeed is now or could be in the future? Dame Gill Morgan: My personal view is that, where co-payment is necessary for something which is essential, we should not be charging co-payments. That does not fit with the NHS and the ethos of the NHS, but, where this is something which is about preference, I think you could begin to explore diVerent ways of thinking about co-payments. For example, we have always made amenity beds available where people have been able to pay an additional sum to have a private room. It seems to me that there are opportunities in that sort of zone to think diVerently because there is some choice and that is why some of my response to this is that it is right at the edge of things that we have always done. You could argue that having a private room, for which we charge an amenity charge, is some sort of way where you could only do it if you have got the money, it is unfair, but at the same time you know that, if the private room is needed for an individual patient for a clinical need, there will not be an amenity bed available. I just think we need to be thinking diVerently about some of these charges and whether there are ways that we can do it where we are not co-paying for fundamental treatment

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because I personally feel very strongly that that is not the ethos of the NHS or the way we should be going. Q454 Chairman: I have got in mind the situation where, if you look at the Calman-Hine report of quite a long time ago now about surgery, and cancer surgery in particular it was looking at, we had hospitals and clinicians who were identified as being better skilled at saving somebody who had to have surgery for cancer than other establishments. It would be very tempting for somebody to say, “I’d like to co-pay on the NHS to go to that hospital with that surgeon”, which Calman-Hine identified where the chance of surviving that cancer is quite a few percentage points higher than not going there. What would you say to that? Dame Gill Morgan: I would find that completely unacceptable, on personal grounds. As far as our members are concerned, it would be very hard and we have never surveyed our members collectively on that, so I cannot speak on behalf of the NHS. Chairman: I understand that and it is not in our script either, but it is just something I thought I would like to test out with you. We will move on to David Lewis now. Mr Amess: Before that, poor Maggie! She has had a terrible time in this Committee and even Richard has been sticking the boot in. I am so sorry the opticians have gone because I just wanted to say to you, Maggie, that I think your glasses are splendid! I bet they were not taken oV the shelf! Mr Campbell: More importantly though, how much did they cost! Q455 Mr Amess: We have with us now this morning Mr Lewis and I am sure that what the Committee would really like to know is what really went on between him, Michael Howard and Miss Widdecombe, but we are not going to pursue those matters and we are going to talk about Patientline. Now, there has been some very, very tough stuV in terms of the criticism of Patientline, huge criticism about the costs of installation when you think that, with the technology developing, they are practically giving TVs and phones away, et cetera, so I think the first thing the Committee would like you to address is how you can defend the very, very high costs of installation. Mr Lewis: Well, of course these systems are very sophisticated systems. These are not simply televisions and telephones at the bedside. When the so-called Patient Power programme, under which they are installed, was specified back in 2005 as part of the NHS Plan, what the NHS was then looking for was a device that would not only provide telephone, television, radio and so on, but would have the capability of doing a lot of other things, providing interactive services for patients at the bedside, being capable of providing access to electronic patient clinical records at the bedside for use by nurses and doctors, and being able to provide the mechanism for patients to order their food at the bedside for dietary management and so on. Therefore, the systems that have been installed are

essentially a PC at every bedside and it is a specially designed PC for the hospital environment, as a result of which the cost of installation is high. It is typically about £1,750 per bed, all of which is funded by the providers who install them who additionally fund the operating costs and that involves having staV in each hospital, typically about five people in each hospital, who keep them clean, who maintain them and who look after patient needs in relation to them. That inevitably results in a substantial amount of cost being incurred. The UK is unique in that this particular type of sophisticated system is funded in this country in a way that it is not anywhere else and that is that at this point it is funded entirely through payments by patients and by their friends and relatives who make calls to patients. As you may be aware, Ofcom, which was still investigating the costs of incoming calls at the time we submitted our evidence to the Committee, has subsequently reported and has concluded that the charges for incoming calls were essentially an unavoidable consequence of the way the funding structure has been set up in the UK where the providers, as was recognised by the NHS at the time, had little choice but to recover the bulk of their costs from charges for incoming calls. The great opportunity, we believe, and we welcome the Ofcom report, is to extend the use of these systems for the purposes for which they were originally designed and selected so that the benefits extend well beyond those of patient entertainment and communication. We hope that the review group that is now being established by the Department of Health will indeed explore those further uses so that we can achieve a much more equitable spread of the cost of the systems between diVerent users. Q456 Mr Amess: You have really sort of guessed many of my questions really, including talking about Ofcom. In terms of the volume of complaints, have you had a lot of complaints about the cost of charges not only from patients, but from Member of Parliament? Mr Lewis: I think it is important to say, first of all, that, by and large, there is a remarkably high level of satisfaction with these services on the part of patients, and the NHS itself conducted research about a year ago which indicated that 90% or thereabouts of patients were satisfied with the services that they received. There are obviously concerns about having to pay at all in the hospital environment within the NHS, but again, by and large, the majority of patients feel that the charges for television and for outgoing calls, which were deliberately capped as part of the original programme, are reasonable and they are happy to pay those. There have been complaints, and there has been quite a significant volume of complaints, about the costs of incoming calls which are set at a much higher level and which are now higher than the norm for telephone calls generally, and those complaints come from callers, friends and relatives who call patients and indeed from Member of Parliament who are reflecting the views of their constituents.

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Q457 Mr Amess: In terms of the technology that you have available, would you share with the Committee what other services you feel you could provide and can you try and seduce us by saying that, if you did provide these extra services, in actual fact you would be saving money for the National Health Service? Mr Lewis: A number of these services not only, in our view, would save money, but produce some significant improvements in patient care, patient satisfaction and indeed patient choice, but, with a PC at the bedside, the scope is very considerable. For example, and these are all things which are now being done, but not to the extent that we would like to see them done, there are two hospitals in the UK where patients now order their food on the system. Q458 Mr Amess: Which are those hospitals? Mr Lewis: They are in the north-east, North Tees and Hartlepool, the first two hospitals to do so. That brings a number of benefits: the information about the menu and its dietary parameters is easily available to the patient; they can order their food a very short time before the meal is actually delivered; it arrives at the right bed because they have not moved bed in the interim and that brings significant reductions in food wastage; it completely eliminates the need to print menu cards; changes to the menu can be done instantly; and it is a means of providing information about what food patients have ordered for the monitoring of their diet. In those two hospitals and the other hospitals that are now looking at it, there are some very tangible savings and clinical benefits. Q459 Mr Amess: Will you answer the direct charge though that one of the reasons your expenses are so high is that you are not getting that which you thought you would from the National Health Service and it is the poor old patient who is lumbered with these costs? Mr Lewis: I think there is an element of truth in that. When this programme was conceived, it was anticipated that things like food-ordering and access to clinical records at the bedside would be widely used and would generate a significant source of income for the providers. The development of that income has been much slower than was originally expected. Had that income developed at the pace that everyone expected at the time, we would have expected to have been able to reduce the level of incoming call charges by now. Q460 Mr Amess: Do you think the current charging agreement does actually have a viable future or do you think the whole thing is going to have to be looked at again? Mr Lewis: We believe it is viable, but unsatisfactory at present and we would very much like to see change and we hope, therefore, that this review group that is being set up by the Department of Health will, first of all, consider a wide range of options, will look at the way these services are funded in other countries which do not involve high levels of charges for incoming calls, will consider ways of encouraging other uses to the system, and also more eVective

operation on the boundaries between the services that the providers oVer and the things that the hospital does. Our belief is that, if there is an open mind in approaching those issues, there are a number of ways in which those charges can be reduced and we very much hope that it will operate to a very tight timetable as it is not something we would like to see drift on for any great length of time and we would like it to work to conclusions within a few months so that we can actually implement some changes quickly. Q461 Mr Amess: This may be a bit diYcult for you to answer, but how much money do you think would have to be generated from the National Health Service to reduce the charges to a reasonable level? Mr Lewis: It is extremely diYcult to answer that question because it depends entirely on the mix of services provided and what some of the additional costs are of providing those services. We do not see a single solution to this, but we do see, if you like, there being a menu of actions which, brought together, should enable incoming call charges to be reduced to a level that callers would consider to be acceptable and would remove a number of other irritations, one of which is the need at present for the warning at the beginning of all incoming calls about the cost of those calls. Q462 Mr Amess: Finally, and you have sort of already answered this, Ofcom and the criticisms— what is it your intention to do about these criticisms? Mr Lewis: Well, I am not usually someone who would make complimentary remarks about a regulator, but they did actually, I think, do a quite thorough job to a reasonably tight timetable. Their conclusions were that the level of incoming call charges, which was the specific bit they were investigating, were a cause for concern, they were a source of complaints and they looked out of line with other telecoms charges. However, they did conclude, first of all, that the level of those charges was heavily influenced by the specifications that had been set by the NHS for these systems back in 2000: the highly sophisticated technology; the requirement to put one of these units at every bed even though it is uneconomic; and the requirement to provide a range of free services for the NHS, such as free radio, free information services and so on. They concluded, as a consequence of that and combined with the cap that has been established on charges to patients, that the providers had very little choice other than to eVectively charge these higher prices to incoming callers, and they described the charges as being the result of a “complex web of government policy and agreements”. In addition to the published report— Q463 Mr Amess: What does that mean, do you think? Mr Lewis: I think you would probably have to ask Ofcom, but I think it relates back to the policy when the programme was set up and the way it was funded. They have published a report and they have also written to the Secretary of State with a series of

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recommendations, we understand, although we have not seen that letter as yet, but hope to do so as part of the work of the review party. Q464 Dr Taylor: Is it fair to say, Mr Lewis, because you have said that your system will have a computer by the bedside which would show an electronic patient record, that the relatives who are paying 49p a minute for their incoming calls are in some way subsidising the national programme for IT? Mr Lewis: Not at present because at present the usage of the system— Q465 Dr Taylor: But it is there. Mr Lewis: Well, indeed. The usage of the system for that purpose is at present very limited. There is just one hospital, Chelsea & Westminster, which is using our system to access an electronic clinical record at the bedside, and very successfully so, so eVectively— Q466 Dr Taylor: Does your warning message say, “Thank you very much for using this service. It is going to cost you 49p, but you are helping the NHS towards its aim of having readily available electronic patient records at the bedside”? Mr Lewis: In principle, that is a correct conclusion. We do not include that in the message for fear of lengthening it further. Q467 Jim Dowd: Because that would cost them a further 49p! We are actually talking about the kind of charges for incoming calls that people were desperate to pay 10 or 15 years ago in the early days of mobile technology, but I will put that to one side. I am sure it is diYcult to estimate, but what proportion of inpatients take advantage of your services? Mr Lewis: A very high proportion do. Approximately 70% of the terminals we have at the bedside at any one time have a patient registered to them and about half of those on any one day will be paying for a service or people will be paying to call them. The other half will be making use of the free services, radio, television, if they are children or have special needs, or may not be using the service on that particular day, so it does have a very high level of usage. Q468 Charlotte Atkins: You have said here that the installation costs are something up to £2,000. Given the changes in technology, is there the opportunity for these costs to come down? It seems to me that you have got something a bit like a white elephant in many situations because the full range of services which are provided in these units are not being exploited, so people are having to pay the cost of more than actually ringing Australia to access a friend or relative in hospital, and I speak with experience here, having ended up with a charge of £60 when a member of my family used your service. It seems to me that they are paying for something which is not being fully exploited. Mr Lewis: I think the answer to that is that they are not white elephants by any means. In fact our technology is regarded outside the UK as being

leading edge, and hospitals in the United States, for example, are bearing the full capital costs of the magnitude you have just described in order to install these systems because they see a very wide range of benefits from them. In a US hospital there is already television and telephone there and US hospitals are paying up to £2,000 a bed in order to provide devices which will provide the full range of clinical services and other services that I have been talking about. Q469 Charlotte Atkins: But it is a white elephant if it is not being used. That is the point. It is not a white elephant in the sense that it is being used in other countries, but it is a white elephant if it is not being appropriately used and the full system is not being exploited, which means in fact, as Richard was saying, that patients’ friends and relatives, by and large, because they are ringing the hospital and they are the ones that are being charged excessively, are subsidising a system which is not being appropriately used in the NHS. Mr Lewis: In that sense, I would agree with you. I think the solution to that is to ensure that they are fully used. This investment is now largely a sunk investment; it has been made and the systems are there. The challenge, I think, is to make sure that the full potential of it is used to improve patient care, to generate the sort of cost savings we were talking about, to reduce medical errors and so on, for which there is considerable potential. Q470 Charlotte Atkins: But the contract was agreed when, in 2000? Mr Lewis: The contracts were specified in 2000, yes. Q471 Charlotte Atkins: So presumably technology has now moved on and you presumably have stage two, stage three of your systems which presumably, given that the cost of computers and other technology is coming down, are not as expensive as they were back in 2000? Mr Lewis: The actual capital cost is very similar. Technology has moved on and it has become slightly more sophisticated but the core costs, which are in designing the physical hardware that goes in at the bedside and all the cabling, have not changed significantly in that period. Q472 Charlotte Atkins: And as to the people who are being exploited eVectively when they ring in, are you doing any sort of analysis about what sort of people are facing these huge charges, because it seems to me that the people who are more likely to use the system are the ones who cannot visit the relative, who are ringing in as a substitute for a visit, and therefore my instinct tells me that the people who face these high charges are more likely to be the people who are less likely to be able to aVord them? Mr Lewis: The evidence we have is anecdotal but it is that the people who use the service to call in do cover a very wide range of both friends and relatives. They certainly do include those who are on lower incomes and those who may not be able to make the trip into hospital and for whom it is an important means of contact, and I think that is a further

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compelling reason for the need to change the structure of the provision of these services to enable a reduction in those charges. Q473 Charlotte Atkins: And also, of course, because the charges come on your normal phone bill, it is quite likely that complaints will not be made direct to yourselves because it is just a nasty shock when your quarterly bill comes through the door. Mr Lewis: That is true and that is one of the reasons why the NHS has insisted and we have wanted to make sure there is a warning at the beginning of every call so that there is less risk of there being an unpleasant shock when callers receive their bill, but it is an inherent problem with this type of service. Q474 Charlotte Atkins: We all know that if you are ringing someone whom you are very worried about the likelihood of you listening very closely to that particular warning message is not going to be great. Mr Lewis: We do have five to six million people who call using Patientline systems each year and the proportion of those who get an unpleasant shock when they receive their telephone bill and are unaware of what they are being charged is quite small. Q475 Charlotte Atkins: Thank you. Gill, did you want to come in? Dame Gill Morgan: Quite a few of those complaints that come do come to individual organisations and it is one of the strands in hospitals, complaints about the charges when the bill comes in. There are a number of reasons why the NHS is not getting the functionality. The first is that when Patientline started it was an orphan project. It was an idea about improving accessibility for patients and linking into things but I do not think at the time, in the way that it was introduced into the NHS, anyone had begun to grasp these other functionalities. Where the NHS is now is that it is not quite ready to get these functionalities because they really do depend, as Richard has pointed out, on having some of the functionality from Connecting for Health universally available. That is why projects like Chelsea and Westminster, which are showing how you can begin to link these things together, saving staV time, giving patients much more information about themselves, giving much more information about individual conditions, are the model for the future. I think things will change but you have to have something to link that system in and that is not yet available uniformly across every hospital in the country. Q476 Dr Taylor: Can they look up on Google all about their illness while they are lying in bed? Mr Lewis: They can indeed. We provide internet access. Q477 Dr Taylor: Internet access as well? Dame Gill Morgan: Yes.

Mr Lewis: A number of hospitals have also asked us to provide access to a variety of diVerent information sources that they have quality control over, which may indeed include NHS Direct online. Q478 Dr Taylor: I shall be very well informed because I am going to visit one of the hospitals in the recess. Coming back to Gill and going back to prescription charges, could you tell us again what the piece of paper you have handed over tells us? Dame Gill Morgan: There was a Commonwealth Fund survey of five diVerent countries in 2002 that asked the question had you ever not cashed a prescription or not had dental treatment, and a whole range of things, and it just showed that in the UK we had some people who had not done things because of money but it gives a comparator internationally. Q479 Dr Taylor: So it does give us a bit of fact? Dame Gill Morgan: It gives you a bit of fact, yes. Q480 Dr Taylor: We have heard rumours that there are problems with free prescriptions in A&E. Dame Gill Morgan: I have not heard anything about problems with free prescriptions in A&E. Q481 Dr Taylor: One really important argument in favour of abolition to me seems to be that with the greater shift of patients from inpatient care to outpatient care and care in the community, even chemotherapy for cancers and things like that, some very deserving patients are losing the free prescriptions from hospital care and are having to pick them up with outpatient care. Is that not going against the whole of the White Paper’s aim and is that not an extra strong reason for abolition? Dame Gill Morgan: It depends. There are diVerent ways of funding those. What a significant number of hospitals do is buy the package which provides the free prescription and the home therapy so that people are still treated as an outreach from hospital, in which case those drugs are not charged through an NHS prescription. It is provided in the same way it would be provided if you were admitted as an inpatient on that oncology ward. Q482 Dr Taylor: Is that widely known? Dame Gill Morgan: It varies from drug to drug. Obviously, if it is a drug that you can take orally then you may be in a diVerent position, but what we are trying to do is take more of the infusions of cancer drugs into people’s homes because if you are feeling pretty rotten, you are feeling pretty sick, you are better oV feeling pretty rotten and sick in your own home and having care provided in your own home, but it is outreach. Q483 Dr Taylor: It was oral agents I was talking about because there are more and more chemotherapy agents transferring from intravenous to oral. Dame Gill Morgan: Yes, but you are again in the position that if you are going to do that, and particularly through a GP’s prescription, the GP has

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to feel comfortable and competent about using those drugs, and therefore it depends whatever shared protocols are developed locally. For many of the more complicated drugs I think it is quite appropriate if GPs say, “We are not prepared to be part of a share-care protocol”, and therefore the care is still provided as hospital care even though it is provided on an outpatient basis. Q484 Dr Taylor: Correct me if I am wrong but if a consultant gives an outpatient prescription to an outpatient, that still calls for a charge, does it not? Dame Gill Morgan: It depends on how it is prescribed. A lot of outpatient prescriptions are still taken within the hospital and people still come in to take some of the therapy. If they are on continuous oral treatment that would be prescribed as a script either by the consultant or by the GP who will continue that. There is a range, depending on whether it an oral type of therapy or whether it is maintenance. It is much more complicated because where in the system you will come depends on the drug, the disease, the stage and a whole set of things. Q485 Dr Taylor: So do you not think the Welsh Assembly is right to aim to abolish prescription charges entirely as this is raising extra complications? Dame Gill Morgan: Again, this is a personal view; I have never tested it with the members, but my personal view is that if we did not have prescription charges that would help because we have some costs. The downside of that is that we would have to find some way of getting that money into the NHS in some other way and then you have got a political debate about whether it should be taxation based. Dr Taylor: I am not asking now but could we have a written note of other ways of raising £450 million? Q486 Chairman: Last week’s answer was general taxation by most of the witnesses. We are not at that stage of the inquiry. Dame Gill Morgan: Exactly. Jim Dowd: Could you give us the next set of lottery numbers as well? Q487 Chairman: I would just like to say one thing on what you have said about this issue that inpatients normally would not pay for any charges, and that is the potential inequity. I asked this question last week and it did not seem that it was true, that people can be discharged from hospital with a month’s supply of something where other people would have to pay or they would have to pay in diVerent circumstances. Is that inequitable, do you think? I know it is people being kind but is it inequitable? Dame Gill Morgan: It probably is inequitable but you would have to look at what the conditions and the types of reasons were and I have no knowledge about who would get a month’s prescription free and who would not, so I would only be guessing. I have not got any evidence on that. One thing I should also say about Patientline, because I do think it is important to look at the other bit, which is what the patients say about this, is that the surveys that have

been done show that 88% of patients really love these things, and certainly have found the availability of a bedside personal phone of great benefit to them. There is very high patient satisfaction and, you are quite right: this is a problem outside the hospital and for relatives rather than for patients. The patients like it and value it. Q488 Chairman: Could I move on to this issue we were talking about earlier on the change in treatment, the acute sector coming out into the community in terms of people’s homes? The other change in pattern that we have had very much in the last few years is people going in now for things like day surgery or even for day chemotherapy treatment where at one time they would have been an inpatient. With regard to travel costs, do you feel that there is a burden there because of the changing pattern of treatment that people have in the Health Service? Dame Gill Morgan: Again, we have never surveyed our members about it but I can talk about a personal position, which is that certainly, when we looked at travel costs in a health authority I was involved in, we exempted people who had to come for chemotherapy, for renal dialysis or for repeated issues. There were no patient transport charges for any of those patients and there were also no car parking charges for those patients because it was recognised that those things were a great burden if you were routinely coming to a hospital or needing care, which is quite diVerent than if you go once in a while. Q489 Chairman: In terms of the assistance people can get with travel costs, are you happy that people get to know about these schemes or with the take-up of these schemes? Dame Gill Morgan: Yes. Certainly one of the most interesting debates which generated most discussion at a local level was about patient transport because patients were very well aware of the issues. It is widely advertised in the majority of hospitals. Again, I do not think we have been quite as imaginative about patient transport as a service as we might have been, so one of the things that some authorities have done is get joint agreements with local government because local government are paying for lots of patient transport, particularly to bring children into special schools and things like that, and in many places there is no connection between the transport plans of all the diVerent organisations, so you have vehicles sitting unused during the day somewhere but another service is using them elsewhere. Quite a lot of health organisations, particularly in rural areas, have funded co-ordination schemes jointly with local government to begin to look at how you get a much more sensible use of something which is very important in rural areas. Q490 Chairman: Should hospitals be encouraged to see car parking as a means of raising revenue? Dame Gill Morgan: I understand why hospitals have gone down that route. Very many hospitals have gone down that route because they are centrally sited

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and, as you have picked up in one of your other discussions, large numbers of people on the street use hospital car parks to avoid paying council charges. I think we are at a point of real change because if you look at why patients choose hospitals, uniformly towards the top of the list is car parking, so I am now aware of a number of hospitals which are not only reducing their car parking costs and fees but are also taking their staV out to park and ride schemes so that the whole of the car parking on site, other than for night staV or unsocial hours, is available to patients. If you want to market your hospital the things that patients will go on is accessibility, car parking and availability, and then one or two clinical indicators, but it is the car parking which is the biggest drive. I think we are going to see a change and more hospitals making car parking free because that will be a competitive edge for them. I think we are at a point now where we are going to see a significant change. Q491 Jim Dowd: Representing an inner London seat, as I do, even there the issue of car parking is important though the transport links to, say, Lewisham or King’s are very good. At Lewisham there was a period when it was free and it was being used by commuters from Kent to access Catford and then coming here. This is my point: if we remove charges how do you stop (a) that recurring or (b) all the spaces being consumed by staV? Dame Gill Morgan: Exactly, and that is why some of the charges have come in. What you would have to do is have some system for people who are recurrent. You could issue a pass when an outpatient invitation was sent. There are ways you can begin to think about handling it diVerently, but most people are not yet at the stage of thinking about that because they are not yet thinking, “What are we going to do to get the competitive advantage?”. Once that is on the agenda, as it already is for foundation trusts, I think you are going to see a massive change in car parking. Q492 Jim Dowd: So what you are saying is that if you just abandoned car parking charges and left it as a free-for-all that would have no administrative cost, whereas if you abandoned charges but still had a managed system that would just add to the overheads of the trust, would it not? Dame Gill Morgan: Indeed, but if it gives you a competitive advantage, and that is why I am linking it with patient choice and people choosing where to go, that is oVset by extra patients who will come to you, because knowing they have got guaranteed car parking when they come, and patients go to hospitals when they are ill, is going to be a massive competitive advantage for organisations, much more direct and understandable than any other clinical indicators that hospitals will present. It will be car parking right up there, I think. The other issue which I think is really interesting about car parking and why a lot of organisations have had to charge for car parking is that in a number of cities in particular there have been planning rules which have not allowed hospitals to build or to have suYcient

car parking spaces because of the impact on roads. I have even heard councillors say things like, “We cannot possibly have extra car parking spaces because it will encourage more people to travel to the hospital”, and I have sat on the other side of the desk saying, “Actually, we want people to come to the hospital when they need the treatment”. There is another side to this, which is that in many hospitals car parking places are in real shortage and a scarce amenity, which is why people are looking at oVplacing their staV and having park and ride schemes. There are now some interesting models of people who are thinking of new ways of putting in multistorey car parks which are actually very cheap in capital terms and very safe, but it would boost the car parking availability for patients, and I think we will see more drives to get those sorts of issues in, which will bring some conflict in terms of planning rules. Q493 Mr Amess: I think you have probably already answered the question, but obviously it is very tough on patients who have to go back regularly for treatment. Could you just articulate what the case is for a voucher system? Dame Gill Morgan: I am aware of hospitals where people going for chemotherapy or renal treatment have special car parks with barriers and they issue a card for people to come in so that you actually have the access for the treatment. I think again that that is a sort of interim stage between completely moving to a complex administrative system and charges, and people already do that sort of thing but it varies because every organisation will be in a diVerent context in the environment and therefore what you might want to do in an inner city area is going to be fundamentally diVerent from what you might want to do in a rural area. Q494 Mr Amess: In addition to the midwifery service apparently a dermatology clinic will soon be opened by Harrogate District NHS Foundation Trust. NHS patients will be able to pay the trust to remove moles and warts, to screen moles or—and I think this is very interesting—to have Botox injections to reduce heavy sweating. Perhaps the Labour leader would take advantage of that when he takes oV his jacket. Can you think of any extra nonclinical services that might be made available in hospitals in the future? Are we going to be sitting round having a se´ance? Dame Gill Morgan: That one I think is very simple. That is a private service providing the things that NHS patients no longer have access to because most organisations have reduced the availability of purely cosmetic therapy. What the hospital is doing is filling a niche and providing a competitive private service for patients who just want to come to the hospital. In terms of other things you might want to charge for, the sorts of things I think people might be interested in, if you assume that the NHS has to provide treatment and therapies that work and have been demonstrated to work, and this will be contentious and we will probably get more comments about this than the rest of the things I

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have said, you might want to say complementary therapies. There is no evidence for the majority of complementary therapies. Therefore you could very well see people oVering complementary therapies and charging for them within an NHS setting. The reality is that for things like cancer therapy, HIV care, a lot of those services already provide complementary therapy as part of an overall holistic package for people, and you could see that you might want to oVer that sort of thing. The other opportunity I think is around things like hotel type facilities. If you went to the private sector you would be oVered a wine list, a better menu. You could begin to see charges being raised in that sort of way, none of which would actually impact on the clinical care of other people. I think it would be very diYcult to oVer a wine list within an NHS hospital because of

the problems we have with alcohol but it is those sorts of extra things, you could say. In the States they call it jacuzzi competition because a lot of the hospitals compete by having en-suite jacuzzis which are better than the en-suite showers and you get into that sort of thing which people start to charge for, which are not clinical and they do not impact on the clinical care you get. That is the sort of area I think people will be looking at. Mr Amess: Thank you. That is very interesting. Chairman: I would like to thank you all and particularly you, Maggie, for answering our questions earlier and helping us in this inquiry, and hopefully in the next few months we will have an inquiry so that you can see if your evidence this morning has influenced us in any way. We will have to wait and see about these issues. Thank you.

Witnesses: Mr Bernie Hurn, Research and Strategy Manager, Simplyhealth Group Ltd (previously HSA Group), and Mr Michael Hall, Chief Executive, Standard Life, gave evidence. Q495 Chairman: Thank you very much for coming. Could I first of all apologise for the lateness of the hour. We were expecting to be into this third session a little earlier. For the record I wonder if you could give me your names and the organisations you are from. Mr Hurn: My name is Bernie Hurn. I am the Research and Strategy Manager for the Simplyhealth Group, formerly known as HSA. Mr Hall: My name is Mike Hall. I am the Chief Executive of Standard Life Healthcare and, just for the information of the Committee, you can probably tell from the lines on my forehead that I have had 30 years’ experience in healthcare, 12 of which were in the NHS and nine of which have been in the private hospital sector before moving to the insurance side. Q496 Chairman: Once again, thanks for coming along. I wonder if I could ask both of you what are the major problems that people experience with NHS charges and what proportion of the population is covered by insurance that helps them to access NHS provided services? Mr Hurn: It is a substantial proportion of the population, in the sense that today are represented here by private medical insurance, cash plans, complementary products and so on. About six and a half million people industry-wide are covered by cash plans and an even larger figure by private medical insurance. It is in excess of 10 million people today and Simplyhealth represent about two and a half million lives as a mutual organisation which in essence has a public concern in that regard. What we represent is predominantly blue collar workers and these people have issues in the cash flow impacts of charges on their monthly cash flow and what we provide is a tool for smoothing that out and enabling them to access NHS services and services surrounding that. Q497 Chairman: Mr Hall?

Mr Hall: As far as the private medical insurance market is concerned, there are just over 3.6 million subscribers to private medical insurance, but those 3.6 million cover a total of over 6.5 million lives, 6.57 million to be precise, which equates to about 11% of the total population. In terms of charges, my view is that because charges have been developed in a fairly piecemeal fashion over the course of the last 50 years I do not think they pass the test of fairness and equity. When I retire my understanding is that I will become entitled to free prescriptions. I do not think that passes that test. I would be more than happy to pay for my prescriptions if that meant that the money I am paying goes back into the NHS to pay for other people in a less privileged position than I. I think that fairness and equity test is diYcult now to prove. There is evidence to the contrary, and I think it is diYcult for people now to understand the range of charges that are now made because they themselves have not chosen to pay for those; they have been decided elsewhere. The success of our business is made up of providing services, obviously at a charge, that people want to buy and our evidence suggests that there is a willingness by people to pay charges. They may not necessarily be the ones that are currently charged for. Q498 Chairman: Would you, for instance, compensate somebody if they had prescription charges or glasses charges under your scheme? Mr Hall: We would not, no. Q499 Chairman: But you would, Mr Hurn? Mr Hurn: We do indeed, and that is 73% of what we pay out across the cash plan industry but, because we are also the largest representation within that group, we are indicative of the industry standard. About 73% of what we pay back is directly related to NHS charges, that is, dental, optical, hospital inpatient stay. The rest of that is made up in what we call POCAH, which is physiotherapy, osteopathy, chiropractic, acupuncture and homeopathy,

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something that the previous speakers alluded to. Those are services that people choose to access which they take responsibility for and we help them to access those services as well. What we look at is what the NHS provides, what the major impact of that is and also, being a mutual, we are driven by what our members need to create a format for access to the rest of those services. Q500 Chairman: Being a mutual, do you see trends in terms of the money that you are paying out for NHS charges? Are they reducing, are they increasing? Are there any diVerentials that you measure now when 10 years ago it was not like that? Mr Hurn: Cash plans pre-date the NHS and have been in existence since 1922, some of them since 1895, so the premise for paying charges has existed for a very long period of time. What we see is that as Government policy is changing and NHS behaviours are changing the needs of our members and their claims behaviour changes. I will give you a couple of examples. One is dentistry and another one is that, just over a year ago when the four hours in A&E targets were introduced and people were being admitted to the ward, we saw a corresponding increase in hospital inpatient stay. What we paid for traditionally was when people used to have loss of income but these days it covers not only loss of income but also a number of the other charges that have been spoken about—telephone charges, car parking charges, so we help to mitigate the impact of those costs. Q501 Chairman: Do you expect, with this concept of out-of-hospital care, to see changes in that way, that people will not be staying in hospital as long, or indeed may not even be going in in a few years’ time compared to five years ago? Mr Hurn: I think there is a diVerence there in that we pay for the event, not necessarily the location. We do have a hospital inpatient stay plan but we also have outpatients and day surgery, so whatever the location of that service is we will still pay for the event. We pay for what the member needs, so whenever the member accesses that within an NHS trust setting or at home or in a GP surgery, whatever the case may be in the future, we will still pay for those. EVectively what we will see is a change of location but not necessarily a huge change in behaviour. Mr Hall: My experience is that we have seen average length of stay in hospital change quite dramatically over the last decade or so from probably seven and a half to eight days, if we go back about 15 years, now down to about two and a half days and that is predicated by the growth in outpatient treatment and day case surgery. Q502 Chairman: Do you think that there is going to be any major change as far as your insuring the patient side is concerned in the future with the proposed changes that are about to take place? Mr Hall: Yes, I suspect so. Originally, because people were hospitalised for longer periods, there was an expectation that they wanted a private room

with an en suite because they knew they were going to be there for some time. Given the choice most of our customers would rather not spend any more time in any hospital than they absolutely need to, so being able to be treated quickly and eYciently with good outcomes, either on an outpatient basis or as a day case, is a preference. Q503 Chairman: In the medium to long term is that a threat to your business? Mr Hurn: No. Mr Hall: No, not at all. In fact, if anything, if the move is towards more cost eVective treatment in a more appropriate setting, then obviously the premiums we charge for access to that may be lower. Q504 Charlotte Atkins: Mr Hurn, we were looking at your evidence and obviously you say that payments should be aVordable to all. You recommend a broadening of charges or the establishment of an aVordable shared responsibility premise-based charge. I am not quite sure what that means. Can you extrapolate for me? Mr Hurn: If you put it in the context of what we do, we have people contributing to a fund of money and these are people who are employed and who tend to be blue collared workers. People have access to that fund on pre-agreed terms and therefore what they have access to they have full knowledge of and it is clear and easy to understand. This is not only driven by our values but also by the FSA, whereby we have to be fair and open to our customers, so therefore they know and realise the implications of them making a claim, not only as to what they are entitled to but also as to the impact on the rest of the group. They therefore have an understanding that there are not unlimited funds, that this is not open-ended, and an understanding of what they are entitled to as a form of responsibility to the rest of the group who are contributing to that. I do think that sometimes public perception of what the NHS entitles them to, of what the open-ended cost would be, is misguided, especially looking at future funding of the NHS and extra services being provided. It is not open-ended. There must be a realisation by people that there is only so much money that we can utilise in one way or another. I think it is part education but it is also part understanding of their behaviour that needs to be brought to people’s attention. Q505 Charlotte Atkins: So you would very much favour keeping NHS charges and not going to a fully funded system out of general taxation? Mr Hurn: We think there is an existing premise for NHS charges and, as I have said, charges pre-date the NHS, but I do think we ought to look at mitigating the impact of those charges because there are a number of people in society who do presently find themselves hugely impacted by charges because they are not on certain benefits but they are not top earners in society and therefore £189 for dentistry, for instance, can make a tremendous impact on them come the end of the month.

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Q506 Charlotte Atkins: Would you like to make a comment, Mr Hall? Mr Hall: The issue for us goes back to the customer or, in the case of the NHS, the patient. Our view is that we should conduct research amongst the customer base, the general public. We know from research we have done that the majority of a crosssection of people we researched, and that is the general public, not our customers, favoured charging as a means of accessing better quality healthcare. There is a strong vote in favour of paying charges. Only 25% of them thought that taxation was the best way to do it so more than double that believed that having control of paying charges themselves was a better solution. The issue is that no-one actually knows what the public would value in terms of charges, which services they would pay for and under what circumstances. Our view is that any charges should be tapered. To have a position where there is a very fine line between when you pay and when you do not pay does not seem equitable to us either, so our view is that it should be tapered according to their income and their situation. It should not just be that you pay 100% or you pay nothing. Q507 Mr Campbell: In the survey that you took of the general public, are we looking at a case of, “I am prepared to pay if I can get in quickly and get my operation before everybody else”? Mr Hall: It was not the question we asked them. Q508 Mr Campbell: Why did you not ask them that because that does happen when you are paying? If somebody asked me that I would say, “Yes, I will pay for it if I can get in quick”, because people have to wait a long time. Mr Hall: That may well be true, that that was the motivation for some people’s answers to would they contribute. Q509 Mr Campbell: I am sure it was. Mr Hall: But that is my point, I think, about asking them what services under what conditions they would pay for, and if a more timely service was something that people would contribute to, thus raising money within the NHS to pay for improved services for everyone, that would seem to me to be a fairly equitable way of distributing those contributions. Q510 Mr Campbell: What you are saying there though is that they who can pay get it done and they who cannot have to wait and hope they get the money out to get them there. Mr Hall: The question we asked them was how they would want the issue of increasing healthcare costs to be dealt with, so it was in the context of a recognition that the cost of healthcare generally was increasing. As I say, over half of them answered in the positive, that they would deal with the increased costs of healthcare by making personal contributions. It was the increased costs of healthcare per se rather than the issue of waiting times or waiting lists.

Q511 Jim Dowd: Let us clarify that. The truth of the matter is that we all pay for healthcare. The question is, by which route. Are you saying that survey was your policy holders or the general public? Mr Hall: The general public. Q512 Jim Dowd: Just so that I am perfectly clear about this, is it a variation on the theme that people actually value more things they pay for rather than things that they get, ostensibly, for nothing? Mr Hall: I think that is a truism in life generally. One of the issues that I believe exists is that there is no notion of value currently. Q513 Jim Dowd: Why? Because the service is free at the point of use? Mr Hall: Yes. That is not an argument to say it should not be; it is an argument to say that people should have the notion of value, so when we reimburse our customers’ costs, even though they do not pay, we do send them a copy of the bill so that they understand the value of the healthcare they have consumed. We have done separate research to try and ascertain the extent to which the public do understand the costs of healthcare, not just ours but in the NHS as well, and that would seem strongly to indicate that there is no notion of value. I think only about one in 10 of the people we surveyed had anywhere close to the cost in the NHS of doing a hip replacement, for example. Most of those other nine were woefully low in their estimation of the total resource cost of providing that service. I think that is a problem. It is a problem that we are consuming something that we have no good notion of value about. Q514 Dr Taylor: I was going to ask you what sorts of things the public would be prepared to pay for but you have said you cannot answer that. Is one of your ideas of the open public consultation you mention in your memorandum to get at just that, what people would be prepared to pay for? Mr Hall: Absolutely. We are a strong advocate for having a system by which the public can contribute themselves to the debate in saying, “These are the things I would value, these are the things I would pay for”. It must be a better system to have people contributing to the things that they think make a diVerence and that they would personally value rather than the current system, as I said before, which has been developed in a piecemeal way, which people do not understand and which lacks that element of equity. Q515 Dr Taylor: You mentioned that charges should be tapered. Would that be on a means tested method or how would that be? Mr Hall: I am not an expert in terms of how one would taper it but it does not seem logical to me that I could get free prescriptions and somebody else on a lower income, simply because they were not retired, could not. Likewise, it would not seem logical to me that somebody who was unemployed could get

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access to services at no charge, yet somebody on a low wage would have to pay the full charge rather than only part of the charge. Q516 Dr Taylor: This point has been made to us by many people. Health savings accounts: are these one of your ideas and, if so, could you tell us a little about them? Mr Hall: Yes. It is premised on a number of things. The first one is that we tend to have been a society fixated on delivering the results of ill health rather than focusing on the benefits of good health. I do not think we have a society where health and wellbeing play enough of a prominent role. I think it makes sense to find ways to incentivise people to take more responsibility for their own health and wellbeing, and that is easier said than done, of course. One of those ways, we are suggesting, could be through the notion of the health savings account, a tax eYcient way, in the same way that cash ISAs are a tax eYcient way of saving, that could be used in part or in whole to contribute either to the consumption of healthcare that is charged for or for other health related services that are deemed by the Department of Health or the Government to be beneficial to health and wellbeing. Whether that is gym membership, whether that is diet or other elements of exercise is not my area of expertise, but it is the notion of encouraging people to save and to spend from those tax eYcient savings in that way. We also considered the concept of a health incentive card. In the same way that commercial enterprises use cards for loyalty schemes why should it not be that you could earn points on, for example, buying fruit and vegetables? That would attract points, and maybe gym membership would attract points or other things deemed to be contributing to health and wellbeing could earn points that could be redeemed either in terms of the health savings account as a cash incentive to that account or in some other way. I think at the moment there is a complete lack of incentive to address the issue of health and wellbeing or saving against the costs of healthcare. Q517 Jim Dowd: Would you get your card taken oV you for going to McDonald’s? Mr Hall: No, but you would get points taken oV. Chairman: Thank you very much for that, Mr Hall. I am quite interested in that type of concept in terms of a potential lifestyle influence. Q518 Anne Milton: Mr Hall, the point you raise about people being unaware of the costs is very valid and the big bee in my bonnet is prescriptions, that if people were aware how much the tablets in the bottle cost (a) I think it would increase compliance because it would encourage people to finish the course and (b) they would be aware of the huge cost of some drugs that are prescribed. I wanted to ask you both about the White Paper and the use of the private and not-for-profit sectors and whether you feel that in the light of the White Paper and the mention of those things it is more or less likely that charges will start creeping in?

Mr Hall: I suspect that it is inescapable that, because of the demands on healthcare and the increasing costs of delivering healthcare, charging will be with us. At the moment my understanding is that current charges accrue at something like just over a billion pounds a year. That is obviously a significant sum of money and with the changing demographics of this country and the growing elderly population I think I am right in saying that in the next 25 years the number of people over 70 is going to increase by 70%. That is a fairly frightening statistic and that debate has already started in terms of pensions but is probably under-discussed publicly in terms of the impact on healthcare. I do believe that charging in some way, shape or form, which retains those elements of fairness and equity, will be with us in the long term. I think that is likely to increase rather than reduce, and therefore I think more innovative ways of identifying what should be charged for and having a mix of other companies, whether they be not-for-profit companies or commercial private sector companies making provisions in those areas, is a reality. Q519 Anne Milton: It makes it more likely? Mr Hall: Yes. Q520 Anne Milton: Mr Hurn? Mr Hurn: I would concur, that there is a likelihood of charges coming in and that we find at the moment that the NHS reforms have seen an increase in demand. The King’s Fund this morning said we are spending more money but we are not necessarily seeing a return on investment. People are going to increase demand and they have also got an increased expectation of what the NHS can deliver. Whether that is sustainable or not is probably not for this debate but poses the question then: if people want it but it is not available on the NHS would they be willing to pay for an extra service, an NHS-plus service? I do think, in view of foundation trusts having to generate an income, having to compete against practice-based commissioning, that there is a high likelihood of charges coming in. Q521 Anne Milton: So, on the premise that the demand for healthcare is infinite, which it probably is, with increasing expectations and decreasing tolerance the choices are stark. It is either increased general taxation to an infinite level—demand is infinite—or you charge? Mr Hall: That would absolutely be my opinion. It is not just the fact that everybody wants access, understandably, to the best quality healthcare but we are as consumers far better informed now on healthcare than we have probably ever been and the internet has been one of the main reasons for that. I know many doctors who find themselves presented with patients armed with printouts from the internet where they are sometimes better informed than the doctor in terms of what the latest drug or treatment is. We are seeing a huge change in that. I am sure you have probably already had evidence about some of the pharmaceutical developments and some of the new classes of drugs that are now starting to become

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available, of which Herseptin is just one. There are many more in the pipeline and if research shows that they are as eYcacious as Herseptin is that will present even more major challenges to the whole of this country. It is not just about the NHS but also in terms of the aVordability of those drugs and with a growing elderly population, and in that same time period I spoke about the 30–34 age group is going to shrink, then the balance of people paying tax to support those in retirement is going to change and that is why I think taxation alone becomes a solution that is in a cul-de-sac. Q522 Chairman: Both of you and other witnesses have criticised the current NHS charges. I think the opening shot was that the King’s Fund said they were a dog’s dinner in terms of how they are at the moment. You were asked earlier to tempt into areas where maybe charging should be expanded or be made more equitable and that leads on from what you have just said. Are there any areas where you would care to speculate on, say, what NHS charges would be like in 10 years’ time in healthcare on things that will have charges as opposed to what we know at the moment have charges? Mr Hall: I would not, actually, and the reason I would not is that I do not think I am a representative sample of the British public because of my knowledge. I would most heavily rely on undertaking that research and that debate on a much wider scale. If you fit the charges to things people are willing to pay for and would value that could take us anywhere, but if it is what people would be willing to pay for then I think that makes charging acceptable. It is really a question of how much additional resource our health services will need in the future, the willingness of people to pay for those, how they wish to pay for them and the amounts they are willing to pay. Until that research is done we will not know whether the equation balances out or whether we have a gap. Q523 Chairman: Mr Hurn, do you have a view on that? Mr Hurn: We do. It is diYcult speculating into the future and it is probably not our place to do so, but it probably comes to stating what a minimum level of treatment would be and then what sits beyond that that people would like to have as, again using the phrase, an NHS-plus service, in other words that then becomes chargeable and the state would underwrite for the catastrophe, for the inability to aVord, but people who can aVord would then proactively look at ways of being able to aVord that. This is not creating a two-tier system but a basic level of what is acceptable for everyone but the ability for people to step up should they want to and should they be able to aVord to. Q524 Jim Dowd: The truth is that in 10 years’ time the NHS charging regime will be logical, reasonable, rational and understandable because, of course, the big event between now and then will be the publication of the report of this Committee which will deal with it all. Can I just say to Mr Hall first,

how do you respond to the Government’s avowed intention to put the private healthcare business out of business and what impact would that have on your business? Mr Hall: The private healthcare business has been around longer than the NHS so I do not know how realistic it is to assume that we will be out of business, but if we ever do go out of business I do not believe it will be because of the Government; it will be because of our customers. Our customers keep us in business because we deliver products and services that they want to buy and that seems to me the way in which the western world works. You stay in business for as long as you have products and services which are valued by the people who purchase them. 11% of the population value the services that we oVer. We give people choice and people exercise that choice and they have done for the last 50-plus years. Q525 Jim Dowd: Regardless of the levels of performance in the National Health Service? Mr Hall: Absolutely. One of the strange things is that you cannot correlate the number of people covered by private medical insurance with the ups and downs of the NHS. I worked in the NHS in the 1970s when waiting lists were probably amongst the worst that they have ever been and that was during a period when private medical insurance saw the largest growth, not because of the waiting lists but because of the building of modern private facilities where people could get treatment. When those hospitals were completed the numbers stayed the same even when the waiting lists went down, and what we see at the moment are numbers covered by private medical insurance ever so slightly increasing, very marginally, I have to say, but at a time when we have seen the biggest decrease in waiting lists. I do not think it is possible to correlate one precisely with the other. In fact, they do not correlate. It really does come down to the perception of the public and the choices that they make. Q526 Jim Dowd: Would it be reasonable to assume that the profile of your policy holders is healthier than the average? Mr Hall: That is a very good question. If you look at the socio-economic split of people who have private medical insurance it is probably not what you would expect to see. 18% of the professional employers and managers group have private medical insurance. I think most people would probably believe that that was an awful lot higher than that. 14% of the selfemployed have private medical insurance and by and large the self-employed are sole traders or are maybe employing one or two other people. If you go to the unskilled, 6% of those are covered by private medical insurance, most normally through their employer. I would say probably, taking your average of the total population, that ours would be slightly healthier but probably not by as much as one would imagine.

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Q527 Jim Dowd: But that is not because of anything you do. It is just a simple fact. Finally, Mr Hurn, are HSA the same people who are the shirt sponsors of Blackburn Rovers Football Club? Mr Hurn: They used to be.

Mr Hurn: The normal growth in payouts across the industry when you look at our average claims ratio will sit somewhere between 75% and 85%. That means that most of the money that comes in goes back out—

Q528 Jim Dowd: I do not hold that against you, by the way. In the note that I have here it says that you paid out claims of approximately £166 million in 2004 and that figure was projected to rise by something over 20% to £200 million-plus in 2005. Is the normal rate of growth, above 20%? Mr Hurn: No. We have been through a period of mergers and acquisitions which has meant that the group has grown.

Q530 Jim Dowd: No, I am talking about the annual change. Mr Hurn: That would be about 6%. Chairman: Simplyhealth Group Ltd does not ring a bell with me but I think HSA does and I and my wife may be covered by one of your policies. I declare that right at the end. Can I say to both of you thanks very much indeed for coming along and answering our questions. It has been a very interesting session once again this morning. All three of the sessions have been very interesting and hopefully it is going to help us to come to some conclusions on this matter.

Q529 Jim Dowd: So that is exceptional? What would be the normal growth in payouts?

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Mr Ronnie Campbell Dr Howard Stoate Dr Richard Taylor

Witnesses: Mr Sean Williams, Board Member and Partner for Competition, and Mr David Stewart, Director of Investigations, Ofcom, gave evidence. Q531 Chairman: Good morning. May I welcome you to the fourth evidence session we are taking in relation to our inquiry into the National Health Service charges. I wonder if I could ask you to introduce yourselves for the record and tell us the positions that you hold. Mr Williams: Thank you very much, Chairman. I am Sean Williams. I am a Board Director of Ofcom. I am also responsible for the competition group in Ofcom, which is where we enforce competition law in the communications markets. I have with me today my colleague David Stewart, who can introduce himself. Mr Stewart: My name is David Stewart, I am Ofcom’s Director of Investigations, which means that I am responsible for our Competition Law Enforcement Team which conducts investigations and reaches conclusions on those Q532 Chairman: Thank you very much, again, for coming. There are no surprises as to why you are here, of course. I would just like to ask you if you could describe your concerns about the lawfulness of the contractual arrangements made between the NHS Trusts and the providers of telecommunication services to patients. We have obviously seen your letter to the Secretary of State and understand that you are hoping they are going to take some action. Could you tell us your views on this? Mr Williams: Yes, indeed. As I say, Ofcom is the competition authority in communications markets. We became aware of the consumer concerns about high charges for calls to hospital patients. We opened an investigation under competition law to see whether or not the high charges were the result of anti-competitive behaviour in breach of competition law. We found in our investigation that they were not a breach of competition law, and that the high prices which we remain concerned about were the result of the arrangements put in place by various bodies in the Government and the NHS. In particular they arise, I think, from a combination of matters of Government policy, matters related to the implementation of that policy by the NHS estates, and by the particular concession agreements and their terms which the providers have agreed with particular NHS Trusts. While we remain concerned about the high prices, our view is that it is a matter for the Government to take into consideration and is not a matter of breach of competition law in any way. Following our investigation the Government

has set up a Patient Power Review Group to work with providers to provide a better solution and hopefully to address these particular problems. Q533 Chairman: Would it be fair to say that you thought it was unfair in the sense that patients’ friends and relatives should be subsidising this system? Mr Williams: I would say that we remain concerned about the high prices. We think the high prices are, as I say, a result of the way the contracts and the arrangements are structured. The concession agreements and the overall framework agreement cap the charges for various services, so it is really a matter for the Department, the NHS and the providers to work out the fairest way to recover these costs, I think. Q534 Chairman: Nowadays an enormous number of people use mobile phones. There are some allegations made that pressure has been put onto NHS Trusts to maintain a mobile phone ban within their establishments. Would we get rid of this problem if that sort of ban were lifted? Mr Williams: I will bring my colleague on this one, but, in general terms, our findings were that there was nothing in the agreements as such which prevented in an inappropriate way the use of mobile phones. But it is a bit more complicated than that. Mr Stewart: The agreements between NHS Trusts and the providers reflect a general requirement in the model agreement, which is that there be a provision saying that the hospitals, to the extent that there are good clinical reasons to do so, will restrict the use of mobile phones. That is not a blanket ban on the use of mobile phones in hospitals, and, amongst other things, we looked at the way in which in a number of cases that provision had been given eVect in practice. One of the things that is clear to us is that it is not a simple or straightforward issue: there are clearly some very important clinical reasons related not only to the need to give patients time undisturbed during their care but also, more recently, with the development of camera phones, some issues around patient privacy. There are some good reasons why hospitals should have and do have the right to restrict the use of mobile technology and we have suggested that one of the roles the Department might play is helping the NHS Trusts to understand their rights and responsibilities so that an eVective balance can be struck. Chairman: Thank you for that.

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Q535 Mr Amess: Gentlemen, I might look as if I am in splendid isolation on this side this morning, but I am very much with you. Is that an Australian accent? Mr Stewart: It is. Mr Amess: Okay. Chairman: That one was not in my brief! Carry on, anyway. Q536 Mr Amess: Gentlemen, it seems to the Committee that the fact that you are having the review is pointing directly towards National Health Service incompetence. I wonder if you could answer that charge. The other thing I wanted to put to you is this: In your report you blamed high incoming call prices on “a complex web of Government policy”. That is a marvellous expression. Could you also enlarge on this complex web of Government policy? Mr Williams: The complex web really has three kinds of component. The first level is Government policy, the Patient Power Programme and the aspiration in Government policy to roll out bedside communications on a national basis to all bedsides. There is then the second level, which is the NHS Trust licence, national licenses or framework agreements, which then implement that intention by means of a framework agreement that specifies the kinds of services, the functionality of these beside communications units, the prices that have to be observed or the caps on the prices that have to be observed. The third level is the specific concession agreements or contracts that the providers have agreed with particular NHS Trusts which then specify further how the particular charges for the actual services are going to be levied. It is in the interplay between those three levels of these arrangements that the result is manifest, which appears to us to be high call prices, particularly for incoming calls, which, in a sense, are necessary for the providers in order to recover the costs of these rather sophisticated units which they put in at bedsides. That is, in a sense, what the complexity is all about. I do not think we are in a position to judge whether or not it is a good implementation of a good or bad policy intention—that really is a matter for the Government—but I think it is worth the providers and the Government getting together to work out whether or not this is the most appropriate way to recover the cost of these services. Mr Stewart: I would add to that. I think it is perhaps useful to clarify that our role is as a national competition authority, and one of the things that is axiomatic in looking at someone’s conduct—in this case that of the providers—under competition law, is that the conduct that is under investigation is conduct that is unilateral conduct or something for which, in eVect, they can be held accountable. Once you reach the point where it is clear that is not the case, there are a number of other factors; in particular, when those factors involve Government policy, then the responsibility of the national competition authority is to stand back from using what in those circumstances is the rather blunt instrument of competition law and hand the issue of how the various interests are meant to be traded oV

back to the Government and back to the Department. I certainly would not agree with the assessment that we have in any way been involved in making an assessment, as Sean says, about the policy or how it has been implemented. That is certainly not the way we see our remit. Q537 Mr Amess: Thank you for rebutting that. I did say I would ask two questions, but, as we have a little bit of time, let us go for a third—and you are Australian: Has Ofcom identified funding arrangements in other countries for these types of systems that avoid high incoming-call charges? If so, could you help the Committee and tell us where these examples are? Mr Williams: At a high level we are aware that there are alternative bases for recovering the costs of the investment necessarily to roll out bedside communications units. I do not know whether my colleague has any further information on that. Mr Stewart: The biggest single diVerence is between those countries where hospitals decide to undertake the capital cost directly—and therefore are not simply recovering the capital cost of these systems purely on a particular group of users, in the way that applies in the UK. We know from evidence which we gathered in our investigation of a number of countries where that is the case— Q538 Mr Amess: Where are these countries? Mr Stewart: Holland and the US, for example, both have systems that are funded, as I understand it, on that basis. Q539 Mr Amess: Are they good examples to apply to England? Mr Stewart: In a sense, it is a financial trade-oV. Do you make an investment directly using public funds and secure a benefit that can then be managed along with all of the other assets in the hospital? Q540 Mr Amess: I just wondered. Holland is a tiny little country and we are tiny with a huge population. America has a state system. I am trying to think how you would apply those two examples. Mr Williams: I think it is just a matter of Government policy. You can take a view that the cost of these services, which are to provide facilities for patients, should be recovered through a commercial payment by patients or not. To be honest, it is not a matter for Ofcom to take a judgment on that. Mr Stewart: To answer the question behind your question: I am not sure what the situation is in Australia. Q541 Dr Taylor: I would like to go on a little bit longer because I too was intrigued by the complex web. I think really we are discovering that the Government ordered a Rolls Royce with absolutely every extra, when there was no way all those extras could be used. If you are having the electronic patient record available, when it is not available (because the NHS computer system is so far behind schedule), they have made Trusts buy a system that

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cannot possibly be used. Is that not right? As we put it to Patientline last week, their message at the beginning of the phone call should have said, “Thank you very much for using this service. It is going to cost you 49p but you are helping the NHS towards its aim of having readily available electronic patient records at the bedside” and Patientline agreed. Are we not within our right to condemn the Department of Health for ordering something as complex as we have which could not be used? Mr Williams: I think it is not for Ofcom to make a judgment about the state of the system. We could say that it is clear to us that it is a highly specified system and that it is costly to install and that the consequence of the costs and the fact that all those costs have to be recovered through charges is that consumers will pay higher prices. Q542 Dr Taylor: Right. I would like just to get a bit of detail. We believe that Chelsea and Westminster are using some of the capability. Can you give us detail? Are they using all the capability? Mr Stewart: We are aware of a few cases where there are services being used by hospitals rather than endusers. We did not look in huge detail at this question, but our understanding is that that relates to issues like gathering orders for patients’ food and other distribution of information of that kind. I am happy to come back to the Committee with details, but the other point to make, I guess, is that that is a question you might put to them. Q543 Dr Taylor: You would not know about any other hospitals that are using the service a bit more fully. Mr Stewart: It is certainly not widespread. There are a number of instances where it is going on, but it is certainly a handful of hospitals. Mr Williams: Again, I think it is really for the providers and the Department to answer that. Q544 Dr Taylor: Would you know if the capability would be there to order pathological investigations, x-rays on the system? Mr Williams: I think you would need to ask the other providers in the Department. Q545 Dr Taylor: Right. Could you see the telecom system in hospitals developing further? In what way would you think it is possible for it to go further— or is this, for the moment, the ultimate if it were fully used? Mr Williams: I think it is something that the Patient Power Review Group will have to work through because there is now a considerable investment in bedside communications. They therefore have an established position and it will be for the providers and the Department to work out how they can best be used and what further functionality and developments there could be. Q546 Dr Taylor: This review group has been constituted already, has it?

Mr Williams: That is my understanding. Mr Stewart: That is right. Q547 Dr Taylor: By the Department of Health. Mr Stewart: That is right, and I believe it is due to report in June this year. Dr Taylor: Thank you. Q548 Chairman: Mr Williams, you said it is really not for you to comment, and I accept that to some extent. Your report was quite hard-hitting. I am looking at the letter you sent to the Secretary of State, in which you said, “Currently there is no skip facility enabling repeat callers having to hear the same message each time they call. This further raises the cost of each call.” That is pretty tough stuV. People reading that will think only one thing: that they are getting ripped oV. In the message that Richard just read out, they do not have to listen to that or pay to listen to it for more than one occasion. Would you not say that is right? Mr Williams: We have remitted to the Department to consider whether or not a skip facility should be instituted in order to skip that message. Q549 Chairman: Technically there is no problem with that. Mr Stewart: That is right and we welcome the commitment on all sides to discuss that issue. We have pushed in our discussions with them that it be on the agenda, so we are very pleased that it is. Chairman: Okay. Q550 Charlotte Atkins: You have not really found any wrongdoing, as such. How worthwhile was your investigation? Mr Williams: We have our own statutory duties to look after the interests of citizens and consumers in the communications markets. It was clearly a matter of public concern that these call prices should be so high. It was clearly, therefore, appropriate for us to look into the matter and I think it was an investigation that was definitely worthwhile. We invested a certain amount of resource, not untypical of such investigations. In this particular instance we found that it was not a matter of the application for competition law but a matter of Government policy. It might have turned out otherwise. It is often the case that we open investigations into matters of concern and at the outset we do not know what the outcome is going to be. Q551 Charlotte Atkins: Any investigation that you do will obviously preclude you doing other investigations if you have limited resources. We have heard from the NHS Confederation that these units are very popular with patients. Mr Williams: Yes, indeed. I think we would endorse the view that they provide valued services to patients. All I would say is that I do not think we have not done something else in our investigations programme because we have done this. Within the discretion we have over what things we should

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investigate and should not, I think we are of the view that we have investigated all those things that we should have done and this was one of them. Mr Stewart: You are right, of course, to observe that we do have limited resources, but, as Sean said, you do not know when you begin an investigation quite where that might lead. You do know that there is an issue of consumer concern and that you have a responsibility to choose from amongst the issues of consumer concern that you see which issues you need to explore further. Having crossed that first hurdle—in other words, having realised that there was a reason to suspect an issue of competition law in this case—we then investigated that, but we did so in a way which I think reflects the fact that, as soon as we were able to reach a conclusion that this was not one to take further forward, the right thing for us to do was to package up those findings and hand those issues back to the Department and back to the providers to see if they could come up with some data solutions. So we have not carried forward the investigation past the point when it was apparent that that was the best way forward, and I think we are satisfied that that means that the investment of resources has been that which is necessary eVectively to discharge our duties and hopefully make some contribution to a way forward but not an overinvestment. I think the most telling outcome really is that, as a consequence of our investigation, there is now a Patient Power Review Group that will be looking at these issues. Q552 Charlotte Atkins: The main issue that comes out of your investigation is the huge cost of incoming calls to patients. Would you see that as one of the areas which the NHS should be looking at most acutely? Mr Stewart: Yes. Q553 Charlotte Atkins: This tax on friends and relatives having to pay for this extraordinarily expensive system.

Mr Williams: It is certainly the case that the issue about the balance of charges between the diVerent users is something that the review group should look at. Q554 Charlotte Atkins: Especially, presumably, as when people are calling in they do not get the shock of the overall cost until they get their telephone bill. Mr Stewart: Q555 Charlotte Atkins: Whereas the patient presumably pays upfront for the use of those calls. Mr Stewart: That is certainly a common theme running through the complaints that have been made to Ofcom. Q556 Charlotte Atkins: And you have made recommendations to the NHS that something should be done about the fact that, very often, despite the message—which presumably people do not listen to very carefully—they are not aware they are going to be charged so hugely for a call to a friend or relative in hospital. Mr Williams: In a sense, our letter to the Secretary of State is our suggestion that they should look at exactly those kinds of issues. Charlotte Atkins: Thank you. Q557 Chairman: Could I thank you both very much indeed for coming along and helping us with our inquiry. I have no doubt that we will be reporting on this in due course—hopefully it will not too long anyway. Mr Williams: Thank you very much, Chairman, for the invitation to come along and help you. We are very happy to help. Q558 Chairman: Hopefully your investigation is going to be helpful in the next few months. Mr Williams: We hope so too.

Witnesses: Rt Hon Jane Kennedy, a Member of the House, Minster of State for Quality and Patient Safety, Ms Rosie Winterton, a Member of the House, Minister of State for Health Services, Dr Felicity Harvey, Head of Medicines, Pharmacy and Industry Group, and Mr Ben Dyson, Head of Dental and Ophthalmic Services, Department of Health, gave evidence. Q559 Chairman: I was going to say welcome back— I think three of you have been in front of us just a few weeks ago—but good morning anyway. I wonder if I could just ask you to introduce yourselves for the record, please. Mr Dyson: I am Ben Dyson. I am Head of Dental and Ophthalmic Services at the Department of Health. Ms Winterton: Rosie Winterton, Minister of State at the Department of Health. Jane Kennedy: Jane Kennedy, Minster of State, Department of Health. Dr Harvey: Felicity Harvey, Head of Medicines, Pharmacy and Industry Group within the Department of Health.

Q560 Chairman: Thank you very much. Welcome to the fourth session of our investigation into NHS charges. You have probably heard this quote on many occasions before. Lord Lipsey, the Social Market Foundation described NHS charges as a “dog’s dinner lacking any basis in fairness or logic”. One of the areas, of course, is the issue that the prescription charges exemptions have not been properly reviewed since 1968. The oYcials told us when they came in that this was for historical reasons, as it were. Does historical inertia justify maintaining a system that is unfair and clearly is not working? Many witnesses have told us that in the last few weeks.

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Jane Kennedy: For the avoidance of any doubt on this, we are very firmly of the view that charges and prescription charges are a valuable and legitimate source of revenue for the National Health Service. We have sought to develop a system in which those people who can aVord to pay are required to contribute, but those people who cannot aVord to pay are exempt—and many other people in fact who could aVord to pay are also exempt. We know the way in which prescription charges have arisen—and you will have heard a lot of evidence about that— and they are part and parcel of the way in which we manage the health service and they are a valuable source of resources. Probably the areas of exemption and the changes that we have been making to the low-income scheme and to the prepayment certificate scheme have been areas in which we have been able to help people on the margins. Chairman: You will look into that a little bit further. Q561 Dr Stoate: As a brief supplementary on that, Minister you said that you felt he principle was right that people who could aVord to pay should be made to pay—and I do not entirely disagree with that principle—but if that is the case why do they not simply remove the mildly illogical exemptions for people, for example, with under-active thyroid compared with those with an over-active thyroid, or exemptions for people who need oral medication for their diabetes as compared with people who do not need oral medication for their diabetes? If you simply want to base it on ability to pay, why have any exemptions at all for those rather arcane conditions, which do not bear much relationship to modern medicine? Jane Kennedy: Because to abolish exemptions would have cost implications. If we were to have a diVerent set of exemptions, there would be some conditions that we may determine were not suitable to be exempt. Q562 Dr Stoate: Why have exemptions at all? Why not simply reduce the cost, say, to a fiver and remove all the exemptions? At least it would be a level playing field for all medical conditions. I am not saying you should do that but what is wrong with that? Jane Kennedy: We reviewed prescription charges through the CSR 1998. We looked at the prescription charging system and, having looked at it, decided that we would not make changes to it. We were not the first government to have done that: since they were introduced, they have been looked at many times, and on each occasion it has been concluded that, whilst there are anomalies in the system—and we accept that—the system we have is probably best left as it is. There will always be groups of patients who feel that their condition should be exempt. I hear the point you are making, but every time we do that there is a cost implication. Q563 Dr Stoate: Minister, you said that it is your view that things should be left alone. You are probably fairly unique in thinking that, because all the witnesses we have heard from, either orally or in

writing, feel the system should not be left alone. If you are saying that it should be, I have to say that you are in the minority with that view. Jane Kennedy: Yes. Probably. I have found the preparation for this inquiry, and the requirement, as you do prepare, to look at the system, very useful. We will look at the recommendations the Select Committee brings forward and we will consider those carefully, but I get representations from patients with a whole range of diVerent conditions who believe they should be exempt from prescription charges, and if you took that route you would eVectively abolish prescription charges. Dr Stoate: I appreciate that. Q564 Chairman: On that, Minister, we had a witness last week, a young adult now, who is a cystic fibrosis suVerer. Twenty-five years ago, when the list was drawn up about long-term conditions, it would have been the case that people with cystic fibrosis would not have survived childhood and consequently there would never have been a question of them having to pay what are multiple prescription costs for their particular condition. It seems completely unfair that that particular case has not been reviewed. It seems that a system that cannot review that—because medical science is moving on—has something wrong with it. But you think it is best left alone. Jane Kennedy: If we were to review it and look at the medical exemptions—but if we were to do it from the point of view of staying cost neutral overall—as I say, you would have to take some conditions out and put others in, and we have taken the view from the outset, when we first reviewed it, that actually the contribution that prescription charges makes to the health service is a valuable one. We have other priorities that we would rather spend the resource on than giving relief in particular cases like this. Q565 Dr Stoate: But even were it cost neutral, you could still come up with a system that was considered to be fairer. The suggestion I have made, for example, of reducing the overall prescription charge for each item but removing some of the exemptions, would be cost neutral, but at least it would be a more level playing field if we are really trying to stick to the principle that those who can aVord to pay should pay. At the moment, that is not the case. Jane Kennedy: It will be interesting to see what your formula is, Dr Stoate. We will have a look at that. Q566 Mr Burstow: Could I pick up on this issue of reviews. With the current scheme of exemptions, 1968, various written answers that I have seen on this refer back to the CSR as being one of the reviews that took place. When the Committee took evidence from oYcials a few weeks ago, we were rather given the impression that there had not been a major, if you like, root and branch examination of the scheme at all. Can you tell me a little bit more about how thorough the examination of the scheme was when the CSR review took place?

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Jane Kennedy: I cannot go into detail but it was a serious examination of the scheme. It was determined that, if we were to begin, for example, to review the list of medical exemptions, you would generate as many losers as winners. Ms Winterton: I can add to that. During the evidence it was said that ministers had looked at it, and I did used to have responsibility for this area. I think, frankly, that every minister who comes in then gets the postbags of letters from people saying why can this condition, that condition, the other condition not be added to it? Because medical science has changed, and, as you said, Chairman, people with cystic fibrosis are living longer, and there are other conditions, some cancer conditions, that are almost long-term conditions now as opposed to killers. It is something that I think ministers look at. As Jane Kennedy has said, one of the issues is that within that there will always be losers. People who have had an expectation, and perhaps for 20 or 30 years have received medication, if all the exemptions were removed would lose that. That is obviously something that I am sure the Committee would want to consider. Q567 Mr Burstow: Just to be clear, it is one thing to have a look at; it is another thing to issue instructions to oYcials to come up with workable options along the lines that Dr Stoate has put forward that will enable you to make a judgment as to whether or not there are better ways of achieving your objectives than the current 1968 exemption scheme. Have you done that, and had specific options looked at and costed? Ms Winterton: That was, I believe, the 1998 review. Jane Kennedy: As I have said, there are anomalies in the current system, but it was diYcult to make a case for removing exemption from one group of patients (however we do it) and extending it to another group. Q568 Chairman: What about when somebody has a long-term condition which they are given a free prescription for, but then something else in their health crops up—which it could potentially in all of us—and they get a free prescription for that which is nothing to do with their long-term condition? It is hardly fair, is it? Jane Kennedy: As I have said, there are anomalies and it is not the perfect system. I mean, 87% of prescriptions are exempt from charges and that has increased since 1997. The cost of prescriptions has been increasing by 10p a year since 1997, and, therefore, in comparison to inflation, the increases have been much lower than inflation. The numbers of people who are helped by the low-income scheme and who now use the prepayment certificate approach are increasing—or, rather, the numbers being helped by the low-income scheme are not, but we believe they are being exempted by other means. We have been seeking to improve the current system without going through the wholesale root and branch review that members of the Committee

clearly think it requires, because we believe that by doing that we will create as much upset and disquiet as we would satisfy. Chairman: That leads very well into our visit last week to a devolved assembly and what they are doing and the wonders of having devolved powers in the United Kingdom now. Richard. Q569 Dr Taylor: Thank you very much. We really heard exactly the same argument from the people in CardiV leading to the diametrically opposite conclusion. Because they told us that any review would simply lead to a diVerent set of anomalies and complications—which is really exactly what you have said—but from that they took the jump and said the only fair thing to do is to abolish the charges, which they are working on at the moment. Obviously it is going to cost them less, but, proportionately, we worked it out and it is about the same—so their proportion is about the same as the £450 million in England. It is very, very hard, I think, to argue it your way round. You are attacking it at the margin: prepayment certificates, the low-income scheme. Do you not really think the only fair thing is to abolish and then work desperately on how we can make the £450 million with a diVerent route? Jane Kennedy: Frankly, no, because we have higher priorities for the health budget. That is the answer. Q570 Dr Taylor: Absolutely. Jane Kennedy: In the end, both the Welsh Assembly and we have come to similar conclusions, if you like, in terms of the evidence that we have been giving to you, but we have taken diVerent decisions as a result of that. It is a question of how you prioritise and that is why the Welsh Assembly have made that decision. Q571 Dr Taylor: Another really dramatic suggestion they were looking at in Wales was getting a Welsh national formulary. We have the British National Formulary at the moment which is absolutely superb, but what we need and what they were looking at in Wales is a sort of breakdown of that into the drugs that the NHS would pay for— probably leaving out some of the ones that it would not, because there were perfectly eVective alternatives. Could you see anything like that happening here, a review to produce a national formulary of the drugs that would be aVorded by the NHS? Jane Kennedy: As Rosie says, the National Institute for Health and Clinical Excellence performs that role for new medicines and for treatments. You are saying that we should look at the way that the national formulary works and use that. It would be interesting. I want to think about it. Q572 Dr Taylor: NICE is superb, as fast as it can go on new medicines, but really I am looking at everything that is in the BNF. Should there be a limitation on some of those, for which there are alternatives that are perhaps cheaper? Jane Kennedy: I do not know if Felicity has a view on that.

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Dr Harvey: I think the BNF includes all licensed drugs. Q573 Dr Taylor: Absolutely. Dr Harvey: In terms of paying for licensed drugs, a doctor, as you well know, can prescribe any licensed drug and, indeed, any unlicensed drug. In fact, as soon as a new drug comes on the market and has been licensed, then they can be prescribed. There is no wait for reimbursement agreements, because that happens automatically through the PPRS. Q574 Dr Taylor: I am getting at an examination of this very basic right of a doctor to prescribe absolutely anything that is in the BNF regardless of price if there is a cheaper alternative. Dr Harvey: I think that has always been a matter of clinical freedom based on the clinician’s decision as to what medication is required for a particular patient. Q575 Dr Taylor: Have we not got to the point, because the financial problems are so intense in so many places, where this form of health care rationing has to be considered?—however politically dangerous it is. Jane Kennedy: I want to give some thought to what you are saying. It would be quite a major step. Q576 Dr Taylor: I know. Jane Kennedy: It would be interesting to see if the Welsh Assembly finally does take that step. I would be reluctant to consider such a step at this stage, but I want to think about what the Committee has got to say. Dr Taylor: Thank you. Q577 Mr Burstow: Before I come on to my question, with reference to the 1998 review it would be very helpful if we could possibly have a note which sets out the options that were considered; the costings, if any, that were done; and the conclusions that were reached. We know the main conclusion—the conclusion was not to change it—but it would be very helpful., if possible to have a note on that. Is that okay? Jane Kennedy: Yes. Q578 Mr Burstow: Thank you. We have been exploring this and in the opening statement from Jane Kennedy we have had some sense of it, but what is the point of health charges? What criteria guide the Government’s policy? We have heard raising revenue is seen as a good purpose. Is that one of the reasons? We have heard it is. Is it also, though, to limit demand for services? Ms Winterton: Could I come in here, Chairman? Going back to your previous quote from Lord Lipsey, I have to say that the system we had of dental charges, for example, was extremely complicated for dentists and for patients: 400 diVerent items of service. In the reforms, we have tried to take that down to a much simpler system, but, of course, in undertaking that review, obviously the questions arose as to whether you should have any system of

charging at all. Certainly, in the dental field, since 1951 there have always been charges for dental work. We wanted to see a system that was much simpler. As I say, if you say, “Should we have this system at all?” you do then have to look at the revenue implications of taking that away, which in the dental service would be about £600 million. Again, as Jane Kennedy has said, when you are reviewing this, those are the kinds of issues you go back to. During the course of the review of dental charges, we did say, “Well, this is something which has existed for a long time”—and I think successive governments, frankly, have looked at and decided it is, in a sense, inbuilt now in these areas. There might be all kinds of reasons why you would consider taking it away, but you would then have to look at the revenue coming from elsewhere, so, overall, I suppose one would go back to the original 1951 decision to introduce it. Once you have got there, then the considerations that govern changing the system obviously come into play, and some of those are the amount of revenue that is collected from that. Q579 Mr Burstow: To summarise, the reason we are doing it is because we have always done it that way. Ms Winterton: If you are looking at it and you are reviewing it, as we did with the dental charges—and of course it crosses your mind: Do you reverse what has been happening for 50 years?—you have to be realistic and say, “This is something that has gone on for 50 years. People to a certain extent do accept it.” And if you look at comparisons with other countries, I think we spend more in public money on dentistry than any other of a comparable nature. You have to say, given all those circumstances, given the history, in particular, of dentistry and charging, do you want to take it away and find the money from elsewhere? Q580 Mr Burstow: Just to expand it beyond dentistry, is that the rationalisation of the position that would apply to all of the health care charges that we currently have within the NHS? Ms Winterton: There are those considerations, yes. I think there are those considerations that if this has been something that, as I have said, successive governments have looked at, I am sure— Jane Kennedy: But there are other charges which you face. If you go to hospital, to park your car you very often, these days, pay a car-parking fee. These are valuable sources of revenue—but they are not just a valuable source of revenue: they also help hospitals manage space, which is at a premium, around the hospital; they help them manage the flows of traYc—and I think it is perfectly legitimate way in which— Q581 Mr Burstow: We are coming on to car-park charges a bit later, so I am not going to trample on that ground, but I do want to ask one other question. It is this: If we did start with a blank piece of paper and the question was being asked: “We have to raise one billion pounds of revenue from the operations of the NHS, and currently we are trying to raise that through charging people with life-threatening

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conditions, by charging for access to their medicines and, in some cases, for their dentistry, would it be appropriate to consider switching, for example, a much greater emphasis on to the hotel cost sides of the NHS (the cost of being accommodated, the costs of, as we are seeing increasingly, the introduction of the telephone service)?” the provision of those sorts of services is nothing to do with the direct treatment and health of the individual but is the hotel and accommodation costs, is that not a more legitimate area to look into to raise revenue, rather than directly on the provision of health care? Jane Kennedy: Certainly if you were comparing it to prescription charges, I do not necessarily agree with that. If you have to go into hospital and you have to go into hospital for treatment, I do not think you should be charged for the care that you receive and the hospital services that you receive. I think if there are enhancements, that is perhaps a diVerent matter—and we will come on to talk about the telephone services and the TV services that are provided—but I think it is important to remember on the prescription charging scheme, for example, if we are dealing with that, that the payment for that is income based. And, whilst there are anomalies in the scheme, those people who cannot aVord to pay or who are on the margins of aVordability are exempt from payment and they are not prevented from getting access to their medicines. It is only those people who are in a position to be able to pay who we ask to contribute to the cost—and they do not pay the full cost: the prescription charge is a contribution to the cost of the medicine. Ms Winterton: I think it is a balance between ensuring that the people who might be deterred because of the cost are protected. Certainly the evidence in the dental field (what people say and surveys that have been carried out) it is not charging which prevents people going to a dentist. I think it is about getting that balance right, between saying that if there is a contribution that is going to be made, let us make sure that we protect the people who might be deterred from going by things such as the lowincome scheme or in certain instances in introducing these prepayment certificates. Q582 Mr Burstow: I think Howard is going to ask some more about that in a minute. I just want to end with this issue of dentistry one more time, and particularly the question of the provision of dentures, which is something that I raised with the minister at the session we had with you back in January. It is this concern we have had put to us both by Citizens Advice and Age Concern, that, for as many as 45% of older people who have no natural teeth, the issue of having access to dentures is very important to them in terms of their health and welfare. At the moment, with the new scheme, there is an increase in the amount that an individual will have to pay for replacing dentures that are needing replacement simply because of wear and tear which is higher than in the situation where someone has lost their dentures, where they are only going to have to pay 30% of the new highest rate. If they got to the point where they are no longer any good through

wear and tear, they are seeing an increase from about £100 to £189, so that is directly increasing the cost, potentially increasing the incentive either to carry on using very inadequate and unsatisfactory worn out dentures or not to have anything at all. Ms Winterton: I think there are a number of issues here. I am not sure of the actual figures of people who have no teeth at all. Q583 Mr Burstow: The figure we have had supplied as evidence is up to 45% of older adults. Ms Winterton: I would look at whether that is people who actually have no teeth. I understood that the figures for people who have no teeth is relatively small and that it is more likely that dentures are for partial dentures, in which case you look at the figure in the higher band, band 3, of £189. Within that band would be included not only preventative health advice but looking at the other teeth, checking up any fillings, any other work that needed to be done, so the whole course of treatment including replacement dentures, would be included in that. That is a cut, from £384, which was the maximum you could pay previously, down to £189. The reason we made that top band much cheaper than it had been before—and Age Concern were particularly pleased that we made that change—was because older people do tend to require more treatment and they do tend to be at the higher end of the payment spectrum—as is the case, as well, with people on lower incomes. We had to strike that balance. Within the system that we have established, there will be some winners and losers, but, overall—and I think that is why the scheme has been welcomed by groups representing older people—we have been able to lower that higher price. Also, referring to your point about the 30%, there is actually no diVerence in the current system. I know we have had this exchange before, but, eVectively, if somebody loses their dentures, there is a decision made that it is probably through no fault of their own—one would hope that people do not go around throwing their dentures in a fit of pique or something—and they only have to pay 30% of the replacement costs. We can have arguments about whether that is the right thing or the wrong thing, but it is an attempt, I think, to be fair in the assumption that people are not being careless with them or just being irresponsible. It is a judgment. But we have kept the system as it is at the moment, because some people would think it was rather mean to have taken it away. Q584 Dr Stoate: I would like to explore some alternative ways to raise revenue from the NHS. Jane, you mentioned that you were not in favour at all of hotel charges for hospital patients—and I have to say I entirely agree with that. As I understand it you are not having any plans to introduce hotel charges. But, as a GP, if I have an elderly person recovering from a chest infection and I have decided that person can no longer manage in the community and really needs some sort of residential care, if I send that person into hospital they do not pay anything at all; if I send that person into a respite home or social services care home they may well

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have to pay for that care. What is the logic in saying to that elderly person, “If I get you into the geriatric unit down the road it will be free; if I get you into the old folks’ home down the road you may have to pay for some of those charges—not the nursing element but the hotel charges.” Where is the logic of charging hotel charges for nursing home patients and no hotel charges for hospital patients for the same condition? Jane Kennedy: Again, it comes back to the same argument we have been having, which is that when you have a system and you consider a reform of that nature, you consider the pros and cons of the proposal, and you have to determine where in your list of priorities for reform and change such a proposal fits. The costs of such a proposal would be very significant. Our view has been that we have other priorities that we will use the revenue that we have, which is finite— Q585 Dr Stoate: I have no problem with your views on priorities of finance, and I entirely accept that the NHS needs to raise money from somewhere to develop and to improve services. I take issue with whether this is the right way. Are there not alternative ways that could be found to raise precisely the same amount of money? Can we not come up with alternative ways? Have other countries not come up with alternative ways that look fairer than ours? If that is the case, why are we not pursuing those alternatives? Jane Kennedy: I would be interested to see the examples that the Committee might have of alternative ways of raising revenue. In the circumstances that we are in at the moment, our view has been that we should not make that change. I am aware that it has been something that has been hotly debated: it was debated very much at the last general election and it has been something that we have considered, but consistently, having considered it, we have taken the view that it is not a high enough priority for us to believe we need to do something about. Q586 Dr Stoate: I have this nagging feeling about unfairness and I hate unfairness. I will give you another very simple example. I have two patients in my surgery: one has an under-active thyroid, one has an over-active thyroid, they both have throat infections. I say to patient (a) with the under-active thyroid, “Here’s your fee prescription” and I say to patient (b) with an over-active thyroid, “You’ve got to go and pay £6.50 for that prescription,” despite the fact that neither condition has anything to do with their thyroid disease and the patients are in all other respect identical. It sounds like a DirectLine advert, but the fact is that that literally does happen. That is just unfair and there has to be a way of reducing unfairness at that level. Jane Kennedy: As I have said, the anomalies in this system are clear. The benefits have changed over time and for those who are entitled to relief from prescription charging the definitions have changed over time. Wherever we have made those changes, the intention has been to preserve an existing entitlement; it has never been to take one away.

Where there is a possibility of extending or increasing entitlement to free prescriptions, we do have to balance the needs of those patients who might benefit from that, against those who would lose as a result, and there would always be some who would—not necessarily if we were to deal with prescription charges in the way that you should, not just around prescription charges, but somewhere else in the health service there would be a cost that would have to be made. Q587 Dr Stoate: I accept that, but, to tie you down a bit, I gather you did not answer the beginning of my question—I have been reminded by the advisers—on alternative countries. Have you looked at alternative countries? If so, which ones, and, if not, why not? I would like to know about the work the Department has done on alternative structures, because there are plenty of good examples from across the world that you could have looked at. Are there any you have looked at, and, if so, what have you found? If you have not looked at them, why not? Jane Kennedy: We have looked at others. We have obviously been following developments in the two devolved administrations. We have looked at Ireland and the experience in Ireland. Looking through my notes, if you will allow me, we have looked at the system in Germany, and in Italy, where the systems are regionally based and regionally determined. We have looked at the system in France, in Spain—right across Europe—in Sweden, Denmark, Finland and the Netherlands. We have tended to look across Europe for comparators. Q588 Chairman: What have you learned from those comparators? Jane Kennedy: There are quite a variety of ways in which they system operates. If you look at Italy, as I have said it is a regionally based system and the amount that is charged is charged per pack of medicines and not per prescription item. Some regions do not have any charge at all but all regions do pay a degree . . . I will get you the detail. Dr Harvey: They pay the diVerence between the reference price and the actual price, because they have reference pricing. Jane Kennedy: It is similar in France. In Spain they have, quite interestingly, diVerent systems depending on whether you are a civil servant or not—which I found intriguing. I see some interest from the advisers at that. Those who are chronically sick in Spain do pay a maximum charge. The equivalent in the UK would be about £1.80, but, again, that is around the definition of illness. We can provide you with this sort of detail if it would help. Q589 Dr Stoate: It would be helpful. There is written evidence that the BMA suggested a nominal charge, say, of £1 for everybody except children. Do you have a response to the BMA’s suggestion? Jane Kennedy: Again, you would be withdrawing an entitlement from a large number of people to achieve that. I would want to look at the findings of this Committee and to look at the recommendations that the Committee makes, but our view is that a review

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of that nature would produce as many people who would be discontent with the outcome as those who would be pleased with it. So we would have some concerns. Q590 Chairman: I accept that entirely, that you would have a situation where, if you were to restrict somebody with a long-term condition just to have free prescriptions for that condition, they would have to pay—and that would be a simple change— for other conditions that came along, but that is taking unfairness out of the system as most people would see it. There cannot be anything wrong with that, can there? Jane Kennedy: Again, it depends how you define long-term condition. You would be extending exemptions in some areas which would have cost implications, and if we were extending it in some areas and trying to do it in a way which was cost neutral you have other areas which would face an increase or a loss of entitlement or the costs would be borne somewhere else within the health service. We keep coming back to that point. We have not been able to find a solution which protects current entitlement and does not bring about a significant cost to the health service. Ms Winterton: Chairman, I can also send some information about dentistry in other countries. Q591 Chairman: We would greatly appreciate that if you could do that. Could I ask both of you, while on this issue: a crude interpretation would be, “We are going to keep it like this because it has been like this for 50 years, other than this three year blip, on prescription charges” but that is not a rule of thumb, that you look at the NHS and say, “We’re going to leave it like that because it has been like that for 50 years,” is it? It is far from it, is it not? You are looking at other areas that you would probably like to change before NHS charges. Jane Kennedy: That is the key, and in the end that has been how we have determined our approach to it. Ms Winterton: There is also an issue in dental care as well. People very often, at the moment, mix NHS care with cosmetic care. There have been a lot of changes that, in a sense, even further complicate that particular system. We have tried to make it clearer to people what they can get on the NHS, with the charge that goes with that, and what they are then charged for privately on top of that. But it has been a growing, if you like, mixed economy in terms of dental care. Jane Kennedy: One more point, where we are having that general discussion, just to reiterate: the numbers of prescriptions that are now exempt from payment is 87%. Of the 13% for which charges are raised, about 5% are now paid under the prepayment certificate, so there is a maximum that is paid in any one year on that. We have improved the low-income scheme and the PPA, the authority who administer the scheme, are looking at introducing monthly payments which would ease the burden on those who do have to pay.

Q592 Charlotte Atkins: For the 13% who do pay, what is the Government’s policy? Is it to raise charges in line with inflation or to keep the income from the charges at generally the same proportion of the NHS budget? Jane Kennedy: Our policy has been to have a nominal increase, almost, in prescription charges since we were elected in 1997. Year on year it has only gone up by 10p per year. The view that we have taken is that to abolish them would be too big a step, but we acknowledge the burden that it can be for those at the margins, just above the low-income scheme level and so on. We have accepted, overall, the contribution that prescription charges costs are making is reducing. Q593 Charlotte Atkins: Basically, the answer to that question is neither—neither to keep it in line with inflation, nor as a proportion of the NHS budget. I understood that in reviewing the system of NHS dentistry charges the new system was required to raise the same proportion of funds as the old one. Is that correct? Jane Kennedy: Yes. Ms Winterton: Yes. Q594 Charlotte Atkins: Therefore, did you decide how this new banded charging system would aVect patient behaviour, because we have heard in a previous inquiry, when we were talking to you, Rosie, that people are predicting that patient behaviour will change and that they will store up treatments, get into a higher band, get greater value for money. When you were looking at that did you make those predictions? Ms Winterton: What we looked at in terms of the new charging system and the relationship between patient behaviour is that, because of the reform system and because of the changes in the NICE guidelines, which mean that instead of going back every six months, if the dentist decides that somebody does not need to come back within six months but could wait maybe one or two years, then the patient behaviour, the patient pattern, if you like, changes. I do challenge this idea that people are going to store up their fillings to get into diVerent bands, frankly. Q595 Charlotte Atkins: Everyone loves a bargain! Ms Winterton: I find it very diYcult to think that people would say, “If I hang on six months to get another filling, I can get that one in the same band.” Do you know what I mean? It is an argument that people make. I find it quite a curious assumption, because I do think that if people were in that bad a position there would be assistance given through the various schemes. The Committee may have a diVerent view, but I just find it a bit bizarre that people would behave like that. I also think that when a person goes for their initial examination under the new system, within one cost, they can have a checkup, they can have a scale and polish, they can have preventative advice and they can have, if necessary, x-rays as well all within that first band. If the dentist were to say (and Ben may correct me if I am wrong

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here), “Look, there is an immediate filling but there is one that will need a little bit of attention within two or three months”, then that would count as a course of treatment. If the dentist says, “This is what is clinically necessary”, then it can extend over that time. I would challenge some of the assumptions that are being made about patient behaviour, but I would say that there are diVerences in the way the system will operate, and the charging system was meant to take into account some of those changes, but overall the system was designed, frankly, just to be simpler for patients to understand, because too many times—and I think I have said this before— constituents have come to me and said, “That NHS is terrible. I have just paid a thousand pounds to have my teeth done.” I say, “No, you have not, because all you can pay on the NHS, as is it stands at the moment, is £384. You should go back to your dentist and say, ‘Wait a minute. What have I paid for on the NHS and what have I paid for privately?’” This system means that there are only three possible payments that people can make, and the dentist, under our regulations, has to make absolutely clear what is NHS and what is private. I think that that is a good change for patients and also, frankly, the system is less complicated for dentists. Q596 Charlotte Atkins: That is great if you can find an NHS dentist to apply those charges. What the Committee would be concerned about is to make sure that the charges were not operating against a preventative dentistry system, to actually encourage people (which is diYcult anyway) to go to a dentist for preventative work. That is the important thing, to make sure that charges do not get in the way of that. Did you consider that when you were drawing up the new system? Ms Winterton: Absolutely. You will notice, I am sure, that within the first band there is an allowance for preventative work. If you move into the second band, the first band comes with you. You are not paying one charge of £15.50 and then another charge of £42.50. It is all encompassed, and so preventative work is allowed for. In terms of the contract itself in saying that the number of treatments can be reduced by 5%, the level of activity, that again is to take into account preventative work. I think there is a wider issue, though, about the whole reforms when it comes to preventative/public health work that, as we allow local commissioning within some of the schemes that are already working, it does allow dentists to be able to do more work, for example in schools, giving oral health advice. I have visited Newham recently which, extraordinarily, has an incredibly low rate of registration but NHS dentists who are longing for people to come through the door, and what the primary care trust has decided to do is to use some of them to go out into schools to say, “Please come and register with a dentist. This is why you should do it”, and at the same time is able to give some oral health advice. Under the new system there is much more flexibility about allowing that kind of work to take place.

Q597 Mr Burstow: I would like to come on to the way in which diVerent policies interact with each other, particularly the very clear policy direction that came from the White Paper about a greater emphasis on community-based treatment. This is going mean that more patients who currently receive free medicines in hospitals will in future have to pay for them. Is that reasonable? Jane Kennedy: We will want to look at that. Clearly it is going to be something we are going to be looking at as we take forward the work and the development of the White Paper. There will be implications for other areas of cost as well, including travel costs, as we allow people to choose where they are being treated, so all of this field is under review. Q598 Mr Burstow: So that we are clear, is there a time line to which that review is working, and when might decisions be made as a result of such a review? Jane Kennedy: The development of the services that we said we would want to encourage in the White Paper will be taken forward over the coming months and years, and the impact of those services upon patients, and particularly, as you say, if they are being prescribed more frequently by GPs performing diVerent roles than they are at the moment or even by pharmacists, then we will want to ensure that they are not disadvantaged. Q599 Mr Burstow: The danger, of course, is that there is never a clear point where a decision is absolutely necessary, because each part of the NHS will reconfigure and rearrange its services at diVerent paces, and so there will never be a point where the whole of the NHS has got to where you want it to be, certainly not in the next few years, and yet this must have, on a locality by locality basis, impacts on the way in which the current prescription policy and exemptions will operate, meaning that some people who hitherto were getting their treatment in hospital may suddenly find themselves confronted with the fact that what was originally free simply because they were in a building, because they are now in their home taking the medication, they are having to pay for it. Jane Kennedy: These are issues that we are keeping closely under review as we take forward the work in developing the services. We will want to ensure that, as we are seeking to improve the services that people receive by delivering it more locally, that they are not disadvantaged in the way that you have said. Q600 Mr Burstow: There is one other specific to consider perhaps in that regard. We have had some evidence indirectly from the British Association of Day Surgery, and they tell us that day case patients are being required to take pay for painkillers which they take once they return home, and this is as a result of a policy that was promulgated from the Department. Is this policy of charging for painkillers for people who have had day surgery consistent with a policy of trying to encourage an increased emphasis on people opting for a day surgery rather than becoming inpatients?

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Ms Winterton: I think we have got to be realistic about what is a deterrent. I had day surgery on my foot and had to buy painkillers, but I think that was preferable to spending four days in a hospital. If you are looking at saying: is that going to stop people going for surgery? Are they going to take an overall view of what they prefer? The usual complaint is that people say that they are having to go unnecessarily into a hospital setting or are staying there too long. I think that, on balance, it is about saying there are some very, very clear advantages to having the day surgery option and probably, if you balanced out all the costs of that to the individual themselves, they might still say they would prefer to take a day surgery approach than have to go into hospital for a week or so with all the attendant costs that there may be to them in that. I think it is a balance. Q601 Mr Burstow: Presumably you would be concerned if that behaviour was stimulated by this new charge for painkillers, if people were making part of their decision about whether they opted for day surgery. Would you actually know? Would you be in a position to have information that would inform on such a situation? Ms Winterton: Patient surveys very often show how people react, and I think the evidence from patient surgeries is that people like to have the minimal time in hospital. I have not seen any evidence. I do not know whether that has been specifically asked in patient surveys, but I have not seen any evidence of people saying, “I much prefer to go into hospital because I can get a free painkiller.” Jane Kennedy: Do not forget, it is not a new charge. It is a charge that has come about because of the diVerent way in which the medicine is being prescribed. There are only 13% of prescriptions that face a charge, and of those 13% there are ways in which you can ameliorate the cost of that. Q602 Mr Burstow: My point is that, as a result of policy decisions and choices you have made, a new set of anomalies start to emerge from something that has not been changed since 1968. Surely that does behove a further examination of the 1968 exemptions in the light of other policy changes. Jane Kennedy: And it is something we want to look at carefully as we take the work on the White Paper forward. Q603 Chairman: Can I ask about the issue of low income families in particular. We heard when we were in CardiV last week that one of the reasons why they were moving in the way that they are is that they believe that prescription charges may act as a form of poverty trap, that people would be deterred from going back into work because of the cost of the prescription when they are in work as opposed to the exemption that they get because they are on meanstested state benefit. Have you any evidence of that? Jane Kennedy: There have been a number of studies. There was a study conducted in Manchester some two or three years ago which was a relatively small study of the impact of charges on those people who had to pay and what they took as a result of that

from their prescription, but we have been reluctant to extrapolate from that because it has been a relatively small study. Professor Peter Noyce conducted that, but it was only 14 pharmacies. What he found was that, yes, people who were being asked to pay a charge were discussing with the pharmacist which items on the prescription were necessary and were there alternatives, over the counter medicines, that might have provided a cheaper alternative, but he found that a very low proportion within that small study were at risk of not taking a medicine that was actually important to them for medical reasons, but that is the only study we have on that front. Q604 Chairman: We had some evidence from the pharmacists last week in relation to that. I am more concerned about this issue of the threshold where you have to pay or do not have to pay. If you go into low-paid work from being unemployed altogether on a diVerent benefit, you then would have to pay your prescriptions. There is no taper in this. You are either exempted from paying prescription charges because of your age or income or condition, in some cases, or you have to pay the full cost of the prescription. What they were saying to us in CardiV is that they believe, and I do not think they have done any great study into this, that it was potentially a disincentive for somebody to go back into work, because, even in low-paid work, they would have to pay the full cost of their prescriptions and not be exempted from paying in that work situation. What worries me about that, Minister, is the potential for social exclusion not to be broken down in society. Of all the areas that this Government wants to work at to bring people back into society, to get them back into work, this particular area might be a disincentive for some people to do that. I do not know if any studies have been done in England about that. Jane Kennedy: I would share your concern. We have not commissioned a study specifically on that, but we do work very closely with the Department for Work and Pensions and we are, as you will know, joint partners with them in the schemes in which we are seeking to help people who are on incapacity benefit return work, and this sort of issue has very much informed the policies as we have been developing them in that scheme. It is one of the reasons why the Low Income Scheme was extended to 12 months rather than six months, so that, even if you have gone back into work and the particular condition for which you got the exemption in the first place is ameliorated and goes away, you can still get relief on prescription charges for the rest of the year. It is that kind of work that we have been doing to try and deal with that problem, should it arise. Q605 Chairman: Do you have any regular meetings yourself with ministers from the Department for Work and Pensions? Jane Kennedy: I have not. That is not to say other colleagues across the Department have not.

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Q606 Dr Taylor: I am coming on to the age-based exemptions, because they do not really seem to make sense when there are lots of people who are retired and well oV who do not need those exemptions. Have you any comments on that? Ms Winterton: There obviously have been manifesto commitments, discussions with organisations representing older people and reintroducing free eye-tests for the over 60s was a very popular measure, widely welcomed and very good in terms of ensuring that a particular group of people who probably did need regular eye-tests were able to get them. That is a debate, in a sense, about how we decide to treat older people, frankly. Q607 Dr Taylor: In any possible review would there be a question of looking at the multi-millionaires in their 60s and 70s and reckoning that they should pay? Ms Winterton: I do not see, particularly on the eyetests for over 60s, a change in that policy in the near future. Q608 Dr Taylor: And prescription charges? Jane Kennedy: We have no plans to do with prescription charges either. You will remember, the largest number of prescriptions is written for people in that older age group. Something like 57% of all prescriptions go to people in that age group. You are more likely as you age to require medical support, medical treatment and medicines, and we have taken the view that we should not take away entitlements, and that is the position that we hold. Ms Winterton: I suspect that Parliament, having voted in some of these changes, would be rather loath to remove them. Q609 Dr Taylor: But you have said that one of the principles is that those who can aVord should pay. Are you not now contradicting that? Jane Kennedy: No, because we have exempted those who are in retirement and are not working. Q610 Dr Taylor: But you have also exempted a lot who could aVord to pay? Jane Kennedy: That is true. Q611 Dr Taylor: Which goes against your principle? Jane Kennedy: If you like, we have refined the principle. Q612 Chairman: Do we not have a problem with extending principles that are in manifestos! Jane Kennedy: We do not mind refining, but extending is more diYcult. Q613 Dr Taylor: I want you to refine another one. War disablement pensioners do not have to pay prescription charges but only in respect of the medication for their disablement. Could not the system be refined so that these lucky patients with an under-active thyroid only get free prescriptions for their thyroid, diabetics only get free prescriptions for

the things directly related to their diabetes. If you can do it for war disablement pensioners, could you not do it more across the board? Jane Kennedy: I am reluctant to begin that sort of review, which would inevitably lead to representations from every patient group who believed that they were a case that should be considered for exemption. We have really discussed that earlier. It is not a policy discussion that is enticing us. It is not high on our priority list. Q614 Dr Taylor: No, we are back to the very strong argument for the abolition and not the review. One other final question. Is it true that a directive came from the Department of Health about out-patient charges that anybody who had been in hospital for less than 24 hours should pay a prescription charge for the drugs that they take away with them? As I am sure you know, one of the rather odd definitions is that if you manage to get a patient out of hospital at 23 hours, rather than 24, they count as a day case and therefore they would have to pay prescription charges, whereas, if they managed to stay 24 and a half hours, they would count as an inpatient and so they would be exempt? Jane Kennedy: I have to apologise. I am not cited on that. I would want to look into that and see. Q615 Chairman: I think since 1948 the definition of an “inpatient” is one who was occupying a bed at midnight. Jane Kennedy: As far as I know, there have been no recent changes to the rules, but I would want to look at what you say. Q616 Dr Taylor: We were told there was a directive sent round from the Department of Health about charging for people who were in for less than 24 hours. Jane Kennedy: It is not something of which I am aware. Q617 Chairman: I hear what you say about the issue of conditions exemptions, and, indeed, it was put to us that is not somebody suVering from depression a long-term condition as well and where do you stop? We heard that in CardiV last week. Would it not be easier to say that, given in 1951 there probably were not as many millionaires living into their retirement, in fact there were not as many millionaires full stop as well as people living into their retirement, and given an exemption on age nowadays when we have got a massive amount of millionaires who are able to get free prescriptions I think from the age of 60 now, is that not something that could be reviewed and stood on its own? I know it sounds like we are into class-bashing, and it is not meant in that respect. NHS charges are another form of tax, in a sense, and these people could well aVord to pay £6.50, could they not? Jane Kennedy: The thing is that you would not introduce a system where you started saying people who had an income or asset base of a million pounds or more had to start paying more or had to start paying for their prescriptions. The vast majority of

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older people who are on acknowledged good pensions have planned for their retirement and taken into account that they will not have to pay prescription charges perhaps to a certain age, and to remove that would be just as controversial as some of the issues that you are asking us to consider in a diVerent context. Q618 Chairman: What about doing it for people who pay the top rate in income tax when they retire? Ms Winterton: Sometimes it can be quite diYcult, when you look at those systems. The cost of administering something like that can actually remove from the amount of revenue that you raise. Q619 Chairman: Have you looked at the costs of administration? Jane Kennedy: No, I must admit, we have not. Ms Winterton: I remember looking at the general admin costs and, at the time when I looked at them—this is all from my own interest, by the way, not some kind of fundamental review—it was fairly clear that the system was relatively simple at the time and the balance of administration was quite low, but I did think from that that, once you started introducing various diVerent levels, it might become more complicated. Q620 Chairman: I accept that from your point of view, but looked at through the Inland Revenue’s eyes it could be quite diVerent, because you are easily picked out if you are on the top rate of income tax. Jane Kennedy: People who pay the top rate of income tax would argue that they already contribute by paying more tax. All of this is a fine balance. I was going to say, if Rosie had not said it, that when you start to have to work at how you administer such a scheme, the benefits that you get from it diminish. It sounds a simple thing to do, but actually doing it and doing it fairly is far more diYcult to achieve. Q621 Chairman: You have not discussed this with the Treasury then? Jane Kennedy: No. Q622 Mr Burstow: The Department for Work and Pensions and the Government as a whole are considering issues around pensions and pension wages in terms of basic state pension entitlement. Is that something which the Department will be keeping in mind in terms of the age at which free prescription, free eye, free dental and other checks become available? In other words, will the age be kept aligned? Ms Winterton: I am sure that those will be part of the discussions that take place if any changes do occur. You mentioned the DWP. I wanted to say that one of the things that was highlighted in the recent Pack report was that people are not claiming some of the benefits, and this particularly related to cancer patients. I did check up on that, and we do try to ensure that “pounds departments” within hospitals and GPs surgeries, and so on, are given leaflets in order to make sure that people can take up the benefits that they are entitled to.

Q623 Mr Campbell: Coming back to the charges again. Should eye-tests and dental checks not be free for everyone on the basis that if you do it early things like oral cancer could be caught early, costing the NHS less in the long run? Ms Winterton: In terms of the eye-tests—as you know, there are various groups who are entitled to free eye-tests—there is not any evidence that paying for an eye-test is deterring people. What we do try to do is to make sure that we have schemes in place, and we have looked at this, particularly, for example, schemes with pharmacists, to actually encourage people to go for eye-tests if they are in at-risk groups. Q624 Mr Campbell: It is a trait that we have got that if they have got to pay they are more reluctant. If I have got to pay for it I will not go. Ms Winterton: Your instinct might say that. I think the reality is, certainly if people feel they are having problems with their eyes or their eyesight is fading, they will go and have an eye-test. There is no evidence that people, frankly, just do not go because they could not aVord it, because again there are the exemptions in there for people who would be on particularly low incomes, and, of course, again, for the over 60s, we have reintroduced free eye-tests, but we do try to encourage groups at risk to be able to go forward for that. Of course in some areas we have introduced regular eye-checks for people with particular long-term conditions. Q625 Mr Campbell: You have not done any costings to say that it is cost-eVective by making it free earlier? Ms Winterton: I think everybody knows that, obviously, if it is caught early—. As I say, the key to this is not saying to people, “You can have a free eyetest” necessarily. The key is getting a message to people that they might be in an at-risk group. If we put adverts everywhere and said there are free eyetests, people who needed it would not necessarily know. That is the key that you have to crack when you are dealing with the type of conditions that you are talking about. It is actually identifying people, getting the message through to them that they need to have an eye-test because they are in an at-risk group, which is in a sense the answer to saving the on-going costs further down the line. It is the people who do not come forward that is the problem, but I do not think it is connected to the fact that they feel they might have to pay for an eye-test, it is more likely because they do not realise they are in an atrisk group. Q626 Mr Campbell: Can I follow on with a question in regard to Mind, people with stress and people with mental problems. We had a witness last week from Mind who came in and when we asked her some questions it was amazing what she had to say. What she did have to say was basically that when a doctor gives a prescription to a patient who has a problem they went on a list, but the list was closed because it was as long as your arm. It was closed up to six months, she said, and so most patients, when they could aVord it, had to go and get their own

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consultation and pay for it, and those that could not pay for it just did not, and, of course, further down the line it was going to cost more money because their condition never got better. Ms Winterton: I do not know whether she would be talking about—. Is she talking about a waiting list to see a psychiatrist? Mr Campbell: Yes. Q627 Dr Stoate: Psychotherapy, I think? Ms Winterton: There are certainly shortages of alternative counselling, and that is why in the manifesto we made a commitment to extend those kinds of services. We have trained more psychotherapists, and we are looking at the moment as to how we can extend that even further. We said in the recent White Paper that we would be looking at two demonstration sites to look at how you can provide some of those wider psychological therapists, because, you are absolutely right, there is a problem. Q628 Mr Campbell: It is a modern day disease? Ms Winterton: Yes. Q629 Mr Campbell: It could happen to anybody in this day and age? Ms Winterton: Yes, and it is something, it is absolutely true, which needs to be expanded. Q630 Mr Campbell: It is pretty shocking when you have a list and it is closed after six months and the doctor cannot get anybody on the list. Ms Winterton: Certainly there are long waiting times for psychotherapy at the moment, but that is why we are taking the action that we are doing. One of things that we have to do in expanding the counselling services is to make sure that we have got an adequate way of monitoring, or regulating those who are carrying out the services, and that is why we are talking at the moment with organisations like the British Association of Psychotherapists and Counsellors, I think it is called, to say how can we get some agreement about the diVerent types of counselling that could be, in a sense, accredited so that if PCTs are commissioning it they know what they are commissioning, because you will find this varies from area to area. Some PCTs, for example, will provide bereavement services, others will not. Sometimes that is because some of them are not quite sure about some of the issues around accreditation. Q631 Dr Stoate: I would like to focus a bit more on the eVects on health of charges. We have had quite a bit of evidence from pharmacists, from GPs and academics that groups of people simply choose which drugs to get from their pharmacist because they cannot aVord them all and some patients do not take their drugs at all. Does the Department have any evidence of the eVect this might have on people’s health? Ms Winterton: With regard to pharmacists, that is exactly why we introduced the use your medicines properly schemes, which I think have been extremely

eVective. What there is evidence about is that, if people do not understand the possible side-eVects of their medication, they can almost stop taking them without going back to, for example, a pharmacist and saying, “Is this right?”, and sometimes the pharmacist will say, “Take it at a diVerent time of day and that might reduce it.” Q632 Dr Stoate: I am more concerned about the eVect of charges on people. We have had pharmacists, and we have interviewed them, saying that they had first-hand experience of patients saying, “I cannot aVord three drugs”, or, “I cannot aVord two drugs. Can you tell me which one I do not need?” and the pharmacists are finding themselves in an extremely diYcult position. Do we have any evidence, any research on the scale of the problem and the eVects it might have? Jane Kennedy: Other than the study that I referred to earlier, no, we do not. We have, of course, the Citizen’s Advice Bureau work that was done a little while ago, in which they estimated about 100,000 people were not getting their medicine. We are looking at some of the representations that they have made and we are working with them to study that. There has also been a MORI poll, I think, but we do not know the scale of the poll. Q633 Dr Stoate: Is it not important that we do some research? We had Hamish Meldrum, for example, from the BMA last week, who is a GP, who felt that it was a significant problem, but he had no way of measuring the scale of it. Is it not something that the Department should be measuring? Ms Winterton: Some of the evidence, or some of anecdotal evidence, put it that way, is that people are not always told about the fact that there are Low Income Schemes, that there are exemption certificates, and so on. Q634 Dr Stoate: With respect, pharmacies will always tell a patient when they are entitled to a free prescription or not. The list is very clear in the pharmacy. They have got details, they have got literature and it the pharmacist’s job is to make sure that patients get free prescriptions if they are entitled to them. I am talking about people who are not entitled to free prescriptions who will then say to the pharmacist, “I cannot aVord three drugs. I can only aVord two, or one. Which one can I aVord to drop?” Surely that must have an implication on health, and why is not the Department doing some research on the scale of that potential problem? Jane Kennedy: As I say, we have that small study which indicated that for that small group of pharmacists the scale of the problem was not as great as you might have feared. We have no plans at the moment to commission any further evidence, but we want to consider that in the light of what the Committee might say. Q635 Dr Stoate: Mr Dyson, you are responsible for optical services. Being a GP, and it is well-known, for example, and any optician will tell you, that certain condition such as glaucoma, hypertension,

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diabetes can be picked up from an eye examination, and they are often conditions which have no symptoms whatever for many years and not until sometimes it is far too late to prevent long-term damage. Do we have any evidence that optical charges are putting people oV attending for routine optical tests who may have those conditions but may have absolutely no inkling that they have got them unless they have an eye-test, and is there anything to show that might be a problem? Mr Dyson: It is perhaps first worth mentioning that diabetics and those diagnosed as having or being at risk of glaucoma are entitled to free sight-tests. Q636 Dr Stoate: I am talking about people who have not been diagnosed with diabetes or glaucoma. Once they have been diagnosed they are in the system. I am talking about otherwise fit, healthy adults who may have very high blood pressure, who may have diabetes, who may have glaucoma and be absolutely unaware of that because, as you know, those conditions do not manifest themselves unless they show signs. I am talking about people who potentially could be diagnosed. I am sent patients, on a fairly regular basis, by opticians because they have had an eye-test and the optician says, “You may have high blood pressure. You may have diabetes. Go and see your doctor.” I am talking about people who have no idea they have got these conditions, and I am concerned about the eVect that the charge may have on preventing such people coming forward for an eye-test? Mr Dyson: We are not aware of any evidence to show that the fact of having to pay for a sight-test has deterred people from coming forward. As we have put forward in evidence before, certainly the experience when free sight-tests were reintroduced for over 60s the overall volume of sight-tests as between the private and the NHS did not change significantly as a result, which implies certainly that the fact that some older people were having to pay for sight-tests privately had not deterred them. Q637 Dr Stoate: But with so many diVerent providers in the field, can you possibly know how many people out there have or have not had a sight-test? Mr Dyson: We know the overall volume of NHS sight-tests and the overall volume of private tests, and that did not change significantly as a result of introducing free sight-tests for over 60s. Q638 Dr Stoate: But you have absolutely no research evidence whatever to back-up any assertions as to whether the charge does or does not put people oV taking care? Mr Dyson: Our view is that the very fact that there was not a significant increase across the board was quite compelling evidence that, on the whole, people had not been put oV by having to have a private sight-test before the change was introduced. Ms Winterton: I go back to the point that the key to this is actually reaching people who may be in at-risk groups and persuading them, as you obviously have,

“You ought to think about going and having an eyetest if X, Y, Z.” As I say, I think that for most people who perhaps are in that age range where their sight begins to fade a little, there is no evidence that they are not going because of a sight-test. I do not think it would be patient behaviour, frankly, because if you feel that there is something wrong you do tend to go. Q639 Dr Stoate: I am not talking about people with any symptoms whatever. I am talking about people who are otherwise, as far as they are concerned, completely fit and well who may well know they should have a dental check-up every year or two, and that is fine, but they have no reason to think that they need an optical test. I was simply concerned about some of those people who might think, “Why would I want to shell out £25 for an eye-test if I have not got any symptoms?” They are the ones I am concerned about, who may store up considerable damage to themselves before somebody says, “You have probably had diabetes for years”, and that can easily happen before any symptoms develop. You may have had high blood pressure for years and you may not be aware of it until you have a stroke, but it may be that it could have been picked up by an optician earlier. Ms Winterton: Yes. As you say, the key is to get to people who are in at-risk groups and say, “Even though you may not be feeling something, it might be worth you going to do that”. It is something that, whilst an eye-test may not be part of the new lifechecks in itself, at least it would help to identify people that you would be saying, “Even if you are not having problems with your eyes, because of your family history, this is something that you should seriously consider doing.” Q640 Mr Campbell: I heard Jane mention the monthly prepayment certificate before. You just mentioned that. I just caught the end of what you said. Jane Kennedy: It is not monthly at the moment. We are looking at that. Q641 Mr Campbell: Could you expand on that? Jane Kennedy: The Prescription Pricing Authority, who are the responsible body for administering the whole scheme and for making sure that reimbursement of prescriptions takes place, are looking at how they could develop such a scheme, and they will be reporting to me shortly on that. Mr Campbell: That is good. Q642 Mr Burstow: In addition to that, are there other options being looked at? Are they essentially looking at potentially a charging cap, so that, once you have paid a certain amount in a given period of time, you do not pay any more? Is that another option that is being considered? Jane Kennedy: It is capped anyway, and at the moment they are looking at both.

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Dr Harvey: It is a four-monthly certificate, but they are looking at monthly payments towards that, and they are also looking at the other thing that was raised by Citizens Advice, which was a reduced price PPC for those holding an HC3. Q643 Chairman: What about the issue of somebody who may not at the beginning of the year, or at any one time, know that they are going into a situation of long-term conditions that is going to mean a lot of medication but, probably three or six months down the road, suddenly realise that the amount of expenditure is quite high? I think one country we had evidence from put an annual cap on what somebody would pay on prescriptions and, if they met that cap, they would not pay any more for the following three months. Have you looked at anything like that? Dr Harvey: We are certainly aware of the situations, particularly in the Scandinavian countries, where that applies. There is the issue of the administration cost around all of that, but I think that is also why we are looking more at the monthly payments for PPCs and issues around the HC3 low-income scheme. Q644 Chairman: Okay. Another area we would like to look at is the cost of travel but in diVerent circumstances than going to your local hospital. I have a constituency case I have been dealing with now for a number of years. One of my constituent’s daughters was living in SheYeld, which is next door to me, and has ended up suVering from mental illness. She had to go into long-term care, and she is still in long-term care now. She was sent initially to Milton Keynes. Her mother could not get down to Milton Keynes to see her. She is an elderly lady and I do not think she has got a lot of income. I eventually got the system to move her a bit nearer. She is now in North Nottinghamshire, but she certainly could not get on a bus to go and see her. Why do we allow this situation? If it might have been a member of a family who went to prison, they could actually get travel costs to go and visit that person in prison. I had a letter from her a few weeks ago saying could we get her even nearer to North Nottinghamshire. If we could move her back to SheYeld she could go and see her on the bus a lot more. Why is it that we pay for people to go and visit prisoners and yet we cannot do that for people in long-term care in situations like that? Ms Winterton: Can I, first of all, make a general point about the mental healthcare provision. It is something that I am looking at, the general commissioning of mental healthcare, particularly in the relationship between the public sector and the private sector and how we can strengthen commissioning so that it is, in fact, closer to home in general. Q645 Chairman: It is very likely that these people will go into a place because of the status of that place, in terms of whether it is a secure unit or not, and, under those circumstances, we are not going to have one in every borough. I accept that entirely. I just think that it is very unfair that under those

circumstances the family could visit, which could be very much for therapeutic reasons, and assist and certainly help a mother to see her daughter, and yet she does not get any assistance in being able to do that. Is that something that you could look at when you are looking at the issue of long-term care? Jane Kennedy: It is something that we could look at. I think we have focused the help in terms of transport on the patient so that the hospital transport scheme is focused on helping patients who have travel costs. This is a fair point, and I can appreciate the diYculties that some families of patients in those circumstances face. We would be happy to consider what the Committee has to say on this. Chairman: If somebody in the family had done wrong to society and been under lock and key, they could get assistance to go see them. Q646 Mr Burstow: Can I pick up this point. There was a report done a couple of years ago by the Social Exclusion Unit, Looking at Making Connections. It was published in 2003. It estimated that about 1.4 million people are put oV taking up healthcare because of issues of access to transport and aVordability of transport and so on. Preparing for this inquiry, what we have found it very diYcult to do is to discern quite how the Department went about responding to the recommendations of that Social Exclusion Unit report. Can you tell us what you did with the recommendations to try and improve information for patients about how they could access transport and, indeed, this issue of how relatives can also have access to transport? Ms Winterton: There are two things. There are instances where people can apply for a social care grant for travel to see relatives in those situations. I think there is also an issue that is being looked at in terms of the wider expansion of the Choose and Book programme, and within that there is a look being taken at transport for visitors as well and I think, particularly in terms of mental health, that is something that we can look at within that. Q647 Mr Burstow: Specifically the Social Exclusion Unit report from three years ago. How was that taken forward? Jane Kennedy: First of all, the White Paper that we have just published sets out ways in which we respond to the recommendations of that report. They had one specific recommendation, which was that we should abolish the hospital transport scheme, which we have resisted because we actually think there is a value in helping those patients who would otherwise face costs specifically. However, there is a broad responsibility for ensuring that, as we are developing services and moving forward with our programme of taking services closer to people in the communities, local transport plans will also be required to play a role in making sure that transport arrangements in any given area take into account the accessibility of health service and health service provision. It is not just a health department responsibility to make sure that health facilities are accessible.

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Q648 Mr Burstow: On that last point—the model of care of having healthcare closer to home—one of the problems that can arise, and certainly in my own area where that model of care has now been put forward and has been taken forward, you may have very localised care facilities but they will not be able to provide the full range of diagnostics. Although you may have a local care hospital or a local facility on your door step, you still have to go right the other side of my local authority area, or further afield, still to get to the one that provides the service that you need. In some cases that may wind up with far more complex journeys than the original journey to the local key hospital. How is that going to be picked up? Is that simply going to be left very much to local transport plans and an interaction between the NHS locally and transport providers? Jane Kennedy: No, because if a patient requires, for medical reasons, to travel a distance for a diagnostic such as that and they fall within a category of patient for which the patient transport service will be able to provide transport, then they will be transported, so that will be provided. As I say, the other element of it is that for those patients who are not so critically ill that they require transport or have a condition which does not qualify for that support, there is the other scheme, which we have defended, which is the hospital transport scheme. Q649 Mr Burstow: So why are 1.4 million people a year turning down healthcare because of transport issues according to the Social Exclusion Unit? Jane Kennedy: As I say, our response to the Social Exclusion Unit report is contained within the White Paper, and if we take services more locally and provide services more locally, for example Clatterbridge Hospital in my area, a big cancer unit, well respected, has been developing for many years a system in which consultants go out and run clinics in localities around Merseyside and Cheshire and North Merseyside, so they will take their services to patients in Southport and deliver chemotherapy services in Southport. The patient does not have to go all the way through Liverpool to the Wirral to receive the treatment at the hospital. This is not rocket science, it is a simple process. It is a very sensible process of taking services out to where people want them, which is as close to home as they can have them. Q650 Mr Burstow: That is a good example of where that will work, but the point that I am making is again from practical work of modelling a better healthcare closer to home model of care. In my area they have recognised that there will be some services that will be provided in satellite facilities, but only one of them. They will not be moving around. There will still be people who have to travel further to get to those facilities. It is how those people are addressed when we know already 1.4 million people a year turn down access to healthcare because of transport diYculties. I am not clear how that is being fixed through what is being put forward. Jane Kennedy: We are taking services closer to people. That is how we are fixing it.

Q651 Chairman: Could I ask you if you are happy that patients have adequate access to information regarding eligibility for assistance with health charges and if the Department do any checks on this. Last week we had in Citizen’s Advice who said that health providers are not required to display information about the NHS Low Income Scheme. I know when you go into a GP’s surgery there are leaflets and all sorts of things in there, but they do not have to provide this information on the NHS Low Income Scheme. They described it as quite amazing that they did not. Do you have any views on that? Jane Kennedy: The Prescription Pricing Authority is working with the Citizen’s Advice Bureau. They have taken that finding very seriously and they are working with them to provide more information and working with the NUS to make sure there is information available to students on healthcare and health advice, so it is something that they are responding to. Ms Winterton: I am not sure if you make something a requirement, if somebody says that they were not then given it, whether you get into some legal diYculties. I am not sure whether that might be an issue if you put a requirement and then somebody says, “Yes, but I was not actually told it”—the definition of how you have displayed some information and whether it was drawn to their attention but there is certainly very heavy guidance, I think, on good practice as to how people’s attention should be drawn to it. Jane Kennedy: For example, pharmacists are not contractually obliged to do it but good practice dictates that it would be something they should do. Q652 Chairman: I suppose that is one of the issues with new GP contracts and everything else as to whether or not you could make it a provision. What you are saying is if somebody says it falls short you then get into a mess of proving or disproving that information was available at the time when somebody went into a surgery. Is that what you are saying? Ms Winterton: It occurs to me that might be an issue around it and trying to do it through good practice may be the preferable route. Jane Kennedy: The HC11 form that does give guidance on the support that is available and on the Pre-payment Certificate is available from pharmacists and GPs and contractors. It is also available in JobCentre Plus and two major supermarkets, I understand. Chairman: You are not prepared to name them. Richard has got a question about that. Q653 Dr Taylor: That is the next question about the HC11. I am ashamed to say I have not looked at one myself but we are told it has got 77 pages and it is the major part of Age Concern’s volunteers’ work, to try to help people fill in this form. How could this be simplified? I think it was the CAB who said, “One thing you could do is say if you are entitled to a means-tested benefit then you get your free

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prescriptions”. That would be so easy and it would save so many people so much time as opposed to this 77 page form. Is it 77 pages? Jane Kennedy: Yes. 79. But it does cover all the costs and all the help that you can get that is available, so it is of necessity detailed. However, there is a quick guide which my glamorous assistant will show you! Q654 Dr Taylor: Does the quick guide separate each of the sorts of things that you can claim for? Jane Kennedy: It gives details of what benefits would passport you through to receiving free prescriptions. Q655 Dr Taylor: Is there a short form on that that they have to fill in to claim it or do they still have to go back to the 79 page book? Ms Winterton: The form is HC1. Jane Kennedy: This is the advice booklet which explains what is available. Q656 Dr Taylor: How diYcult is the form because Age Concern pointed out the extensive amount of time their members spend helping older adults complete the form? How many pages is the form? Jane Kennedy: I do not have an answer on that but we can find out. However, the patient partnerships have done a survey of opinion on the form. I think 94% of those who responded to the survey said they found the form easy to fill in. We need to check because you have obviously got diVerent information from us. Q657 Dr Taylor: It is just from Age Concern. Jane Kennedy: The HC1 form is 16 pages. Q658 Dr Taylor: The form is 16 pages? Jane Kennedy: Yes, 16, one-six.24 Q659 Dr Taylor: Could you possibly leave us a form because I think it would be terribly useful if we saw it. Ms Winterton: Would you like this quick guide? Dr Taylor: Absolutely. Yes, please. Q660 Chairman: He is all right, he does not need them anyway. Can I ask you about best practice within the NHS for getting information about the Low Income Scheme. Could we take it as read that would be the case for the private providers that the NHS do now contract with, that we are likely to see these things in the areas where people go for private provision as well? Jane Kennedy: Yes. Certainly we will look to make sure it is understood that such advice should be available. Q661 Chairman: We may be going on a visit to one or two of these so we look forward to seeing them displayed in these areas. Dr Harvey: In terms of the transport scheme, as part of the consultation that will be taking place over a three month period one of the issues they are going 24

Note by witness: The Prescription Pricing Authority (PPA) oVer an HC1 form completion service which is available by phone.

to be looking at is how to raise awareness of the HC2 and HC3 for the Low Income Scheme help with travel costs for both staV and patients. Q662 Chairman: We are moving on to another area now. You probably know that last week we had Patientline in here and questioned them, and earlier today we had Ofcom questioning them as well about their report and their letter that was sent to the Secretary of State in relation to the policy on telecommunications in hospitals. Could you comment on the failings of the Department in regards to its policy on telecommunications services and what clearly most people would say is an inability to protect patients’ relatives particularly and friends from unreasonably high charges? Ofcom were very diplomatic this morning but it is quite clear from the contents of the letter they sent to the Secretary of State on incoming telephone charges that they are extortionate—my words, not theirs— in terms of what people have to pay to phone a relative. How wrong do you think coming to a contract with these people was? Jane Kennedy: First of all, I would say Ofcom had undertaken an investigation into the provision of these services. They have now dropped that investigation because the Department and the contractors have expressed a willingness to work with Ofcom to address some of these criticisms that have been raised. There were about 70 complaints raised, which is a significant number, but when you think of the total number of people who have been using the services actually it is a relatively small number of people who are complaining. The majority of the complaints were about the costs. Among those people who have been using the service there is quite a high customer satisfaction rate with the services that they are receiving. In comparison with what was there before the services are seen as a very big improvement. Q663 Chairman: I accept that, but Ofcom stated in their letter to the Secretary of State that they had: “not therefore reached a final conclusion in respect of the lawfulness under competition law of the contractual arrangement entered into by the NHS Trusts and the providers”. That does suggest this particular contract is suspicious, even to suggest it may or may not have been lawful in their view. It was not against competition law, they have clearly said that, but they have not passed it back to you with any glowing references about the scheme. They made it quite clear you need to do a critical analysis of what people have signed up for here. Jane Kennedy: On the day that Ofcom communicated with us to say that they were not taking their inquiry forward we made quite clearly a statement to say we accepted we need to review the arrangements and that is what we are doing and we will be in a position to announce the membership of the review group very shortly. It would be wrong of me to go into too much detail about what the perceived shortcomings might be in the current scheme. I need to let that group of people do their work.

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Q664 Chairman: You do not think that in any way the Department was duped into buying what some people would say is an expensive toy? Jane Kennedy: I take comfort from the fact that a lot of the users of the service have said that they think they are getting a good service. Q665 Chairman: I have to say my niece, who has just had a child, is in Rotherham Hospital and I was there Sunday evening and she said the system they have got there is wonderful, but I am not sure the relatives who have been phoning in will think that when they get the phone bills. Jane Kennedy: If I can just add one further point. The reason why I think these services are important is my elderly father-in-law went into hospital and spent a long time in hospital in his declining months. His one pleasure in life was watching Liverpool Football Club. His daughter took a television set in so he could watch the FA Cup Final when Liverpool were playing in a recent FA Cup Final, as they often do, and she was told she could not plug the TV in until it was checked by an electrician. She left the TV with the hospital ward for them to do that, it was never plugged in and the old gentleman did not get to see the last FA Cup that he would have been able to see with Liverpool playing. To have a service that is there that they can purchase that is there to provide that kind of service to patients is infinitely better than that kind of experience. If we have not got it right here we are working with the contractors to see what we can do to improve it. Q666 Mr Campbell: Sometimes it is a bit of a ripoV though. Jane Kennedy: I hear that criticism. Chairman: I have to say I was hospitalised in 1992 and I hired a television at the bottom of my bed and it kept me sane in a sense. I did not like visitors because they were interrupting my viewing pattern! Q667 Charlotte Atkins: I think we are being a little bit complacent here. Yes, of course the system is great for patients but it is a nasty shock for people who are ringing in when they get a huge bill. Maybe the complaints are not very high because they get it in their quarterly telephone bill three months later. That is the issue, is it not? Jane Kennedy: You have to appreciate that when we said we would develop this scheme it was to be at no cost to the NHS, therefore the contractors are investing significant sums in the roll-out and development of this facility for patients. Part of the quid pro quo of that is that they have to recover their costs. These are all issues that we will want to look at. We have taken the Ofcom comments very seriously and we want to review the arrangements. Q668 Charlotte Atkins: Maybe you could have a look at the people who are calling in and are being subjected to these very high costs. It may well be that you are talking about poorer friends and relatives of people in hospital who cannot aVord to visit them in hospital or are unable to for whatever reason. Is it not the case also that, yes, they have got to recoup

their costs but the point is they are recouping their costs for a very expensive bit of kit which is not being fully used by the NHS? Jane Kennedy: One of the criticisms which I heard was that when people ring in, the first 25 seconds or so is a message that says you are going to be charged at premium rate and this is how much it is going to cost you. If you are ringing in regularly that is not only irritating but also quite an expense. We are going to look at all of this and I just want to give the Committee— Q669 Charlotte Atkins: It costs more to ring in than it does to ring Australia. When you are given the cost in a message when you are anxious to talk to a friend or relative it does not always sink in what the total price will be. Of course, you are right, it is an irritation to have that message especially if you are a repeat caller who constantly has to pay to hear this irritating message. Jane Kennedy: I am one of those people who is very irritated by telephone menus anyway, so I have a lot of sympathy for callers in those circumstances. I really cannot say much more at this point other than we are working with Ofcom and the companies and I will be announcing the membership of the review group soon. Q670 Charlotte Atkins: Will you also be looking at whether the NHS is going to have any prospect of using this expensive kit or will it just be not a toy but an expensive white elephant? Jane Kennedy: It has got about 40% usage, so perhaps part of the review may well look at how we can promote use of it. There are alternatives. There are payphones still in most hospital wards and very often TV rooms too. There are alternatives to this service if patients or relatives choose not to use it. The basis on which we allowed it to go forward was that it should not cost the Health Service any money. Working through that sort of detailed contract, there have to be ways of paying for it. Q671 Charlotte Atkins: Real competition would be the use of a mobile phone. Are you going to be looking at the issues around the use of mobile phones? I appreciate that there are clinical reasons why mobile phones should not be used but that would be the alternative choice for most relatives and patients. Jane Kennedy: I had not intended that this review would look at the extended use of mobile phones in hospitals. I am told yes, we will be looking at mobile phones. Charlotte Atkins: Excellent. An immediate change of policy, marvellous. Q672 Dr Stoate: It is called manifesto-plus. Jane Kennedy: But not as part of this review. Q673 Chairman: I think that was one of the things in the Ofcom letter to the Secretary of State, the issue of mobile phone usage in hospitals. Could I move on

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to another area which is the issue of hospitals and car parking. Should hospitals use parking to raise money? Jane Kennedy: I see absolutely nothing wrong with it. Q674 Chairman: Do you think that Trusts are providing enough free parking for regular attendees, such as cancer patients? We have gone from 10 years ago when you would probably go into the acute sector for a week or a fortnight to now where you go in every day for an hour a day. Do you think Trusts ought to be issued with guidelines saying that regular patients like that should be exempt from charges? Jane Kennedy: It is very much for local Trusts to determine how they are going to manage their car parking facilities. The vast majority do have exemptions from charges. Hospital staV are pretty good usually at advising patients when they might get exemptions from car parking. It is very much a matter for local determination. Q675 Chairman: Do you keep a check on them at all? Jane Kennedy: I think we are content that the policies are being applied properly. Most hospitals will say it is enabling them to manage, as I said earlier on this morning, the space around them more eYciently, it discourages other people who are not using the hospital from using the car parking space, which in an inner city area is quite a problem for hospitals, and there are exemptions in place. Obviously nothing is ever perfect but I think they are getting it broadly right. Q676 Chairman: No concerns about having it on a pro rata basis? Some of these car parking charges are very high, as high as airports and everything else. I know you are not there for 24 hours but they are quite high charges for a short stay on occasions. You do not really have a view, that is a matter for the Trust, is it? Jane Kennedy: I would pay easily—I am not sure what it is in Liverpool now—a pound an hour to park in the city centre to go shopping. I think these are comparative charges and, therefore, fair in that context. Q677 Chairman: Dame Gill Morgan from the NHS Confederation last week was sitting where you are sitting and she said that car parking will increasingly be used as a competitive lever by hospitals to attract patients. Would you be happy to see hospitals build large car parks to win patients over? Jane Kennedy: I do not see it as a draw for patients, I see it as a service for patients, and I am sure that staV would welcome it as well. Q678 Chairman: Looked at through eyes like that, in view of what you said earlier about this issue of a sustainable transport system and taking things out into the community, it could have an adverse eVect if we were to see this type of competition as far as transport was concerned, forget the health side of it. Do you think that there is a danger of that?

Ms Winterton: I know in my constituency the constant complaint is there is not enough parking and the residents nearby say “people visiting the hospital park outside our house” and visitors and others say it is diYcult. I think it is quite important that hospitals do respond to that. If people are saying this is making life diYcult not only for them but for people who might want to come and see them, making life diYcult for local residents, I think what she may be getting at is if hospitals feel that is something that patients are asking for they will respond to it. I think that is quite good, it can make people feel quite valued if they think the hospital is responding to the points they have been making about the facilities available. Q679 Charlotte Atkins: One of the areas which I am concerned about is chiropody. It increasingly seems to be moving into the private sector so elderly people, who rely very much on chiropody and it can have a real impact on their mobility, are being charged for that valuable service by default. Ms Winterton: I think there has been a longstanding argument about chiropody services. What I have been impressed with is the way that nowadays, particularly for people with diabetes, for example, who do need very good chiropody services, and beyond that podiatric services, increasingly in the way some of the centres are operating they do provide that. There are always issues between whether people in terms of having their nails cut have that on the NHS or whether you ensure that because of the terrible long-term eVects of something like diabetes and you do not have proper corresponding chiropody services, you look at exactly what might happen if it is not treated. It is important to think we do target our resources where there is going to be the most eVect, in a sense, and where it is going to make a real clinical diVerence. Q680 Charlotte Atkins: I can understand that, but if you are elderly and are unable to cut your own toenails, the impact of that can be as devastating as if you have a condition which requires you to have professional help. If you literally cannot cut your toenails then it will aVect your ability to walk and mobility. I have had constituents who have said they are unwilling to go to a chiropodist to have their toenails cut because they do not think this is something they should be doing on the NHS sometimes, and some who can aVord to will go private but there are others who will not be able to aVord to do that on a regular basis. Ms Winterton: I think there may be some examples where PCTs may commission those kinds of services for particular groups and perhaps it might be helpful if we look into where there are good examples of that for the Committee. Charlotte Atkins: I think so otherwise we are talking about a whole group of elderly people being housebound when there is no need for that to happen.

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Q681 Chairman: Could I ask you about the likely eVect of changes in the NHS to the structures of charging. This “greater diversity of providers” mentioned in the White Paper, does that not suggest there is likely to be an extension of charges? Ms Winterton: I do not think that should automatically follow from that. The White Paper is about looking at how we can provide more NHS services in the community, making it more convenient to people, making it closer to home, but it is not allowing within that an ability to say if you have day care surgery that comes under a diVerent provider—I accept the point about the following medication—that provider would be allowed to charge for the service. It is about NHS services being oVered in a diVerent setting. Q682 Chairman: I have not got the White Paper with me but what about areas of alternative medicine? I go along to a private sector person for acupuncture. I know you can get it in some pain clinics in hospitals but I decided to do that myself. It is mainstream in some parts of the NHS and I could foresee a situation where a GP could turn round and say, “Maybe acupuncture is a way of doing it. My commissioning says I can give you one hour and we will see how that goes”, whereas somebody might then go along and say, “For a small charge I will extend what the GP has commissioned”. Do you see things like that could happen? Jane Kennedy: GPs are limited in what they can charge for NHS patients who are on their list. It is a very limited range of services that they can charge for and we have not got any plans to change that. If somebody like yourself was looking for acupuncture provided through a referral from a GP you would not be able to be charged for it unless it was on that very narrow list. In eVect, the patient would have to come oV the NHS list for the doctor to then say, “If you want to go privately”— Ms Winterton: I think NICE is looking at some of the alternative therapies that are available. Q683 Chairman: The White Paper suggests that will be part and parcel of looking after people’s wellbeing. Ms Winterton: If NICE looks at therapies that it thinks are eVective it can, in a sense, recommend those. It might be up to individual PCTs as to whether they want to fund them completely in the first instance. Q684 Chairman: What would you say if you had a private provider who was in deficit and they said they would like to develop some chargeable services at the margins of their activities? Presumably you would not be able to stop them. In the case of a Foundation Trust, if they were to oVer services like this would you say that was simply a matter for the independent regulator? Jane Kennedy: Foundation Trusts are strictly limited in how much private work, if you want to call it that, they can do. They are specifically prevented in law from expanding the private provision that they

provide within that Trust faster than their expansion of service delivery through NHS provision. There is a private patient cap. Chairman: You will know where this is going because we took evidence on this last week from a National Health Service Foundation Trust. I am going to bring Charlotte in now. Q685 Charlotte Atkins: I would be interested to know what your view is of the Jentle midwifery scheme at Queen Charlotte’s. We had evidence from Dame Gill Morgan who said it made her feel slightly uneasy and she described it as an “uncomfortable situation”. What is your view? Jane Kennedy: I would share that view. I have asked for a report arising from the evidence you have received about this and I am looking for oYcials to investigate what has been developed at Queen Charlotte’s. The other response to make is one-toone midwifery support is part of the National Service Framework, it is a commitment we made in our manifesto. The brake on us delivering that is the lack of midwives and we are working hard, as in other areas, to increase the numbers of people in that area. I think it has increased by 2,200. Progress is being made on that score but it is slow. In the meantime I want to really understand what is happening in this particular case because I am also uncomfortable with what I have heard about this example. Q686 Charlotte Atkins: In your view, a one-to-one midwifery service should be available to people on the NHS? Jane Kennedy: Yes. Q687 Charlotte Atkins: It should not be seen as a way of getting half price private treatment? Jane Kennedy: It is what we believe should be the service that women should get from the Health Service, yes. The only reason they are not getting it is because we do not have enough midwives to be able to provide it and that is why we are increasing the numbers and trying to raise the profile of midwifery as a career and promoting it as a career. Q688 Charlotte Atkins: Schemes such as the Jentle midwifery scheme could reduce the number of midwives still further. Jane Kennedy: It has caused a degree of concern to me, yes. Q689 Chairman: Could I ask you a question I asked a witness last week. Do you think there is anything diVerent in principle from that additional charge that there is in Chelsea Hospital to the charge for a prescription? Ms Winterton: In a sense where you have to draw the line is if we were in a situation whereby something that should be provided because it is clinically necessary is being charged for quite independently, that would be very diYcult. The issue of a prescription charge is that it is something which is in law for whatever for reason but it has been accepted as a generalised way of operation, it is a national

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scheme that applies everywhere. The general principles outwith that are that it is sometimes possible for people to provide extra facilities but it is a very fine line when it comes to what is clinical treatment. That would be my instinct. Jane Kennedy: I think as far as this particular case is concerned, if you are a young woman pregnancy and childbirth is probably the single greatest risk to your health that you are going to face in that period of your life and, therefore, if we have established what we believe should be the national standard of service that you should get when you are facing that level of risk I think we should be providing that and that should be a provision the Health Service should provide. In this case what is of particular concern is that what is being oVered is the national standard as opposed to an additional service. Chairman: I think we were told that the only diVerence—they are both deemed to be NHS patients—is you would have a named midwife who would be with you in all prenatal situations and with you at the birth as opposed to having a midwife with you at the birth. Charlotte Atkins: They have extras as well, that was obviously clear. Q690 Chairman: That was my next question. In principle is that what your initial thoughts are about the uneasiness on this? Jane Kennedy: I want to look in detail at what has happened here before coming to any judgment on it. Q691 Chairman: The other thing that was said to us, and I would just like your views on this, and it is quite cold, I accept this, was that this scheme has raised quite a large amount of money for that particular hospital which they have reinvested back into employing people in there and improving their service, as it were, presumably for everybody as opposed to just these people who are paying this extra money. What do you feel about that? Jane Kennedy: We are going to face this kind of initiative happening. We want to be sure that when such initiatives are being taken forward by NHS Trusts, they are doing it in a way which does not set precedents for other examples that we would not wish to see happen. We do need to be well informed about what exactly is being developed. Q692 Charlotte Atkins: Can you just outline what the Government responsibilities are in terms of these sorts of services being oVered by independent hospital Trusts? What responsibilities do you have? They operate independently, so what is the role of the Government in this respect? Ms Winterton: In this particular instance I presume it is a Foundation Trust. Jane Kennedy: No, this one is not. Q693 Charlotte Atkins: In general, if it was an independent Trust, what would your responsibilities be? Ms Winterton: If it was a Foundation Trust then obviously Monitor are given guidelines, as Jane Kennedy set out, as to the extent to which they can

oVer private or add-on facilities. If there was felt to be something going outside of that then it is possible for ministers, in this case it would be Norman Warner, to draw that to the attention of Monitor, particularly if it had been raised by Members of Parliament, the public and so on. Q694 Chairman: The other one that we got information on was a dermatology clinic in Harrogate. I cannot remember exactly, I have not got the letter with me, but they were removing moles and what was described to us as “cosmetic things” and they were charging for that whilst other things were being done on the National Health Service. Do you have any views on that? Ms Winterton: Again, that is something Norman Warner has asked for further information about because it is not quite clear in terms of what I have seen whether in a sense that was cosmetic surgery being oVered or it is something which should be part of the clinical pathway, if you like. Q695 Chairman: One of the things in the letter was about botox. There are botox clinics up and down the land now. If they are oVering that service in an NHS establishment but charging for it, what would your feelings be about that? Obviously it is cosmetic. You would not be against that, would you? Jane Kennedy: I am less concerned about that than I am the maternity example. I do not have the thorough detail but what I understand of the second example is they are oVering services that otherwise would not be available on the NHS because it is treatments that are not being done for clinical reasons and in those circumstances it does not seem to me too unreasonable for a Trust to do that. Q696 Chairman: It is a bit like a large part of dentistry which is cosmetic as opposed to a medical or clinical need. Ms Winterton: It may well be. As I say, I do not know the complete details of it. I know that Norman Warner has asked for more information about it. Chairman: We will be interested to hear your views on that. Q697 Mr Campbell: Now that we have got a lot of private providers coming into the Health Service, do you see the charges increasing over this period of time? Ms Winterton: As we have said, the key to the way that we invited private providers in is to always say that these are services which are provided free to NHS patients. That is the way the contracts are drawn up. There is no question of saying in any sense the patient has to contribute to the cost of their operation. Q698 Mr Campbell: If I want to go to a hospital with a gourmet meal with a glass of wine, a pint of beer in my case, would I have to pay for that? Ms Winterton: I suspect you might, yes. Free beer on the NHS is not necessarily the point.

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Q699 Mr Campbell: These private people are getting in there and doing the business and I expect over time we will get these gourmet meals in hospital but will there be a cap put on it? Ms Winterton: There are issues here that if a private hospital was oVering a service, it would not be able to charge back for the beer because it would be on the tariV as would take place in any other. It might say to you that it was making beer available and you might want a pint, if it was allowed in the circumstances. That might be something that would make you say, “I would quite like to go there because I get a free pint”. Howard is looking horrified by this. Q700 Dr Stoate: Just the opposite. When I was a junior doctor we used to prescribe sherry and brandy for medicinal purposes. Long may it continue. Ms Winterton: Put that in a review. Q701 Mr Amess: I think these Ministers have done a brilliant job of blocking everything that we have slung at them. Ms Winterton: You always say that. Q702 Mr Amess: They have even managed to survive the vicious attacks of Dr Richard Taylor this afternoon! I shall always remember that expression “refine the principles”. On that very point, as far as the National Health Service is concerned, does the Government think that the NHS will have to be redefined so that there will be a core package of services provided by the NHS above which you could have varying degrees of payments according to the income of the patient? This would be the bottom line of what you could get on the NHS and the rest of it, depending on what money the patient had, you could be charged for all sorts of other services. Jane Kennedy: I do not think I accept that scenario. We have brought forward and established National Service Frameworks in a wide range of fields and they set a national standard by which we expect the NHS to deliver services. What we have done is say it does not always have to be provided through an NHS organisation, it is possible to allow other organisations to provide these services albeit paid for by the NHS. In a sense we already have a definition of what services should be available through the NHS. What we have been discussing this morning is where on the edge of that definition it might be possible for NHS organisations and others, and indeed the state, to raise resources by charging. That is the debate that we are having today and we will continue to have, I am sure. Ms Winterton: I think it goes back to the Chairman’s point about the television that he rented during his time in hospital because in a sense that was something that gave a great deal of comfort and relieved the boredom perhaps or whatever. Q703 Chairman: I was in traction at the time.

Ms Winterton: It is about saying if people want some of those extras, if you like, that not everybody wants all the time, they can have those. The very basic principle is that clinically necessary treatment is free and will remain so under this Government. Jane Kennedy: On the point Mr Campbell raised about the gourmet meal and drink, the whole trend of hospital treatment these days is towards a shorter and shorter stay in hospital. You could expect to be genuinely asked the question if you are being oVered a gourmet meal in hospital, what are you doing in hospital when you could be at home? The Health Service is going through a huge amount of change, not just the reforms that we are bringing to it but the way in which treatments are being delivered is being transformed by the way in which new medicines and treatments are being developed and the new innovations that are coming down the road. We have to have a service, a public service, that responds to that as well as providing a service that protects and provides the quality of service that we all expect and demand. Q704 Mr Amess: Finally, looking into your crystal ball, surely it must be the case that in five years’ time there will be more charging because the way things are going with the endless demand there is no way we can keep collecting it all from taxation. Surely it will be the case that in five years there will have to be a lot of charges. Ms Winterton: Do you mean demands for diVerent treatments? Q705 Mr Amess: Yes. Ms Winterton: In a sense that is the system that we have where drugs and treatments are looked at as to whether they are eVective, whether they are safe, whether it is something that should be widespread across the whole of the NHS. There is a system which does look at those issues as to exactly what we can expect the National Health Service to provide but, as I say, that is rather diVerent from what one might talk about as added extras that are not to do with a clinical treatment. Q706 Mr Amess: Surely there is a worry that with an ageing population, okay not in five years but ten, 15, 20 years, with less of a proportion working I do not quite see where the money is going to come from just through taxation because of the huge demands. Jane Kennedy: The prescription charge, if we take that as an example, was 45p in 1979. It rose to about £5.80 in 1998 and it has gone up by 10p a year since then. That is a slowing down in the overall charge rate. When you couple that with the reduction in the number of people who are having to pay, or rather the growing number of people being exempt, then the experience of people in the prescription charge field is that charges are declining in the sense that we are charging fewer people. In the end it is clearly a matter of political judgment as to how far you allow the boundary of charging to encroach. Our position is quite clear: patients should receive the treatment

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that they need at the point they need it and it should be free and not dependent upon their ability to pay, with the exception of prescription charges. Chairman: And dental charges and optician’s charges. Q707 Mr Amess: I am sure that I speak on behalf of everyone, all those who were here last week to hear the evidence from the lady who was suVering from cystic fibrosis, when I say if anything comes out of this inquiry we really, really, really hope that when you look at our report—I understand the reasons for not changing anything but the evidence that we were given last week really moved us. Ms Winterton: Did you have a private Member’s bill on that? Mr Amess: Might have!

Q708 Dr Taylor: A very quick question. Having looked at HC1 I am absolutely horrified. It is the most impossible form anybody could ever have to fill in even if they were 50 with an IQ of 150. Could you consider the Citizens Advice Bureau’s suggestion to “simply state anyone on a means-tested benefit should be eligible for exemption from charges” and look into that and see what that would mean in financial terms. This is horrifying. Jane Kennedy: I am happy to look at what the Citizens Advice Bureau recommended on that score. Chairman: Ministers, could I thank you for coming. I know we have had quite a long session again today but thank you very much indeed. I hope we will be able to make some recommendations that go beyond the review that we have had for the last 25 years.

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Written evidence Supplementary memoranda from the Department of Health (CP 01A) During the session with Department of Health oYcials on NHS charges on 19 January, the Committee asked for two additional pieces of information in relation to optical services. First, they asked for confirmation of the assurances which have been given by the Minister of State for Health Services in relation to the implications of the ophthalmic clauses of the Health Bill. These have been put on the record in Hansard on 11 January.1 Second, the Committee asked for the figures for the real terms increase in expenditure on NHS funded sight tests. These figures are set out in the attached table which is drawn from a recently published Statistical Bulletin for 2004–05 prepared by the Health and Social Care Information Centre. These figures show a 68% real terms increase in expenditure on NHS sight tests between 1994–95 and 2004–05.

Table GENERAL OPHTHALMIC SERVICES EXPENDITURE, ENGLAND, AT 2004–05 PRICES

Financial Year

Total gross expenditure2, 3, 4

£ million Cost of sight test provision5

Cost of glasses provision6

275.0 279.7 286.7 285.5 277.4 321.1 321.3 327.0 318.6 328.5 340.0

112.6 113.4 117.4 121.3 119.5 166.9 171.5 176.0 171.4 178.0 189.1

162.1 166.0 169.0 163.9 157.5 153.5 149.3 150.3 146.5 149.4 149.7

1994–95 1995–96 1996–97 1997–98 1998–99 1999–2000 2000–01 2001–02 2002–037 2003–04 2004–05

Re-used with the permission of the: Family Health Services Authority Annual Accounts (1992–93 to 1995–96), Health Authority Annual Accounts (1996–97 to 1998–99), Health Authority Audited Summarisation Forms (1999–2000 to 2001–02), Strategic Health Authority Audited Summarisation Forms (2002–03), Primary Care Trust Audited Summarisation Schedules (2002–03 to 2004–05) I hope that this provides the Committee with the information sought. Department of Health 1 February 2006

1 2 3 4

5

6

7

HC Deb, 11 January 2006, col 721W. Expenditure is on a resource or accruals basis. Revalued to 2004–05 prices using GDP deflators (December 2005). Includes; cost of grants to supervisors of ophthalmic optical graduate trainees, not counted in the cost of sight tests or the cost of glasses provision. An estimated proportion of total expenditure based on more detailed breakdown of costs available in same year’s cash monitoring data. Comprises fees paid to OOs and OMPs, including payments for domiciliary visits, help given towards private sight tests and employers’ superannuation contributions. An estimated proportion of total expenditure based on more detailed breakdown of costs available in same year’s cash monitoring data. Comprises the cost of vouchers and repairs and replacements. The consistency of data may have been aVected by the changeover in accounting responsibilities from Strategic Health Authorities to Primary Care Trusts from 1 October 2002. Cost of sight tests and glasses estimated, assuming same proportions as in 2001–02.

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PATIENT CHARGES FOR MEDICINES IN SOME OTHER EUROPEAN COUNTRIES

General 1. Co-payment systems for medicines vary considerably from country to country within the EU. The diVerent co-payment arrangements are related to the relevant country’s health care system, and the country’s pricing and reimbursement policies for pharmaceuticals. It is therefore diYcult to make direct comparisons between countries. 2. Broadly speaking the systems can be divided into (1) countries with cap based systems (Sweden, Denmark, Ireland), (2) countries with a fixed charge (UK, Italy), (3) countries with a percentage based charge (Spain, France), and (4) countries which use a mixture of the three (Germany, Finland). 3. However, these are very broad categories, and most systems have an element of other systems in them. For example, in the UK where patients purchase a pre-payment certificate, this places a maximum on the prescription charges that an individual pays in a year. In Denmark and Sweden, patients pay the full cost of their medicines until they reach a threshold and the cap kicks in. The caps usually relate to the maximum amount spent in a month or over a year. 4. In addition, most systems operate with reduced co-payments and exemptions for certain groups. Germany and France exempt the chronically ill, while Spain operates with reduced co-payments for the same group. Other countries also have some form of reduced co-payment or exemptions for certain medical conditions and age. Country

Reduced co-payment and Exemptions

Germany

Under 18 year olds, chronically ill

Spain

Chronically ill, over 65 year olds, the disabled, those injured at work or suVering from toxic syndrome

France

Certain serious diseases, chronic conditions, invalids, expectant mothers, the unemployed, those on low income

Ireland

Long Term Illness Scheme—covers certain medical conditions (diabetes, cystic fibrosis, multiple sclerosis)

UK

Medical exemptions, over 60 years old, under 16 year olds, people on low income, expectant mothers.

5. In all the countries looked at patients must contribute towards their medication, except in the Netherlands where relatively few medicines actually attract a co-payment. 6. Below is a more detailed description of each country’s co-payment system. All information is based on the IMS publication “Concise Guide: Pharmaceutical Pricing & Reimbursement”, published in 2005. There may have been policy changes aVecting the co-payment systems in these countries subsequent to the IMS publication, hence, the information may not be one hundred percent accurate.

Germany 7. According to the 2004 healthcare reform bill, patients have to pay 10% of the cost of their prescribed drugs. However, the minimum patient co-payment per pack is £3.40 (ƒ5) and the maximum is £6.70 (ƒ10). The co-payment can never be more than the price of the drug. Patients are also obliged to pay any diVerence between the reference price and the actual price of the product dispensed. 8. Only the following patients qualify for exemption from co-payments; — Under 18 year olds; — chronically ill patients who have paid out as least 1% of gross family income for medical treatment and services in any full year. Chronically ill persons are defined as those needing to see a doctor at least once every quarter for the same condition, and who also fall into one of the following groupings: patients in nursing care; patients who are severely handicapped or have diminished ability to work; patients in need of continual medical treatment; and — anyone who has paid out at least 2% of their gross income on co-payment charges. 9. Social benefit recipients and families benefit from reduced maximum co-payments.

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Italy 10. Co-payments diVer from region to region. 11. The most common systems are: — co-payments per pack—they usually range from £0.70 (ƒ1) to £1.40 (ƒ2), with a maximum of between £2 (ƒ3) to £3.70 (ƒ5.5) per prescription; and — co-payments per prescription—usually £0.70 (ƒ1) per prescription. Some regions have no prescription charges. 11. In all regions, patients are obliged to pay any diVerence between the reference price and the actual price to secure a drug priced about the reference price level. Spain 12. Patients pay nothing for drugs dispensed in hospitals, 10% for drugs for certain chronic conditions, 40% for the majority of prescription drugs, and 100% for non-reimbursed products and advertisable OTCs. 13. There is a maximum charge for the chronically sick of £1.80 (ƒ2.63) per prescription. Pensioners (over 65), the disabled (with more than 33% disability), as well as those who have been injured at work or suVer from toxic syndrome, are all exempted from any form of co-payment. In 2003, these groups accounted for 69% of reimbursed prescriptions. 14. Under the reference price system all patients who reject substitution and insist on receiving a medication priced above the reference price are obliged to pay the full price of the drug. In reality, this is largely theoretical, as manufacturers have cut their prices. France 15. Patients are liable for the non-reimbursed portion of the drug price (0%, 35% or 65%), although 92% of the population takes out complementary health insurance, provided by Mutuelles or commercial insurers, to cover the cost of co-payments. 16. Full reimbursement is granted for: — drugs prescribed for the treatment of 30 serious diseases; — the treatment of other chronic conditions; — patients requiring multiple therapies; and — exempt patients: invalids, expectant mothers and the unemployed, and those on low incomes with universal sickness coverage. 17. For dugs included in the reference price reimbursement system, patients are required to pay any diVerence between the reference price and the price of the drug dispensed. Few complementary insurance schemes cover the excess over the reference price. Sweden 18. Patients are required to pay the full cost of all reimbursable medicines (except insulin) until they reach a threshold of £63 (SKr 900) over a one-year period from the date of first purchase. Patients then pay a proportion of costs up to £302 (SKr 4,300), above which any additional medicines prescribed are free of charge for the remainder of the year. 19. Around 10–15% of the population qualify under this scheme each year. The cost of prescriptions for children under 18 within a family may be added together. Patients are also liable for any excess if they refuse to accept substitution of the prescribed product. This is not included in the annual accumulated total spend. 20. Patients are issued with an Apoteket card, which is used to access a database storing information on the reimbursement status of the patients. Denmark 21. All reimbursable medicines have equal reimbursement status. Patients are required to pay the full cost of all reimbursable medicines until they reach a threshold of £47 (DKr 520) over a one-year period from the date of first purchase. Patients then pay a proportion of costs up to £343 (DKr 3,805), above which any additional medicines prescribed are free of charge for the remainder of the year. 22. Patients under 18 years of age are not covered by the lower limit of £47. Instead, a reimbursement rate of 50% applies for all expenditure up to £114, before the rates for over 18s kick in. There are no general exemptions, although the poor and pensioners in financial need can get help paying for their medicine from the local authority.

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23. Each pharmacy uses the Danish Medicines Agency’s nationwide database, the Central Reimbursement Register, which ensures that patients receive the correct reimbursement rate. 24. Hospital patients are not required to pay for their medicines. Finland 25. Patients are required to contribute the following: — drugs in the basic refund category: £6.70 (ƒ10), plus 50% of the remaining cost; — lower special reimbursement category: £3.40 (ƒ5), plus 25% of the remaining cost; and — upper special reimbursement category: £3.40 (ƒ5). 26. The co-payment is valid for all prescriptions in the same reimbursement category collected by the patient at the same time. For instance, if a patient has three diVerent prescriptions for the basic refund category, there is a single charge of £6.70 (ƒ10) and reimbursement is 50% of the total sum exceeding £6.70. 27. The annual limit for a patient’s expenses on reimbursable drugs was set at £407 (ƒ604.72) in 2004. If this sum is exceeded by more than £11 (ƒ16.82), the patient receives full reimbursement. 28. The reimbursement scheme reimbursed 64.5% of medicine expenses in 2003. Ireland 29. Medical cards, held by around 29% of the population, entitle patients to free medication. A smaller proportion of people (2%) are also eligible to receive free medication through the Long Term Illness Scheme, which covers 15 listed medical conditions, including diabetes, cystic fibrosis and multiple sclerosis. Only drugs for the treatment of the patient’s listed conditions are provided without a co-payment. 30. Patients who do not qualify for a medical card and are required to pay their prescription drug costs in full can apply for a Drugs Payment Scheme Card on an individual or family basis. Under the scheme, patients contribute up to £52 (ƒ78) a month towards the cost of their prescriptions. Once this threshold is exceeded, the Health Board pays the remainder of the bill. 36% of the population applied for the card in 2003. Netherlands 31. Under the reimbursement scheme, only products listed Annex 1A of the positive list require patients to make a co-payment. (Annex 1A: similar interchangeable products reimbursed according to a reference price system.) Even in Annex 1A patients receive reimbursed medical products free of charge unless the product is priced above the maximum reimbursement level. As manufacturers tend to bring the price of their products down to the reimbursement level to maintain market share by avoiding patients having to pay outof-pocket, relatively few products attract a co-payment. Patient’s co-payment constituted 0.5% of total pharmaceutical expenditure in 2003. Including payment for OTC products, the proportion rose to 3.5%. Department of Health February 2006 CHARGING OPTIONS FOR PRESCRIPTION CHARGES, DENTAL AND OPTICAL CHARGES CONSIDERED AS PART OF THE 1998 CSR PRESCRIPTION CHARGES Introduction This paper sets out the scenarios that were analysed in relation to prescription charges, dental charges and eligibility for optical services as part of the Comprehensive Spending Review in 1998. Ministers decided to make no change to prescription charges and dental charges as a result of the review. Free sight tests for those aged 60 and over were re-introduced in 1999. Medical exemptions — Restriction of medical exemption to items intended to treat the qualifying condition—estimated savings of £15–£20 million per year. — Increasing the list of exemptions to include other exemptions—it was concluded that it was not possible to estimate the cost prior to agreement on the additional conditions to be included and an assessment of the medicine utilisation of the groups concerned.

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Health Committee: Evidence Ev 107

Prescription charge for over 60s as income threshold — Introduce prescription charges for those aged 60 or over with an income above a defined income threshold—the savings would depend upon the threshold above which those aged 60 or over were required to pay charge. Low flat rate charge with no exemptions with annual pre-payment certificate charge available at 25 times the prescription charge. — A flat rate of £1 per item with no exemptions would save £120 million. — A £2 charge per item would produce additional charge income of £410 million. A medium flat rate charge (eg £4.00) with exemptions for all children up to age 18 and for non disablement pensioners, possibly with a more generous low income exemption, but without automatic exemptions for other exempt groups. — A charge of £4.00 was estimated to produce additional income for the NHS of around £250 million a year. Introduce a system of co-payments which linked the charge payable to the cost and/or relative eVectiveness of the item dispensed. — The increase or reduction for such a system would depend upon the level of the charge and the exemptions from that charge. Charge per prescription rather than by item — A charge per script would limit outlay for patients requiring more than one item. It was estimated that this would reduce prescription charge income by £50 million. It was estimated that other costs would result from a change in patient behaviour such as where medicines that otherwise were purchased over the counter would be added to a prescription. Dental charges — Free dental examinations for all NHS patients—estimated cost £120 million per annum. — Free dental examinations for those aged 60 or more—estimated cost £20 million a year. Sight tests — Universal eligibility for NHS sight tests—estimated cost £120 million per annum. — Free sight tests for those aged 60 or more—estimated cost £30 million. Cross cutting issue — Extend exemption for free prescriptions, dental treatment, sight tests and optical vouchers available to 16 to 18 olds in full time education to all young people in this age range. — The cost of this option was estimated to be £5 million per annum. Review the low income scheme — This was discussed in principle but no details were considered. Department of Health February 2006 PRESCRIPTION CHARGES FOR HOSPITAL PATIENTS The Committee raised the question of a directive from the Department about out-patient charges and that anyone who had been in hospital less than 24 hours should pay a charge for the drugs they take away with them. The position is that no “directive” has been issued. The 1977 NHS Act itself provides that no charge shall be made for a patient who is residing in hospital. We do not have a definition of “residing” in the Charges Legislation but if asked we advise that this would involve an overnight stay. We do not mention “less than 24 hours”. If the patient has had an overnight stay, their discharge medication would be free of charge because it was supplied to them while they were still residing in hospital. It would be for the Trust to apply the Charges Legislation and to decide if a patient was “residing” at the time medication was supplied to them.

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Ev 108 Health Committee: Evidence

HOSPITAL PARKING SPACES AND INCOME

England

Total parking spaces

Income from staV Parking £

Income from visitor Parking £

378,720

15,130,961

62,755,934

Notes: Figures provided on a voluntary basis. 80% of NHS Hospital Trusts responded. Source Estates Return Information Collection 2004–05.

Trust Name New Forest PCT Norwich PCT South Gloucestershire PCT Havering PCT Kingston PCT Bromley PCT Greenwich PCT Barnet PCT South Manchester PCT Daventry and South Northamptonshire PCT North Peterborough PCT South Peterborough PCT Tendring PCT Epping Forest PCT Southend-on-Sea PCT Central Derby PCT Mansfield District PCT North East Lincolnshire PCT Newark and Sherwood PCT Hillingdon PCT Airedale PCT Enfield PCT Barking and Dagenham PCT City and Hackney PCT Tower Hamlets PCT Newham PCT Haringey Teaching PCT Blackburn with Darwen PCT North Dorset PCT Bournemouth PCT Bradford City PCT Bradford South and West PCT North Bradford PCT Doncaster Central PCT Central Manchester PCT Dartford Gravesham and Swanley PCT Herefordshire PCT Hertsmere PCT Milton Keynes PCT

Total parking spaces available No 322 996 416 553 211 301 359 671 166 204 50 21 554 51 283 86 444 88 64 571 223 1,219 210 218 254 426 333 486 59 290 190 179 111 299 397 415 70 516

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

164 52 142 158 173 175 50 21 — 49 — 59 287

— — — — — — — — — — — — — — — — —

— 48,615 — — — — — — — — — — — — — — —

61 299 211 550

— — — 4,680

— — — —

210 2 229 407 287 405 12 — 207 138 111 — 382 2

— 14,003 — — — — — — — — — — — —

— 5,110 — — — — — — — — — — — —

199





322 215 296

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Unit: PAG6

Health Committee: Evidence Ev 109

Trust Name North Manchester PCT South Hams and West Devon PCT Torbay PCT TraVord South PCT West Norfolk PCT Solihull PCT West Lincolnshire PCT Lincolnshire South West Teaching PCT Carlisle and District PCT Eden Valley PCT West Cumbria PCT Newcastle PCT North Tyneside PCT Hartlepool PCT Harlow PCT Morecambe Bay PCT North Hampshire PCT Isle of Wight PCT West Wiltshire PCT South Wiltshire PCT Newbury and Community PCT Reading PCT Slough PCT Wokingham PCT Vale of Aylesbury PCT Burntwood Lichfield and Tamworth PCT Wyre Forest PCT North East Oxfordshire PCT Cherwell Vale PCT Oxford City PCT South East Oxfordshire PCT South West Oxfordshire PCT North Tees PCT Selby and York PCT East Yorkshire PCT Yorkshire Wolds and Coast PCT Eastern Hull PCT West Hull PCT Eastern Wakefield PCT Wakefield West PCT Mid-Hampshire PCT Chesterfield PCT Gedling PCT Amber Valley PCT North SheYeld PCT North Lincolnshire PCT North Eastern Derbyshire PCT Melton Rutland and Harborough PCT Leicester City West PCT Doncaster East PCT

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

219 208 143 209 256 462 284 132 137 324 518 —

226 178 82 143 260 107 153 67 51 324 262

— — — — — 13,646 — — — — —

— 1,856 — — — — — — — — —

50 94 756 361 25 501 75 273 343 330 170 221 586 169 29 123 123 153 435 172 641 352 196 306 124 207 141 40 545 48 349 32 252 363 900 190 193

25 12

— —

— —

360 25 — — 158 343 330 170 219 — 101 25 94 62 129 344 138 251 207 132 306 119 207 131 2 541 — 343 32 252 354 884 — 193

— — — — — — — — — — — — — — — — — — — — — — — 2,400 — — — — — — — — — —

— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —

Total parking spaces available No

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Unit: PAG6

Ev 110 Health Committee: Evidence

Trust Name Doncaster West PCT Nottingham City PCT SheYeld West PCT SheYeld South West PCT South East SheYeld PCT Erewash PCT Bassetlaw PCT Broxtowe and Hucknall PCT Greater Derby PCT Eastern Leicester PCT Plymouth PCT Chorley and South Ribble PCT West Lancashire PCT Heywood and Middleton PCT Salford PCT TraVord North PCT Stockport PCT Bebington and West Wirral PCT Southport and Formby PCT Ashfield PCT RushcliVe PCT East Hampshire PCT Portsmouth City PCT South West Kent PCT Bexhill and Rother PCT Hastings and St Leonards PCT Mid-Sussex PCT Bath and North East Somerset PCT West of Cornwall PCT South and East Dorset PCT South West Dorset PCT North Devon PCT Exeter PCT East Devon PCT Mid Devon PCT Somerset Coast PCT Mendip PCT Teignbridge PCT Southern Norfolk PCT Bracknell Forest PCT Windsor Ascot and Maidenhead PCT Chiltern and South Bucks PCT Blackwater Valley and Hart PCT Hyndburn and Ribble Valley PCT Burnley Pendle and Rossendale PCT North Liverpool PCT Luton PCT Bedford PCT Bedfordshire Heartlands PCT Huntingdonshire PCT

Total parking spaces available No 127 — 50 92 67 290 147 227 226 208 878 226 358 36 170 238 384 136 173 130 174 388 773 276 126 52 263 448 535 607 402 250 332 650 365 194 119 241 215 92 500 119 155 340 56 102 353 213

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

127 — 15 92 67 243 127 174 19 — 878

— — — — — — — — — — —

— — — — — — — — — — —

278 36

10,821 —

6,573 —

119 — — — 92 —

— — — — — —

— — — — — —

381 184 — — 263 339 388 207 382 80 313 567 335 91

— — — — — — — — 133 — 9,019 — — 4,500

— — — — — — — — 11,193 13,000 7,382 — — 14,600

163 59 92 500 119

— — — — —

— — — — —

282 — 25 69 348 158

— — — — — —

— — — — — —

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Unit: PAG6

Health Committee: Evidence Ev 111

Trust Name Welwyn Hatfield PCT North Hertfordshire and Stevenage PCT South East Hertfordshire PCT Royston Buntingford and Bishop’s Stortford PCT Maldon and South Chelmsford PCT Colchester PCT Uttlesford PCT Billericay Brentwood and Wickford PCT Thurrock PCT Basildon PCT Great Yarmouth PCT Watford and Three Rivers PCT Dacorum PCT St Albans and Harpenden PCT Hammersmith and Fulham PCT Birkenhead and Wallasey PCT Cheshire West PCT Central Cheshire PCT Eastern Cheshire PCT Ellesmere Port and Neston PCT Derbyshire Dales and South Derbyshire PCT Rotherham PCT East Lincolnshire PCT Central Liverpool PCT South Liverpool PCT Preston PCT Fylde PCT Wyre PCT Ashton Leigh and Wigan PCT Leeds West PCT Leeds North East PCT East Leeds PCT South Leeds PCT Leeds North West PCT High Peak and Dales PCT Blackpool PCT Bolton PCT StaVordshire Moorlands PCT Dudley South PCT Dudley Beacon and Castle PCT Newcastle-under-Lyme PCT Ealing PCT Hounslow PCT Halton PCT Warrington PCT St Helens PCT Knowsley PCT Oldham PCT Calderdale PCT North Kirklees PCT

Total parking spaces available No 152 191 — 280 153 1,069 122 213 122 151 50 310 57 72 43 632 337 345 49 178 101 368 491 491 212 857 289 66 171 120 144 — 140 211 388 137 506 289 485 438 300 414 473 275 535 350 340 505 236 177

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

52 191

20,872 —

— —

282 93

— —

47,906 —

122 — 64

— — —

— — —

43 200 21

— — —

— — —

506





57 368 192 156 49 857 — 66 113 31 144 — 34 144 388 137 — 138 — —

— — — — — — — — 5,640 — — — — — — — — — — —

— — 14,350 — — — — — — — — — — — — — — — — —

330 165 120 148 — 58

— — — — — —

— — — — — —

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Unit: PAG6

Ev 112 Health Committee: Evidence

Trust Name Durham Dales PCT Darlington PCT Hinckley and Bosworth PCT Charnwood and North West Leicestershire PCT South Leicestershire PCT Barnsley PCT Bristol North PCT Bristol South and West PCT Cambridge City PCT South Cambridgeshire PCT East Cambridgeshire and Fenland PCT Broadland PCT North Norfolk PCT Chelmsford PCT Castle Point and Rochford PCT Ipswich PCT SuVolk Coastal PCT Central SuVolk PCT Waveney PCT SuVolk West PCT Bury PCT Rochdale PCT South Somerset PCT Taunton Deane PCT Swindon PCT Kennet and North Wiltshire PCT Brent PCT Harrow PCT Camden PCT Islington PCT Croydon PCT Derwentside PCT Durham and Chester-le-Street PCT Easington PCT Sedgefield PCT Gateshead PCT South Tyneside PCT Hambleton and Richmondshire PCT Craven Harrogate and Rural District PCT Scarborough Whitby and Ryedale PCT Sunderland Teaching PCT Middlesbrough PCT Langbaurgh PCT East Elmbridge and Mid Surrey PCT East Surrey PCT North and East Cornwall PCT Central Cornwall PCT Poole PCT Cheltenham and Tewkesbury PCT West Gloucestershire PCT

Total parking spaces available No

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

160 176 155 990 114 780 384 387 198 152 447 219 315 51 82 48 87 116 148 171 195

130 23 155 — — — 224 180 198 152 447 61 94 — — — — — — — 208

— 22,776 — — — — — — — — — — — — — — — — — — —

— — — — — — — — — — — — — — — — — — — — —

118 122 292 844 180 111 156 69 211 22 149 24 120 113 206 245 886 281 560 401 385 — 60 372 284 96 170 310

118 25 — — 46 111 — — 82 5 56

— — — — 10,201 — — — — — 6

— — — — 22,726 — — — — — 6

60 113 116 193 456 225 224 401 385 — 40 372 209 50

— — — — — — — — — — — — — —

— — — — — — — — — — — — — —

62





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Unit: PAG6

Health Committee: Evidence Ev 113

Trust Name Cotswold and Vale PCT Southampton City PCT Maidstone Weald PCT Medway PCT Swale PCT Guildford and Waverley PCT North Surrey PCT Surrey Heath and Woking PCT Adur Arun and Worthing PCT Western Sussex PCT Kensington and Chelsea PCT Westminster PCT Lambeth PCT Southwark PCT Lewisham PCT Wandsworth PCT Tameside and Glossop PCT Huddersfield Central PCT South Huddersfield PCT Ashford PCT Canterbury and Coastal PCT East Kent Coastal PCT Shepway PCT Eastbourne Downs PCT Sussex Downs and Weald PCT Northamptonshire Heartlands PCT Northampton PCT Fareham and Gosport PCT Eastleigh and Test Valley South PCT South Birmingham PCT Shropshire County PCT Walsall PCT South Sefton PCT Richmond and Twickenham PCT Sutton and Merton PCT North Somerset PCT Rugby PCT Crawley PCT Horsham and CHanctonbury PCT Coventry PCT North Stoke PCT South Stoke PCT Oldbury and Smethwick PCT Rowley Regis and Tipton PCT Wednesbury and West Bromwich PCt Telford and Wrekin PCT East StaVordshire PCT Cannock Chase PCT South Western StaVordshire PCT North Warwickshire PCT

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

352 757 67 310 285

— — — — —

— — — — —

306 193 149 121 36 12 57 54 133 309 486 — —

— — — — 9,180 2,562 — — — — — — —

— — — — — 9,712 — — — — — — —

— 257 257 5

— — — —

— — — —

44





166 293 103 51 262 92 26

— — — — — — —

— — — — — — —

288







836 446 157 144

46

5,259

22,610

165 144

— —

— —

— 68 117 223 1,051

0 — — 12 1,042

0 — — — —

— — — — —

Total parking spaces available No 535 757 259 426 419 753 878 427 368 384 126 86 144 200 276 604 486 96 114 184 227 367 72 189 408 527 177 559 55 677 649 1,103 241 104 798 94 26

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Unit: PAG6

Ev 114 Health Committee: Evidence

Trust Name South Warwickshire PCT Redditch and Bromsgrove PCT South Worcestershire PCT Wolverhampton City PCT North Birmingham PCT Heart of Birmingham Teaching PCT Eastern Birmingham PCT Redbridge PCT Waltham Forest PCT Royal Surrey County Hospital NHS Trust Weston Area Health NHS Trust East Somerset NHS Trust United Bristol Healthcare NHS Trust South Devon Health Care NHS Trust Bradford Teaching Hospitals NHS Foundation Trust Southend Hospital NHS Trust Royal Free Hampstead NHS Trust The Royal National Orthopaedic Hospital NHS Trust North Middlesex University Hospital NHS Trust The Hillingdon Hospital NHS Trust North East London Mental Health NHS Trust Kingston Hospital nHS Trust Avon Ambulance Service NHS Trust Essex Ambulance Service NHS Trust Gloucestershire Ambulance Services NHS Trust Mersey Regional Ambulance Service NHS Trust StaVordshire Ambulance Service NHS Trust South Yorkshire Ambulance Service NHS Trust Taunton and Somerset NHS Trust Royal National Hospital for Rheumatic Diseases NHS Foundation Trust West Dorset General Hospitals NHS Trust NuYeld Orthopaedic NHS Trust Walsall Hospitals NHS Trust Wirral Hospital NHS Trust St Helens and Knowsley Hospitals NHS Trust The Cardiothoracic Centre Liverpool NHS Trust Royal Liverpool Childrens NHS Trust The Mid Cheshire Hospitals NHS Trust Christie Hospital NHS Trust Lincolnshire Ambulance and Health Transport Service NHS Trust Northern Devon Healthcare NHS Trust Bedford Hospitals NHS Trust Ealing Hospital NHS Trust Luton and Dunstable Hospital NHS Trust York Health Services NHS Trust Scarborough and North East Yorkshire Health Care NHS Trust

Total parking spaces available No

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

532 376 570 666 121 447 448 200 276 1,162 868 518 1,030 1,650

206 338 370 — — —

1,233 — — — — —

44,931 16,929 — — — —

109 451 334 183 252 350





— 12,500 137,214 80,555

272,529 103,893 284,256 337,764

1,072 394

540 231 148

696,000 — 116,370

861,000 548,369 267,506

589

528

22,200



1,877 739 797 291

374



444,383

— 5 15 225 2 30 387

— — — — — — 210,407

— — — — — — 350,093







90 250 1,104 797

16,952 48,000 — —

133,286 380,000 — 281,214

819





245

54,464

138,567

331 1,000 1,113 628 1,053 1,119

309 836 164 406 437

72,578 24,444 — — 76,516

238,858 152,431 189,957 914,352 380,026

1,012

869



195,000

196 228 89 245 1,263 22 848 443 1,355 2,358 1,699 155 1,025 1,733 653

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Unit: PAG6

Health Committee: Evidence Ev 115

Trust Name Harrogate and District NHS Foundation Trust Airedale NHS Trust Nottingham City Hospital NHS Trust SheYeld Children’s NHS Trust Queen Elizabeth Hospital Kings Lynn NHS Trust Royal United Hospital Bath NHS Trust Poole Hospitals NHS Trust Heatherwood and Wexham Park Hospitals NHS Trust Milton Keynes General Hospital NHS Trust Basildon and Thurrock University Hospitals NHS Foundation Trust Essex Rivers Healthcare NHS Trust South DOWNS Health NHS Trust Frimley Park Hospital NHS Foundation Trust Dorset Health Care NHS Trust Royal Bournemouth and ChrisTchurch Hospitals NHS Foundation Trust Cumbria Ambulance Service NHS Trust South Tyneside NHS Foundation Trust Royal Cornwall Hospitals NHS Trust Aintree Hospitals NHS Trust Clatterbridge Centre for Oncology NHS Trust Liverpool Womens NHS Foundation Trust Walton Centre for Neurology and Neurosurgery NHS Trust Barking Havering and Redbridge Hospitals NHS Trust Barnsley Hospital NHS Foundation Trust Queen’s Medical Centre Nottingham University Hospital NHS Trust The Rotherham NHS Foundation Trust Chesterfield Royal Hospital NHS Foundation Trust Bedfordshire and Hertfordshire Ambulance and Paramedic Service NHS Trust West Middlesex University NHS Trust Queen Elizabeth Hospital NHS Trust Bromley Hospitals NHS Trust Whipps Cross University Hospital NHS Trust Leeds Mental Health Teaching NHS Trust West Yorkshire Metropolitan Ambulance Service NHS Trust Papworth Hospital NHS Foundation Trust Peterborough and Stamford Hospitals NHS Foundation Trust James Paget Healthcare NHS Trust Ipswich Hospital NHS Trust West SuVolk Hospitals NHS Trust Cambridge University Hospitals NHS Foundation Trust Queen Mary’s Sidcup NHS Trust

Total parking spaces available No

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

1,403 2,000 215 1,082 1,145 1,462

331 590 800

120,499 — 192,369

302,101 — 748,004

621 437 267

93,330 114,090 232,790

372,119 599,288 390,499

1,944 1,274

585 465

— 74,403

475,000 337,733

1,368



1,039,481

— 340 12

— 101,828 —

— 683,271 —

2,483 2,368 318

598 — 49 732 375 97

— — 79,246 63,043 145,000 —

476,708 — 290,005 474,301 587,000 —

298

74

30,096

84,952

3,214

718 368

— 47,000

1,013,029 313,000

2,415 1,076

794 1,076

352,751 —

636,804 234,922

272

40,203

352,249







351 453 326 393

115,087 — — —

413,377 356,866 350,000 —

135





1,503 1,804 1,275

498 432 1,225



458,187

412,000

188,000

854

997 316

276,152 2,000

1,151,556 148,000

1,475 730 1,298 634 1,905 192

352 810 640 971 1,071 863 601

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Unit: PAG6

Ev 116 Health Committee: Evidence

Trust Name Royal Berkshire Ambulance Service NHS Trust Somerset Partnership NHS and Social Care Trust Royal Devon and Exeter NHS Foundation Trust Nottinghamshire Healthcare NHS Trust Southampton University Hospitals NHS Trust Dorset Ambulance NHS Trust SheYeld Teaching Hospitals NHS Foundation Trust Wiltshire Ambulance Service NHS Trust Portsmouth Hospitals NHS Trust Royal Berkshire and Battle Hospitals NHS Trust Oxfordshire Learning Disability NHS Trust Two Shires Ambulance NHS Trust Guy’s and St Thomas’ NHS Foundation Trust The Lewisham Hospital NHS Trust St Mary’s NHS Trust Mayday Healthcare NHS Trust St George’s Healthcare NHS Trust Cornwall Partnership NHS Trust West Country Ambulance Services NHS Trust South Warwickshire General Hospitals NHS Trust Mid StaVordshire General Hospitals NHS Trust University Hospital of North StaVordshire NHS Trust Burton Hospitals NHS Trust Good Hope Hospital NHS Trust Northern Lincolnshire and Goole Hospitals NHS Trust East Cheshire NHS Trust Countess of Chester NHS Foundation Trust Calderstones NHS Trust King’s College Hospital NHS Trust Sherwood Forest Hospitals NHS Trust Plymouth Hospitals NHS Trust West Midlands Ambulance Service NHS Trust University Hospitals Coventry and Warwickshire NHS Trust Hampshire Ambulance Service NHS Trust The Whittington Hospital NHS Trust West London Mental Health NHS Trust Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust The Royal Wolverhampton Hospitals NHS Trust Hereford and Worcester Ambulance Service NHS Trust Coventry and Warwickshire Ambulance NHS Trust City Hospital Sunderland NHS Foundation Trust Hereford Hospitals NHS Trust George Eliot Hospital NHS Trust Birmingham Women’s Health Care NHS Trust

Total parking spaces available No

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

281 536

197 —

— —

— —

2,391 3,194 96

543 1,178 50

— 368,705 —

— 1,405,556 —

— 2,367 1,774 155 280 278 219

— 1,096 432 84 — 252 40 —

— — 98,300 — — 418,152 20,004 54,000

— 1,119,602 689,000 — — 641,272 253,563 —

1,159 449 515 1,051 1,315

516 418 21 362 508

181,199 — — — 63,168

605,276 — — 487,574 451,639

3,329 997 965

1,062 412 235

114,998 — 89,057

521,998 403,876 528,000

2,423 1,287

925





504 129 —

14,198 — —

370,378 — —

676

146,000

700,000

2,492 324 115 1,502

1,599 — 105 878

— — 32,114 —

267,019 — 15,634 37,459

620 1,797

620 411

— —

29,970 637,513

















491 1,241 547

1,200 173 312 40

135,455 — 92,000 23,457

238,387 — 227,000 53,073

493 703 1,647 2,143 500

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Unit: PAG6

Health Committee: Evidence Ev 117

Trust Name North StaVordshire Combined Healthcare NHS Trust Norfolk and Norwich University Hospital NHS Trust South Manchester University Hospitals NHS Trust Salford Royal Hospitals NHS Trust TraVord Healthcare NHS Trust Northgate and Prudhoe NHS Trust Greater Mancehster Ambulance Service NHS Trust Bolton Hospitals NHS Trust Lancashire Ambulance Service NHS Trust Tameside and Glossop Acute Services NHS Trust Norfolk and Waveney Mental Health Partnership NHS Trust East Anglian Ambulance NHS Trust Winchester and Eastleigh Healthcare NHS Trust Swindon and Marlborough NHS Trust North Hampshire Hospitals NHS Trust Dartford and Gravesham NHS Trust Dudley Group of Hospitals NHS Trust Newham Healthcare NHS Trust Barts and The London NHS Trust Tavistock and Portman NHS Trust North Cumbria Acute Hospitals NHS Trust North Cumbria Mental Health and Learning Disabilities NHS Trust Newcastle North Tyneside and NorthumberLand Mental Health NHS Trust Kettering General Hospital NHS Trust Northampton General Hospital NHS Trust Oxfordshire Mental Healthcare NHS Trust Oxfordshire Ambulance NHS Trust Salisbury Health Care NHS Trust Northamptonshire Healthcare NHS Trust Great Ormond Street Hospital for Children NHS Trust Doncaster and Bassetlaw Hospitals NHS Foundation Trust Moorfields Eye Hospital NHS Foundation Trust Lincolnshire Partnership NHS Trust Medway NHS Trust Queen Victoria Hospital NHS Foundation Trust Oxleas NHS Trust Kent Ambulance NHS Trust Worthing and Southlands Hospitals NHS Trust Surrey Ambulance Service NHS Trust Royal West Sussex NHS Trust The Royal Marsden NHS Foundation Trust Sussex Ambulance Service NHS Trust Birmingham Children’s Hospital NHS Trust

Total parking spaces available No

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

849 2,876 2,399 2,087 744 541

914 573 417

470,000 380,000 415,716

518 700,000 641,978

525





457 1,742 390 1,074

— 401 20 777

— 17,273 — 105,846

— — 398,467

981 472 1,418 1,381 1,301 1,185 2,132 687 446 103 1,404

981





437 453 336 — 216 32 6 611

87,000 138,000 — — — 69,000 61,097 35,000 73,595

532,000 674,000 217,854 — 186,671 — — — 113,096

354

271





193 1,142 1,780 700 69 1,887 1,094

600 660 220 22 490 1,094

— 33,417 8,154 — 31,116 —

214,979 434,131 38,350 — 304,084 —









893 — 329 488 122 1,084 — 360

63,560 — — 182,000 — — — 92,807 — 18,000 50,000 — 91,389

205,617 — — 804,000 46,240 — — 649,733 — 520,000 180,000 — —

757 1,692 1,462 285 1,041 — 1,141 53 468

448 195 1 69

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Unit: PAG6

Ev 118 Health Committee: Evidence

Trust Name Royal Liverpool and Broadgreen University Hospitals NHS Trust Mid Essex Hospital Services NHS Trust Chelsea and Westminster Healthcare NHS Trust Hammersmith Hospitals NHS Trust Hinchingbrooke Health Care NHS Trust The Princess Alexandra Hospital NHS Trust Homerton University Hospital NHS Foundation Trust South West London and St George’s Mental Health NHS Trust Heart of England NHS Foundation Trust Isle of Wight Healthcare NHS Trust Gateshead Health NHS Foundation Trust Leeds Teaching Hospitals NHS Trust North Essex Mental Health Partnership NHS Trust South StaVordshire Healthcare NHS Trust Wrightington Wigan and Leigh NHS Trust Royal Orthopaedic Hospital NHS Trust University Hospital Birmingham NHS Foundation Trust Barnet Enfield and Haringey Mental Health NHS Trust London Ambulance Service NHS Trust University College London Hospitals NHS Foundation Trust Cambridgeshire and Peterborough Mental Health Partnership NHS Trust Pennine Care NHS Trust Royal Brompton and Harefield NHS Trust Leicestershire Partnership NHS Trust SuVolk Mental Health Partnership NHS Trust County Durham and Darlington Priority Services NHS Trust The Newcastle upon Tyne Hospitals NHS Trust Gloucestershire Hospitals NHS Foundation Trust Northumbria Health Care NHS Trust Derby Hospitals NHS Foundation Trust Oxford RadcliVe Hospital NHS Trust Surrey Hampshire Borders NHS Trust Ashford and St Peter’s Hospitals NHS Trust East Kent NHS and Social Care Partnership Trust Surrey Oaklands NHS Trust Surrey and Sussex Healthcare NHS Trust Gloucestershire Partnership NHS Trust South Tees Hospitals NHS Trust 5 Boroughs Partnership NHS Trust Morecambe Bay Hospitals NHS Trust Tees East and North Yorkshire Ambulance Service NHS Trust

Total parking spaces available No

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

1,607 2,126 360 1,043 943 558

139 715 160 166 301 212

252,079 64,282 78,893 498,751 76,607 39,995

225,432 624,063 267,517 277,875 288,332 318,164

3,974

574 1,129 289 809

285,360 56,000 88,400 819,029

997,519 250,000 277,800 661,824

790 988 1,670 344

760 — 417 293

— — 129,280 —

— — 461,830 —

590

117,000

1,500,000

1,188 1,042

728 78

— —

— —

1,143 1,243 695 901 260

1,143 1,022 145 901 175

— — 50,000 — —

— — — — —

822 3,840

762 1,258

— 426,098

— 1,039,136

2,432

1,054 23 1,049

— — 132,664

325,002 — 1,261,758

565



642,590

250 293 221

— — 6

— 527,378 6

655 634

— 74,369

— 352,370

72





1,278 2,758 1,129

3,697 254 1,790 506 250 1,267 618 2,574 615 2,116 80

3312493005

Page Type [O]

12-07-06 01:32:43

Pag Table: COENEW

PPSysB

Unit: PAG6

Health Committee: Evidence Ev 119

Trust Name Central and North West London Mental Health NHS Trust South London and Maudsley NHS Trust East Midlands Ambulance Service NHS Trust Bedfordshire and Luton Community NHS Trust North West London Hospitals NHS Trust Humber Mental Health Teaching NHS Trust North Bristol NHS Trust North East Ambulance Service NHS Trust Barnet and Chase Farm Hospitals NHS Trust Avon and Wiltshire Mental Health Partnership NHS Trust Epsom and St Helier NHS Trust East Kent Hospitals NHS Trust North Tees and Hartlepool NHS Trust Tees and North East Yorkshire NHS Trust Southport and Ormskirk Hospital NHS Trust Hampshire Partnership NHS Trust Central Manchester and Manchester Children’s University Hospitals NHS Trust Mersey Care NHS Trust Lancashire Care NHS Trust Pennine Acute Hospitals NHS Trust North West Surrey Mental Health NHS Partnership Trust West Sussex Health and Social Care NHS Trust South of Tyne and Wearside Mental Health NHS Trust Hull and East Yorkshire Hospitals NHS Trust United Lincolnshire Hospitals NHS Trust University Hospitals of Leicester NHS Trust Maidstone and Tunbridge Wells NHS Trust West Hertfordshire Hospitals NHS Trust East and North Hertfordshire NHS Trust Stockport NHS Foundation Trust East London and The City Mental Health NHS Trust South Essex Partnership NHS Trust Worcestershire Acute Hospitals NHS Trust Worcestershire Mental Health Partnership NHS Trust Hertfordshire Partnership NHS Trust Buckinghamshire Mental Health NHS Trust Devon Partnership NHS Trust North Cheshire Hospitals NHS Trust Berkshire Healthcare NHS Trust Calderdale and Huddersfield NHS Trust Cheshire and Wirral Partnership NHS Trust East Sussex Hospitals NHS Trust East Sussex County Healthcare NHS Trust Doncaster and South Humber Healthcare NHS Trust

Total parking spaces available No

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

280 1,059 660 555 2,604 777 3,495 78 1,890







819 744 895 13 749

247,155 — — — 7,279

1,154,337 7,684 526,560 — 1,100,922

2,136 1,849 3,165 2,434 1,700 1,470 1,090

1,211 542 991 944 1,333 566 1,021

— — 111,000 245,790 — 206,000 —

— 1,037,500 1,319,113 860,043 — 656,200 —

3,676 2,437 715 4,595

686 1,435

701,161 —

385,249 —

3,083

338,631

1,114,564

87 564

318 4

— 191

— 5,342

494 3,094 3,699 4,049 2,439 730 2,142

457 3,094 1,302 1151 1,243 845 734 719

— 8,500 — — — — 148,818 144,983

— 753,601 1,104,542 — 315,000 — 483,840 301,849

260 937 2,544

96 — 876

— — —

— —

652 1,167 353 615 1,839 277 1,637 1,090 2,079 683

375 — 381 — 602 240 496 524 550

— — — — — 38 66,673 — —

— — — — 430,000 — 207,406 — 648,000

803

778





3312493005

Page Type [E]

12-07-06 01:32:43

Pag Table: COENEW

PPSysB

Unit: PAG6

Ev 120 Health Committee: Evidence

Trust Name Mid Yorkshire Hospitals NHS Trust South West Yorkshire Mental Health NHS Trust Brighton and Sussex University Hospitals NHS Trust West Kent NHS and Social Care Trust Sandwell and West Birmingham Hospitals NHS Trust Blackpool Fylde and Wyre Hospitals NHS Trust Derbyshire Mental Health Services NHS Trust Lancashire Teaching Hospitals NHS Foundation Trust County Durham and Darlington Acute Hospitals NHS Trust Buckinghamshire Hospitals NHS Trust East Lancashire Hospitals NHS Trust Birmingham and Solihull Mental Health NHS Trust Bolton Salford and TraVord Mental Health NHS Trust Shrewsbury and Telford Hospitals NHS Trust Northumberland Care Trust Bradford District Care Trust Manchester Mental Health and Social Care Trust Camden and Islington Mental Health and Social Care Trust Witham Braintree and Halstead Care Trust SheYeld Care Trust Sandwell Mental Health NHS and Social Care Trust Bexley Care Trust

Total parking spaces available No

Total parking spaces available for patients/ visitors No

Income from staV £

Income from visitors £

2,974 1,192

887 540

30,000 1,896

125,000 9,588

1,550 1,013

1,068 774

36,000 —

446,849 —

3,025 2,672 815

1,020 872 334

130,500 121,000 —

894,210 419,000 —

2,760

917

225,276

744,610

2,873 2,532 2,605

1,006 743 1661

125,280 484,452 90,730

159,065 690,052 120,270

865 1,750 350 681 —

10 1,328 280 681

— — — —

— 654,000 — —

65 137 681

— 37 681

— — —

— — —

463 108 378,720

252 108 156,031

— — 15,130,961

— — 62,755,934

1,589

72,714,000

153,038,000 6,494,000 11,824,000 18,650,000 87,751,000 5,186,000

236,706,000 207,374,000 101,870 3,992 4,573 37,901 97,859 41,134

267,413 286,095

91,483

5,820 14,472 153,847 193,198

4,968

6,472 12,805 12,929 12,499

13,675

85,238 479,538 235,456

30,969 3,321 1,537 13,414 78,834 41,662

556,018 449,501

21,041

207 742 251,795 303,664

8,200 4,948

1,671

43,024 790

7,968 408,967 37,232

35,084

132,839 7,313 6,110 51,315 176,693 82,796

823,431 735,596

112,524

6,027 15,214 405,642 496,862

8,200 9,916

13,675 43,024 7,262 12,805 14,600 12,499

93,206 888,505 272,688

474,199 383,587 1,033,057

545,155

101,870 3,992 4,573 37,901 97,859 41,134

267,413 286,095

91,483

5,820 14,472 153,847 193,198

4,968

6,472 12,805 12,929 12,499

13,675

85,238 479,538 235,456

190,524 175,891 434,239

235,414

17,100

114,826 333,211

10,876 70,724

9 16 0 700 1,309 0

26,600 23,911

0

0 742 13,557 15,754

0

0 0 0 0

0

36 30,848 0

17,244 17,433 52,404

21,356

2,065

9,174 47,309

13 1,643

2 56

3

296

Day Cases

HES

31,677

147,264 138,699

61,662 79,231

3,960

41,096

93,798

63,486 39,429 139,267

68,523

21,337 8,702 8,475 48,262 98,840

58,946 39,453 40,720

30,523

37,159

A&E Attendances

HES

30,960 3,305 1,537 12,714 77,525 9,985

382,154 286,891

21,041

176,576 208,679

0 207

8,200 988

1,671 0

0 1,928 790

7,932 284,321 37,232

202,945 150,834 407,147

219,862

15,919

89,425 324,031

12,498

707 1,870

135

6,510

Outpatient Attendances

HES

129 359 197

583 35

878 1,055

391

20 47 512 574

68

43

20 48

43

309 1,597 802

511 558 1,380

676

74

396 1,057

57 218

71 109

27

191

Available beds No.

HES

1,167 462 485 438 677 1,103

730 2,142

555

352

310 57 72 1,113 1,053

0 280

70 102 353 213 152 191

618 3,495 2,136

1,145 0 1,381 1,887

22

Total parking spaces available No. 416 501 75 448 384 387 292 844 170 310 535 94 868 1,030 291 196

ERIC

2.33 13.59 11.83 3.45 1.28 5.74

1.04 2.34

1.37

3.20 2.85 1.53 2.17 1.82

0.00 4.12

17.65 3.94 2.67 4.34

1.63

1.63 2.35 2.66

2.63 3.38 0.00

1.70

0.27

4.11 5.28 2.36 5.44 2.32 4.48 2.43 0.92

4.98

2.90

Total Parking Spaces per Bed

ERIC

83

102 16 20 30

76 66

4

32 24

22 6

18

9 19 13 11 13

27 111 95

73 0 63 53

0

17 32 13 53 37 8 11

Total disabled parking spaces No. 13 0 0 13 25 30 0 0

ERIC

28.3%

15.0%

9.0% 9.0%

3.8% 5.9%

11.0% 28.6%

6.4%

13.0% 5.5% 8.2% 21.2% 6.8%

12.2% 12.4% 7.8%

13.9% 10.8%

16.7%

73.3%

27.4% 9.1% 14.1% 15.9% 14.7%

3.8% 11.2% 16.7%

% disabled parking spaces 4.4%

ERIC

ERIC

293

0 107 0 0

845 734

0

836 406

200 21

282

69 348 158 52 191

221 895 1211

437 0 453 490

0

0.00 3.15 0.00 0.00 0.00 1.53

1.20 0.80

0.00

2.06 1.05 0.00 1.63 0.70

0.00 4.15

17.40 2.93 0.91 4.34

0.00

0.58 0.60 1.51

0.86 0.88 0.00

0.65

0.00

Total Total parking spaces parking spaces available available for for patients/ patients/ visitors visitors No. No/Bed. 296 0 0.00 0 339 3.77 224 180 0 0.00 0 0.00 0.00 62 1.09 352 1.52 92 4.38 334 0.94 252 0.22 0 15

ERIC

0

0 13,646 0 0

0 148,818

0

24,444 0

0 0

0

0 0 0 20,872 0

6 0 0

114,090 0 138,000 31,116

0

0 0 0 0 137,214 0 0

Income from staV £ 0 0 0 0 0 0 0 0

ERIC

0

0 0 0 0

0 483,840

0

152,431 914,352

0 0

47,906

0 0 0 0 0

6 526,560 0

599,288 0 674,000 304,084

0

0 0 0 272,529 284,256 0 0

Income from visitors £ 0 0 0 0 0 0 0 0

ERIC

1.00

2.50 0.67

1.50 2.50

0.50

1.50

0.95

0.80 1.00

1.17

0.63 0.70

2.00

Average fee charged per hour for patient/visitor parking £

ERIC

0.25

0.30

0.20

6.00

0.30

0.49

1.00

Average fee charged per hour for staV parking £

ERIC

PPSysB

RWR 5D1 5HT 5HV 5M1 5M3

RWG RWH

RV7

34,866,000

5,928,000 2,604,000 1,024,000 101,081,000 133,854,000

1,641,000 1,741,000

2,117,000 3,915,000 7,008,000 5,001,000 592,000 9,593,000

78,503,000 354,384,000 154,549,000

283,675 207,696 598,818

190,524 175,891 434,239

17,984 309,741

235,414

17,100

114,826 333,211

32,226 93,567 8,475 261,687 803,391

27,974 32,012

19,113

67,109

In-Patient Bed Days

HES

Pag Table: COENEW

RFU

5GV 5GW 5GX RC1 RC9

5GJ 5GK

12,981,000

160,145,000 14,485,000 138,249,000 126,801,000 74,474,000

58,946 40,162 42,646

27,974 32,012 21,350 22,843 8,475 146,861 470,180

58,946 68,136 74,658

30,661

19,113

10,876 70,724

49,774

43,965

67,109

111,074

Estimated Total OutPatients per Year

Estimated Total InPatients per Year

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen)

DB

DB

12-07-06 01:32:43

5CP 5GC 5GD 5GE 5GG 5GH

RTQ RVJ RVN

RD1 RHR RN3 RNZ RTE

Trust Name SOUTH GLOUCESTERSHIRE PCT WEST WILTSHIRE PCT SOUTH WILTSHIRE PCT BATH AND NORTH EAST SOMERSET PCT BRISTOL NORTH PCT BRISTOL SOUTH AND WEST PCT SWINDON PCT KENNET AND NORTH WILTSHIRE PCT CHELTENHAM AND TEWKESBURY PCT WEST GLOUCESTERSHIRE PCT COTSWOLD AND VALE PCT NORTH SOMERSET PCT WESTON AREA HEALTH NHS TRUST UNITED BRISTOL HEALTHCARE NHS TRUST AVON AMBULANCE SERVICE NHS TRUST GLOUCESTERSHIRE AMBULANCE SERVICES NHS TRUST ROYAL NATIONAL HOSPITAL FOR RHEUMATIC DISEASES NHS FOUNDATION TRUST ROYAL UNITED HOSPITAL BATH NHS TRUST WILTSHIRE AMBULANCE SERVICE NHS TRUST SWINDON AND MARLBOROUGH NHS TRUST SALISBURY HEALTH CARE NHS TRUST GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST GLOUCESTERSHIRE PARTNERSHIP NHS TRUST NORTH BRISTOL NHS TRUST AVON AND WILTSHIRE MENTAL HEALTH PARTNERSHIP NHS TRUST HERTSMERE PCT LUTON PCT BEDFORD PCT BEDFORDSHIRE HEARTLANDS PCT WELWYN HATFIELD PCT NORTH HERTFORDSHIRE AND STEVENAGE PCT SOUTH EAST HERTFORDSHIRE PCT ROYSTON BUNTINGFORD AND BISHOP’S STORTFORD PCT WATFORD AND THREE RIVERS PCT DACORUM PCT ST ALBANS AND HARPENDEN PCT BEDFORD HOSPITALS NHS TRUST LUTON AND DUNSTABLE HOSPITAL NHS TRUST BEDFORDSHIRE AND HERTFORDSHIRE AMBULANCE AND PARAMEDIC SERVICE NHS TRUST BEDFORDSHIRE AND LUTON COMMUNITY NHS TRUST WEST HERTFORDSHIRE HOSPITALS NHS TRUST EAST AND NORTH HERTFORDSHIRE NHS TRUST HERTFORDSHIRE PARTNERSHIP NHS TRUST SOLIHULL PCT DUDLEY SOUTH PCT DUDLEY BEACON AND CASTLE PCT SOUTH BIRMINGHAM PCT WALSALL PCT

Operational Income £ 1,545,000 13,398,000 3,800,000 12,819,000 2,276,000 1,217,000 6,255,000 8,951,000 642,000 9,432,000 16,450,000 268,000 64,201,000 324,596,000 21,872,000 14,871,000

FINANCE

Page Type [O]

RBB

Trust Code 5A3 5DH 5DJ 5FL 5JF 5JG 5K3 5K4 5KW 5KX 5KY 5M8 RA3 RA7 RB1 RB5

SOURCE:

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Health Committee: Evidence Ev 121

65,959,000 42,648,000

116,871,000 107,282,000 182,969,000 39,271,000

71,056,000

74,492 38,230

66,783 169,605 316,615 26,914

52,739

392,567 300,705

87,258 51,115

182,749 273,696 327,809 143,811

34,136

385,143 345,544

131,294 40,744 967 1,317 56,223 13,837 31,208

80,461

15,975

68,565

685,314

547,270 70,736 424,134

409,140 162,069

84,163

471,096

161,750 89,345

249,532 443,301 644,424 170,725

86,875

777,710 646,249

27,979 138,570 40,744 967 1,317 56,223 13,837 31,208

80,461

68,218

325,140

1,100,724

946,861 111,119 784,277

678,630 235,998

140,610

733,485

514,960 447,573

74,492 38,230

66,783 169,605 316,615 26,914

52,739

392,567 300,705

27,979 7,276

52,243

256,575

415,410

399,591 40,383 360,143

269,490 73,929

56,447

262,389

226,452 201,693

2,711

65,851

In-Patient Bed Days 5,177

HES

6,995 2,594

9,688 7,651 26,743 4

4,133

19,934 6,675

0 0

0

0

38,208

30,089 6,427 29,733

23,249 10,922

1,108

24,547

17,047 20,789

0

0

Day Cases 0

HES

12,107

58,549 76,818 82,438

84,999 106,127

53,143 13,837 31,208

127,708 40,744

80,461

200,893

79,475

140,388

90,856 45,167

96,247

72,055 75,230

42,738

3,606

A&E Attendances

HES

68,156 48,521

114,512 189,227 218,628 143,807

30,003

280,210 232,742

967 1,317 3,080 0

3,586

0

0

15,975

68,565

446,213

376,793 64,309 314,926

295,035 105,980

83,055

350,302

199,406 149,861

21,645

Outpatient Attendances 0 0 0 16,040

HES

202 133

257 545 929 104

217

1,189 943

14

86 22

227

856

1,280

1,232 125 1,056

812 216

193

834

206 19 13 61 680 601

Available beds No. 4

HES

298

1,025 1,733 2,368 318

155

2,358 1,699

136 173 56 632 337 345 49 178 491 212 275 535 350 340 241 228

463

1,589

3,025

2,758 344

2,132 468

547

1,797

666 121 447 448 1,355 965 500

Total parking spaces available No. 157 144

ERIC

2.61

4.17 3.12 2.55

0.72

1.95 1.85

106.00

1.93

1.68

1.82

2.40

2.25 2.55 0.00

2.71 2.17

2.76

2.15

3.23 6.05 37.25 19.48 1.99 1.61

Total Parking Spaces per Bed 7.85

ERIC

12

16.2%

2.2% 24.5% 10.3%

92 10

10.5% 11.3%

9.7% 26.7% 35.0% 12.6% 1.3%

18.6% 40.8%

28.0% 6.3%

8.7%

14.9%

19.3% 3.8% 27.5%

21.7%

10.0%

21.9%

28.0% 11.1%

10.0%

% disabled parking spaces 4.8% 4.2%

ERIC

18

10

116 90

32 44 42 13 3

29 20

11 16 7 32 0

22

152

111 11 162

15

4

90

37 0 0 0 70 26

Total disabled parking spaces No. 8 6

ERIC

74

375 97

819

1104 797

330 165 120 103 225

156 49

0 0 25 506

252

1020

574 293 590

69

40

411

0.65

3.33 0.00 0.40

0.00

0.91 0.87

24.50

0.00

0.91

0.00

0.81

0.47 2.17 0.56

0.00 0.32

0.20

0.49

1.80 0.00 0.00 0.00 0.37 0.39

30,096

145,000 0

0

0 0

0 0 0 0 0

0 0

0 0 0 0

0

130,500

285,360 0 117,000

0 91,389

23,457

0

0 0 0 0 48,000 89,057

Income from staV £ 0 0

370 0 0 0 250 235

ERIC

ERIC

Total Total parking spaces parking spaces available available for for patients/ patients/ visitors visitors No. No/Bed. 165 8.25 144

ERIC

84,952

587,000 0

0

0 281,214

0 0 0 0 0

0 0

0 0 0 0

0

894,210

997,519 0 1,500,000

186,671 0

53,073

637,513

0 0 0 0 380,000 528,000

Income from visitors £ 0 0

ERIC

0.40

0.37 0.75

1.00

4.00 1.50

3.75

5.00

4.00

1.09

0.33

1.20

0.50

1.80

1.00

2.00 0.75

Average fee charged per hour for patient/visitor parking £

ERIC

0.20

0.60

0.60

0.30

0.20

0.30

0.60

0.20

0.20 0.40

Average fee charged per hour for staV parking £

ERIC

PPSysB

REP RET

RBS RBT REM REN

RBQ

211,545,000 164,673,000

27,979 7,276

52,243

256,575

415,410

399,591 40,383 360,143

269,490 73,929

56,447

262,389

288,508 245,880

226,452 201,693

67,094

85,497

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen) 5,177

Pag Table: COENEW

RBL RBN

5,162,000 2,964,000 11,203,000 8,440,000 3,104,000 4,077,000 1,146,000 5,595,000 6,591,000 8,275,000 5,269,000 5,212,000 4,587,000 11,431,000 2,000,000 50,113,000

42,870,000

165,369,000

281,832,000

241,064,000 43,740,000 85,031,000

165,053,000 132,939,000

63,457,000

199,865,000

19,646 64,383

2,711

Estimated Total OutPatients per Year

Estimated Total InPatients per Year 5,177 65,851

DB

DB

12-07-06 01:32:43

5F8 5F9 5G9 5H2 5H3 5H4 5H5 5H6 5HA 5HC 5J1 5J2 5J3 5J4 5M5 RB6

TAJ

RXT

RXK

RR1 RRJ RRK

RNA RQ3

RLU

Trust Name OLDBURY AND SMETHWICK PCT ROWLEY REGIS AND TIPTON PCT WEDNESBURY AND WEST BROMWICH PCT WOLVERHAMPTON CITY PCT NORTH BIRMINGHAM PCT HEART OF BIRMINGHAM TEACHING PCT EASTERN BIRMINGHAM PCT WALSALL HOSPITALS NHS TRUST GOOD HOPE HOSPITAL NHS TRUST WEST MIDLANDS AMBULANCE SERVICE NHS TRUST THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST BIRMINGHAM WOMEN’S HEALTH CARE NHS TRUST DUDLEY GROUP OF HOSPITALS NHS TRUST BIRMINGHAM CHILDREN’S HOSPITAL NHS TRUST HEART OF ENGLAND NHS FOUNDATION TRUST ROYAL ORTHOPAEDIC HOSPITAL NHS TRUST UNIVERSITY HOSPITAL BIRMINGHAM NHS FOUNDATION TRUST SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS TRUST SANDWELL MENTAL HEALTH NHS AND SOCIAL CARE TRUST BEBINGTON AND WEST WIRRAL PCT SOUTHPORT AND FORMBY PCT NORTH LIVERPOOL PCT BIRKENHEAD AND WALLASEY PCT CHESHIRE WEST PCT CENTRAL CHESHIRE PCT EASTERN CHESHIRE PCT ELLESMERE PORT AND NESTON PCT CENTRAL LIVERPOOL PCT SOUTH LIVERPOOL PCT HALTON PCT WARRINGTON PCT ST HELENS PCT KNOWSLEY PCT SOUTH SEFTON PCT MERSEY REGIONAL AMBULANCE SERVICE NHS TRUST WIRRAL HOSPITAL NHS TRUST ST HELENS AND KNOWSLEY HOSPITALS NHS TRUST THE CARDIOTHORACIC CENTRE - LIVERPOOL NHS TRUST ROYAL LIVERPOOL CHILDRENS NHS TRUST THE MID CHESHIRE HOSPITALS NHS TRUST AINTREE HOSPITALS NHS TRUST CLATTERBRIDGE CENTRE FOR ONCOLOGY NHS TRUST LIVERPOOL WOMENS NHS FOUNDATION TRUST WALTON CENTRE FOR NEUROLOGY AND NEUROSURGERY NHS TRUST

Operational Income £ 8,838,000 2,315,000 2,194,000 10,392,000 1,190,000 8,447,000 6,972,000 124,710,000 106,570,000 59,684,000

FINANCE

Page Type [E]

RL4

Trust Code 5MG 5MH 5MJ 5MV 5MW 5MX 5MY RBK RJH RKA

SOURCE:

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Ev 122 Health Committee: Evidence

Trust Name EAST CHESHIRE NHS TRUST COUNTESS OF CHESTER NHS FOUNDATION TRUST RQ6 ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS TRUST RTV 5 BOROUGHS PARTNERSHIP NHS TRUST RVY SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST RW4 MERSEY CARE NHS TRUST RWW NORTH CHESHIRE HOSPITALS NHS TRUST RXA CHESHIRE AND WIRRAL PARTNERSHIP NHS TRUST 5D9 HARTLEPOOL PCT 5E1 NORTH TEES PCT 5J8 DURHAM DALES PCT 5J9 DARLINGTON PCT 5KA DERWENTSIDE PCT 5KC DURHAM AND CHESTER-LE-STREET PCT 5KD EASINGTON PCT 5KE SEDGEFIELD PCT 5KM MIDDLESBROUGH PCT 5KN LANGBAURGH PCT RTC COUNTY DURHAM AND DARLINGTON PRIORITY SERVICES NHS TRUST RTR SOUTH TEES HOSPITALS NHS TRUST RVW NORTH TEES AND HARTLEPOOL NHS TRUST RVX TEES AND NORTH EAST YORKSHIRE NHS TRUST RXP COUNTY DURHAM AND DARLINGTON ACUTE HOSPITALS NHS TRUST 5CC BLACKBURN WITH DARWEN PCT 5D4 CARLISLE AND DISTRICT PCT 5D5 EDEN VALLEY PCT 5D6 WEST CUMBRIA PCT 5DD MORECAMBE BAY PCT 5F2 CHORLEY AND SOUTH RIBBLE PCT 5F3 WEST LANCASHIRE PCT 5G7 HYNDBURN AND RIBBLE VALLEY PCT 5G8 BURNLEY PENDLE AND ROSSENDALE PCT 5HD PRESTON PCT 5HE FYLDE PCT 5HF WYRE PCT 5HP BLACKPOOL PCT RE6 CUMBRIA AMBULANCE SERVICE NHS TRUST RJX CALDERSTONES NHS TRUST RMD LANCASHIRE AMBULANCE SERVICE NHS TRUST RNL NORTH CUMBRIA ACUTE HOSPITALS NHS TRUST RNN NORTH CUMBRIA MENTAL HEALTH AND LEARNING DISABILITIES NHS TRUST RTX MORECAMBE BAY HOSPITALS NHS TRUST RW5 LANCASHIRE CARE NHS TRUST RXL BLACKPOOL FYLDE AND WYRE HOSPITALS NHS TRUST RXN LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST RXR EAST LANCASHIRE HOSPITALS NHS TRUST 5CD NORTH DORSET PCT 5CE BOURNEMOUTH PCT

Trust Code RJN RJR

SOURCE:

Estimated Total OutPatients per Year 154,351 301,107

Estimated Total InPatients per Year 126,488 180,380 388,849 159,115 187,737 162,702 272,286 146,214

Operational Income £ 85,335,000 0

284,236,000

87,893,000 120,223,000

174,415,000 152,884,000 106,064,000

370,557 242,554 127,446 402,068

329,114,000 182,642,000 109,279,000 261,407,000

545,284

237,361 50,333 319,364 214,511 368,963 335,085 412,889 76,617

37,295,000

184,586,000 121,519,000 184,372,000

244,855,000

258,179,000 14,355,000 5,385,000

559,517 24,997

972,406 101,614

786,356

691,134 263,462 702,677

60,589

412,889 76,617

335,085

319,364 214,511 368,963

50,333

36,388 901

29,020

21,341 15 21,447

0

33,329

0

0

10

0 1 0 0

47,800 22,422 1 22,302

4 0 0 0

101

138,578 10,782

107,686

87,767

97,497

65,896

52,566

7,058 32,602

25,606 8,877

140,922

106,556 98,210

23,825

94,844

87,107

114,006

A&E Attendances 53,373 58,310

HES

384,551 13,314

314,565

252,932 48,936 224,500

10,256

208,698

1,042

312

1,620 463 23,310 421 786 546

0

454,849 152,447 35,883 378,416

22,128

35,546 238,919 35,796

28,177 230,629

447,374

Outpatient Attendances 96,092 225,630

HES

1,292 240

1,157

1,054 706 1,137

199

738

206

15

62

20 109 71 316

1,261 816 596 1,410

26 94 484

32

511 837 948

536 627

1,198

Available beds No. 402 536

HES

2,605 486 59

2,760

2,116 715 2,672

354

857 289 66 137 192 493 390 1,404

333 137 324 518 756 226 358 340

2,574 2,434 1,700 2,873

50 172 160 176 22 149 24 120 401 385 822

2,437 1,839 1,090

615 1,470

1,607

Total parking spaces available No. 1,287

ERIC

1.75 2.01

2.34

1.93 0.99 2.39

2.23

1.79

2.42

57.13

3.54

5.27 2.84 6.56 2.83

1.98 2.98 2.76 1.93

4.62 15.42 4.10 1.77

2.58

5.44 2.19 2.04

1.15 2.47

1.38

Total Parking Spaces per Bed 3.20

ERIC

152 35 2

158

117

77

13

36 23 0 32 0 0 5 2 15 10 80

18 6 18 34 54

87 40 137

23 4 10 35

4 7 28 8 2 3

112 97 34

80 100

72

99

Total disabled parking spaces No.

ERIC

ERIC

ERIC

9.2% 8.6% 16.7%

17.2%

13.4%

12.1%

4.8%

11.6% 50.0% 13.1%

0.0% 3.6%

3.7%

12.9% 8.2%

6.3% 11.8% 5.6% 13.0%

9.2% 3.0% 13.6%

38.3% 1.0% 2.6% 4.6%

16.0% 5.1% 21.5% 34.8% 40.0% 5.4%

7.8% 16.1% 6.5%

12.2% 17.7%

51.8%

1661 405 12

917

872

634

271

278 282 0 857 0 66 137 0 129 20 611

287 51 324 262

944 1333 1006

60 401 385 762

25 138 130 23 5 56

1435 602 524

655 566

139

1.12 1.67

0.78

0.58 0.00 0.78

1.70

0.78

0.63

57.13

2.94

1.96 2.84 3.32 0.00

0.00 1.16 2.16 0.68

2.31 15.42 4.10 1.64

2.10

3.20 0.72 0.98

1.22 0.95

0.12

Total Total parking spaces parking spaces available available for % disabled for patients/ parking patients/ visitors spaces visitors No. No/Bed. 0.00 19.6% 504

ERIC

90,730 0 0

225,276

121,000

74,369

0

10,821 0 0 0 0 0 0 0 0 0 73,595

0 0 0 0

245,790 0 125,280

0 0 0 0

0 0 0 22,776 0 6

0 0 0

0 206,000

252,079

14,198

Income from staV £

ERIC

120,270 0 0

744,610

419,000

352,370

0

6,573 0 0 0 0 0 0 0 0 0 113,096

0 0 0 0

860,043 0 159,065

0 0 0 0

0 0 0 0 0 6

0 430,000 0

0 656,200

225,432

370,378

Income from visitors £

ERIC

0.93

0.60

0.40

0.49

0.50

0.75

0.60

0.50

0.57

0.58 1.80

0.33

1.50

1.00

Average fee charged per hour for patient/visitor parking £ 0.25

ERIC

0.50

0.40

0.50

0.10

0.50

0.50

0.40

0.50

0.60

0.50

6.00

0.16

0.12

0.60

Average fee charged per hour for staV parking £

ERIC

PPSysB

451,271

371,770 48,951 333,714

10,256

237,361

42,759

3,624

18,762

5,431 30,626 20,035 69,200

370,557 242,554 127,446 402,068

4,732 338 23,288 103,363

7,087

0 14,050 22

0 6,562

13,672

Day Cases 4,886 17,167

HES

Pag Table: COENEW

307,923

53,608

3,624

42,759

53,608

312

18,762

42,759

3,936

27,227 9,340 23,310 421 7,844 33,158

5,431 57,853 29,375 92,510 421 7,844 51,920

979,762 515,633 163,330 943,708

2,220,000 1,166,000 8,379,000 2,809,000 20,179,000 5,137,000 4,434,000 11,946,000 5,784,000 5,583,000 2,533,000 5,903,000 2,335,000 15,536,000 38,222,000 37,244,000 211,983,000

609,205 273,079 35,884 541,640

4,736 338 47,113 125,491

7,188

162,702 272,286 146,214

159,115 187,737

388,849

In-Patient Bed Days 126,488 180,380

HES

12-07-06 01:32:43

5,431 30,626 20,035 69,200

4

4,732 338 23,288 103,363 23,825 22,128

101

7,087

198,248 620,099 182,032

187,292 512,035

963,901

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen) 280,839 481,487

Page Type [O]

2,148,000 2,356,000 1,544,000 1,440,000 2,831,000 7,844,000 1,956,000 3,855,000 2,727,000 2,623,000 72,191,000

35,546 347,813 35,818

28,177 324,298

575,052

DB

DB

FINANCE

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Health Committee: Evidence Ev 123

5AA 5CL 5CR 5CX 5F4 5F5 5F6 5F7 5HG 5HQ 5J5 5JX 5JY 5LH RBV RM2

RWN TAG

RRD

50,307,000

2,561,000 10,846,000 1,332,000 4,298,000 8,535,000 6,518,000 532,000 2,873,000 5,088,000 4,258,000 3,794,000 1,938,000 6,081,000 5,127,000 108,338,000 230,146,000

90,848,000 3,348,000

88,798,000

146,529,000 173,935,000 118,796,000

22,485,000 1,867,000 9,219,000 2,558,000 1,425,000 7,256,000 19,506,000 657,000 2,105,000 7,377,000 4,010,000 2,102,000 3,892,000 169,777,000 52,612,000 0

27,377

184,342

249,471 591,872

1,040 50,993 17,924 22,403 53,831 38,574

1,040 50,993 17,923 22,403 53,831 38,574 63,125 257,083

1

132,391 7,630

156,965

226,869 225,001 156,230

233,451

239,506

10,984

10,158 15,213

6,843 14,562

19,766

93,094

10,235 21,427

606

0 1

0

20,887 19,621 18,271

17,643

32,019

0

10 0

29 0

36

4

Day Cases 2,913 1,320 1,056 0 0 0 0 10,265 24,113 18,587 11,308 62 38,224

HES

73,691

1,040 50,993 6,740 22,403 53,831 38,310

17,623

40,770

97,230 70,291 76,189

99,893

82,888

20,838

48,949 920 12,351

58,754

38,877 47,080 48,100 55,148

A&E Attendances 7,176 7,083 27,606 24,854 2,971

HES

176,111 239,671

264

10,577

0 5,706 0 198 945 816

18,602 0

27,377

199,528 253,097 175,681

221,505

0 307,361

916 11,240 2,987

587 2,195

0

763

25,423

87,708 164,721 130,819 169,328 11,985 211,221

Outpatient Attendances 17,986 8,719 29,564 9,834 6,884 3,641

HES

36 206 794

21

29 10

512 47

444

643 761 498

652

768

33

20 51 76 26 88 36

118 56

297

Available beds No. 116 109 135 85 110 44 52 345 618 429 717 504 878

HES

486 653 2,399

166 299 219 209 36 170 238 384 171 506 505 195

937 137

790

1,475 2,126 558

96 554 51 283 94 153 1,069 122 213 122 151 51 82 1,072

536

Total parking spaces available No. 607 402 194 119 118 122 96 518 1,263 848 1,462 634 1,905

ERIC

13.50 3.08 2.97

8.13

1.67 3.04

1.90

2.30 3.04 1.18

0.00

1.40

4.52 2.42 3.39

3.67 0.91 12.86 2.94 3.00

1.79

1.50 2.02 2.36 2.04 1.27 2.27

Total Parking Spaces per Bed 5.10 3.59 1.38 1.43 1.20 2.44

ERIC

16.1% 133.3% 11.4%

43 16 68

13 10 109

13 28 9 0 24 23

7 6 11 15 4

12 6

33

62 18

92

6 21 7 6 3 5 49

2 0 5 7 14 19

2.7% 4.1% 19.0%

16.2% 11.1%

8.0%

10.9%

4.9% 10.5% 11.1%

4.0%

16.2%

4.3%

8.7% 8.5%

21.2% 0.0% 6.7%

10.9%

4.9%

116.7% 20.4%

10.2%

4.0%

6.8% 24.0% 4.0% 3.3% 4.7%

8 6 2 6 18

0

% disabled parking spaces 6.8% 8.9% 13.2%

ERIC

Total disabled parking spaces No. 14 34 12

ERIC

ERIC

486 245 573

119 0 113 0 148 208

173 0 226 143 36

0 37

760

715 212

0 0 231 5 1368

122 0 64

50 0 49 0 12 93

0

13.50 1.16 0.71

8.67

0.00 0.82

1.83

0.00 1.02 0.45

2.18

0.30

4.52 0.00 1.78

0.00 0.88 0.00 0.38 1.82

0.00

Total Total parking spaces parking spaces available available for for patients/ patients/ visitors visitors No. No/Bed. 207 1.74 382 3.41 91 0.65 0.00 118 1.20 25 0.50 50 183 0.53 387 0.62 0.00 267 0.37 12 0.02 598 0.71

ERIC

0 54,464 380,000

0 0 5,640 0 0 0

0 0 0 0 0

0 0

0

64,282 39,995

0 0 0 0 0

0 0 0

0 0 0 0 0 0

0

232,790 0 0

0 0 0 12,500 210,407

Income from staV £ 0 133 4,500

ERIC

0 138,567 700,000

0 0 0 0 0 0

0 0 0 0 0

0 0

0

624,063 318,164

0 0 548,369 0 1,039,481

0 0 0

0 0 0 0 0 0

0

390,499 0 476,708

0 0 0 103,893 350,093

Income from visitors £ 0 11,193 14,600

ERIC

1.50 1.00

1.75 0.69 0.67

0.83

1.00

1.50

1.00

0.60 0.10

0.27

0.20 0.30

0.10

0.90

0.60 0.50

0.60 0.50

0.90 1.00 0.79 0.50

Average fee charged per hour for staV parking £

ERIC

Average fee charged per hour for patient/visitor parking £

ERIC

PPSysB

186,346 334,789

40,770 5,706 17,623 198 945 816

150,993 7,631

40,770 5,706 17,623 198 945 816

18,602 1

544,514 568,010 426,371

572,492

661,774

55,821 16,069 14,546 10,168 16,129 32,078 2,987 10,984

763 19,802

118,521

In-Patient Bed Days 35,192 34,982 40,062 25,989 35,906 14,589 18,081 102,286 201,447 138,751 229,492 99,672 275,423

HES

Pag Table: COENEW

63,125 257,083

1

132,391 7,630

156,965

317,645 343,009 270,141

339,041

233,451 226,869 225,001 156,230

422,268

48,978 1,507 14,546 10 916 32,078 2,987

763 36

25,427

239,506

10,984

10,158 15,213

6,843 14,562

19,766

93,094

136,850 235,914 197,506 235,784 12,047 308,199

Estimated Total OutPatients per Year 28,075 17,122 58,226 34,688 9,855 3,641

Estimated Total InPatients per Year 35,192 34,982 40,062 25,989 35,906 14,589 18,081 102,286 201,447 138,751 229,492 99,672 275,423

Operational Income £ 6,828,000 2,587,000 1,247,000 1,752,000 1,147,000 668,000 736,000 71,352,000 148,465,000 102,450,000 137,932,000 65,887,000 151,534,000

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen) 63,267 52,104 98,288 60,677 45,761 18,230 18,081 239,136 437,361 336,257 465,276 111,719 583,622

12-07-06 01:32:43

RDE RQ8 RQW

RHP 5AH 5AJ 5AK 5DC 5GL 5GM 5GN 5GP 5GQ 5GR 5JN 5JP RAJ RB4 RDD

Trust Name SOUTH AND EAST DORSET PCT SOUTH WEST DORSET PCT SOMERSET COAST PCT MENDIP PCT SOUTH SOMERSET PCT TAUNTON DEANE PCT POOLE PCT EAST SOMERSET NHS TRUST TAUNTON AND SOMERSET NHS TRUST WEST DORSET GENERAL HOSPITALS NHS TRUST POOLE HOSPITALS NHS TRUST DORSET HEALTH CARE NHS TRUST ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST SOMERSET PARTNERSHIP NHS AND SOCIAL CARE TRUST DORSET AMBULANCE NHS TRUST TENDRING PCT EPPING FOREST PCT SOUTHEND ON SEA PCT HARLOW PCT MALDON AND SOUTH CHELMSFORD PCT COLCHESTER PCT UTTLESFORD PCT BILLERICAY BRENTWOOD AND WICKFORD PCT THURROCK PCT BASILDON PCT CHELMSFORD PCT CASTLE POINT AND ROCHFORD PCT SOUTHEND HOSPITAL NHS TRUST ESSEX AMBULANCE SERVICE NHS TRUST BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST ESSEX RIVERS HEALTHCARE NHS TRUST MID ESSEX HOSPITAL SERVICES NHS TRUST THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST NORTH ESSEX MENTAL HEALTH PARTNERSHIP NHS TRUST SOUTH ESSEX PARTNERSHIP NHS TRUST WITHAM BRAINTREE AND HALSTEAD CARE TRUST SOUTH MANCHESTER PCT CENTRAL MANCHESTER PCT NORTH MANCHESTER PCT TRAFFORD SOUTH PCT HEYWOOD AND MIDDLETON PCT SALFORD PCT TRAFFORD NORTH PCT STOCKPORT PCT ASHTON LEIGH AND WIGAN PCT BOLTON PCT OLDHAM PCT BURY PCT ROCHDALE PCT TAMESIDE AND GLOSSOP PCT CHRISTIE HOSPITAL NHS TRUST SOUTH MANCHESTER UNIVERSITY HOSPITALS NHS TRUST

DB

DB

FINANCE

Page Type [E]

RH5

Trust Code 5FN 5FP 5FW 5FX 5K1 5K2 5KV RA4 RBA RBD RD3 RDY RDZ

SOURCE:

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Ev 124 Health Committee: Evidence

5EH

RXJ 5AC

3,100,000

108,283,000 4,665,000 34,080

87,043 908 29,608

44,724 1,534

697,533 398,093

93,542 500,703 212,442

21,321

154,985 205,269

20,006 3,964 920 36,467 5,368 10,410 11,331 204,624 299,381

6,284 5,922 5,799 25,003 18,556

182,185 150,326 38,913

212,659

68 147,323 196,008 14,604

176,889

63,688

131,767 2,442

1,198,236 610,535

114,863

182,253 297,649 234,921 14,604 20,006 3,964 7,204 42,389 5,799 30,371 28,966 11,331 359,609 504,650

389,548

935,366

2,008 214,992 57,654 13,223 147,809 17,312 9,846 918,671

91,160 21,316

113,325

1,593,052 625,056 206,033

200,462 1,040,728

651,431

599,414 435,146

34,080

87,043 908

500,703 212,442

93,542

154,985 205,269

6,284 5,922 5,799 25,003 18,556

68 147,323 196,008 14,604

176,889

338,766

8 201,491 46,772 4,442 52,119 15,288 5,502 429,558

41,667 21,316

85,726

657,840 289,949 179,468

164,845 368,557

252,154

241,680 201,531

In-Patient Bed Days 263,509 118,473

HES

1,321

0 0

37,898 19,192

1

8,992 12,607

0 4 0 5 0

1,025 5,422 118 0

8,002

33,319

356 0 2 0 559 0 101 36,350

3,385 0

0

62,162 16,882 7

0 32,766

26,804

8,303 8,261

Day Cases 17,375 7,728

HES

185,739 94,154

82,459 74,599

5,363 10,410

36,086

18,566

39,007 34,356

54,174

129,790

94,329

92,488

4,722

18,566

241,198 76,330

160,847

75,212

94,113 77,004

A&E Attendances 70,150 49,820

HES

28,287

44,724 1,534

473,896 284,747

21,320

0 11,331 113,173 212,175

1,440 3,964 920 377

142,153 110,548 38,795

150,483

433,491

1,644 8,779 10,880 8,781 2,643 2,024 4,243 358,434

27,542 0

27,599

631,852 241,895 26,558

35,617 478,558

297,261

255,318 148,350

Outpatient Attendances 241,955 138,142

HES

113

529 53

1,542 866

238

443 627

432 519 596 57 86 22 78 82 21 98 53

540

1,092

600 106 29 155 159 18 1,404

131 72

301

2,249 870 759

540 1,195

840

679 621

Available beds No. 850 406

HES

900

1,013 204

3,165 2,439

1,301 1,129 1,090 397 276 259 426 419 184 227 367 72 1,185 1,692 285 506

2,367 324 1,418

322 361 25 40 388 773 155 757 559 55 3,194

0

865

4,595

1,243 3,676

1,670

1,742 1,074

Total parking spaces available No. 2,087 744 457

ERIC

8.11

1.86 22.67

2.09 2.74

1.53

2.80 2.65

3.03 2.11 1.70 6.96 2.94 11.26 3.61 3.43 1.77 2.32 7.06

2.59

2.03

3.06 2.17

2.37 3.02 5.17 5.91

2.35 5.01

0.00

2.02 0.00 1.13

2.31 2.61

2.04

2.32 1.74

Total Parking Spaces per Bed 2.34 1.93

ERIC

35

51 11

109 62

23 60 2

35 54 87 21 8 13 32 37

212 2 42

35 8 3 127

25 21 2 4 26 2

324 77 17

45 102

104

99 50

9

Total disabled parking spaces No. 92

ERIC

4.0%

6.6% 6.3%

11.0% 5.0%

12.3%

10.4% 4.8% 8.5% 5.5% 4.3% 19.4% 10.3% 13.0%

9.6%

19.3%

6.8% 10.8%

4.6%

0.5%

7.8% 5.8% 8.0% 200.0%

10.5% 10.7% 170.0%

4.4% 14.9%

24.9%

24.7% 6.4%

% disabled parking spaces 22.1%

ERIC

ERIC

884

774 175

991 1243

0 488 0

336 1129 1021 382 184 67 310 285

1096 0 437

44 1178

757

381

322 360 25 2

3083 719 10

1022 686

417

401 777

7.96

1.42 19.44

0.65 1.40

0.00

0.00 0.76

0.78 2.11 1.59 6.70 1.96 2.91 2.63 2.34 0.00 0.00 0.00

0.80

0.94

2.44 0.80

0.00 1.49 0.00 5.91

2.35 5.00

0.00

1.35 0.84 0.01

1.90 0.49

0.51

0.53 1.26

Total Total parking spaces parking spaces available available for for patients/ patients/ visitors visitors No. No/Bed. 417 0.47 0.00 0

ERIC

0

0 0

111,000 0

0 182,000 0

0 56,000 0 0 0 0 0 0

0 0 87,000

0 368,705

0

0

0 0 0 0

338,631 144,983 0

0 701,161

129,280

17,273 105,846

0

Income from staV £ 415,716

ERIC

0

0 0

1,319,113 315,000

0 804,000 0

217,854 250,000 0 0 0 0 0 0

1,119,602 0 532,000

0 1,405,556

0

0

0 0 0 0

1,114,564 301,849 0

0 385,249

461,830

398,467

0

Income from visitors £ 641,978

ERIC

0.56 1.00

1.00 2.50

4.35 2.00 1.00

1.50

0.83

3.00

0.30

0.38

1.44 1.25

0.50

0.35 0.60

Average fee charged per hour for patient/visitor parking £ 1.50 0.80

ERIC

0.10

0.60

0.20

0.16

0.13

0.47 0.70

0.42 8.00

0.34

0.40

Average fee charged per hour for staV parking £ 0.13 0.40

ERIC

PPSysB

338,498,000 218,942,000

111,645,000 106,415,000 126,014,000 3,289,000 1,141,000 1,634,000 5,332,000 1,420,000 13,377,000 7,676,000 6,537,000 2,463,000 98,506,000 140,776,000 32,407,000 56,941,000

596,600

2,000 13,501 10,882 8,781 95,690 2,024 4,344 489,113

8 201,491 46,772 4,442 52,119 15,288 5,502 429,558 338,766

49,493

27,599

935,212 335,107 26,565

35,617 672,171

399,277

357,734 233,615

41,667 21,316

85,726

657,840 289,949 179,468

164,845 368,557

252,154

241,680 201,531

Estimated Total OutPatients per Year 329,480 195,690

Estimated Total InPatients per Year 263,509 118,473

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen) 592,989 314,163

Pag Table: COENEW

RVV RWF

RN5 RR2 RW1 5CM 5FF 5L2 5L3 5L4 5LL 5LM 5LN 5LP RN7 RPA RPH RTM

335,426,000 28,952,000 122,174,000

3,361,000 2,255,000 153,000 1,531,000 33,958,000 29,477,000 10,982,000 26,921,000 17,185,000 446,000 361,007,000

73,795,000

422,704,000 0 104,774,000

87,494,000 432,633,000

174,525,000

143,263,000 102,869,000

DB

DB

12-07-06 01:32:43

RHU RKD RN1

5A1 5DF 5DG 5E9 5FD 5FE 5G6 5L1 5LX 5LY RHM

TAE

Trust Name SALFORD ROYAL HOSPITALS NHS TRUST TRAFFORD HEALTHCARE NHS TRUST GREATER MANCHESTER AMBULANCE SERVICE NHS TRUST BOLTON HOSPITALS NHS TRUST TAMESIDE AND GLOSSOP ACUTE SERVICES NHS TRUST WRIGHTINGTON WIGAN AND LEIGH NHS TRUST PENNINE CARE NHS TRUST CENTRAL MANCHESTER AND MANCHESTER CHILDREN’S UNIVERSITY HOSPITALS NHS TRUST PENNINE ACUTE HOSPITALS NHS TRUST STOCKPORT NHS FOUNDATION TRUST BOLTON SALFORD AND TRAFFORD MENTAL HEALTH NHS TRUST MANCHESTER MENTAL HEALTH AND SOCIAL CARE TRUST NEW FOREST PCT NORTH HAMPSHIRE PCT ISLE OF WIGHT PCT MID-HAMPSHIRE PCT EAST HAMPSHIRE PCT PORTSMOUTH CITY PCT BLACKWATER VALLEY AND HART PCT SOUTHAMPTON CITY PCT FAREHAM AND GOSPORT PCT EASTLEIGH AND TEST VALLEY SOUTH PCT SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST PORTSMOUTH HOSPITALS NHS TRUST HAMPSHIRE AMBULANCE SERVICE NHS TRUST WINCHESTER AND EASTLEIGH HEALTHCARE NHS TRUST NORTH HAMPSHIRE HOSPITALS NHS TRUST ISLE OF WIGHT HEALTHCARE NHS TRUST HAMPSHIRE PARTNERSHIP NHS TRUST DARTFORD GRAVESHAM AND SWANLEY PCT SOUTH WEST KENT PCT MAIDSTONE WEALD PCT MEDWAY PCT SWALE PCT ASHFORD PCT CANTERBURY AND COASTAL PCT EAST KENT COASTAL PCT SHEPWAY PCT DARTFORD AND GRAVESHAM NHS TRUST MEDWAY NHS TRUST KENT AMBULANCE NHS TRUST EAST KENT NHS AND SOCIAL CARE PARTNERSHIP TRUST EAST KENT HOSPITALS NHS TRUST MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST WEST KENT NHS AND SOCIAL CARE TRUST DAVENTRY AND SOUTH NORTHAMPTONSHIRE PCT MELTON RUTLAND AND HARBOROUGH PCT

Operational Income £ 194,632,000 81,680,000 53,066,000

FINANCE

Page Type [O]

RW6 RWJ RXV

RT2 RW3

RRF

RMC RMP

Trust Code RM3 RM4 RMA

SOURCE:

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Health Committee: Evidence Ev 125

5AN 5E2 5E3 5E4 5E5

1,336,000 8,812,000 9,988,000 764,000 2,416,000

79,120,000

71,489,000 71,911,000 113,071,000

89,200 4,084 13,426

101,368

113,086 129,430

101,903

326,320

78,255,000

277,996,000

62,829 880 27,783 9,637

16,379

152,932 25,522

12,236

477,310

248,932 350,440 212,269 427,162

308,474

19,809

15,392 2,622 9,680 1,987 224,195

1,203 27,036 49,272 145

152,029 4,964 41,209 9,637

117,747

266,018 154,952

114,139

803,630

427,189 605,787 416,164 781,220

526,845

76,119

36,699 1,203 48,562 55,751 25,916 5,675 58,391 28,448 26,082 8,594 408,257

25,106 28,577 13,878

55,989 44,599

264,265 1,605,275

155,713

426,819 496,682

4,511 30,712

32,799 90,306

89,200 4,084 13,426

101,368

113,086 129,430

101,903

326,320

178,257 255,347 203,895 354,058

218,371

56,310

21,526 6,479 25,771 5,675 42,999 25,826 16,402 6,607 184,062

36,699

18,078 28,577 7,991

49,657

212,091 677,162

123,436

173,796 202,906

3,993 30,672

13,381 48,721

In-Patient Bed Days 1,646

HES

200 3 100

19

12,452 12

0

49,628

15,744 17,350 22,657 37,783

21,837

5,890

0 0 0 0 15 0 2 0 21,789

0

0 0 74

0

0 69,973

0

16,729 27,683

0 0

1,964 2,194

Day Cases 0

HES

18,618 6,229

53,039

40,835

77,756

60,555 60,301 42,886 68,273

64,734

57,890

9,678

15,377

9,456 49,272 145

42,313

224,692

68,650 77,116

A&E Attendances

HES

9,590 877 9,065 3,408

16,360

99,645 25,510

12,236

349,926

172,633 272,789 146,726 321,106

221,903

13,919

1,987 144,516

2,622

1,203 17,580

5,813

7,028

6,332 2,286

52,174 633,448

32,277

518 40 0 167,644 188,977

17,454 39,391

Outpatient Attendances 5,430

HES

24 329 15 65

408

338 512

502

1,006

569 756 631 1,032

747

201

101 22 93 15 105 43 58 19 561

128

88 70 31

239

815 2,240

448

14 102 10 512 660

46 188

Available beds No.

HES

88 641 352 196 306

260

472 943 1,143

981

2,876

1,503 1,804 1,275

50 198 152 447 219 315 48 87 116 148 171 1,082

996 50 21 256 215

901 4,049

1,094

114 527 177 1,142 1,780

Total parking spaces available No. 190 208 155 990

ERIC

1.65 23.47 3.02

0.68

2.71 2.35

1.95

2.86

2.71 2.39 2.04 0.00

0.00

3.63 9.95 3.42 3.20 0.78 1.61 2.47 5.70 2.03

1.71

3.05 3.07

3.57

1.09 1.79

2.70

8.14 5.55 17.70 2.10 2.72

2.46 4.76

Total Parking Spaces per Bed 19.00

ERIC

59 11 18 16

11

20 61

68

77

35 62 31 151

14

11 12 11 35 8 14 0 0 0 0 15 57

54 3 1 12 12

87 72

51

0 33 9 26 53

Total disabled parking spaces No. 0 15 0 0

ERIC

23.5% 5.3% 13.6% 5.2%

6.3%

6.6% 5.3%

6.9%

8.4%

7.0% 14.4% 2.5% 15.1%

10.4%

9.2%

25.6% 6.1% 7.2% 7.8% 13.1% 14.9%

25.1% 6.0% 4.8% 4.6% 20.3%

9.7% 6.3%

4.7%

12.8% 180.0% 4.3% 8.0%

0.0%

% disabled parking spaces

ERIC

251 207 132 306

175

301 1143

981

914

498 432 1225 997

135

43 198 152 447 61 94 0 0 0 0 0 621

215 50 21 260 59

901 1151

1094

0.65 13.80 2.03

0.46

0.86 2.35

1.95

0.91

0.90 0.57 1.96 1.04

0.67

3.63 2.77 1.02 0.00 0.00 0.00 0.00 0.00 1.17

1.71

3.10 0.84

0.77

1.09 0.51

2.70

0.00 2.71 0.50 1.10 1.01

0 0 0 0

0

76,607 0

0

0 0 0 0

0

288,332 0

0

518

188,000 1,151,556 470,000

458,187

0

0

0 0 0 0 0 0 0 0 0 0 0 372,119

48,615 0 0 0 0

0 0

0

0 0 0 214,979 434,131

Income from visitors £ 0 0 0 0

ERIC

412,000 276,152

0

0 0 0 0 0 0 0 0 0 0 0 93,330

0 0 0 0 0

0 0

0

0 0 0 0 33,417

Income from staV £ 0 0 0 0

0 257 5 600 660

ERIC

ERIC

Total Total parking spaces parking spaces available available for for patients/ patients/ visitors visitors No. No/Bed. 0 0.00 0 155 2.46 0 0.00

ERIC

0.50

0.66

1.80 1.00 2.00

0.80

0.25

2.00

1.00

1.00

1.00 1.00

Average fee charged per hour for patient/visitor parking £

ERIC

0.20

0.66

0.40 0.40 0.13

0.30

0.30

Average fee charged per hour for staV parking £

ERIC

PPSysB

RT6

RMZ RQQ RT1

RMY

178,257 255,347 203,895 354,058

218,371

116,636,000 163,965,000 103,751,000 80,899,000

0

56,310

21,526 6,479 25,771 5,675 42,999 25,826 16,402 6,607 184,062

36,699

7,028

18,078 28,577 7,991 5,887

6,332 44,599

52,174 928,113

49,657

212,091 677,162

32,277

253,023 293,776

173,796 202,906 123,436

518 40

19,418 41,585

13,381 48,721 3,993 30,672

Estimated Total OutPatients per Year 5,430

Estimated Total InPatients per Year 1,646

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen) 7,076

Pag Table: COENEW

RM1

RGP RGQ RGR RGT

RGN

19,456,000

52,942,000 19,001,000 0 3,941,000 1,272,000 2,977,000 996,000 8,224,000 2,961,000 9,100,000 247,000 1,459,000 3,949,000 656,000 12,203,000 1,159,000 4,585,000 96,003,000

123,230,000 513,404,000

94,573,000

2,133,000 5,234,000 3,029,000 110,957,000 153,066,000

DB

DB

12-07-06 01:32:43

RGM

5A2 5AF 5AG 5CY 5G1 5GF 5GT 5JH 5JJ 5JK 5JL 5JM 5JQ 5JR 5JT 5JV 5JW RCX

Trust Name LEICESTER CITY WEST PCT EASTERN LEICESTER PCT HINCKLEY AND BOSWORTH PCT CHARNWOOD AND NORTH WEST LEICESTERSHIRE PCT SOUTH LEICESTERSHIRE PCT NORTHAMPTONSHIRE HEARTLANDS PCT NORTHAMPTON PCT KETTERING GENERAL HOSPITAL NHS TRUST NORTHAMPTON GENERAL HOSPITAL NHS TRUST NORTHAMPTONSHIRE HEALTHCARE NHS TRUST LEICESTERSHIRE PARTNERSHIP NHS TRUST UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST NORWICH PCT NORTH PETERBOROUGH PCT SOUTH PETERBOROUGH PCT WEST NORFOLK PCT SOUTHERN NORFOLK PCT HUNTINGDONSHIRE PCT GREAT YARMOUTH PCT CAMBRIDGE CITY PCT SOUTH CAMBRIDGESHIRE PCT EAST CAMBRIDGESHIRE AND FENLAND PCT BROADLAND PCT NORTH NORFOLK PCT IPSWICH PCT SUFFOLK COASTAL PCT CENTRAL SUFFOLK PCT WAVENEY PCT SUFFOLK WEST PCT QUEEN ELIZABETH HOSPITAL KINGS LYNN NHS TRUST PAPWORTH HOSPITAL NHS FOUNDATION TRUST PETERBOROUGH AND STAMFORD HOSPITALS NHS FOUNDATION TRUST JAMES PAGET HEALTHCARE NHS TRUST IPSWICH HOSPITAL NHS TRUST WEST SUFFOLK HOSPITALS NHS TRUST CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST NORFOLK AND NORWICH UNIVERSITY HOSPITAL NHS TRUST NORFOLK AND WAVENEY MENTAL HEALTH PARTNERSHIP NHS TRUST EAST ANGLIAN AMBULANCE NHS TRUST HINCHINGBROOKE HEALTH CARE NHS TRUST CAMBRIDGESHIRE AND PETERBOROUGH MENTAL HEALTH PARTNERSHIP NHS TRUST SUFFOLK MENTAL HEALTH PARTNERSHIP NHS TRUST NORTH EAST LINCOLNSHIRE PCT SELBY AND YORK PCT EAST YORKSHIRE PCT YORKSHIRE WOLDS AND COAST PCT EASTERN HULL PCT

Operational Income £ 12,029,000 663,000 3,764,000 11,386,000

FINANCE

Page Type [E]

RT5 RWE

RP1

5JD 5LV 5LW RNQ RNS

Trust Code 5EJ 5EY 5JA 5JC

SOURCE:

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Ev 126 Health Committee: Evidence

RNH RNJ RQX

RGC

113,888,000 480,478,000 0

169,776,000 160,555 351,807 181,092

253,883

517,581

16,559 165,783

33,526 8,108

65,644

132,577

331,794

295,805

197,784

13,770

71,679

148,521

243,120 669,128 263,367

456,245

746,037

2,352 11,067 2,325 6,070 46,037 596 9,399 27,401

11,026

439,345

516,589

38,715

335,684

257,474 31,728 90,474

351,187

432,073 46,062

273,539 41,428 162,536

77,769 409 22,542 48,154

534,592

14,303

32,241 8,370 16,743 30,116

446,423

71,986

190,131 444,107

403,675 1,020,935 444,459

710,128

1,263,618

67,996 11,067 2,325 39,596 54,145 596 25,958 193,184

143,603

771,139

812,394

236,499

349,454

405,995 31,728 162,153

513,723

705,612 87,490

110,010 8,779 39,285 78,270

981,015

86,289

750,124

309,648

530,000 398,137

32,966 37,137

160,555 351,807 181,092

253,883

517,581

16,559 165,783

33,526 8,108

65,644

132,577

331,794

295,805

197,784

13,770

71,679

148,521

162,536

273,539 41,428

32,241 8,370 16,743 30,116

446,423

71,986

306,017

119,517

243,961 176,956

26,531 20,193

In-Patient Bed Days

HES

9,676 24,152 7,608

20,738

39,508

0 0

754 40

0

0

26,268

17,230

0

16,195

9,269

7,286

16,013

16,860 1,695

30 0 0 0

42,669

0

35,778

15,675

20,929 14,507

7 35

Day Cases

HES

76,332 157,092 91,502

197,262

290,665

38,741

139,165

77,841

50,036

80,675

144,415

75,949

77,124

116,237

133,469

40,202

63,699 69,429

1,689 9,434

A&E Attendances

HES

157,112 487,884 164,257

238,245

415,864

2,352 11,067 2,325 5,316 7,256 596 9,399 27,401

11,026

273,912

421,518

38,715

269,453

169,513 31,728 81,205

190,759

339,264 44,367

615 409 22,542 48,154

375,686

14,303

274,860

134,254

201,411 137,245

4,739 7,475

Outpatient Attendances 2,155

HES

424 998 523

765

1,512

624

136 114 48

181

454

981

952

787

44

263

439

485

139 60 60 105 4 821 173

1,465

281

1,058

400

774 585

104 101

Available beds No.

HES

687 446

1,071

1.79 0.41 0.00

1.35

2.13

1.60 2.89 3.85 3.94 1.27 3,214

3.07

553

0.22

1.79

0.00

1.52

0.00

0.00

0.26

0.00

0.42 2.51

4.76 20.66 14.20 1.49

2.05

2.76

2.27

0.00

1.73 1.47 2.20

4.02 8.77

Total Parking Spaces per Bed

ERIC

210 218 254 200 276 739

65

1,890

1,188

115 103 0

671 1,219 426 156 69 394 589

3,094

777

80

2,423

281 1,119 1,012

Total parking spaces available No. 124 252 245 886

ERIC

22 10

39

92

10

6 20 13

16

7

105

44

0

8 4 0

22 76 8 12 5 16 73

92

36

8

90

7

20 48 28

Total disabled parking spaces No. 6 12 17 16

ERIC

10.2% 31.3%

12.0%

12.8%

9.2%

2.9% 1000.0% 5.7%

14.0%

6.0%

7.6% 66.7%

10.8% 13.8%

13.9% 13.8% 2.0%

3.0%

4.8%

11.1%

9.7%

2.1%

8.9% 11.0% 3.2%

% disabled parking spaces 5.0% 4.8% 8.8% 3.5%

ERIC

331

216 32

326

718

109

210 2 229

0

749

728

0

105 6 0

158 550 407 0 0 148 528

3094

744

72

925

0.56 0.03 0.00

0.41

0.47

0.01 2.60 0.00 1.56 0.00

0.00

0.00

0.71

0.00

0.93

0.00

0.00

0.24

0.00

0.16 2.25

1.12 9.32 13.57 0.00

2.05

2.64

0.87

0.83

1.39 0.57 1.89

69,000 61,097

0

0

0

0 14,003 0

0

0

7,279

0

0

32,114 35,000 0

0 4,680 0 0 0 116,370 22,200

8,500

0

0

0

120,499

0 76,516 0

Income from staV £ 0 0 0 0

225 437 869

ERIC

ERIC

Total Total parking spaces parking spaces available available for for patients/ patients/ visitors visitors No. No/Bed. 119 252 193 3.16 456 4.51

ERIC

0 0

350,000

1,013,029

0

0 5,110 0

0

0

1,100,922

0

0

15,634 0 0

0 0 0 0 0 267,506 0

753,601

7,684

0

0

302,101

0 380,026 195,000

Income from visitors £ 0 0 0 0

ERIC

0.67

1.00

0.43

0.50

1.60

3.00

3.00

0.60

3.00

1.00 2.00

0.50

1.00

1.50

1.20 2.00

1.50

Average fee charged per hour for patient/visitor parking £

ERIC

0.50

0.75

0.60

0.45 0.15

0.28 1.00

0.50

1.00

0.62

1.00

Average fee charged per hour for staV parking £

ERIC

PPSysB

310,266,000

20,199,000 7,341,000 6,941,000 22,409,000 12,584,000 5,882,000 2,912,000 98,342,000

114,946,000

239,254,000

106,753,000

166,728,000

0

127,524,000 18,145,000 196,007,000

124,583,000

119,517 306,017

286,039 221,181

6,435 16,944

26,531 20,193 243,961 176,956

Estimated Total OutPatients per Year 2,155

Estimated Total InPatients per Year

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen) 2,155

Pag Table: COENEW

RF4

5A4 5C2 5C3 5C4 5C5 5NA 5NC RAT

TAF

RVL

RRV

RRP

RP6

RKE RNK RP4

17,288,000 17,123,000 15,309,000 47,898,000 11,853,000 339,850,000 61,278,000

309,778,000

74,976,000

50,742,000

210,583,000

58,065,000

10,538,000 159,368,000 90,275,000

DB

DB

12-07-06 01:32:43

RAP

5A9 5C1 5C9 5K7 5K8 RAL RAN

RWA

RV9

Trust Name WEST HULL PCT NORTH LINCOLNSHIRE PCT HAMBLETON AND RICHMONDSHIRE PCT CRAVEN HARROGATE AND RURAL DISTRICT PCT SCARBOROUGH WHITBY AND RYEDALE PCT YORK HEALTH SERVICES NHS TRUST SCARBOROUGH AND NORTH EAST YORKSHIRE HEALTH CARE NHS TRUST HARROGATE AND DISTRICT NHS FOUNDATION TRUST NORTHERN LINCOLNSHIRE AND GOOLE HOSPITALS NHS TRUST TEES EAST AND NORTH YORKSHIRE AMBULANCE SERVICE NHS TRUST HUMBER MENTAL HEALTH TEACHING NHS TRUST HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST BARNET PCT ENFIELD PCT HARINGEY TEACHING PCT CAMDEN PCT ISLINGTON PCT ROYAL FREE HAMPSTEAD NHS TRUST THE ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST THE WHITTINGTON HOSPITAL NHS TRUST TAVISTOCK AND PORTMAN NHS TRUST GREAT ORMOND STREET HOSPITAL FOR CHILDREN NHS TRUST MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST BARNET ENFIELD AND HARINGEY MENTAL HEALTH NHS TRUST UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST BARNET AND CHASE FARM HOSPITALS NHS TRUST CAMDEN AND ISLINGTON MENTAL HEALTH AND SOCIAL CARE TRUST HAVERING PCT BARKING AND DAGENHAM PCT CITY AND HACKNEY PCT TOWER HAMLETS PCT NEWHAM PCT REDBRIDGE PCT WALTHAM FOREST PCT NORTH EAST LONDON MENTAL HEALTH NHS TRUST BARKING HAVERING AND REDBRIDGE HOSPITALS NHS TRUST WHIPPS CROSS UNIVERSITY HOSPITAL NHS TRUST NEWHAM HEALTHCARE NHS TRUST BARTS AND THE LONDON NHS TRUST HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

Operational Income £ 4,825,000 1,470,000 2,437,000 2,077,000

FINANCE

Page Type [O]

RV1

RJL

RCD

5KK RCB RCC

Trust Code 5E6 5EF 5KH 5KJ

SOURCE:

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Health Committee: Evidence Ev 127

6,177

3,080

228,317

191 248

46,274 967

2,718 112,525 10,030

23,025

32,045 27,686 16,646 111,050 28,052 10,725

407,542

377,206

194,606 943,415

106,796

209,716 523,726

234,494

2,718 144,570 37,716 16,646 157,324 29,019 10,725 191 3,328

129,821

784,748

404,322 1,467,141

41,179 241,976

860 2,799 312,547 705,412

810,731 32,961 1,714

200,184

802,303 203,785

6,177

32,045 27,686 16,646 111,050 28,052 10,725 0 3,080

106,796

377,206

209,716 523,726

30,569 181,163

548 2,709 141,083 288,983

288,649

176,158

344,866 103,377

160,727 138,550 136,614 209,366 279,275 171,838

22,211 38,041 43,416

39,045

3,190

3,602 0 0 314 967 0 191 0

0

34,986

4,293 72,529

0 0

312 0 13,247 37,405

29,753

0

17,145 6,582

12,361 9,977 7,831 15,927 0 15,396

0 0 0

0

Day Cases 177

HES

60,545

248

23,793

56,276 10,030

162,241

58,777 130,811

49,306 114,459

182,261

102,996

94,777

16,356 36,181 86,996 97,375 79,572 105,888

15,582

A&E Attendances

HES

164,582

0

22,167

2,718 52,647

23,025

210,315

131,536 740,075

10,610 60,813

90 108,911 264,565

310,068 32,961 1,714

24,026

337,296 93,826

199,328 147,824 140,032 288,011 42,885 265,554

662 617 2,670

6,699

Outpatient Attendances 18,777

HES

570

12

110 110 50 423 109 41

502

1,296

726 1,735

364 728

39 10 474 980

946

698

1,071 387

125 203 81 512 427 394 588 663 449

152

Available beds No. 635

HES

1,315

350 586 289 300 649 836 446 0 68 117 223 89

2,432 78 494

3,840

541 193

113 206 560

2,604 0

280

1,043 695

571 43 414 473 180 111 126 86 1,877 628 810 219 1,502 360

Total parking spaces available No. 260

ERIC

2.32

5.67

5.33 2.63 6.00 1.44 7.40 10.88

1.05

1.88

0.00 2.16

0.91 0.48

0.00 0.00

6.87

3.52

0.36

1.00 1.67

3.88 2.26 4.76 67.57 1.76 1.17 0.68 1.72 3.02 1.53 2.05 0.31 1.37 0.74

Total Parking Spaces per Bed 0.43

ERIC

57

0 8 10 14 0

37 32

12 27 14

109 2 21

51 154

16

4 9 25 45 57

80

11.2%

116.7% 0.0%

22.3% 69.6%

10.1%

4.3%

10.3% 15.4% 4.6%

17.6% 12.2%

3.0%

3.5% 7.8% 11.2% 91.8% 4.8%

9.8%

33.1% 17.2%

3.9% 11.3%

0 34 18 55 25

34.8% 7.2% 19.4% 8.3% 11.2% 9.1%

13.0%

% disabled parking spaces 15.6%

ERIC

16 8 7 1 42 15

39

Total disabled parking spaces No. 15

ERIC

508

0 0 0 12 2

166 46

280 0 138

1054 13 457

289 1258

525

113 116 224 49 1200

819

166 145

0 878 160

46 111 36 12 374 164

0.89

0.00

0.00 1.25 0.00 0.37 0.41 0.00

0.97

0.81

0.42 0.71

0.88 0.00

0.09 1.14

3.87

1.11

0.00

0.16 0.35

2.03 0.00 0.00 0.00 0.45 1.17 0.19 0.24 0.60 0.40 0.00 0.00 0.80 0.33

63,168

0 0 0 0 0

0 5,259

0 0 0

0 0 0

88,400 426,098

0

0 0 0 79,246 135,455

247,155

498,751 50,000

54,000 0 78,893

10,201 0 9,180 2,562 0 0

0

Income from staV £ 0

Total Total parking spaces parking spaces available available for for patients/ patients/ visitors visitors No. No/Bed. 96 0.16 299

ERIC

ERIC

ERIC

451,639

0 0 0 0 0

0 22,610

0 0 0

325,002 0 0

277,800 1,039,136

0

0 0 0 290,005 238,387

1,154,337

277,875 0

0 37,459 267,517

22,726 0 0 9,712 444,383 189,957

0

Income from visitors £ 0

ERIC

0.83

0.28

0.43

1.00

0.30

1.90

1.50 0.50

0.50 2.80

0.50 0.50 1.80 0.38 2.80

0.50

0.40

Average fee charged per hour for patient/visitor parking £

ERIC

0.30

0.10

0.30 0.39

0.40

0.41

2.00

0.80

0.40 0.40

0.40

0.40

Average fee charged per hour for staV parking £

ERIC

PPSysB

113,838,000

18,746,000 3,812,000 4,802,000 5,027,000 19,452,000 9,493,000 6,617,000 11,290,000 647,000 2,550,000 2,787,000 25,262,000

213,283,000 55,332,000 67,994,000

97,237,000 520,902,000

10,610 60,813

312 90 171,464 416,429

548 2,709 141,083 288,983 30,569 181,163

522,082 32,961 1,714

24,026

457,437 100,408

662 22,828 40,711 59,772 36,181 459,412 393,726 364,049 619,192 322,160 547,565

662 617 2,670 16,356 36,181 298,685 255,176 227,435 409,826 42,885 375,727

288,649

176,158

344,866 103,377

45,744 15,582

6,699 15,582

In-Patient Bed Days 196,674

HES

Pag Table: COENEW

RJD

TAC 5DQ 5HR 5HW 5M2 5ME 5MF 5MK 5ML 5MM 5MN RB7

RTF RVK RW9

RR7 RTD

62,973,000 125,079,000

264,348,000 9,898,000 4,124,000 3,875,000 992,000 5,020,000 62,635,000 54,214,000

142,313,000

401,094,000 176,463,000

160,727 138,550 136,614 209,366 279,275 171,838

22,211 38,041 43,416

39,045

Operational Income £ 141,552,000

4,013,000 6,798,000 6,640,000 3,987,000 12,294,000 5,050,000 18,067,000 13,791,000 128,742,000 105,340,000 107,421,000 271,207,000 198,480,000 207,908,000

Estimated Total OutPatients per Year 18,954

Estimated Total InPatients per Year 196,674

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen) 215,628

12-07-06 01:32:43

RM6 RNP

RV8 5D7 5D8 5KF 5KG 5KL RE9 RLN

RV3

Trust Name EAST LONDON AND THE CITY MENTAL HEALTH NHS TRUST HILLINGDON PCT HAMMERSMITH AND FULHAM PCT EALING PCT HOUNSLOW PCT BRENT PCT HARROW PCT KENSINGTON AND CHELSEA PCT WESTMINSTER PCT THE HILLINGDON HOSPITAL NHS TRUST EALING HOSPITAL NHS TRUST WEST MIDDLESEX UNIVERSITY NHS TRUST ST MARY’S NHS TRUST WEST LONDON MENTAL HEALTH NHS TRUST CHELSEA AND WESTMINSTER HEALTHCARE NHS TRUST HAMMERSMITH HOSPITALS NHS TRUST ROYAL BROMPTON AND HAREFIELD NHS TRUST CENTRAL AND NORTH WEST LONDON MENTAL HEALTH NHS TRUST NORTH WEST LONDON HOSPITALS NHS TRUST NEWCASTLE PCT NORTH TYNESIDE PCT GATESHEAD PCT SOUTH TYNESIDE PCT SUNDERLAND TEACHING PCT SOUTH TYNESIDE NHS FOUNDATION TRUST CITY HOSPITAL SUNDERLAND NHS FOUNDATION TRUST NORTHGATE AND PRUDHOE NHS TRUST NEWCASTLE NORTH TYNESIDE AND NORTHUMBERLAND MENTAL HEALTH NHS TRUST GATESHEAD HEALTH NHS FOUNDATION TRUST THE NEWCASTLE UPON TYNE HOSPITALS NHS TRUST NORTHUMBRIA HEALTH CARE NHS TRUST NORTH EAST AMBULANCE SERVICE NHS TRUST SOUTH OF TYNE AND WEARSIDE MENTAL HEALTH NHS TRUST NORTHUMBERLAND CARE TRUST BURNTWOOD LICHFIELD AND TAMWORTH PCT STAFFORDSHIRE MOORLANDS PCT NEWCASTLE-UNDER-LYME PCT SHROPSHIRE COUNTY PCT NORTH STOKE PCT SOUTH STOKE PCT TELFORD AND WREKIN PCT EAST STAFFORDSHIRE PCT CANNOCK CHASE PCT SOUTH WESTERN STAFFORDSHIRE PCT STAFFORDSHIRE AMBULANCE SERVICE NHS TRUST MID STAFFORDSHIRE GENERAL HOSPITALS NHS TRUST

DB

DB

FINANCE

Page Type [E]

RQN RT3

5AT 5H1 5HX 5HY 5K5 5K6 5LA 5LC RAS RC3 RFW RJ5 RKL RQM

Trust Code RWK

SOURCE:

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Ev 128 Health Committee: Evidence

155,017,000

65,051

292,880 20,265 16,132 98,366 46,894 45,588 28,275 49,415 28,392 27,998 47,578 43,665 168,454 102,567 288,221 257,395

227,934

11,056

455,220 20,315 10,173 13,505 17,066 15,112 30,895 34,822 15,486 17,811 42,925 36,042 293,907 164,568 428,630 360,770

44,179

76,107

748,100 40,580 26,305 111,871 63,960 60,700 59,170 84,237 43,878 45,809 90,503 79,707 462,361 267,135 716,851 618,165

272,113

527,616 630,533 840,180 212,076

465,128 843,200 141,800 324,824 1,803 37,178 2,038 117,443 47,550

440,961 489,431 387,520 1,008,855

2,978 338 4,413

691,151

76,823

191,813

372,968 130,138

65,051

292,880 20,265 16,132 98,366 46,894 45,588 28,275 49,415 28,392 27,998 47,578 43,665 168,454 102,567 288,221 257,395

227,934

202,178 238,958 312,402 73,920

23,151 13,408

36,134

197,537 320,433 120,794 317,696

164,041 185,259 139,022 360,089

4,413

292,954

56,666

164,414

150,962 57,724

3

25,932 28 19 1 25 143 0 375 49 97 38 1,231 15,369 13,961 38,941 34,338

0

16,465 12,214 23,229 12,889

0 0

96

13,422 25,383 0 0

16,045 23,460 14,928 28,444

0

35,041

3

0

14,952 2,653

Day Cases 69,390

HES

134,237 20,287 10,154 3,403 17,041 14,969 30,895 34,447 15,437 17,714 42,887 34,811 70,095 34,082 72,089 63,446

98,578 164,988 140,018

15,912 34,142

117,062 116,724

98,389 80,294 73,102 145,674

103,309

54,932 2,811

A&E Attendances 135,665

HES

11,053

208,443 116,525 317,600 262,986

0

295,051 0 0 10,101

44,179

210,395 214,373 364,531 125,267

137,107 380,660 21,006 7,128 1,803 948 2,038 78,380

162,486 200,418 160,468 474,648

2,978 338

259,847

20,154

27,399

152,122 66,950

Outpatient Attendances 319,223

HES

229

930 71 54 306 152 135 80 181 116 102 153 137 542 322 952 849

830

85 50 230 599 727 957 241

110

609 915 439 1,062

561 551 444 1,216

11

868

194

566

454 217

Available beds No. 1,168

HES

449 515

1,042 1,849 208 143 878 535 250 332 650 365 241 372 284 1,650 1,000 2,483

1,278

1,159

278 703 1,462 1,059 108 211 211 604 104 798 797

301 359 144 200 276 640 971 854

1,750

988

849

997 620

Total parking spaces available No. 3,329

ERIC

1.97

2.12 2.77 2.65 2.83 3.57 1.87 4.15 3.42 4.20 2.39 2.42 2.54 3.02 3.29 2.61 0.00

1.61

0.00 1.08 0.00

6.57 2.08 2.44

1.65

0.46 0.72 3.40 0.85

1.32 1.45 1.88 0.00

2.12 7.14

1.82

3.80

1.60

2.20 2.84

Total Parking Spaces per Bed 2.87

ERIC

24 1

4 106 11 4 43 26 8 14 38 18 18 22 15 67 29 103

5.7% 4.8%

5.1% 19.6% 6.2% 4.9% 4.9% 6.7% 10.0% 4.5% 6.7% 5.4% 11.0% 5.9% 7.2% 19.1% 9.4% 14.1%

156.8% 12.8%

1.9% 5.5% 15.9% 15.2% 17.6% 5.0%

2 9 13 47 9 13 809 25

6.6%

17.5%

28.8% 4.9% 15.8% 18.5% 4.5% 6.0% 8.8% 15.5% 9.1%

9.8%

7.5% 3.2%

% disabled parking spaces 15.0%

ERIC

7 0 72

15 7 9 10 6 21 40 49 23

130

50

31 20

Total disabled parking spaces No. 159

ERIC

418 21

78 542 178 82 878 388 80 313 567 335 163 372 209 350 309 732

516 195

108 164 82 309 51 262

40 0 1084

52 142 57 54 133 351 453 316 252

1328

0

1.83

0.62 2.37 1.52 2.83 2.59 0.60 3.91 2.98 3.85 1.61 2.42 1.87 0.64 1.02 0.77 0.00

0.00

0.00 0.48 0.81

3.36 1.02 0.80

1.28

0.07 0.00 2.52 0.00

0.72 0.68 0.70 0.23

0.84 1.93

1.38

0.00

0.00

0.91 2.84

0 0

0 0 0 0 0 0 0 9,019 0 0 0 0 0 80,555 72,578 63,043

181,199 50,000

0 0 0 0 0 0

20,004 0 0

0 0 0 0 0 115,087 0 2,000 418,152

0

0

0 0

Income from staV £ 114,998

412 620

ERIC

ERIC

Total Total parking spaces parking spaces available available for for patients/ patients/ visitors visitors No. No/Bed. 1062 0.92

ERIC

0 0

0 1,037,500 1,856 0 0 0 13,000 7,382 0 0 0 0 0 337,764 238,858 474,301

605,276 180,000

0 0 0 0 0 0

253,563 0 0

0 0 0 0 0 413,377 356,866 148,000 641,272

654,000

0

403,876 29,970

Income from visitors £ 521,998

ERIC

2.40 0.33 0.45

0.60 1.00

0.83

1.17

2.00

1.80

1.50

1.16 2.30 1.00 1.25

1.00 0.50 1.40

2.00

1.00 0.12

Average fee charged per hour for patient/visitor parking £ 0.28

ERIC

0.30 0.20 0.15

0.90

0.16 0.40

0.20

0.20 0.20

0.25

Average fee charged per hour for staV parking £ 0.10

ERIC

PPSysB

82,107,000 61,646,000

192,588,000 246,428,000 1,542,000 1,552,000 16,547,000 5,269,000 2,751,000 6,038,000 3,865,000 6,005,000 1,081,000 3,773,000 3,535,000 145,868,000 77,502,000 228,850,000 0

325,438 391,575 527,778 138,156

202,178 238,958 312,402 73,920

23,151 13,408

36,134

267,591 522,767 21,006 7,128 1,803 1,044 2,038 94,292 34,142

276,920 304,172 248,498 648,766

2,978 338

398,197

20,157

27,399

222,006 72,414

197,537 320,433 120,794 317,696

164,041 185,259 139,022 360,089

4,413

292,954

56,666

164,414

150,962 57,724

In-Patient Bed Days 312,939

HES

Pag Table: COENEW

RJ8 RJ9

RRU RVR 5CV 5CW 5F1 5FM 5FQ 5FR 5FT 5FV 5FY 5KR 5KT RA9 RBZ REF RH8

146,620,000 359,904,000 112,269,000 291,289,000 482,000 8,766,000 3,399,000 38,667,000 2,025,000 12,256,000 154,207,000 149,361,000 333,532,000 0

1,896,000 3,891,000 4,043,000 16,949,000 20,382,000 130,090,000 165,431,000 93,762,000 145,240,000

177,378,000

81,142,000

86,967,000

98,527,000 50,840,000

Estimated Total OutPatients per Year 524,278

Estimated Total InPatients per Year 312,939

Operational Income £ 295,327,000

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen) 837,217

12-07-06 01:32:43

RQY

RJ2 RJZ RPG RV5 TAK 5A5 5K9 5LG 5M6 5M7 RAX RJ6 RJ7 RPY

Trust Name UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE NHS TRUST BURTON HOSPITALS NHS TRUST ROBERT JONES AND AGNES HUNT ORTHOPAEDIC AND DISTRICT HOSPITAL NHS TRUST NORTH STAFFORDSHIRE COMBINED HEALTHCARE NHS TRUST SOUTH STAFFORDSHIRE HEALTHCARE NHS TRUST SHREWSBURY AND TELFORD HOSPITALS NHS TRUST BROMLEY PCT GREENWICH PCT LAMBETH PCT SOUTHWARK PCT LEWISHAM PCT QUEEN ELIZABETH HOSPITAL NHS TRUST BROMLEY HOSPITALS NHS TRUST QUEEN MARY’S SIDCUP NHS TRUST GUY’S AND ST THOMAS’ NHS FOUNDATION TRUST THE LEWISHAM HOSPITAL NHS TRUST KING’S COLLEGE HOSPITAL NHS TRUST OXLEAS NHS TRUST SOUTH LONDON AND MAUDSLEY NHS TRUST BEXLEY CARE TRUST KINGSTON PCT CROYDON PCT WANDSWORTH PCT RICHMOND AND TWICKENHAM PCT SUTTON AND MERTON PCT KINGSTON HOSPITAL NHS TRUST MAYDAY HEALTHCARE NHS TRUST ST GEORGE’S HEALTHCARE NHS TRUST THE ROYAL MARSDEN NHS FOUNDATION TRUST SOUTH WEST LONDON AND ST GEORGE’S MENTAL HEALTH NHS TRUST LONDON AMBULANCE SERVICE NHS TRUST EPSOM AND ST HELIER NHS TRUST SOUTH HAMS AND WEST DEVON PCT TORBAY PCT PLYMOUTH PCT WEST OF CORNWALL PCT NORTH DEVON PCT EXETER PCT EAST DEVON PCT MID DEVON PCT TEIGNBRIDGE PCT NORTH AND EAST CORNWALL PCT CENTRAL CORNWALL PCT SOUTH DEVON HEALTH CARE NHS TRUST NORTHERN DEVON HEALTHCARE NHS TRUST ROYAL CORNWALL HOSPITALS NHS TRUST ROYAL DEVON AND EXETER NHS FOUNDATION TRUST CORNWALL PARTNERSHIP NHS TRUST WESTCOUNTRY AMBULANCE SERVICES NHS TRUST

DB

DB

FINANCE

Page Type [O]

5A7 5A8 5LD 5LE 5LF RG2 RG3 RGZ RJ1

RXW

RRE

RLY

RJF RL1

Trust Code RJE

SOURCE:

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Health Committee: Evidence Ev 129

RW8

85,505,000

92,676,000 153,794,000 30,291,000

29,402,000 90,438,000 42,422,000 47,729,000 163,630,000

110,032

124,704

25,274

21,617 348,335 12,798

8,808 421,000

66,190 263,159 42,098

184,165

62,642 206,443

288,634

159,244

222,576

25,756

279,990 24,271 307,302

2,236 161,105 69,058 203,787

149,978

87,807 611,494 54,896

71,450 627,443

343,409

511,210

135,788

2,236 441,095 93,329 511,089

16,987 1,641 58,142 72,740 74,984 25,254 47,167 8,707 51,997

102,837 21,639 4,376

111,392

883,532

151,735 411,245 494,446 1,680,969

124,704

66,190 263,159 42,098

62,642 206,443

159,244

222,576

25,756

2,236 161,105 69,058 203,787

16,633 1,641 53,457 24,691 20,715 22,698 28,765 4,717 24,876

90,401 21,639

111,392

331,842

33,254 143,864 207,387 661,596

4,141 65,091

In-Patient Bed Days 339,234 139,588 23,597

HES

0

0 15,899 0

0 22,659

12,380

30,128

5,489

0 18,367 0 23,887

354 0 0 0 0 3 345 0 227

0 0

0

45,389

5,579 12,229 20,712 71,877

0 0

Day Cases 24,981 34 0

HES

126,615

116,462

48,344

61,333

9,877

84,070

70,018

21,571

4,055 48,049 54,269 2,553 8,881

145,352

47,494 66,144 73,139 193,575

A&E Attendances 97,195

HES

25,274

21,617 205,821 12,798

8,808 281,879

123,441

197,173

94,666

191,605 24,271 199,345

9,176 3,990 5,323

630

4,376

12,436

360,949

65,408 189,008 193,208 753,921

2,111 1,305 13,419

0 0

Outpatient Attendances 288,490 15,562 0

HES

562

434 720 152

221 622

475

626

74

523 202 596

95

19 10 169 78 60 81 88

347 69

1,325

141 501 649 2,041

18 220

15

Available beds No. 1,065 564 74

HES

564

250 1,267 87

0 1,141 53 254 1,790

1,041

288 1,162 730 1,298

681 126 52 263 0 60 753 878 427 368 384 189 408

803

1,076

215

Total parking spaces available No. 2,143 615 111 32 193 127 50 92 67 368 780 245

ERIC

1.01

0.61 2.12 0.45

1.10 3.18

2.24

1.52

0.00

7.58 2.25 3.61 1.89

3.26

0.00 2.00 3.98 11.55 5.21 4.60 3.84

2.04 2.57

1.48

0.00

1.47 0.00 1.46 0.00

36.80 2.88

5.75

Total Parking Spaces per Bed 2.09 0.93 1.50

ERIC

13

11 54 4

50

66 1

40

12

16 45 97 33

42 11 22 27 0 21

43 7 3 14 0 3

58

89

54 74

Total disabled parking spaces No. 72 0 6 4 19 10 5 13 8 25 54 25

ERIC

325.0%

4.4% 18.4% 1.3%

8.8%

14.7% 100.0%

11.1%

9.8%

9.7%

10.0%

8.2%

13.7% 5.7% 14.8% 22.3%

7.5%

5.3%

6.3%

7.5%

10.0%

14.7% 6.9%

83.3%

5.4% 12.5% 9.8% 7.9% 33.3% 14.1% 11.9% 6.8%

% disabled parking spaces 10.7%

ERIC

893

4

250 293 318

565

448 1

360

122

0 451 0 340

306 193 149 121 0 257

681 0 0 263 0 40

778

0.01

0.61 0.49 1.64

0.00 1.00

0.88

0.52

1.65

0.00 0.87 0.00 0.49

2.06

0.00 1.33 0.00 4.03 2.35 1.86 1.21

2.04 0.00

1.44

0.72

0.00 0.80 1.46 0.00

191

0 0 0

0

0 18,000 0

92,807

0

0 101,828

0

0 0 0 0 0 0

0 0 0 0 0 0

0

63,560

47,000 0

Income from staV £ 146,000 0 0 0 0 0 0 0 0 0 0 0

Total Total parking spaces parking spaces available available for for patients/ patients/ visitors visitors No. No/Bed. 676 0.66 0 0.00 111 1.50 32 193 127 15 92 5.75 67 368 36.80 0 0.00 30 368 1076

ERIC

ERIC

ERIC

5,342

0 527,378 0

642,590

0 520,000 0

649,733

46,240

0 683,271

0

0 0 0 0 0 0

0 0 0 0 0 0

0

205,617

313,000 234,922

Income from visitors £ 700,000 0 0 0 0 0 0 0 0 0 0 0

ERIC

0.50

2.00

1.00

1.50

0.58

1.00

1.00

1.50

0.95

0.70

Average fee charged per hour for patient/visitor parking £ 0.35 1.20

ERIC

0.50

0.12

0.50

0.10

1.00

0.63

0.10

Average fee charged per hour for staV parking £ 0.50

ERIC

PPSysB

RTN RTP RW7

RPQ RPR RQ2 RTJ RTK

9,034,000

131,111,000

4,685 48,049 54,269 2,556 18,402 3,990 27,121

354

4,376

12,436

551,690

118,481 267,381 287,059 1,019,373

16,633 1,641 53,457 24,691 20,715 22,698 28,765 4,717 24,876

90,401 21,639

111,392

331,842

33,254 143,864 207,387 661,596

2,111 5,446 78,510

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen) 749,900 155,184 23,597

Pag Table: COENEW

RPL

92,204,000 5,032,000 1,172,000 6,527,000 5,982,000 4,890,000 13,232,000 17,566,000 3,444,000 3,233,000 3,669,000 2,686,000 5,258,000 0 940,000 132,081,000 125,778,000 130,812,000

95,418,000

0

69,203,000 78,510,000 124,811,000 136,109,000

2,111 1,305 13,419

Estimated Total OutPatients per Year 410,666 15,596

Estimated Total InPatients per Year 339,234 139,588 23,597

4,141 65,091

DB

DB

12-07-06 01:32:43

RPC

TAH 5FH 5FJ 5FK 5KP 5KQ 5L5 5L6 5L7 5L8 5L9 5LR 5LT 5MA 5MC RA2 RDR RDU

RXE

RP5

Trust Name PLYMOUTH HOSPITALS NHS TRUST DEVON PARTNERSHIP NHS TRUST DONCASTER CENTRAL PCT NORTH SHEFFIELD PCT DONCASTER EAST PCT DONCASTER WEST PCT SHEFFIELD WEST PCT SHEFFIELD SOUTH WEST PCT SOUTH EAST SHEFFIELD PCT ROTHERHAM PCT BARNSLEY PCT SOUTH YORKSHIRE AMBULANCE SERVICE NHS TRUST SHEFFIELD CHILDREN’S NHS TRUST BARNSLEY HOSPITAL NHS FOUNDATION TRUST THE ROTHERHAM NHS FOUNDATION TRUST SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST DONCASTER AND BASSETLAW HOSPITALS NHS FOUNDATION TRUST DONCASTER AND SOUTH HUMBER HEALTHCARE NHS TRUST SHEFFIELD CARE TRUST BEXHILL AND ROTHER PCT HASTINGS AND ST LEONARDS PCT MID-SUSSEX PCT EAST ELMBRIDGE AND MID SURREY PCT EAST SURREY PCT GUILDFORD AND WAVERLEY PCT NORTH SURREY PCT SURREY HEATH AND WOKING PCT ADUR ARUN AND WORTHING PCT WESTERN SUSSEX PCT EASTBOURNE DOWNS PCT SUSSEX DOWNS AND WEALD PCT CRAWLEY PCT HORSHAM AND CHANCTONBURY PCT ROYAL SURREY COUNTY HOSPITAL NHS TRUST SOUTH DOWNS HEALTH NHS TRUST FRIMLEY PARK HOSPITAL NHS FOUNDATION TRUST QUEEN VICTORIA HOSPITAL NHS FOUNDATION TRUST WORTHING AND SOUTHLANDS HOSPITALS NHS TRUST SURREY AMBULANCE SERVICE NHS TRUST ROYAL WEST SUSSEX NHS TRUST SUSSEX AMBULANCE SERVICE NHS TRUST SURREY HAMPSHIRE BORDERS NHS TRUST ASHFORD AND ST PETER’S HOSPITALS NHS TRUST SURREY OAKLANDS NHS TRUST SURREY AND SUSSEX HEALTHCARE NHS TRUST NORTH WEST SURREY MENTAL HEALTH NHS PARTNERSHIP TRUST WEST SUSSEX HEALTH AND SOCIAL CARE NHS TRUST

Operational Income £ 261,801,000 85,629,000 6,509,000 2,329,000 1,246,000 1,383,000 708,000 11,720,000 3,218,000 11,742,000 58,817,000 29,876,000

FINANCE

Page Type [E]

RCU RFF RFR RHQ

Trust Code RK9 RWV 5CK 5EE 5EK 5EL 5EN 5EP 5EQ 5H8 5JE RB8

SOURCE:

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Ev 130 Health Committee: Evidence

8,549

43,795

3,265 44,437 10,408 19,727

2,811

83 4,399

45,950 41,020

36,309

30,256 29,257 17,947

1,994

63,522

83 7,664 44,437 13,219

66,565 29,257 45,950 58,967

64,738

8,549

5,108

115,374 755,706 1,103 9,804

1,016,037 67,253

126,433

3,635

727,098

344,246

43,386 66,206 17,412 81,445 12,295 24,221 6,969 8,453 10,767 22,105 50,065 4,252 7,801 12,566 100,714 553,298

817,395

23,142 467,171

565,760 14,866

19,914

62,744

92,232 288,535 1,103 4,696

450,277 52,387

106,519

1,805

482,382

206,740

53,145 338,563

3,098

5,101 373

5,164 3,139 909

49,732

11,106 48,268

468,324

43,795

3,265 44,437 10,408

17,947

30,256 29,257

62,744

92,232 288,535 1,103 4,696

450,277 52,387

106,519

1,830

244,716

137,506

32,280 17,938 17,412 31,713 12,295 19,057 3,830 7,544 10,767 17,004 49,692 4,252 4,703 12,566 47,569 214,735

349,071

252

0 0 0

2,222

0 0

354

0 28,507 0 2

33,504 0

0

48

29,317

11,880

0 2,812 0 0 0 0 0 1 0 0 0 0 0 0 3,148 21,057

24,284

Day Cases 28,984 0

HES

19,475

931

45,950 26,306

24,030

8,549

112,777

125,121

96,984

68,401

99,530

5,101 373

260 3,139 908

49,732

16,626

120,463

A&E Attendances 101,916

HES

0 83 4,399 0 1,880

0 12,492

1,640 0 12,279

5,106

23,142 325,887

407,135 14,866

19,914

1,757

356,081

126,459

49,997 217,976

3,098

4,904

11,106 28,830

323,577

Outpatient Attendances 285,400 410

HES

67 154

12 146 40

12

55

103 97

219

16

327 922

1,320 254

320

28

764

419

94 29 67 103 48 53 12 27 30 52 163 18 21 49 158 669

1,072

Available beds No. 1,067 296

HES

491 388

277 2,532 86 444 64 284 132 545 48 349 363 0 290 147 227 226 130 174 101

69 3,697 353

280 700

155

1,774

281

1,274

516 273 343 330 170 221 29 123 123 153 435 92 500 119 443 1,944

1,550

Total parking spaces available No. 2,079 683

ERIC

7.33 2.35

10.83 1.19 2.53

18.92

5.18

3.53 3.86

2.43

12.35

1.05 3.28 12.29 27.75

2.75 1.16

2.16

5.17

2.48

2.94

4.30 4.55 8.79 3.51 3.78 3.95 2.42 4.56 4.10 2.64 2.67 5.11 25.00 2.38 3.12 2.83

1.62

Total Parking Spaces per Bed 2.01 2.47

ERIC

25 26

18 98 4 29 5 22 8 25 0 17 18 0 13 12 14 8 9 10 4

0 138 23

1 23

4

46

8

39

22 24 8 11 7 31 2 7 7 10 27 7 28 6 43 47

102

Total disabled parking spaces No. 69

ERIC

13.0% 6.7%

7.0%

5.3% 9.4% 8.0% 42.1% 9.8%

5.0% 5.1%

7.5% 13.2% 6.8% 10.1% 8.2% 14.4% 11.9% 4.6%

0.0% 13.2% 6.0%

10.5%

4.8%

10.6%

4.1%

8.4%

11.1% 15.2% 2.3% 3.3% 4.1% 14.2% 8.0% 7.4% 11.3% 7.8% 7.8% 7.6% 5.6% 5.0% 47.8% 8.0%

9.6%

% disabled parking spaces 12.5%

ERIC

ERIC

192 388

240 743 59 287 61 153 67 541 0 343 354 0 243 127 174 19 92 0 57

22 1049 381

0 220

84

432

197

465

199 158 343 330 170 219 25 94 62 129 344 92 500 119 90 585

1068

2.87 2.35

7.67 0.00 1.43

14.50

4.34

3.46 3.77

2.42

6.65

0.91 0.96 8.43 17.94

0.78 1.25

0.68

2.80

0.61

1.07

1.66 2.63 8.79 3.51 3.78 3.91 2.08 3.48 2.07 2.22 2.11 5.11 25.00 2.38 0.63 0.85

1.12

Total Total parking spaces parking spaces available available for for patients/ patients/ visitors visitors No. No/Bed. 550 0.53 0.00

ERIC

0 0

38 484,452 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 132,664 0

0 8,154

0

98,300

0

74,403

0 0 0 0 0 0 0 0 0 0 0 0 0 0 16,952 0

36,000

Income from staV £ 0

ERIC

14,350 0

0 690,052 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 1,261,758 0

0 38,350

0

689,000

0

337,733

0 0 0 0 0 0 0 0 0 0 0 0 0 0 133,286 475,000

446,849

Income from visitors £ 648,000

ERIC

1.00

2.00

0.59

1.00

1.00

0.38

0.50 1.00

0.25

1.00

Average fee charged per hour for patient/visitor parking £ 1.60

ERIC

0.30

0.18

0.50

0.30

0.10

0.60

Average fee charged per hour for staV parking £

ERIC

PPSysB

6,072,000 7,093,000

99,009,000 231,375,000 4,983,000 8,620,000 368,000 4,079,000 3,801,000 14,954,000 2,928,000 2,932,000 1,994,000 17,845,000 4,410,000 1,236,000 11,397,000 1,378,000 3,720,000 15,788,000 2,101,000

15,121,000 452,102,000 49,245,000

26,143,000 86,618,000

1,830

244,716

137,506

32,280 17,938 17,412 31,713 12,295 19,057 3,830 7,544 10,767 17,004 49,692 4,252 4,703 12,566 47,569 214,735

349,071

In-Patient Bed Days 333,731 94,437

HES

Pag Table: COENEW

5H9 5HN

RWX RXQ 5AL 5AM 5AP 5D2 5D3 5EA 5EC 5ED 5EG 5EM 5ER 5ET 5EV 5EX 5FA 5FC 5H7

RNY RTH RWT

RHY RNU

28,630,000

200,465,000

22,923,000

101,669,000

5,841,000 5,133,000 7,172,000 6,671,000 4,001,000 4,786,000 2,681,000 7,546,000 10,175,000 2,682,000 2,678,000 8,405,000 6,773,000 3,908,000 63,648,000 159,336,000

290,496,000

Estimated Total OutPatients per Year 416,300 410

Estimated Total InPatients per Year 333,731 94,437

Operational Income £ 205,931,000 67,012,000

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen) 750,031 94,847

12-07-06 01:32:43

RHX

RHW

RH1

Trust Name EAST SUSSEX HOSPITALS NHS TRUST EAST SUSSEX COUNTY HEALTHCARE NHS TRUST BRIGHTON AND SUSSEX UNIVERSITY HOSPITALS NHS TRUST MILTON KEYNES PCT NEWBURY AND COMMUNITY PCT READING PCT SLOUGH PCT WOKINGHAM PCT VALE OF AYLESBURY PCT NORTH EAST OXFORDSHIRE PCT CHERWELL VALE PCT OXFORD CITY PCT SOUTH EAST OXFORDSHIRE PCT SOUTH WEST OXFORDSHIRE PCT BRACKNELL FOREST PCT WINDSOR ASCOT AND MAIDENHEAD PCT CHILTERN AND SOUTH BUCKS PCT NUFFIELD ORTHOPAEDIC NHS TRUST HEATHERWOOD AND WEXHAM PARK HOSPITALS NHS TRUST MILTON KEYNES GENERAL HOSPITAL NHS TRUST ROYAL BERKSHIRE AMBULANCE SERVICE NHS TRUST ROYAL BERKSHIRE AND BATTLE HOSPITALS NHS TRUST OXFORDSHIRE LEARNING DISABILITY NHS TRUST TWO SHIRES AMBULANCE NHS TRUST OXFORDSHIRE MENTAL HEALTHCARE NHS TRUST OXFORDSHIRE AMBULANCE NHS TRUST OXFORD RADCLIFFE HOSPITAL NHS TRUST BUCKINGHAMSHIRE MENTAL HEALTH NHS TRUST BERKSHIRE HEALTHCARE NHS TRUST BUCKINGHAMSHIRE HOSPITALS NHS TRUST CENTRAL DERBY PCT MANSFIELD DISTRICT PCT NEWARK AND SHERWOOD PCT WEST LINCOLNSHIRE PCT LINCOLNSHIRE SOUTH WEST TEACHING PCT CHESTERFIELD PCT GEDLING PCT AMBER VALLEY PCT NORTH EASTERN DERBYSHIRE PCT NOTTINGHAM CITY PCT EREWASH PCT BASSETLAW PCT BROXTOWE AND HUCKNALL PCT GREATER DERBY PCT ASHFIELD PCT RUSHCLIFFE PCT DERBYSHIRE DALES AND SOUTH DERBYSHIRE PCT EAST LINCOLNSHIRE PCT HIGH PEAK AND DALES PCT

DB

DB

FINANCE

Page Type [O]

RD8

5CQ 5DK 5DL 5DM 5DN 5DP 5DT 5DV 5DW 5DX 5DY 5G2 5G3 5G4 RBF RD7

RXH

Trust Code RXC RXD

SOURCE:

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Health Committee: Evidence Ev 131

140,475 166,637

281,807

80,872

77,257 141,434 322,378

406,590

1,566 290

1,202 704,835

1,566 290

1,202 423,028 270,714 210,896

6,352 42,454 600

6,352 42,454 600

130,239 44,259

619

119,762

248,596 352,572 780,613

912,660

122,199 64,344 108,531 24,929 88,235 336,684

619

38,890

171,339 211,138 458,235

506,070

74,226 6,886 16,241 5,486 43,961 194,600

47,973 57,458 92,290 19,443 44,274 142,084

85,086 13,760

1,161,874 155,439

254,095 643,742 101,539 819,177

459,800

568,931 855,570

140,475 166,637

281,807

80,872

77,257 141,434 322,378

406,590

47,973 57,458 92,290 19,443 44,274 142,084

61,406 7,025

478,046 133,002

193,918 252,074 82,653 335,292

178,499

301,568 310,328

In-Patient Bed Days

HES

17,042 0

34,022

0

7,904 13,574 23,924

21,567

0 0 0 0 2,320 15,482

159 0

44,545 0

3 28,387 0 44,375

20,938

22,323 38,307

Day Cases

HES

48,312

1,202 109,377

6,352 42,454

40,773 58,196 134,616

151,860

47,478 124 1,142 5,486 15,475 55,943

14,004

186,625

103,082

99,275

59,035

155,294

A&E Attendances

HES

64,885 44,259

279,629

1,566 290

600

619

38,890

122,662 139,368 299,695

332,643

26,166 123,175

26,748 6,762 15,099

9,517 6,735

452,658 22,437

60,174 264,006 18,886 336,428

201,328

245,040 351,641

Outpatient Attendances

HES

485 579

970

281

250 417 875

1,300

137 349 304 58 135 436

238 20

1,447 534

1,308 811 350 1,124

597

1,033 992

Available beds No.

HES

1,403 863

223 290 190 179 207 141 120 144 0 140 211 236 177 96 114

652

491 1,241 2,544

0

0

2,492

1,051 532 376 570 1,051

415 169 26

3,699 815

660

2,391 1,647 757

2,000 2,415

Total parking spaces available No. 331

ERIC

2.84 1.69

0.00

16.11 10.56 4.97

2.15

1.50 2.98 2.66

1.92

2.24 1.97 6.48 4.25 2.63

2.47 8.45

2.40 1.63

2.43 0.00

1.80

0.00

1.97 2.41

Total Parking Spaces per Bed

ERIC

36 46

8 0 14 9 17 15 6 12 0 3 15 22 9 6 5 70

19

27 25 102

0

0

129

6.1% 11.7%

13.0%

15.5%

8.8% 10.4%

6.8% 6.5% 8.2% 11.5% 19.4% 8.3%

3.8%

5.1%

15.6% 8.0% 11.6%

8.1%

4.8% 10.7% 7.1% 8.3%

22 24 30

500.0% 8.9% 11.5%

10.1% 10.8%

18.5% 13.0%

14.2%

30.1%

590 393

211 0 207 138 207 131 31 144 0 34 144 0 58 0 0 540

375

173 312 876

0

0

1599

206 338 362

1042

2 101 26

1302 334

329 23 0

543

272

800 794

1.19 0.77

0.56

0.00 11.50 3.83

1.24

0.53 0.75 0.91

1.23

2.22 0.00 3.55 2.52 0.91

0.01 5.05

0.84 0.67

1.06 0.02

0.41

0.50

0.79 0.79

0 0

0 0 0 0 0 2,400 0 0 0 0 0 0 0 0 0 696,000

0

0 92,000 0

0

0

0

1,233 0 0

0

0 0 0

0 0

0 0 0

0

40,203

192,369 352,751

Income from staV £

Total Total parking spaces parking spaces available available for % disabled for patients/ parking patients/ visitors spaces visitors No. No/Bed. 13.8% 13.2%

ERIC

ERIC

ERIC

ERIC

50

10 9 3

132 36

61 3 4

77

82

110 105

Total disabled parking spaces No.

ERIC

0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 861,000

0

0 227,000

0

0

267,019

44,931 16,929 487,574

0

0 0 0

1,104,542 0

0 0 0

0

352,249

748,004 636,804

Income from visitors £

ERIC

0.50

1.50 0.30 2.00

1.00

0.50 0.30 0.73

0.81

0.67

1.88 1.00

Average fee charged per hour for patient/visitor parking £

ERIC

0.30

0.10

0.90

0.40 0.30

0.30 0.70

Average fee charged per hour for staV parking £

ERIC

PPSysB

86,164,000 98,079,000

3,149,000 4,546,000 1,728,000 4,891,000 1,000,000 3,071,000 1,558,000 4,097,000 15,312,000 11,622,000 6,769,000 2,094,000 1,992,000 6,033,000 4,199,000 0

58,808,000

77,428,000 84,487,000 227,004,000

22,701,000

16,550,000

310,903,000

23,680 6,735

683,828 22,437

60,177 391,668 18,886 483,885

281,301

267,363 545,242

61,406 7,025

478,046 133,002

193,918 252,074 82,653 335,292

178,499

301,568 310,328

Estimated Total OutPatients per Year

Estimated Total InPatients per Year

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen)

Pag Table: COENEW

RCF RGD

5AW 5CF 5CG 5CH 5E7 5E8 5HH 5HJ 5HK 5HL 5HM 5J6 5J7 5LJ 5LK RAE

RWQ

RLQ RLT RWP

RL6

RL5

11,365,000 8,318,000 7,000 8,910,000 52,790,000 15,451,000 7,500,000 17,553,000 82,751,000

280,475,000 94,216,000

234,050,000 146,149,000 78,025,000 60,527,000 62,214,000

88,427,000

251,969,000 279,861,000

DB

DB

12-07-06 01:32:43

RKB

5CN 5DR 5M9 5MD 5MP 5MQ 5MR 5MT RJC

Trust Name LINCOLNSHIRE AMBULANCE AND HEALTH TRANSPORT SERVICE NHS TRUST NOTTINGHAM CITY HOSPITAL NHS TRUST QUEEN’S MEDICAL CENTRE - NOTTINGHAM UNIVERSITY HOSPITAL NHS TRUST CHESTERFIELD ROYAL HOSPITAL NHS FOUNDATION TRUST NOTTINGHAMSHIRE HEALTHCARE NHS TRUST SHERWOOD FOREST HOSPITALS NHS TRUST LINCOLNSHIRE PARTNERSHIP NHS TRUST DERBY HOSPITALS NHS FOUNDATION TRUST EAST MIDLANDS AMBULANCE SERVICE NHS TRUST UNITED LINCOLNSHIRE HOSPITALS NHS TRUST DERBYSHIRE MENTAL HEALTH SERVICES NHS TRUST HEREFORDSHIRE PCT WYRE FOREST PCT RUGBY PCT COVENTRY PCT NORTH WARWICKSHIRE PCT SOUTH WARWICKSHIRE PCT REDDITCH AND BROMSGROVE PCT SOUTH WORCESTERSHIRE PCT SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST HEREFORD AND WORCESTER AMBULANCE SERVICE NHS TRUST COVENTRY AND WARWICKSHIRE AMBULANCE NHS TRUST HEREFORD HOSPITALS NHS TRUST GEORGE ELIOT HOSPITAL NHS TRUST WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST WORCESTERSHIRE MENTAL HEALTH PARTNERSHIP NHS TRUST AIREDALE PCT BRADFORD CITY PCT BRADFORD SOUTH AND WEST PCT NORTH BRADFORD PCT EASTERN WAKEFIELD PCT WAKEFIELD WEST PCT LEEDS WEST PCT LEEDS NORTH EAST PCT EAST LEEDS PCT SOUTH LEEDS PCT LEEDS NORTH WEST PCT CALDERDALE PCT NORTH KIRKLEES PCT HUDDERSFIELD CENTRAL PCT SOUTH HUDDERSFIELD PCT BRADFORD TEACHING HOSPITALS NHS FOUNDATION TRUST AIREDALE NHS TRUST LEEDS MENTAL HEALTH TEACHING NHS TRUST

Operational Income £ 28,504,000

FINANCE

Page Type [E]

RWD RXM

RHA RK5 RP7 RTG RV6

RFS

RCS RFK

Trust Code RBX

SOURCE:

NHS CAR PARKING STATISTICS 2004/05

3312493005 Unit: PAG6

Ev 132 Health Committee: Evidence

Trust Name WEST YORKSHIRE METROPOLITAN AMBULANCE SERVICE NHS TRUST LEEDS TEACHING HOSPITALS NHS TRUST CALDERDALE AND HUDDERSFIELD NHS TRUST MID YORKSHIRE HOSPITALS NHS TRUST SOUTH WEST YORKSHIRE MENTAL HEALTH NHS TRUST BRADFORD DISTRICT CARE TRUST

Grand Total

TAD

RR8 RWY RXF RXG

Trust Code RGH

SOURCE:

38,595,781,000

105,651,000

677,981,000 233,065,000 267,982,000 96,222,000

Operational Income £ 59,128,000

FINANCE

111,478 54,192,504

66,357,607

14,464

944,771 525,349 598,788 32,431

Estimated Total OutPatients per Year

Estimated Total InPatients per Year 761,466 314,452 417,133 119,069

DB

DB

66,357,607

125,942

1,706,237 839,801 1,015,921 151,500

DB Total Inpatient and Outpatients (Excl. Visitors, StaV and Workmen)

54,192,504

111,478

761,466 314,452 417,133 119,069

In-Patient Bed Days

HES

3,801,828

0

49,350 30,941 39,344 0

Day Cases

HES

17,837,180

231,672 128,065 195,481

A&E Attendances

HES

44,718,599

14,464

663,749 366,343 363,963 32,431

Outpatient Attendances

HES

181,123

338

2,512 967 1,814 534

Available beds No.

HES

NHS CAR PARKING STATISTICS 2004/05

378,720

681

3,974 1,637 2,974 1,192

Total parking spaces available No. 601

ERIC

2.11

2.41

1.57 1.61 2.22 2.24

Total Parking Spaces per Bed

ERIC

16,803

65

140 70 123 45

Total disabled parking spaces No.

ERIC

9.5% 10.8%

156031

681

809 496 887 540

0.87

2.41

0.32 0.49 0.66 1.02

15,130,961

0

819,029 66,673 30,000 1,896

Income from staV £

17.3% 14.1% 13.9% 8.3%

ERIC

ERIC

ERIC

Total Total parking spaces parking spaces available available for % disabled for patients/ parking patients/ visitors spaces visitors No. No/Bed.

ERIC

62,755,934

0

661,824 207,406 125,000 9,588

Income from visitors £

ERIC

1.17

0.66 1.20 0.86 0.67

Average fee charged per hour for patient/visitor parking £

ERIC

0.53

0.30 0.30 0.50 0.30

Average fee charged per hour for staV parking £

ERIC

3312493005 Page Type [O] 12-07-06 01:32:43 Pag Table: COENEW PPSysB Unit: PAG6

Health Committee: Evidence Ev 133

3312493006

Page Type [E]

12-07-06 01:32:43

Pag Table: COENEW

PPSysB

Unit: PAG6

Ev 134 Health Committee: Evidence

Supplementary letter from Lord Warner, Minister of State, Department of Health (CP 01B) At the fourth evidence session by the Health Committee into NHS charges attended by Rosie Winterton MP and Jane Kennedy MP, you made enquiries about a new dermatology clinic being run by Harrogate and District NHS Foundation Trust (NHSFT) and asked for Ministers’ views on the treatments being oVered. I am sure you will appreciate that due to their independent status within the NHS and the diVerent accountability framework within which they operate, Ministers are no longer in a position to assess, validate and provide information relating to operational management in NHSFTs in the same way we would for NHS Trusts. The most common approach is to refer questions relating to the day to day activities of NHSFTS to the relevant Chair for answer. In this particular case, I have been informed by the Chair of Harrogate and District NHSFT that its dermatology clinic has been set up to fill a gap in service provision for its community. The clinic oVers a range of cosmetic dermatology treatments which are not ordinarily available to NHS patients as a result of a loclly agreed cosmetic exclusion policy at PCT level eg removal of benign moles, warts and skin blemishes, and injections to reduce excess sweating. While the Department of Health does not call upon the NHS to operate a cosmetic exclusion policy, I am informed that such a policy has been in place locally at Harrogate and District Trust since 2003. NHSFTs do not have powers to impose charges for any NHS services, however, legislation permits NHSFTs to impose charges for other services in certain limited circumstances and provided specific conditions are met. As Jane Kennedy highlighted during the evidence session, NHSFTs are also specifically prevented in law from expanding private patient clinical activity faster than their expansion of clinical activity for NHS patients. Moreover, as public benefit corporations, any operating financial surpluses made by NHSFTs need to be reinvested to promote their public benefit mandate. NHSFTs are also overseen by Monitor, the Inepdnent Regulator of NHS Foundation Trusts, for compliance with their terms of authorisation. NHSFTs are at the forefront of our programme of change and we share their enthusiasm to promote innovation and enterprise and are committed to their continuing development. While NHSFTs are free to set up new ventures (including entering into joint ventures) without Ministerial consent, these initiatives must be consistent with their public benefit purpose and terms of authorisation. Further details about the clinic may be obtained by writing to the Chair of Harrogate and District NHSFT. I trust you find this helpful. Lord Warner Department of Health 4 April 2006

Supplementary memorandum submitted by the British Dental Association (CP 11A) Further to the oral evidence Dr Lester Ellman of the British Dental Association presented to the Health Select Committee on Thursday 9 February 2005, there were a number of points that came out of the session, which may be helpful for the committee to be clarified.

Questions 333, 346 and 355 Children being seen on the NHS on condition of parents taking up a private dental plan Ms Charlotte Atkins and Mr Mike Penning raised the issue of constituents, and for Mr Penning personally, who have been told by their dentists that their children will continue to be seen on the NHS on condition that they [the parents] take up a private dental plan. Under the current General Dental Service (GDS) system there is nothing that prevents dentists from making it a condition of treating children on the NHS for their parents to be signed up privately. It is also important to put this issue in context. The BDA believes this practice of “condition” is a very recent phenomenon—happening only in the last two to three years, and exists at very few dental practices across the country. Nonetheless, the BDA does not encourage members to take this course of action. Under the new GDS Regulations, coming into eVect on 1 April 2006, dentists can continue to hold their current contract value and attached Units of Dental Activity (UDAs) for the number of NHS children they have, but the policy of condition will not be allowed. However, there may be circumstances, where PCTs have agreed that dentists have a children-only NHS list and so the dentists will see all adults on a private basis.

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The BDA fully supports this specific aspect of the Department of Health’s (DH’s) wide ranging reforms of NHS dentistry, as it allows dentists to prioritise child oral health, to foster a good oral health regime in children and provide a key NHS dental service to children in areas that need it.

Question 379 The BDA’s collective view about the new GDS contract Dr Richard Taylor voiced the issue of the BDA’s collective view about the new GDS contract. As Dr Ellman highlighted in his evidence to the committee (answer to Question 353), the BDA did not negotiate the contract with the DH: Due to the way the primary legislation—the Health and Social Care (Community Health and Standards) Act 2003—was drafted, it was entirely a Government contract, which the profession could input into at a later date, via discussions with the minister and oYcials. The BDA has made it clear to members throughout the reforms process that each individual General Dental Practitioner (GDP) needs to decide whether the new GDS contract is right for their patients, for them and for their businesses. The BDA oVers advice and guidance to members on how best to plan for their futures. Some will be happy with the proposals being oVered by their local PCTs, others will not be and will take appropriate decisions. However, throughout the process, the BDA has made its “collective” feelings clear on the contract—in December 2004, the BDA suspended discussions with the DH on the arrangements for a new base contract, arguing that key elements of the draft contract would not allow dentists to spend more time with their patients, to adopt a more quality-driven and preventive approach to oral healthcare, and improve the working lives of the dental team and the patient experience. Dr Ellman was quoted as saying, “we have been proactive in our discussions with the Department of Health but the traYc has been almost entirely one way”. We supported the DH’s decision in January 2005 to postpone the implementation of the contract from October 2005 to April 2006, citing the National Audit OYce’s (NAO) report, Reforming NHS Dentistry: Ensuring eVective management of risks. November 2004, which raised significant concerns about the state of readiness among the PCT charged with delivering NHS dentistry. The BDA continued infrequent discussions with the DH, and agreed on a few issues, such as the childrenonly NHS list, but the overall well publicised BDA belief is that the new contract is untested and that the new way of monitoring targets for dentists is causing confusion across the NHS which is unable to cope with the new arrangements. In a BDA press release of 2 February 2006, “New dentistry contract will fail patients, British Dental Association warns Minister”, we called on the Government to suspend the contractual requirement that means dentists must achieve an allocated number of “units of dental activity” (UDA) as part of the new monitoring system, as well as asking for greater clarity about funding for those practices which want to expand or have expanded during or after the test year (October 2004 to September 2005). Dr Ellman is as quoted as saying: “The situation is a shambles for both patients and the profession. Our fear is that the new contract will do nothing to improve access to care for patients or improve the quality of care. The Government claims to be committed to preventive care yet that does not seem to apply to dentistry. We’re now faced with a contract that puts dentists on a new treadmill and means they can’t give the care and time that they want to give to patients. This is bad for patients, bad for dentists and disastrous for NHS dentistry.” These comments were supported by the BDA’s General Dental Practice Committee, following the motion: “The British Dental Association believes that the Government’s aims of securing patient access, improving oral health and raising the quality of patient care will not be achieved by the imposition of this target driven NHS contract.”

Question 38 Changes to the dental contract in Wales The new GDS contract in Wales is devolved to the Welsh Assembly. BDA Wales/Cymru’s General Dental Practice Committee has been in discussions with the Welsh Assembly Government (WAG) regarding the precise details of the Welsh new GDS. The WAG has cautiously followed the “English model” towards the proposed GDS contract, but has made two significant improvements—changes to the output leeway and monitoring trigger. The DH claims that to “get dentists oV the treadmill” they are going to set the individual practitioner contract values according to the level of item of service activity and earnings in the current year, minus 5% activity. In Wales, the proposed level of activity for equal funding is going to be lower—10% less. This is a very welcome move for dentists in Wales as, in theory, it gives them more time to spend with each patient, oVering preventive care and advice and gives them a slight freedom from the treadmill.

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In reality we are concerned that as dentists are already working to address the needs of the people of Wales who have poorer oral health than in England, there will be little opportunity to free up time without aVecting the standard of service and waiting times for treatment. The monitoring trigger, a device used by PCTs and LHBs to oversee activity outputs by individual practitioners, and is one of the contract measures—in England a 4% drop in agreed activity triggers an investigation by the PCT and has to be made up within 60 days. In Wales the LHBs will not contact practices until the contract figure falls by 5% from the agreed contract value and, if there is good reason there will be no need to make up the diVerence. This is particularly pertinent in the transitional period where dentists and LHBs will have to get used to the new ways of working very quickly. Again, this is advantageous to NHS dentists in Wales as it theoretically allows them flexibility and time to deal with the additional demands of administering a practice which include more clinical governance activity, the training requirements of staV, especially dental nurses and increasing health and safety requirements related to recent legislation. However, WAG has been slow to develop its strategy for the future of dental services, with their legislative programme a considerable number of months behind Westminster, but with the same 1 April deadline. To date, the GDS contract regulations are due to be debated in the Welsh Assembly on 1 March. This delay has inevitably caused considerable anxiety for BDA members. Question 401 Free oral health risk assessment programme In 2003, the BDA produced a report, Oral Healthcare for Older People: 2020 Vision, which emphasised that the reform of the NHS dental charging system needed to take account of the anticipated growth in the number of older people in England. It came up with 21 recommendations, including: — A free oral health risk assessment should be available to patients from age 60, with referral to a dentist for a strategic long-term oral healthcare plan oVered to those identified as likely to need complex restorative care. — Planned reform of NHS dental charges should take account of the growth in the older persons population and the fact that older people are more likely to require more complex treatment and also tend to be among the least able to aVord to pay. — Information about full and partial exemption from NHS dental charges should be simplified and publicised to older people and carers. — Free NHS examinations for patients aged 65 and over is likely to improve the oral health of the nation’s older person’s population greatly. Free dental examinations have already been introduced in Wales for people aged under 25 and those over 65 years. The Scottish Executive are currently implementing free dental checks for all, with over 60’s being the first section of the population to receive it. The BDA supports preventative-led dentistry and supports the principle behind this policy. In fact, the BDA favours the development of a comprehensive oral health assessment as part of basic oral healthcare provision. However, it needs to be fully funded and the BDA has serious reservations, on two grounds, about the Scottish Executive’s free dental checks policy—funding and workforce. There is neither a suYcient workforce nor money to provide and fund this initiative. We are concerned that patients’ expectations would be raised and it will be left to dentists to deal with the consequences. Also, during the legislative scrutiny of primary legislation, which introduced this policy, the Smoking, Health and Social Care (Scotland) Act 2005, the Scottish Parliament’s Finance Committee raised questions about the funding and financing of this policy.8 However, given that the BDA would support “in principle” the ending of NHS dental charges, the action points above, were charges to be abolished, should be encouraged as “good practice” in the provision and delivery of oral healthcare for older people. The expert reference group for the report included representatives from the BDA, dental schools, the British Society for Gerodontology, Help the Aged and Age Concern. The BDA also played a key role in the Gerodontology Society’s December 2005 report, Meeting the Challenges of Oral health for Older People: A Strategic Review. This report was commissioned and funded by the Department of Health. It recommended, among other issues: — The Department of Health should consider ways of encouraging older people to use dental services on a more regular basis. 8

“Your [the Scottish Executive Health Department] testimony this morning has convinced Parliament’s Finance Committee that this financial memorandum does not fulfil the legislative purpose that is laid down for it constitutionally.” “The Committee is inviting you to go back to consider whether the financial consider whether the financial memorandum fulfils its constitutional purpose of itemising fully the financial resources that will be required to implement the provisions in the bill.” (Scottish Parliament OYcial Report. Finance Committee. 1 March 2005. Columns 2433–4).

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— All older people moving to care homes should receive an oral health and oral health risk assessment that considers both preventive and treatment needs. — The Department of Health must continue to ensure the availability of free, comprehensive care for low income older people. Please find included with this supplementary memorandum copies of both reports—Oral Healthcare for Older People: 2020 Vision and Meeting the Challenges of Oral health for Older People: A Strategic Review. I hope this is helpful. James Clark Parliamentary OYcer, British Dental Association 24 February 2006

Supplementary memorandum from the Citizens Advice (CP 20A) Further to our appearance on 2 February, there were certain additional points we would like to make the Committee aware of. Much of the CAB advice work which takes place in over 1,000 healthcare settings across England and Wales focuses on tackling problems of low income and debt, thus helping relieve the stress and anxiety which often underscore patients’ clinical symptoms. Typically the CAB adviser will run regular sessions in the GP surgery or other health setting to see patients referred by their health professional. A fundamental part of the work will be to ensure patients have claimed all the benefits to which they are entitled, and so helping with claims under the NHS Low Income Scheme would be central to this work. The presence of CAB advisers in the health setting also means they are well placed to encourage the general promotion of help with health costs through the display of publicity material and claim forms. For example, one bureau working in a mental health venue noticed that patients were being asked to attend psychotherapy sessions in the evening, at a time when there was no facility open to enable them to get refunds of travel costs. Following intervention by the bureau, this has been rectified. One of the fundamental purposes of DWP is the alleviation of poverty, so issues around the cost of health charges and take up of the Low Income Scheme (LIS) must be of concern to them. In addition a key strand of their current plans is to provide greater support to people with health conditions and disabilities seeking to move into work. Ensuring that this group, many of whom are on incapacity benefit, are not prevented by financial reasons from accessing the healthcare they need, should therefore be a key concern. The MORI figures we quote in our report Unhealthy Charges suggested that some 750,000 people are failing to get their prescriptions dispensed because they cannot aVord the charge. We understand that the Department of Health believes that some 44,000 have benefited from the April 2004 easement on entitlement. This suggests that significant further reforms are still needed. One option would be to extend exemption from prescription charges to anyone receiving a means tested benefit (ie housing or council tax benefit as well as IS/JSA). This would be a better way of ensuring people on Incapacity Benefit and on a low income receive the help they need, than relying on them claiming under the LIS. It would also have the eVect of extending help further up the income scale. In addition, one way to promote take up of the Low Income Scheme (LIS) would be to develop greater links between DH and DWP, in order to take advantage of DWP benefit delivery mechanisms. For example Jobcentre Plus is moving to a “Standard Operating Model” in which applications for incapacity benefit, income support and jobseeker’s allowance are taken in a single phone call which is intended to capture the applicant’s circumstances and to establish entitlement to benefits. This would provide an excellent opportunity to identify claimants entitled to help under LIS, as on the one hand much of the information required for the HCI is common to that required for IS/JSA, and on the other hand a key group to target is people claiming incapacity benefit but not entitled to IS/JSA. Please do let me know if you would like any further information. Liz Phelps Citizens Advice 13 February 2006

Supplementary memorandum submitted by the Association of Optometrists, Association of British Dispensing Opticians and the Federation of Ophthalmic and Dispensing Opticians (CP 26A) We would like to thank the Committee for inviting us to give evidence as part of your inquiry into NHS charges. We both enjoyed being part of such a lively discussion. There were a few issues that were raised that we promised we would clarify.

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Under 16s During the session you asked about the take up of sight tests for children. According to oYcial statistics 21.6% of NHS sight tests are carried out on children under 16. In the year to 31 March 2005 11.7 million NHS sight tests were performed in total, therefore 2.53 million children had a free sight test. This equates to approximately a quarter of the total population of children under 16 in England. According to oYcial statistics the total population of children under 16 in England is 9.75 million (OYce of National Statistics). 26.5% of vouchers or approximately half a million vouchers went to children under 16. Given the importance of eye health and also the early detection of visual impairment on the development and wellbeing of children, we strongly recommend as a minimum that all children should have a sight test before the age of eight years old. Ideally all pre-school children should have a sight test to ensure early detection and if necessary, the early treatment of eye disease. Domiciliary Care Our major concern in relation to domiciliary sight tests is that over one million older people live at home or in care, unable to visit a high street optician unaided, yet only 344,000 domiciliary sight tests were carried out in the year ending 31 March 2005. As we mentioned during the session, research carried out by the University of York found that over 189,000 people with visual impairments fall each year at an estimated cost to the NHS of £269 million (York University study, 2003). Complex Lenses During the discussion about voucher values we pointed out that the voucher value does not cover the cost of spectacles, although two thirds of practices do subsidize this and oVer a range of spectacles for that voucher value. We did not have time to raise the point that the level of reimbursement for complex lenses, ie those of a high prescription, is particularly low and does not reflect the cost of these lenses. Generally speaking people who require very high prescriptions and who would qualify for a complex voucher would want to have the best thinnest lenses that they could aVord in order to improve the cosmetic appearance of their spectacles. The allowances, which are currently a supplement of £12.40 or £31.30 for single vision and for bifocal lenses are insignificant against the actual retail cost of these expensive lenses and should be increased. For accuracy, we would also like to explain to the Committee that eligible patients do make payments when using hospital services, when there is a clinical need for contact lenses. The charge is £48 per lens, and therefore £96 for a pair. This charge is close to the actual cost of the lenses which therefore means that NHS patients are eVectively paying for their lenses. This payment is made whether the contact lenses are dispensed at the hospital or elsewhere. National Service Framework We would like to stress again the importance of eye health for people of all ages. Increasing public and parents awareness of the importance of having regular sight tests is crucial in reducing the incidences of eye disease and preventing avoidable blindness. That is why the optical bodies have given their support to the RNIB campaign, “Open Your Eyes”. We believe that the Government should include eye care in all relevant National Service Frameworks and public health white papers. In particular, we would hope to see a question about eye examinations in the first (self-assessment) part of the new NHS Life Check. We also hope to see the inclusion of eye care and the availability of free domiciliary NHS sight tests for vulnerable people in the forthcoming Next Steps publication under the Older People’s National Services Framework. These would be steps in the right direction in the promotion of eye health to the public. We enclose a copy of our policy document, “Primary Eye Care in England—A Vision for the Future”, which sets out our proposals for a national services framework for improving optical health. We also enclose a copy of a recent report by Professor Nick Bosanquet, “Developing a New Partnership Contract for Community Eye Care in England”. We hope that the Committee will find these publications useful. Should the committee have any further questions relating to eye care services please do not hesitate to contact us and we will be happy to provide you with any further information you require. David Cartwright President College of Optometrists Lynn Hansford Chairman Association of Optometrists 15 February 2006

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Supplementary memorandum submitted by Mind (CP 19A) Mind would like to thank the Committee for the opportunity to give evidence relating to NHS charges and the eVect they have, particularly on those who experience mental distress. During the evidence session on 2 February 2006, the Committee requested that Mind forward information relating people who pay for treatment prescribed by their doctor, in particular those who had paid for counselling and talking therapies. The Committee was also interested in the impact of not receiving prescribed care. These issues were explored in Mind’s Hidden Costs of Mental Health report, published in 2003, a copy of which is attached. The report found that of the 455 respondents (all of whom had a diagnosed mental health problems): — 64% had paid for some form of care or treatment (prescribed or non-prescribed) for their diagnosed mental health problem. The average monthly payment for this group was £68, and included counselling and talking therapies, complementary therapies, drugs and medication, exercise, and other forms of help. — Of the total group, 34% had paid for drugs or medication which had been prescribed by their doctor. — 45% of respondents had paid out of their own pocket for any form of care or treatment prescribed by their doctor. Of this group 21% had paid for prescribed counselling or talking therapies, and 25% had paid for recommended complementary therapies. — Of those paying for treatment, only one fifth were paying the equivalent of a single prescription or less (£6.20 in 2002–03).The average monthly spend for those paying for treatments which had been prescribed by their doctor was £37. — 58% of respondents stated that they had missed out on some form of care or treatments which they felt would have been beneficial, most commonly because they could not aVord it. The most common treatment which had not been received was counselling or other talking therapy. — Of those who had paid for treatment or who didn’t get a treatment they felt would have been beneficial, almost one half (47%) felt their recovery had been held back or their ability to cope had been reduced as a result of not getting the treatment they wanted or having to pay for it. From this it can clearly be seen that many people who experience mental distress pay a significant amount out of their own pocket for care and treatment for their mental health problem. The amount paid, even for prescribed care, can be significant and can result in people not being able to access the help they need, or experiencing hardship through being required to pay for care they need. It is of particular concern that so many are prescribed counselling or other talking therapies by their doctor but cannot receive this due to the NHS being unable to provide this within a reasonable timescale. The NICE guidelines for depression and anxiety indicate that talking therapies should be the first line treatment for those experiencing mild to moderate depression and anxiety. Mind therefore feels that inability to provide this constitutes a failure of the NHS in its duty to provide adequate care and treatment to people experiencing mental health problems. Mind would be happy to provide any further information if the Committee would find it helpful. Moira Fraser Policy OYcer, Mind 20 February 2006

Supplementary memorandum submitted by Simplyhealth (formerly HSA Group) (CP 27A) By way of further submission from Simplyhealth HSA following our evidence to the Select Committee on Health’s discussion on co-payments, we advise the committee as follows. A Society is defined by its care for all citizens. To that end, in our view, the role of the state is to secure the appropriate acceptable level of health care for all citizens through general taxation that should be available to all citizens, all over the country, all the time. This should be funded through a general taxation that is a specific percentage of GDP, for example 9.5% of GDP. Political parties can argue over the exact percentage as they see fit, but health services will then be funded directly by what we earn as a country and out choice about the quaity of service for everyone will be absolutely clear. It is important to understand that there are no markets or services of any kind in any area of our lives where we can all have the very best of everything all the time, how and where we want it. This is not the case with food or shelter or education. It is unreasonable therefore to expect it of healthcare, it is not possible.

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If, however, we are all clear about what is available from the state we can make informed choices about what else we would then like for ourselves as individuals. Not everyone takes responsibility for their health in the same way. A large part of the population spends billions of pounds each year helping themselves through high quality foods, vitamins and supplements, alternative therapy, exercise regimes, health insurance, screenings, and other health related behaviours and activities. The NHS by no means represents the whole healthcare spectrum in the UK today as many people do much to help themselves. Equally, many do not. They are content to abuse their health in the belief that if they hit the wall of illness the NHS is there to fix it all. Consequently (and there are great parallels with education), they will not invest in any way to promote their own wellbeing. It is unrealistic and wrong to determine the whole healthcare regime for the UK on the taxation only route for healthcare as you will actively work against those who do something to help themselves and they should be encouraged. What the state needs are the institutions that define clearly for the public what level of treatment they can expect to be provided through taxation. Bodies like NICE will define, for example, which drugs the state will provide and their accountability is to do this within the budget that society through an elected government mandated them to levy in direct taxation. If this is clear, then the private sector will step in and provide access to alternative if that is what people want to buy. We need to be very careful not to prejudge what people will spend their disposable income on. Many, in all income groups, will decide between a mobile phone or Sky TV on the one hand, and a healthcare product of some sort on the other, and we do those people an injustice if we think this is necessarily an income related decision. Insurance schemes for healthcare start from as little as £1 per week. Our evidence is that this is an attitudinal decision and not an income one. If clarity does not exist then people will not understand what the state considers the acceptable standard of healthcare and will not be able to make informed choices about whether or not that is enough for them. Being brutally honest, the 11% of the population who purchase PMI today, pay twice for healthcare because they are not being oVered by the state something they find acceptable even when it is free! Cashplan customers are people who take the initiative and prepare for healthcare issues, partly because they cannot aVord the surprise that a crown brings with it at £300 and partly because they are placing healthcare at the top of their agenda of things that matter to them. By helping people to understand clearly that there is no appeal against NICE or other institutions that define our acceptable level of healthcare, those people will then define what else matters to them. The concern today about a two tier healthcare system is antiquated and ideological, something we believe the public are tired of. There are many tiers in healthcare depending on what you can aVord, where you live, who you know and how educated your are. The state’s role is to protect us all with what we choose to aVord, to defind the inclusive regime behind that is the true cornerstone of the NHS, but then leave the rest to the people to decide for themselves. We believe this would be preferred by the vast majority of people, whilst remaining inclusive and aVordable to the nation. Des Benjamin Chief Executive, Simplyhealth 14 February 2006

Memorandum submitted by Hammersmith Hospitals NHS Trust (CP 39)

Jentle Midwifery Scheme at Queen Charlotte’s and Chelsea Hospital Queen Charlotte’s and Chelsea Hospital is part of Hammersmith Hospitals NHS Trust. Queen Charlotte’s has been in existence since 1739, making it the oldest maternity hospital in the country. Over time the hospital has moved several times, most recently from Goldhawk Road to the Hammersmith Hospital site. It now occupies a purpose-built hospital which is only five years old, which is one of the most modern in the UK and specially designed to provide the best possible accommodation for mothers and babies. In addition, it has a Birthing Centre run exclusively by midwives, where women with uncomplicated pregnancies can choose to give birth.

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It is one of the UK’s leading maternity hospitals providing a full range of services for pregnant women and new born babies. It is a tertiary centre of excellence for high risk pregnancies and births. It has a pioneering midwifery unit and a full complement of staV—there are no vacancies. In partnership with Imperial College it is also one of the UK’s leading research centres into conception, pregnancy, birth and neonatology. The hospital contains: — Maternity and gynaecology outpatient areas. — Early pregnancy assessment unit. — Ultrasound suite. — Centre for Fetal Care. — Birth Centre. — Large labour ward with individual birth rooms and operating theatres. — 44 antenatal/postnatal beds. — Eight private patient beds. — 40 cot Neonatal Unit. — 33 inpatient gynaecological beds, including day care area. — Paediatric ambulatory care unit. The Jentle Midwifery Scheme The Jentle Midwifery scheme was established in 2004 at Queen Charlotte’s and Chelsea Hospital to provide an additional service to women who request one-to-one midwife support, from the same named midwife throughout their pregnancy. The hospital already provides a free one-to-one midwifery service for mothers where there is a clinical necessity—such as diYcult social-economic circumstances or those for whom there is an expectation of a diYcult birth. The Jentle Scheme is unlike a typical private system; the scheme directly enhances what the NHS at Queen Charlotte’s oVers—a highly professional and safe service. Expectant mothers participating in the scheme receive exactly the same medical interventions as other NHS mothers, including scans and other tests. The main diVerence that the scheme oVers mothers-to-be is one-to-one care from a dedicated midwife, available 24 hours per day, throughout the pregnancy. There is also more flexibility over where and when ante-natal support can be oVered. Mothers not on the scheme have access to the same advice, scans, ante-natal information, birthing experience, equipment, specialist back-up as mothers who have paid for the scheme, except that it is not with the same midwife guaranteed at all times. The scheme costs £4,000 and has generated over £160,000 of income which is reinvested in the trust’s NHS maternity services. 74 women have so far participated in the scheme and 51 babies have been delivered. The scheme is covered by the Clinical Negligence Scheme for Trusts for which the Trust has level 2. Hammersmith Hospitals NHS Trust February 2006

Memorandum submitted by the All Party Parliamentary Group on Primary Care and Public Health (CP 40) Introduction The prescription charge was first introduced in 1952, and apart from it being abolished for three years in 1965 the charge has increased over the years. Several organisations and politicians have called for a review of the prescription charge, especially the exemption criteria, but as far as the All Party Parliamentary Group on Primary Care and Public Health is aware, there has been no systematic evaluation of the scheme. In recent years the scheme has been criticised as being outdated with unacceptable inequities and anomalies and the All Party Parliamentary Group feel it is time to explore these criticisms. According to the NHS, the principles of the charges themselves are based on the fact that those who can aVord to contribute should do so whilst those who are likely to have diYculty in paying should be protected. The Group wanted to look more deeply into this principle in order to gauge whether this is indeed working in practice and also if it can be sustained into the future. The Group sought written and oral evidence from a number of organisations including pharmacy bodies, PCTs, allied health professionals, think tanks as well as voluntary organisations and medical institutions. Written and oral evidence was received through addressing specific questions regarding the current prescription charge scheme:

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Q1 Background From your perspective what are the rules and history of the scheme? What are the criteria for exemption from the prescription charge? Are you aware of a previous review and what the outcome of this was? Q2 The Current Situation From the experience of clinicians, patients and pharmacists of the scheme in practice—what works and what does not work? Do you have an assessment of the contribution the scheme makes to the NHS? Do you know of the experience of other countries in Europe with regard prescription charges and co-payment and the lessons that may have emerged from this experience? Q3 The Future Can you tell us your views on the possible alternatives to the scheme taking account of the Wanless “fully engaged scenario” as described in the report to the Treasury, Securing our Future Health: Taking a Long-Term View, produced in 2002? Summary of Evidence The written and oral evidence provided by organisations (please see appendix 1 for details of those organisations who contributed)9 to the specific questions asked of this inquiry by the All Party Parliamentary Group are noted:

Q1 Background (a) From your perspective what are the rules and history of the scheme? (b) What are the criteria for exemption from the prescription charge? (c) Are you aware of a previous review and what the outcome of this was? (a) Since the NHS was established in 1948 the principle has been to provide healthcare for all based on need not on the ability to pay except where regulations prove otherwise. Initially the prescription charge was introduced in 1952 based on a charge per form. In 1956 a charge per item was introduced. The charge was abolished in 1965 and reintroduced in 1968 due to a higher demand in prescriptions dispensed. A charge is payable for each prescribed item or quantity dispensed unless the patient is entitled to free prescriptions. Patients who require a lot of items or regular medication may buy a prescription prepayment certificate (PPC). The charge from 1 April 2005 is £6.50 per item, or a fee of £33.90 for a four month PPC and £93 for a 12 month PPC for an unlimited number of items. (b) In 1968 the Government introduced exemption criteria which have never been reviewed. Entitlement to exemption is based on: — the method of delivery, eg to an in-patient or supplied and administered by a GP; — the type of medication, ie contraception or for the treatment of STI; — the age of the patient; — the patient’s condition; or — the patient’s income. The current arrangements mean that around 50% of the population are exempt from prescription charges and in 2004 around 87% of prescription items dispensed in the community were free of charge. 8.4% were charged at the point of dispensing with another 4.7% of items going to PPC holders with no further charge paid at the point of dispensing. (c) In 1998 the Comprehensive Spending Review (CSR) for 1999–2002 was published by HM Treasury. An internal review of prescription charges was undertaken as part of the formulation of government policy and this fed into the outcome of the CSR. 9

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As far as prescription charges were concerned, the then Secretary of State concluded that the charging arrangements should remain unchanged for the rest of the Parliament. No undertakings or commitments have been made since, however the House of Commons Health Select Committee is currently conducting an inquiry into “co-payments and charges in the NHS” with the last oral evidence session taking place on 16 February 2006.

Q2 The Current Situation (a) From the experience of clinicians, patients and pharmacists of the scheme in practice—what works and what does not work? (b) Do you have an assessment of the contribution the scheme makes to the NHS? (c) Do you know of the experience of other countries in Europe with regard prescription charges and copayment and the lessons that may have emerged from this experience? (a) The prescription charge scheme (PSC) is seen by all respondents as unfair for the following reasons: — it exempts some patient groups but not others; the list of medical conditions exempt from prescription charges has not been updated since 1968 and excludes several chronic conditions that have become prominent since then, such as cancer, multiple sclerosis, arthritis and HIV/AIDS; patient groups such as diabetics are exempt, but those suVering from cystic fibrosis, chronic asthma, hypertension and a variety of dermatological conditions are not; — the blanket nature of some exemptions means that some people with high incomes are exempt while some people with low incomes are not exempt; for example, the PCS exempts anyone aged 65 and over and all pregnant women; and — it presents a financial barrier to access to prescribed drugs for people with low incomes, particularly those whose earnings are just above the threshold for receipt of government benefits. In evidence from 2001 the National Association of Citizens Advice Bureaux and MORI showed that 28% of those who had paid prescription charges had failed to have all or part of the prescription dispensed because of the cost (38% of single parent households and 37% of those with long term problems). MORI estimated that around 750,000 people fail to get their prescriptions dispensed because of cost. The report identified a “poverty trap” in which patients just above the level of income support, for example those receiving incapacity benefit, get no help at all, and those with long term health problems were more likely to find charges diYcult to aVord, despite the season ticket scheme. Doctors, nurses and pharmacists have reported that patients ask if all the medicines prescribed are really necessary as they are unable to pay for them all. There are also patients who want large amounts of drugs dispensed to reduce the number of prescriptions. There are patients who are unable to pay for all the items on the prescription at once who seek several prescriptions (one for now, one for later). These scenarios can result in admission to secondary and acute services as well as an overall increase in morbidity. The availability of prescriptions for medicines that are legally classified as pharmacy only (P) and which are sold under the supervision of the pharmacist leads to a perverse situation in which those who are exempt from prescription charges will go to the GP simply to get OTC medicines on “free” prescription. Some people try to avoid having to pay prescription charges by going to an A & E department instead of seeing their GP. (b) At present 87% of prescriptions are obtained free of charge. The prescription fee of £6.40 appears to represent good value for money since according to DH figures for 2004; the average net ingredient cost of a non-exempt item was £14.32. Income from prescriptions is estimated at £500 million per annum this is 40% of all income raised from NHS charges. While it only represents 1% of the cost of the NHS, it is nevertheless an additional contribution. (c) In 2004 Lexchin and Grootendorst surveyed literature from a range of countries on “eVects of prescription drugs users fees on drug and health service use and on health status of vulnerable populations.” The literature concluded, “Virtually every article we reviewed supports the view that cost sharing through the use of co-payments (charges) or deductibles decreases the use of prescription medicines by the poor and the chronically ill.”

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France/USA The medical care systems in France and the USA work to insurance-based systems, where patients generally pay the full cost of their medicines and are reimbursed for a proportion of the cost by their insurer, rather than paying a fixed prescription charge. An international review of studies found that, in the USA, limiting the level of reimbursement reduced the use of essential as well as non-essential medicines. The eVect on vulnerable groups, such as patients with major psychiatric illness, was particularly marked and substantially increased costs in, for example, acute mental health services. Czech Republic The Czech Republic has a public insurance system which provides ´ of all patients with drugs for a very small payment. For people with chronic illness or for emergency outpatients all drugs are free if generic or on a specific list which is updated by the government every six months. For expensive drugs there is a system of co-payment between the government and the patient. Doctors can prescribe from the list or in consultation with the patients, choose drugs more specific to their needs which will then require co-payment. Every pharmacy has a budget for certain drugs and diVerent prices for co-payment. Ireland Ireland has a General Medical Services (GMS) scheme, which provides drugs free to approximately 30% of the population and a drug payment scheme for the rest of the population. If the total cost per month, per family, exceeds ƒ85, all further drugs are free. The number of people who qualify for the GMS scheme has decreased and one of the key challenges is to find a way to help those on modest incomes who cannot receive free prescriptions, yet for whom the cost of the consultation and prescriptions threshold of ƒ85 is too high. Under the GMS scheme, doctors are less concerned about the cost of the drugs prescribed; there is little incentive to keep costs within the budget as no penalties are incurred if they are exceeded. Patients can also discuss the choice of the cost of their prescription; for example, inhalers for asthma are available to patients on a sliding scale of ƒ10 to ƒ30. Poland Prescription drugs in Poland are divided into three categories of price. The Ministry of Health has a special agency with responsibility for their allocation. (i) Basic drugs, mainly generics and simple remedies. Patients pay a low standard fee, which is described precisely (ie number of tablets). If more expensive drugs are needed, then patients pay the diVerence. (ii) 50/50 government/patient payment, which also applies to the cheapest, generic drugs. (iii) 30%/70% government/patient—which applies to any drugs. Spain Spain has a private system and a separate system for civil servants. Under the private system, the working population pays 40% of the cost of drugs. When they retire at 65, drugs are free. The civil servants pay 30% of the cost, but do not have free drugs after they retire at 60. There are specific drugs identified for chronic illnesses, for which patients pay a small amount. There are economic incentives for doctors to use a recommended list of drugs based on clinical eVectiveness rather than opt for new, expensive drugs as a first choice. Q3 The Future Can you tell us your views on the possible alternatives to the scheme taking account of the Wanless “fully engaged scenario” as described in the report to the Treasury, Securing our Future Health: Taking a Long-Term View, produced in 2002? Taking into account the Wanless “fully engaged scenario” there is likely to be an increased demand for drugs as the population lives longer and has more time to develop chronic conditions, normally associated with older age, and there are more older people. Experience from the recently introduced Quality and Outcomes Framework in general practice shows that if you are going to manage conditions such as diabetes and heart disease eVectively, there will be a need to use an increasing range of medicines. Although there is

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the possibility of improved lifestyles, including diet, smoking and exercise, lessening the incidence of chronic conditions, this is unlikely to stem the demand for drugs because at best, it will delay the onset of these conditions rather than prevent them. Abolish the Prescription Charge Scheme If the objective is to improve eYciency by promoting more appropriate and cost-eVective use of drugs and to reduce expenditure on pharmaceuticals, there appears to be no logic in applying a demand-side measure to a prescribed medicine. There is also no evidence to suggest that user charges are successful in controlling overall levels of health care expenditure. It would be more eVective to introduce supply-side measures aimed at influencing the behaviour of prescribers (GPs) and suppliers (pharmacists). Abolishing the PCS would remove any financial barriers for those not currently exempt, thereby enhancing equity and bringing drug coverage in line with other NHS services (that is, free at the point of use). It was acknowledged that abolition may well drive more people into surgeries and increase GP workload which counters the current move towards health policies including individual responsibility and self-care. Low level payment on all prescriptions This would see the removal of all exemptions and the introduction of a low level payment, for example a £1 payment that all patients would pay per prescription or item. This might mitigate against inappropriate use of the exemption status (ie: for OTC medicines) but be low enough to ensure that those on low incomes or on multiple medication could still aVord it. Change the rules governing the Prescription Charge Scheme Raising the income threshold for exemptions would enhance equity but result in revenue losses. It would still leave those whose incomes fell just above the exemption cut-oV at a disadvantage. Updating the list of exempt conditions to take into account developments in drug technology would ensure that the system was more equitable for patients with diVerent conditions. Ensuring that patients with chronic conditions have access to appropriate prescription drugs without financial barriers could have a positive impact on eYciency by reducing inappropriate utilisation of health services due to poor drug compliance. It would also result in a reduction in revenue. Introduce a system of variable co-insurance based on cost-eVectiveness Introducing a system of variable co-insurance based on cost-eVectiveness aims to increase microeYciency. It may also contribute to controlling drug expenditure, as has happened in Italy and New Zealand. Unless combined with other measures such as an out-of-pocket maximum or exemptions for poorer people, a variable co-insurance system would negatively aVect equity. Depending on how it is introduced, there might be significant costs of obtaining cost-eVectiveness information and administrative costs. The following suggestions closely follow proposals set out by Walley (Walley 1998): — abolish the flat-rate charge and introduce variable co-insurance rates based on the costeVectiveness of diVerent drugs (see Table 1 below); — all drugs approved by the MHRA and available on the UK market would be assigned to one of the four categories in the variable co-insurance system set out below; the lists would need to be updated on a regular basis; most new drugs would be B or C initially, but a few might be A immediately; — in the short term patients currently exempt might be entitled to B list drugs free of charge to give GPs time to adjust their prescribing behaviour and to allow time for evaluation of the reformed scheme; a reduced co-insurance rate for B list drugs might be considered in order to preserve equity for low-income households, although the use of means testing carries administrative costs and is inconsistent with the principle of universality; and — protect low-income households and people with chronic conditions from excessive out-of-pocket costs by setting an annual out-of-pocket maximum; this would replace the pre-payment certificates, which currently cap prescription drug expenditure at £91.80 per year or three instalments of £33.40. Co-insurance rates and cost-eVectiveness thresholds would need to be calculated on the basis of information about the value and volume of drugs consumed in each category, the willingness to pay and aVordability of diVerent co-insurance rates and the cost-eVectiveness thresholds and recommendations of NICE.

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Table 1 EXAMPLES OF A VARIABLE CO-INSURANCE CHARGING SCHEME Category

Description

Co-insurance rate

A

— a selection of eVective medicines — suYciently comprehensive to allow treatment of all major conditions — free of charge to all

B

— medicines either no more eVective than A list medicines or oVer minor benefits at a disproportionate cost? — might require a low co-payment, perhaps related to the cost of the prescription, to a pre-set maximum? — a maximum cumulative annual co-payment per patient should also be set? — GPs might be allowed to endorse a prescription for exceptional patients who would benefit more from the B list than the A list drug, but would have to justify this

20%

C

— medicines for which eVective alternatives are already listed; for example, branded preparations where a generic equivalent is available or which are largely directed at patient convenience, such as many modified release preparations — patients pay 50% of the cost of these medicines

50%

D

— medicines not funded by the NHS at all (negative list)

0%

100%

Source: Walley 1998 Conclusions After careful consideration of the evidence provided by organisations the Group feels that it would be unrealistic to ask the Government to abolish prescription charges. However, with the current phasing out of prescription charges in Wales and the intention to eventually abolish prescription charges the outcome of which will be evaluated, the Group recommends that this is considered carefully by Government when the time is right. The Group noted that Scotland has considered the abolition of the prescription charge scheme and decided against it. There is clearly a balance to be struck between equity, fairness and dependency in and on the NHS. Supply-side restrictions cannot exist in isolation and demand-side controls need to be constructed more around incentives than the creation of barriers. At the very least the Group feels that the Government undertake an urgent review of the exemption criteria with advice on changes from doctor, nurse and pharmacist representatives. The Group also feel that the pre-payment certificate system should be reviewed since even the instalments of £33.40 can be diYcult to pay for some people on lower income and yet it is just above the threshold for full exemption. The Group advises that a monthly payment structure should be considered with appropriate safeguards in place to avoid abuse of the system. All Party Parliamentary Group Primary Care and Public Health 10 February 2006

Memorandum submitted by the International Glaucoma Association (CP 37) Introduction The question of co-payments and charges is best divided between health service provision and amenities, although there may be some areas, such as car parking, where the two overlap. Consideration should be given to: The potential health consequences of a financial disincentive to the take up of the service. The quality of life of the patient and those issues related to health outcomes. In all cases, the transparency of charges should be improved, so that people can make a properly informed choice when making their decision. In this submission I will be concentrating on optical services as this is our area of expertise. I have listed our responses in the order of the terms and references, followed by a detailed review of optical provision.

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1. Equitable and Appropriate Charges (a) Treatments (i) Prescriptions Not equitable across a range of long term conditions eg a Type II Diabetic patient may not require medication for the control of their condition, but they are entitled to NHS funded prescriptions. A glaucoma patient for whom eye drop medication is essential for the preservation of sight must pay unless entitled to NHS funded prescriptions for another reason. (ii) Dentistry Generally equitable and appropriate where provision is available. However exemptions do not apply to private treatment which is often the only treatment available in a given area. Dentistry is only a partial NHS service with many citizens unable to take up the minimal NHS service provision for routine check up appointments. (iii) Optical Services Generally equitable and appropriate, however the limitations of funding in terms of the examinations available under NHS funding leave many conditions under-detected. (b) Hospital Services (i) Telephone and TV Generally equitable, however, it is often the case that no extra provision is made for people of limited means and the level of charging especially for incoming calls to patients is excessive. (ii) Parking Generally equitable, but too little provision is made for disabled or elderly patients and visitors. 2. Optimal Level of Charges Charging in the NHS should be set at a level where it does not act as a disincentive to those who are required to pay, to take up the service concerned. Both dentistry and optometry detection referable diseases for which the symptoms are not immediately apparent, the treatment of the conditions is vital to the health of the individual concerned. Prescription charging has a significant impact on the take up of prescribed medications. 3. Is the System of Charging Sufficiently Transparent No. A specific example being an NHS funded eye examination for a relative of a person with glaucoma. Only one of the three necessary tests is funded by the NHS with the other two being chargeable additions to a test that is supposedly NHS funded in order to detect glaucoma at the earliest possible stage. 4. Criteria to Determine Who Should Pay and Who Should be Exempt Simple ability to pay is an insuYcient ground for this decision as it is important to include the disincentive to seek treatment for asymptomatic conditions that a charge causes. Many conditions are better treated at an asymptomatic stage and many cannot be reversed if they become symptomatic. Glaucoma and diabetic retinopathy (the two leading causes of preventable blindness in the UK) are prime examples, but likewise intracranial cancers, hypertension, ocular hypertension, diabetes, multiple sclerosis, etc (optical detection), mouth cancers (dentistry) may be missed without routine examinations. 5. Making Patients Aware of the Exemptions Exemption criteria are complicated, and in many cases diYcult to understand. It is probable that a person actively seeking will make their initial descisions on the basis of a perceived cost, rather than fact. This is of particular concern in people with.

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6. Whether Charges Should be Abolished From a practical point of view it is probably impossible to abolish most of these charges. However, in terms of prescription charges there is clear evidence of a disincentive to comply with prescribed treatment regimes for chronic conditions (particularly those which are asymptomatic) which is seriously detrimental to the long term outcomes in such cases. Access to primary care ophthalmic services may also be reduced due to a perception that an appointment, (whether charged for or not), will result in the need for replacement spectacles and a pressure to purchase these from the optometrist practice concerned (ie the mixture of medical and commercial activities within the one facility).

Review of Optical Services The purpose of the standard General Optic Council eye examination (the eye test) is generally considered to have two parts: 1. to correctly identify and rectify, by means of spectacles or other optic aids, poor vision caused by long or short sightedness, astigmatism or other deficiency. 2. to detect signs of ocular disease or abnormality that requires referral to an ophthalmologist within the secondary care system. A consequence of the standard test to examine the interior of the eye (ophthalmoscopy or slit lamp microscopic examination) in the detection of high blood pressure, diabetes, some types of cancer, multiple sclerosis and other systemic conditions can be detected in the eye, often before symptoms become apparent. Technically an optometrist does not diagnose referable diseases such as glaucoma, diabetic retinopathy or macular degeneration, this being the role of the ophthalmologist or hospital specialist. In terms of glaucoma, the Government has recognised the importance of early diagnosis of this condition, by means of the provision of NHS funded eye tests for first degree relatives of glaucoma suVerers over the age of 40 ever since the introduction of eye test fees. However, the Government has not recognised the importance of the two additional tests required for the earliest possible detection of glaucoma in a primary setting by providing funding for these tests to be carried out. In 1996 this Association carried out a large scale analysis of 275,000 eye tests by 189 diVerent optometrists across England and Wales to establish the relative eVectiveness of the diVerent modes of glaucoma screening10. This research showed that the one mandatory and funded tests (ophthalmoscopy) would only detect about 25% of the detectable people with glaucoma who were presenting for an eye test. The additional two tests; tonometry—a measurement of the pressure within the eye and perimetry; a check of the field of vision gave a detection rate of about 75% and about 100% respectively (when applied in addition to one another). These two additional tests are available in most optometric practices today, but both may attract a charge despite the possibility of the remainder of the test being NHS funded. From the patients’ point of view, these charges seem suspect because their test is being funded as a result of their increased risk of developing glaucoma, yet if the purpose of the NHS funded eye test is to find early cases of glaucoma in people at increased risk of developing the condition and these tests are essential for that early diagnosis is to be achieved. Glaucoma is more common in the elderly population, the re-introduction of the NHS funded tests was an important advance, however the failure to fund all three tests needed for about 100% detection rate, has reduced their value preservating sight. The transparency of charging and also the NHS receiving value for money by minimising sight loss will inevitably become more severe as the general population ages and as newer diagnostic techniques such as the Heidelberg Retinal Tomograph become more readily available in primary practice. It is not unreasonable for people who are able to pay for an eye test, to be asked so to do. Where there are known additional risk factors or disincentives for people to use the facilities provided by the optometric community, there should be a significant and sustained eVort encouraging people to ensure their long term vision by going for a test. It is important to note that some racial groups are at particular risk of certain conditions and these groups often have a low usage of chargeable NHS services. A prime example of this are people of African Caribbean origin who are more prone to developing glaucoma than the Caucasian population and that such glaucomas tend to be more diYcult to control eVectively, making early detection even more of a priority if vision is to be preserved for life. Glaucoma remains the leading cause of preventable blindness in this country with approximately 50% of those with the condition currently undetected and consequently without treatment. This is because the most common forms of glaucoma do not give warning symptoms until a late stage when irreversible damage has already been done to their vision. 10

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As one eye tends to fill in for the other, glaucoma does not usually become symptomatic until between 40% and 50% of the visual field has been lost. A loss of this magnitude would generally be considered to equate to a loss of between 80% and 90% of the nerve fibres within the optic nerve. These losses cannot be recovered and are permanent. While treatments for glaucoma are now very eVective, the combination of the natural loss of nerve fibres that occurs with age and the losses due to the glaucoma means that the remaining 10% or so of nerve fibres at the time of symptomatic presentation are extremely vulnerable and permanent visual impairment is much more likely than for someone diagnosed at an earlier stage. Approximately 2% of people over the age of 40 have glaucoma in the UK with less than half detected and under treatment. If the precursor condition to glaucoma (ocular hypertension) is added to the equation, as many as 2.2 million people are at increased risk of permanent visual impairment. The second most common cause of preventable blindness in the UK, and the leading cause among the working age population is diabetic retinopathy. Diabetic services are well developed in most parts of the country, with eye tests being provided by the NHS without charge to the patient. However, the best way to detect signs of diabetic change within the eye is through a special form of ophthalmoscopy, called fundoscopy, which requires that the pupil be dilated for the examination. While as with glaucoma, many, probably most optometrists do not make an additional charge for this test, when combined with the additional liability to glaucoma of diabetic patients and their consequent best practice requirement for the additional two glaucoma tests, this is another potential point of misunderstanding or missed diagnosis due to a lack of understanding of the system. To the patient NHS funded means “free” and any additional charges are likely to be viewed with suspicion which means that some will opt not to have the necessary additional tests, and also that their confidence in the eye care professional concerned may be damaged. This concern also applies to dentistry where it is not the treatment of damaged teeth that is the most significant element of the work, but rather then detection of other conditions such as cancer that can be extremely significant in terms of the health of an individual and the population as a whole. Summary All charges levied for NHS treatment are by their nature undesirable, some areas such as optometry are of particular concern because of the prevalence of serious sight or life threatening disease within the population. The standard eye test does not provide a comprehensive examination in terms of the detection of some of these conditions at the most appropriate stage and this undoubtedly results in unnecessary blindness that is disproportionately biased towards the less educated and aZuent communities within society. The costs of this blindness also fall disproportionately on both the people and the social services within these communities. More should be done to highlight the exemptions to charges that are already in place and much more should be done to provide comprehensive examinations (to prevent false negative results from tests) and to encourage take-up of the available services. Particularly in the area of optometric services, a more realistic scale of payment to the optometrist should be considered taking into account the provision of tonometry and perimetry and any other tests that may be necessary for the timely detection of ocular disease. The introduction of shared care community based systems for the management of glaucoma is an ideal opportunity to improve the provision of these essential detection systems. International Glaucoma Association January 2006

Memorandum submitted by Ms Anna Dixon and Ms Sarah Thomson (CP 44) Anna Dixon is Lecturer in European Health Policy in the Department of Social Policy at the London School of Economics and Political Science and currently a Commonwealth Fund Harkness Fellow in Health Care Policy based at the University of Oregon, USA. Author of numerous articles on health care financing including co-editor of Funding Health Care: options for Europe (Open University Press, 2002) Sarah Thomson is Research OYcer in Health Policy at LSE Health and Social Care and a Research OYcer at the European Observatory on Health Systems and Policies and author of numerous articles and chapters on user charges and private health insurance Summary This evidence focuses on user charges that apply to prescription drugs within the English National Health Service (NHS). We present evidence to suggest that the prescription charge scheme (PCS) as currently designed results in inequities in access. User charges may be appropriate to achieve certain objectives such as utilization of cost-eVective drugs but they are a weak instrument compared to incentives for providers on the supply side (eg doctors, nurses and pharmacists). We present data on types of user charging schemes

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found in other countries and recommend that a system of variable coinsurance rates be considered for drugs in the NHS. We would argue that rational use of cost-eVective health care can best be promoted through ensuring that the behaviour of providers is controlled. Are Charges Equitable and Appropriate? 1. User charges may be appropriate depending on their objectives and how they are implemented. Economic theory underlies arguments put forward both in favour of and against user charges for health care. There are a number of stated objectives that user charges may achieve: — reducing unnecessary or excess utilisation; — reducing overall expenditure (cost containment); — raising additional revenue; and — directing utilisation to more appropriate care/services. 2. Neo-classical economists claim that the use of health services exceeds socially beneficial levels when health care costs are fully covered by insurance or free at the point of use. Because the price of using health services is eVectively zero, individuals make use of more health care then they would if they had to pay for it at the point of use (Arrow 1963; Pauly 1968). It is often argued that user charges (such as prescription charges) will reduce “excess” utilisation and selectively discourage the use of health services that provide little value to the individual. 3. A number of arguments are used to criticise the neo-classical economic model which would suggest user charges are inappropriate: — the diverse nature of health care “goods”; — the existence of information asymmetries in the health care market; — individuals may not be well-informed about their own need for health care; — individuals may be unable to distinguish between eVective and ineVective or harmful treatment; — health care providers are usually better informed than patients; and — providers can influence both the type and quantity of health services used (Evans 1984). 4. The case for user charges as a means of reducing excess utilisation is weak, particularly when charges are applied to health services that are used as a result of a provider’s recommendation, referral or prescription (Chalkley and Robinson 1997). 5. The prescription charge scheme (PCS) in the NHS may be regarded as inequitable for the following reasons: — it exempts some patient groups but not others; the list of medical conditions exempt from prescription charges has not been updated since 1968 and excludes several chronic conditions that have become prominent since then, such as cancer, multiple sclerosis, arthritis and HIV/AIDS; patient groups such as diabetics are exempt, but those suVering from cystic fibrosis, chronic asthma, hypertension and a variety of dermatological conditions are not; — the blanket nature of some exemptions means that some people with high incomes may be exempt while some people with low incomes may not be exempt; for example, the PCS exempts anyone aged 65 and over and all pregnant women (although the latter could be seen as a means of protecting the health of the foetus); and — it presents a financial barrier to access to prescribed drugs for people with low incomes, particularly those whose earnings are just above the threshold for receipt of government benefits. 6. The PCS (along with other NHS charges) undermines a core principle of the NHS, which is to provide services that are free at the point of use (Department of Health 2000). What is the Optimal Level of Charges? 7. There is no optimal level at which user charges should be set. Such a decision will depend on the balance between revenue raised (income), administrative costs (direct expenditure) and the ability to control expenditure. We look at these issues in turn. Revenue raising 8. The revenue-raising potential of user charges may be limited by the existence of protection mechanisms, high transaction costs, fraud or providers’ reluctance to enforce charges (Brandt, Horisberger et al. 1980; Evans and Barer 1995). However, increasing the financial burden on individuals lowers equity in access to health care. Those with low incomes are most likely to be discouraged from using health services, while those in poor health will suVer most from lower levels of use. Attempts to exempt these groups of

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people are not always successful (Brandt, Horisberger et al. 1980) and the claim that any extra revenue raised can be directed towards people with low incomes or in poor health may be diYcult to substantiate in practice. Administrative costs 9. The costs of administering the PCS exemptions may be high relative to the amount of revenue generated by non-exempt prescriptions. If the objectives of the PCS are to generate revenue while preserving equity, then the use of prescription charges is a weak instrument. Expenditure control 10. The PCS is unlikely to succeed in controlling expenditure in the long term for various reasons and may encourage ineYcient patterns of health services utilisation. 11. Prescription drugs are provider-initiated care (that is, initiated by the prescribing doctor, usually the general practitioner, and not the patient). Consequently, a demand-side incentive such as the PCS is unlikely to have much impact on controlling drug expenditure. Supply-side controls such as prescribing budgets and prescribing guidelines are more eVective in ensuring the rational use of drugs. Furthermore, total expenditure on pharmaceuticals is generally rising due to increases in the cost per item rather than volume. Therefore, pricing regulation is more likely to have an impact on overall spending than volume controls. 12. Prescription charges are a weak instrument for deterring frivolous or unnecessary consumption of high-cost or low-eVectiveness pharmaceuticals. As a result of prescription charges a patient may choose not to fill a prescription or not to take a full course of medication by not filling a repeat prescription, but this behaviour might lead to worse health outcomes. Also, because charges apply to all prescription drugs, regardless of whether they are high or low cost, branded or generic, high or low eYcacy, they do not encourage cost-eVective patterns of drug utilisation or substitution of generic drugs by pharmacists. 13. User charges are unlikely to contain health care costs in the long term, as spending on health care is primarily driven by supply-side factors (Evans and Barer 1995). What Criteria should Determine who Should Pay and Who Should be Exempt? 14. Prescription charges in the United Kingdom (UK) are flat-rate payments; regardless of the cost of the drug, the patient pays the same amount, with the remaining cost met by the NHS. Drugs received in hospital or from a hospital pharmacy are not subject to co-payments. The current system of exemptions from prescription charges is extensive, accounting for about 85% of all prescriptions dispensed. 15. Lowering the charge could reduce financial barriers for some non-exempt categories of patients. 16. The current system of means-tested exemptions means that those who fall just above the threshold are disadvantaged. Raising the income threshold for exemptions would enhance equity but result in revenue losses. It would still leave those whose incomes fell just above the exemption cut-oV at a disadvantage. As will all means testing, there is a trade-oV between targeting benefits and the need to keep down administrative costs. 17. The current system of charges results in inappropriate utilisation patterns. Drugs prescribed in hospital are not subject to any charges, but in an attempt to shift costs to primary care, hospitals are increasingly reducing the amount of drugs prescribed on discharge. This requires individuals to go to their general practitioner for follow up prescriptions after discharge from hospital. The availability of prescriptions for P category drugs leads to a perverse situation in which those who are exempt from prescription charges will go to the general practitioner simply to get OTC drugs on “free” prescription. Some people may try to avoid having to pay prescription charges by going to an A & E department instead of seeing their general practitioner. Standardisation of charging across settings would reduce this problem. 18. Updating the list of exempt conditions to take into account developments in drug technology would ensure that the system was more equitable for patients with diVerent conditions. Ensuring that patients with chronic conditions have access to appropriate prescription drugs without financial barriers could have a positive impact on eYciency by reducing inappropriate utilisation of health services due to poor drug compliance. It would also result in a reduction in revenue. Should Charges be Abolished? 19. If the objective is to improve eYciency by promoting more appropriate and cost-eVective use of drugs and to reduce expenditure on pharmaceuticals, there appears to be no logic in applying a demand-side measure to a prescribed substance. Furthermore, there is no evidence to suggest that user charges are successful in controlling overall levels of health care expenditure. It would be more eVective to introduce supply-side measures aimed at influencing the behaviour of prescribers (general practitioners) and suppliers (pharmacists).

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20. Abolishing the PCS would remove any financial barriers for those not currently exempt, thereby enhancing equity and bringing drug coverage in line with other NHS services (that is, free at the point of use). 21. It would be useful to evaluate the phased abolition of prescription charges in Wales.

User charges in other countries 22. There are a variety of diVerent forms that user charges may take in diVerent health care systems. These include: — flat-rate payments: fixed fees per item prescribed or per prescription; — co-insurance: the patient pays a fixed percentage of the total cost of a good or service; — deductible: the patient pays the full costs of goods and services consumed directly out of pocket up to a defined ceiling after which the services are free (costs being met by the insurer or the NHS); deductibles can apply to specific cases or to a period of time (usually a year); — extra billing: the patient pays the diVerence between the reimbursement value and the actual price of the good or service (see reference pricing, below). 23. In the pharmaceutical sector extra billing is often used where a fixed or reference price is set for a group of drugs with similar therapeutic eVects. This may be set at the average price of the drugs in the group, the price of cheapest drug in the group or benchmarked to the price of similar drugs in other countries or the price of the generic alternative. The reference price is the amount that the insurer or the NHS pays. If the patient chooses a drug that is more expensive than the reference price, they must pay the diVerence themselves. 24. Other features of user charge schemes exist in other countries: — annual out-of-pocket maximum: in order to limit the total amount spent by an individual in the course of a year, a maximum ceiling may be set on the total amount of out-of-pocket payments; for example, a chronic disease patient who requires a lot of medication might have to pay for their drugs, but if, after nine months, they had reached the out-of-pocket maximum they would not need to pay for drugs consumed in the rest of the year; — variable co-insurance: in some countries diVerent levels of co-insurance (for example, 20%, 50%, 100%) apply to diVerent groups of drugs depending on their eYcacy/cost-eVectiveness; for example, a 20% co-insurance rate might apply to generic drugs, whereas “lifestyle” drugs with no proven eYcacy might carry a 100% co-insurance rate. 25. Examples of specific charging policies in diVerent countries and their impacts are evaluated in more detail in Thomson S and E Mossialos (2004), “Influencing demand for drugs through cost sharing” in Mossialos E, M Mrazek and T Walley Regulating pharmaceuticals in Europe: striving for eYciency, equity and quality, Open University Press, which is attached for your information.

Recommendations 26. User charges can be used to encourage more cost-eVective patterns of utilisation. This is achieved by conveying price signals to users to opt for certain types of health care or follow a particular system of referral or to providers responsible for prescribing treatment (via users) (Brandt, Horisberger et al 1980). Introducing a system of variable co-insurance based on cost-eVectiveness aims to increase micro-eYciency. It may also contribute to controlling drug expenditure, as has happened in Italy and New Zealand. 27. A variable co-insurance system would negatively aVect equity unless there was no charge for eVective prescription drugs. Combining co-insurance with other measures such as an out-of-pocket maximum or exemptions for poorer people would help to preserve equity. Depending on how it is introduced, there might be significant costs of obtaining cost-eVectiveness information and administrative costs. 28. The following suggestions closely follow proposals set out by Walley (Walley 1998): — abolish the flat-rate charge and introduce variable co-insurance rates based on the costeVectiveness of diVerent drugs, with no charge for eVective prescription drugs (see Table 1 below); — all drugs approved by the Medicines and Healthcare products Regulatory Authority and available on the UK market would be assigned to one of the four categories in the variable co-insurance system set out below; the lists would need to be updated on a regular basis; most new drugs would be B or C initially, but a few might be A immediately; — in the short term patients currently exempt might be entitled to B list drugs free of charge to give general practitioners time to adjust their prescribing behaviour and to allow time for evaluation of the reformed scheme; a reduced co-insurance rate for B list drugs might be considered in order to preserve equity for low-income households, although the use of means testing carries administrative costs and is inconsistent with the principle of universality;

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— protect low-income households and people with chronic conditions from excessive out-of-pocket costs by setting an annual out-of-pocket maximum; this would replace the pre-payment certificates, which currently cap prescription drug expenditure at £33.40 per quarter or £91.80 per year11. 29. Co-insurance rates and cost-eVectiveness thresholds would need to be calculated on the basis of information about the value and volume of drugs consumed in each category, the willingness to pay and aVordability of diVerent co-insurance rates and the cost-eVectiveness thresholds and recommendations of NICE. Table 1 EXAMPLES OF A VARIABLE CO-INSURANCE CHARGING SCHEME Category

Description

A

— a selection of eVective medicines — suYciently comprehensive to allow treatment of all major conditions — free of charge to all — medicines either no more eVective than A list medicines or oVer minor benefits at a disproportionate cost — might require a low co-payment, perhaps related to the cost of the prescription, to a pre-set maximum — a maximum cumulative annual co-payment per patient should also be set — general practitioners might be allowed to endorse a prescription for exceptional patients who would benefit more from the B list than the A list drug, but would have to justify this — medicines for which eVective alternatives are already listed; for example, branded preparations where a generic equivalent is available or which are largely directed at patient convenience, such as many modified release preparations — patients pay 50% of the cost of these medicines — medicines not funded by the NHS at all (negative list)

B

C

D

Co-insurance rate 0

20%

50%

100%

Source: Walley 1998. These views are our personal views and do not represent the position of either the London School of Economics or the European Observatory on Health Systems and Policies Ms Anna Dixon and Ms Sarah Thomson London School of Economics 28 February 2006

Memorandum submitted by David Magnus (CP 35) Hospital Car Parks—East and North Hertfordshire NHS Trust Table 1 below shows the increase in visitors car park charges that came into force on 3 October 2005. For three, four and six to 10 hours the charges were doubled. Table 2 shows that the new charges are excessive when compared to the corresponding charges at council-run short-stay car parks in five town centres in the Trust Area. In addition I would like to make the following points: The Trust’s car parks are funded by cash payments from those members of the public who use them, whereas the remainder of the Trust’s activities is funded mainly by central government and the general taxpayer, and by National Insurance contributions. I believe it is therefore logical to expect the The Trust’s accountants should treat the car park as a separate business enterprise operating within the Trust, with its own capital assets, its own cash income, and its own relevant outgoings. Any fair and reasonable assessment of car parking charges should match the case income against those outgoings that are not already paid for by central government. Otherwise, if the charges are set too high, then: (1) the car park operation will become a profit-making concern, subsidising the other loss-making clinical and medical departments through the excess cash payments of car park users; and 11

These currently have to be purchased in advance and awareness of them is low.

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(2) because the car park users are also taxpayers, any excess cash payments they make will in eVect be an unfair tax surcharge. I suggest these consequences are unacceptable and represent a corruption of the fundamental principles of the NHS. I also believe that the new charges were deliberately pitched at an excessively high level in order to help rescue the Trust from its overall financial deficit of £8.6 million in 2004–05. In that case it would appear that visitors to the Trust’s hospitals have been unfairly targeted, just because it is easy to do so by manipulating the pay machines in the car parks. This is blatant overcharging for non-medical ancillary services. Table 1 INCREASE IN CHARGES Time, hours Old charge, £ New charge, £ % increase

1

2

3

4

5

6–10

2.00 2.00 0

2.00 2.00 0

2.00 4.00 100

2.00 4.00 100

2.50 4.00 60

2.50 5.00 100

Table 2 COMPARATIVE CHARGES, £ Time,hours Stevenage Hitchin Letchworth GC Hertford Welwyn GC Average E & NH Trust % excess

1

2

3

4

0.80 0.50 0.40 0.50 1.00 0.64 2.00 212

1.00 0.50 0.50 1.10 1.00 0.82 2.00 144

2.20 2.00 1.00 1.70 2.00 1.78 4.00 125

2.50 3.00 2.00 2.20 3.00 2.54 4.00 57

David Magnus 16 January 2006

Memorandum submitted by Dr GeoV Searle (CP 38) I am a Consultant Psychiatrist in Bournemouth. I have recently taken on a role leading a Community Crisis Response Team. I was unaware of your inquiry until I saw a news item in the BMA news two days ago. I would like to raise two points. 1. The current charging rules have a serious impact on those with serious mental illness who require long term treatment. Such patients are invariably on disability benefit and pay prescription charges. They never have enough cash in hand to buy pre-payment certificates. For those on three or four medications long term the prescription charges are a considerable burden and expense, and for those with doubts about the need for medication the charges are a great excuse not to comply with needed treatment. At present on occasion Health workers have to “mistakenly” fill in the prescription as if the patient is on income support. 2. I have taken over a crisis intervention team and we are trying to find flexible alternatives to in-patient care. However as our patients are not in hospital they have to be charged for their medication—which is very diYcult and complex for my team (especially if we are giving the patients their medication and monitoring their compliance). The cost can also be considerable for any patient on three or four medications when doses are changed frequently or prescriptions are kept short to guard the patient from a dangerous overdose. Overall the current NHS charging for medication rules are a significant obstruction to modern psychiatric practice. I would be happy to give oral evidence. This is an individual submission. Dr G F Searle 30 January 2006

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Memorandum submitted by Professor Peter C Smith (CP 36) Introduction Most health care is directed at individual patients, seeking to improve the duration and quality of life. It is therefore perfectly feasible to charge patients a fee for their use of health care. Indeed it is worth recalling that until recently doctors in all countries relied mainly on patient fees to provide their income, and that this system is still dominant in much of the developing world. It was only in the latter half of the twentieth century that socialised medical care has become widespread in developed countries. User charges in health care have two broad roles: to raise finance for the health system, and to send signals to patients who would otherwise face a zero price for access to health care. Developed countries do not currently rely to any great extent on charges as a significant source of finance. However, there has been a persistent concern with the dangers of “moral hazard” in health care.12 That is, in the absence of direct prices, patients may use health care when it is not warranted. Moreover, given the power of doctors to influence patient behaviour, moral hazard might be exacerbated by “supplier induced demand”, particularly in systems where doctors’ incomes rely directly on attracting high levels of business.13 This note assesses the current role of user charges in developed health systems, and possible future options for the English National Health Service. User Charges in High Income Countries Figure 1 shows that direct user charges (out of pocket payments) account for between 10% and 20% of health system revenue in high income countries. Most of the “other” private expenditure relates to voluntary private insurance. In particular, in countries such as France and Ireland, patients are in principle liable for quite high user charges. However, many citizens take out voluntary private health insurance to secure protection from out of pocket payments. Note that the OECD has not been able to report these data for the UK since 1997. Figure 1 Private expenditure as % total health expenditure 2001 0

10

Australia Canada France Germany Ireland Italy Japan New Zealand Norway Spain Switzerland United States UK (1996)

20

30

40

50

60

Out of Pocket Other private

(Source: OECD Health Data 2004). The especially low reliance on user charges in the United Kingdom reflects the founding principle of a NHS “free at the point of access”. Eversley relates the fraught history of NHS charges, the imposition of which in 1951 led to the resignation of Aneurin Bevan, hastening the demise of the Atlee government14 An attempt to abandon prescription charges by the Labour government in 1965 was soon reversed in 1967, and further increases were subsequently imposed in 1975 under pressure from the International Monetary Fund. In 2004 prescription charges in England accounted for income of £446 million, with only 8.9% of 12

13

14

Zweifel, P and Manning, W (2000), “Moral hazard and consumer incentives in health care”, in J P Newhouse and A J Culyer (ed), Handbook of health economics, Amsterdam: Elsevier. McGuire, T (2000), “Physician agency”, in J P Newhouse and A J Culyer (ed), Handbook of health economics, Amsterdam: Elsevier. Eversley, J (2001), “The History of NHS Charges”, Contemporary British History, 15(2), 53–75.

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prescriptions directly attracting the full charge of £6.20.15 The vast majority of prescriptions are exempt from charges on grounds of age (young and older people), sickness (certain chronic conditions), maternity, or low income. The Welsh and Scottish government intend to abolish prescription charges.

Recent Developments in Europe Western Europe countries have traditionally sought to model their health systems on the principle of “solidarity”. This implies universal coverage, and contributions to the financing of health care according to ability to pay, irrespective of age or level of sickness. User charges appear to contradict the principle of solidarity. Yet, as expenditure on health care has grown inexorably, there has been growing interest in imposing some modest charges.16 In general, these new charges do not raise a significant volume of finance for the health system—indeed in some circumstances the sums involved are outweighed by the collection costs. Rather, the main purpose of these experiments is to encourage patients to use the health system to better purpose, by discouraging treatment when benefits are small and creating incentives for eYcient use of services when it is justified. Examples of objectives underlying charging schemes include: — moderating the number of physician and hospital visits;17 — encouraging use of cheaper generic drugs, through the use of “reference prices”;18 — directing patients through gatekeeper physicians;19 — encouraging the use of less costly or higher quality “preferred” providers; and — encouraging early discharge of patients from hospital. Most of these initiatives have been directed at cost containment, and many other experiments in a similar vein could be envisaged, such as charging patients for outpatient visits, but oVering a full or partial rebate if the appointment is honoured (in order to discourage “did not attends”). Moreover, user charges could in principle be used to encourage healthier behaviour on the part of patients. For example, one could envisage a scheme of exemption from charges if a patient complies with a course of treatment in its entirety. There follows a brief sketch of a few recent European innovations. Sweden was one of the first of the traditional public sector systems to experiment with quite small user charges across a wide range of health services. Children and young people are generally exempt, and the maximum annual liability for charges has traditionally been set at quite a low level (ƒ90 in 2001). Charging on this modest scale appears to have been generally accepted as reasonable, but it has resulted in reduced utilisation amongst low income patients, and a concern that equity of access may be compromised.20 Some countries in eastern Europe are experiencing especially severe problems with financing health care, and are therefore experimenting with more radical approaches to charging, especially where a tradition of “informal” payments to doctors and other professionals exists.21 A particularly ambitious scheme of “diagnosis based reimbursement” is being introduced in the Slovak republic. A national tariV for reimbursing providers is set for all interventions, according to diagnosis. Patients will then be reimbursed for a proportion of the costs of treatment, depending on the diagnosis group. The proportion reimbursed depends on the estimated benefits and costs of treatment, and there is full reimbursement for 33% of diagnoses. This scheme is consistent with the prescriptions of the economic theory of “optima” commodity taxation.22 However, as experience unfolds, it will be important to see whether it is in practice sustainable, whether unintended behavioural responses on the part of doctors or patients emerge, and whether the lack of exemptions leads to especially adverse outcomes for poor and sick people. 15 16

17

18

19

20

21

22

House of Commons (2005), Hansard 27 January 2005 : Column 561W, London: The Stationery OYce. Robinson, R (2002), “User charges for health care”, in E Mossialos, A Dixon, J Figueras and J Kutzin (ed), Funding health care: options for Europe, Buckingham: Open University Press. Gericke, C, Wismar, M and Busse, R (2003), Cost-sharing in the German health care system. Discussion Paper, Berlin: Department of Health Care Management, Technische Universita¨t Berlin. Grabka, M, Schreyo¨gg, J and Busse, R (2005), Verhaltensa¨nderung durch Einfu¨hrung der Praxisgebu¨hr und Ursachenforschung—eine empirische Analyse. DIW Discussion Paper 506, Berlin: Deutsches Institut fu¨r Wirtschaftsforschung. Kanavos, P and Reinhardt, U (2003), “Reference Pricing For Drugs: Is It Compatible With US Health Care?” Health AVairs, 22(3), 16–30. Bellanger, M and Mosse´, P (2005), “The search for the Holy Grail: combining decentralised planning and contracting mechanisms in the French health care system”, Health Economics, forthcoming. Andersen, R, Smedby, B and V‰gero¨c, D (2001), “Cost containment, solidarity and cautious experimentation: Swedish dilemmas”, Social Science and Medicine, 52(8), 1195–1204. Lewis, M (2002), “Informal health payments in central and eastern Europe and the former Soviet Union: issues, trends and policy implications”, in E Mossialos, A Dixon, J Figueras and J Kutzin (ed), Funding health care: options for Europe, Buckingham: Open University Press. Smith, P (2005), “User charges and priority setting in health care: balancing equity and eYciency”, Journal of Health Economics, 24, 1018–1029.

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Evaluating User Charge Experiments There is in general a shortage of reliable evidence on the impact of user charges on the utilisation of health care and the consequences for the health of patients. The major exception is the celebrated RAND experiment, under which over 2,000 US patients were randomly assigned to one of four charging regimes over an extended period.23 One group of patients enjoyed complete freedom from charges, while those at the other extreme were charged 95% of fees for virtually all care, up to a maximum annual “catastrophic” liability of about $6,000 at current prices. The experiment resulted in consistent reductions in utilisation across all types of health care as the charges became more severe. For example, physician consultations varied from 4.55 per annum amongst those incurring no charges, to 2.73 amongst those in the highest charging scheme, a reduction of 40%. However, with one major exception, evaluation of the experiment did not detect any material variations in health outcome associated with charging. Researchers have therefore concluded that—for most of the population—charges succeeded in encouraging less profligate use of health care without serious health consequences. The one important exception was the finding that charging had a seriously adverse eVect on those who were both poor and suVering from poor health. The RAND evaluation estimated that for this disadvantaged group there were a wide range of serious consequences, in spite of some cost subsidy for low-income families. For example, when charges were imposed, hypertension was less well controlled in this group, to the extent that the annual likelihood of death rose approximately 10%.24 It has proved much more diYcult to evaluate the consequences of user charges where there is no experimental design. However, when statistical analysis has been undertaken in other countries, it appears to corroborate the RAND results. For example, results from Belgium suggest a distinct impact of charges on demand for GP home visits and oYce visits, except amongst older or disabled patients.25

A Future Role for User Charges? In the light of the above discussion, the question arises: what is the most appropriate role for user charges in a modern health system? Experience in high income countries suggests a persistent tension between the equity goal of assuring universal access to health care and the eYciency goal of assuring frugal use of health services. In short, unless carefully designed, user charges designed to curb excessive demand amongst the bulk of the population could have ruinous financial or health consequences for a relatively small number of poor people with health problems. It is therefore important to view the design of user charges within the broader objectives and institutions of the health system as a whole. With the notable exception of the United States, there is a general consensus that public funding of tightly regulated delivery should lie at the core of the modern health system. However, there is also a growing trend in such systems towards the use of small but symbolically important user charges. Why this should be the case may be a matter for psychologists, sociologists and political scientists to explain, as—from an economic perspective—they appear insuYcient to aVect demand materially, except amongst the very poor, who are often exempt. Rather, the intention of new charging initiatives seems to be to influence very specific aspects of patient behaviour, and to act as a signal of preferred behaviour. In this respect, in conjunction with a system of carefully crafted exemptions, they may oVer an important policy option for influencing demand. Moreover, the may help reassure the taxpayer that patients are being encouraged to use the services they pay for responsibly. However, beyond the largely symbolic nature of these recent developments, I believe that in the more medium term the accelerating pace of technological innovation and the inexorable rise in patient demands may require a more fundamental rethink of the role of charges. At present, European countries are (just about) able to ensure that most mainstream interventions are included in their statutory package, allowing policy makers to claim that coverage is comprehensive. However, there is growing evidence that such a policy may become financially unsustainable, and that policy may have to resort to increased use of explicit rationing of health care.26 If it does, the central policy problem is to decide which health care technologies should be subsidised from public funds. User charges policy then flows naturally from the choice of the subsidised treatments. Once the “public” package of care is chosen, patients would still be free to purchase the remaining unsubsidised interventions at market prices, or to purchase complementary private insurance to cover such interventions. This is the essence of the Slovak experiment. I have shown elsewhere that, from an economic perspective, the choice of interventions in the public package should be guided solely by the expected health benefits they 23

24

25

26

Newhouse, J (1993), Free for all? Lessons from the RAND health insurance experiment, Cambridge MA: Harvard University Press. Newhouse, J P (2004), “Consumer-Directed Health Plans And The RAND Health Insurance Experiment”, Health AVairs, 23(6), 107–113. Van De Voorde, C, Van Doorslaer, E and Schokkaert, E (2001), “EVects of cost sharing on physician utilization under favourable conditions for supplier-induced demand”, Health Economics, 10(5), 457–471. Coulter, A and Ham, C (2000), The Global Challenge of Health Care Rationing, Maidenhead: Open University Press.

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bestow in relation to costs.27 Equity concerns should in my view be tackled not by the health care system, but by the tax system used to finance the public package. However, if political considerations demand that the package should be skewed in favour of diseases of the poor, then this does not aVect the general principle of explicit definition of the package. The scope of the statutory package will be determined by the public’s willingness to pay the necessary taxes—in particular, the willingness of the healthy and the rich to subsidise the sick and the poor.28 It is therefore essential that the package is of high quality, so that richer people do not choose to use private care in preference to publicly subsidised care. If quality is poor, widespread resistance to paying the taxes required to finance the public package may arise, making the public system unsustainable. In England, the National Institute for Health and Clinical Excellence (NICE) is charged with evaluating new technologies, and issuing associated clinical guidelines. Therefore, although a daunting technical undertaking, NICE could in principle be given the expanded remit of recommending the entire scope of the publicly subsidised package. Charges (partial or total) would then be paid by patients on interventions that fell outside the chosen package. Indeed one could envisage that—if a technology fails its cost-eVectiveness criterion—NICE could nevertheless determine the (lower) price at which the intervention or drug that could be included in the public package. The patient would then be asked to fund the diVerence between the NICE price and the provider’s price. Whether charges are symbolic or substantive, the issue of exemptions has proved a problematic issue for policy makers. For example, successive UK governments have introduced exemptions for prescription charges on the grounds of age (young and old), health needs (an apparently arbitrary selection of conditions) and income, resulting in a very low proportion of patients being liable for charges. Clearly exemptions can often be arbitrary and pervert the intended economic signals. Yet equally, the evidence from RAND and other experiments is that at least some disadvantaged patients will suVer catastrophic financial or health eVects if some system of abatement of charges is not put in place. The solution to exemptions adopted in many countries has been to set a maximum liability for health care in any one year, perhaps as a proportion of total income. The intention is to ensure citizens experience some of the incentive eVects of user charges, but are protected from ruinous health care expenditure. In summary, therefore, I believe that the publicly funded health system of the future should look something like the following: — an explicit set of interventions is subsidised by public funds (the “health basket”), the choice of which is guided by the criterion of cost-eVectiveness; — the size of the health basket is determined by the willingness of the population to pay the necessary taxes; — there should be no compromise on the quality of publicly funded health care, the intention being that all citizens should use the public sector for interventions within the health basket; — charges (partial or total) are paid by patients on interventions that are not deemed cost-eVective; — those able and willing may purchase voluntary (complementary) insurance to protect against such “economic” charges; — there may in addition be small “symbolic” charges even on fully subsidised interventions, as signals of preferred behaviour—these cannot be insured in the private market, otherwise the incentive eVect is lost; and — there may need to be a carefully crafted system of exemptions from symbolic charges to protect very poor or very sick citizens, perhaps in the form of a maximum percentage of annual income; however exemptions will not apply to interventions that lie outside the statutory package. This system may at first glance appear unattractive compared to the stated principle of a comprehensive NHS, free at the point of access. Yet many commentators feel that it will be infeasible to adhere to that principle indefinitely, as the scope of health care increases inexorably and the limits to popular willingness to pay the necessary taxes are reached. If this is the case, the proposals set out here oVer policy makers a framework for making the hard choices that follow in a systematic and fair fashion. Adoption of such a system may also help convince the public that taxes are being spent wisely, in line with both eYciency and fairness criteria, so maximising the chances of creating a high quality statutory package of broad scope. It will take political courage to implement such explicit rationing, but the alternative may be steadily to reduce the scope and quality of the NHS by stealth, and reduce the widespread support for tax funding of the NHS, an outcome that cannot be to the general public good. Professor Peter C Smith January 2006 27

28

Smith, P (2005), The statutory health care package under private health insurance. Paper presented to World Bank conference on Voluntary Health Insurance in Developing Countries, Wharton Business School, University of Pennsylvania De Graeve, D and Van Ourti, T (2003), “The distributional impact of health financing in Europe: a review”, The World Economy, 26(10), 1459–1479.

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Memorandum submitted by John Mohan, University of Southampton (CP 45) ANALYSIS OF CAR PARKING (PROVISION, CHARGES AND INCOME) AT NHS TRUSTS Summary This analysis demonstrates that there are substantial variations between NHS trusts in the availability, cost of and income generated by parking for patients and their visitors. It is possible to develop statistical explanations of some of these variations but in others there does not appear to be a systematic pattern. In summary there is: — Variability in the availability of parking whether this is expressed in terms of ratio of parking spaces to beds (a measure of hospital capacity) or to the ratio of parking spaces to patient numbers (a measure of demand for parking spaces). Some, but by no means all, of this variation seems to be related to site constraints. — Variability in parking charges which does not appear to be systematically related to demand (the ratio of patients to parking spaces), suggesting that other unobserved factors aVect the way prices are set for car parking. There is some evidence that prices in London and the South East are higher than elsewhere. — Variations in the cost to the patient of car parking: on the figures provided by the department, these range up to a maximum of £4.35 though in the majority of cases a figure of £1 per hour is more usual. It is not possible to estimate the total cost per patient because we do not have data on the number of times they attend hospital from this source, and nor do we have details about how patients get to hospital. — Great variability in the income generated by car parking. When this is related to the Trust operating income, in the great majority of cases it accounts for under 0.25% of the budget but there were 15 cases where it exceeded 0.5% of the budget and in two cases it exceeded 1%. If this reflects the costs of establishing and running car parks, it is not easy to see why the cost of running car parking should vary to this extent.

Introduction 1. The Department of Health supplied data to the Committee on a range of variables pertaining to the provision and cost of car parking and to revenues derived from charges for parking at NHS acute hospital trusts. The data were drawn from a number of statistical returns which Trusts make to the department. They included information on: total numbers of inpatients, patients, and casualty attendances at each trust; average number of beds available; total trust income; the proportion of the site which was occupied by buildings; numbers of parking spaces, sometimes broken down to give the numbers available for staV, visitors, and places reserved for disabled drivers; total income derived from parking for visitors and patients; the hourly parking rate charged to visitors and patients. The data related to trusts, not to individual hospital sites. Information was provided on 203 hospital trusts, containing nearly 150,000 beds. 2. The data do not include information on several variables which it would have been desirable to include in the analysis, such as: the availability of parking in the vicinity of each Trust; accessibility by public transport; and the modal split of journeys to hospital (ie the proportion of journeys made by various modes of transport). In addition not all hospitals were able separately to identify the provision of parking specifically for patients and their visitors (as opposed to staV) or the revenue generated by it. 3. Several additional variables were computed from the data, such as average income per parking space, the ratio of parking income to the operating income of the trust, average income from parking per patient treated, and indicators of patient throughput, such as the number of patients treated per bed. It was also possible to identify which Strategic Health Authority each trust was located in, permitting some contrasts between places to be assessed. The analysis largely consisted of tests for diVerences between means, correlation and regression analysis; further details are available from the author. 4. Evidence from the Department of Health29 argued that car park charges will vary because the situations of and constraints on trusts will vary, so the imposition of a central directive on Trusts was not feasible, as it could not have dealt with the range of local circumstances. As they pointed out, some trusts were in heavily-built-up areas while others were in rural locations with large amounts of land. Trusts also incur costs in running car parks and the Committee was told that these should not be a charge against the NHS budget, so charges had to be levied to cover them. NHS Trusts therefore had to make individual decisions on the provision of and charges for car parking; there are no national instructions or guidelines, and the matter is left to individual trusts. They are not obliged to provide car parking, nor to charge for it, but if they wish to charge for it they are free to do so within income generation rules. 29

Ev 9 Volume II and Qq 77-88.

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5. Consequently it is not surprising that there are clear variations in the availability of parking, the cost of it to patients and visitors, and the income generated by it. But are these variations justified by the circumstances of individual Trusts? Here I examine the pattern of car parking charges and the variations that exist, and I seek to identify any systematic underlying factors that might explain the pattern. Availability 6. There is great variability in the availability of car parking, whether this is measured in terms of the ratio of car parking spaces per bed or in terms of the ratio of patients to parking spaces. Of those hospitals giving specific figures for patient and visitor parking, 45 trusts have at least one parking space per bed, 12 have at least two, and the maximum value is 3.3. As might be expected the ratio seems to be lowest in urban general hospitals, and provision is significantly lower in London, with an average of 0.5 spaces per bed compared to 0.79 at hospitals outside it. 7. Provision is, as the Department suggested, strongly associated with availability of land—one measure of this was the extent to which the Trust site was built up (measured by the ratio of the area occupied by buildings to the area of the site as a whole). This is strongly negatively correlated with the ratio of parking spaces per bed, and it is a strong predictor of the availability of spaces—in other words, the more constricted the hospital site the fewer parking spaces, and this will account for some of the diVerences between London trusts and others. Provision of parking is not associated with throughput—there are no significant statistical associations, suggesting that site constraints are more important. To some extent, therefore, this supports the Department’s view. 8. There are also significant variations in the ratio of patients (inpatients and outpatients combined) to parking spaces, which is a better measure of demand for car parking than the total number of beds in a Trust. There are a number of Trusts where there are more than 10 patients per parking space per day, and in around a quarter of all hospitals there are roughly five patients for every available parking space per day. We do not know how many visitors should be added to this total, though many of these will visit in the evenings when outpatients are generally not attending). Of course, many Trusts are in city centres where it can reasonably be assumed that many patients and visitors will arrive by public transport. 9. Provision for disabled drivers can be assessed because figures were given for the numbers of disabled parking spaces, although the dataset did not allow exploration of the availability of concessionary spaces (eg the extent to which permits were made available to individuals to exempt them from charges in unreserved parking places; evidence to the Committee suggested that some Trusts grant concessions to those attending for regular outpatient appointments). There are variations in the availability of such spaces but in the great majority of trusts they accounted for up to 25% of patient and visitor parking spaces, and the ratio of spaces per bed does not seem to vary systematically with hospital size, location or patient throughput. It is associated with site constraints, but not as strongly as is the case for the ratio of all parking spaces to beds, suggesting that Trusts are giving some priority to the needs of disabled drivers. Cost to patients 10. While nearly half of all hospitals charge less than £1 per hour (this is consistent with the Department’s oral evidence that this is the median charge), 41 (or 27%) charged at least £1.50 per hour, the maximum being £4.35. The hospitals in London appear to charge more than their counterparts elsewhere, since the average hourly rate for car parking in London hospitals in the sample was £1.42 compared to an average outside London of £1.08; this diVerence is statistically significant. Of course, there are numerous, central London hospitals which do not provide car parking themselves. Patients and visitors travelling by car therefore must rely on local car parks and the average cost of parking for those who do attend London hospitals by car, including NHS and non-NHS car parks, would most likely be significantly higher than elsewhere. If parking charges for the South East of England are compared with those elsewhere, the average charge is £1.41 compared to £0.97, which is a significant diVerence. 11. It could be argued that higher prices were a way of rationing parking space and if so we might expect to be able to relate these charges to the availability of parking or to the ratio of patients per parking space. However there appears to be no systematic relationship between the hourly charges for parking, the availability of parking, and throughput; whatever it is that determines parking prices is not captured in these statistics. It is possible that the pricing policies adopted by Trusts relate to the availability of parking and the degree of congestion in the surrounding area. 12. Much concern was expressed by witnesses to the Committee about the costs incurred by individual patients, but calculating the income from parking per patient is not possible because the data only give us total numbers of attendances, which does not tell us how many times a particular patient went to hospital as part of their course of treatment. There are some patients who, depending on the nature of the treatment, will incur higher parking charges (this point was made repeatedly in evidence to the inquiry; several organisations observed that there is quite a diVerence between attending for a very short outpatient checkup, and having to spend most of the day in hospital on a regular basis, receiving chemotherapy). Nor do the data include information on exemption policies of individual Trusts and we have no information on the numbers who travel by public transport.

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Income 13. There have been suggestions that car parking is being used as an income generation measure for Trusts so that the prices charged are higher than might be justified if the aim was solely to cover costs. One way to explore this is to see whether there are variations in the income generated by car parking both in absolute terms and as a proportion of a trust’s total operating income; the higher the figure the more plausible would be a suggestion that Trusts were raising more money than was strictly justified. 14. There are variations in income per parking space which to a large degree are a combination of charges and throughput of patients. However there is a substantial range—over £2,000 per parking space in several provincial hospitals (Southend, Sutton Coldfield, Frimley Park and Epsom) to less than a quarter of this even within the same region, such as East and North Hertfordshire, North Hampshire, and Queen Mary’s Sidcup. Generally hospitals in London and the South East have a higher average score on this indicator than is the case elsewhere in the country. 15. As for the proportion of income generated by car parking charges, in the majority of cases, this proportion is very small—for over half of the Trusts reporting this information, it accounted for less than 0.25% of the hospital’s budget. However, in 15 cases, hospital parking revenue accounted for more than 0.5% of the Trust’s annual expenditure, and in two cases it exceeded 1% of the revenue expenditure of the hospital trust. For comparison, figures provided by the Department suggested that the total income from car parking at NHS Trusts was c £62 million, or around 0.1% of the NHS’s budget. 16. If, as the Department of Health implied, the primary aim of NHS Trusts is to cover the costs of running car parks, it is not clear why there should be such large variations between apparently similar institutions, particularly when the third-largest figure recorded was 0.7%. The proportion of a Trust’s operating income derived from parking is statistically related to patient throughput, which we might expect—the more rapid the turnover of patients, other things being equal, the greater the demand for parking spaces. Interestingly, however, hospitals in London and the South East of England typically generated a lower proportion of their revenue from car parking than was the case elsewhere in the country. We would probably expect property and labour costs to be higher in these regions which would imply that above-average costs would be incurred in running car parks. 17. What about NHS foundation trusts? Some data were supplied for NHS foundation trusts. There are diVerences between these trusts and non-foundation trusts in respect of hourly charges and the income per patient are not statistically significant. It does appear that for foundation trusts, car parking income, when expressed as a proportion of the revenue budget, is significantly higher than is the case with non-foundation trusts. However, since only 16 foundation trusts reported data to this analysis, this result should be treated with some caution, and as the data relate to the first year of operation of Foundation Trusts, it probably reflects the historic pattern of charges and is not necessarily a consequence of the change of status of these Trusts. Conclusions 18. There are clear variations in the availability and cost of parking at NHS hospital trusts. The question is whether the variations are justified. If the Department of Health is correct these variations should reflect site constraints and local circumstances such as demand for parking. To some extent this is true of provision, which is associated with site constraints, but not of charges (though these are higher in London and the South East) or the income raised from them. In particular variations in the proportion of income raised by parking charges are not easily explicable in terms of site constraints or throughput of patients. 19. As lengths of stay continue to decline, and as the number of patients treated as day cases or as outpatients continues to grow, the numbers of people competing for these spaces will rise, posing additional problems of managing transport to and parking at hospitals. 20. Some of these demands might be mitigated if more people travelled to hospital by public transport, or if more services were delivered locally, eg through GP surgeries. Otherwise the numbers of people competing for these spaces are going to rise. Trusts could deal with these demands by increasing prices as a rationing mechanism, which would impose additional costs on patients of the kind described by several witnesses to this inquiry. Alternatively they could deal with them by providing more parking spaces, or by developing travel plans which would facilitate access to hospital by public transport. John Mohan School of Social Sciences, University of Southampton May 2006

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Oral evidence - United Kingdom Parliament

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