Examination of Witnesses (Questions 819
- 839)
TUESDAY 15 JUNE 2004
DR VIVIENNE
NATHANSON, DR
JOHN CHISHOLM
AND MR
TREVOR PHILLIPS
David Winnick: Dr Nathanson, Dr Chisholm,
Mr Phillips, I am very pleased that you have been able to come
along and give evidence to us on the whole concept of identity
cards. We have received your written documentation and obviously
we have some questions. My colleague, Mr Marsha Singh, would like
to ask you some questions.
Q819 Mr Singh: I think I am right
in saying that you support the Government in trying to reduce
inappropriate use of the health service but that you are concerned
about the possible bureaucracy that that might involve and you
are concerned about emergency treatment and infectious diseases.
Do you think those areas should be contained within the Bill or
are you happy to leave them to Regulation later on?
Dr Nathanson: In terms of supporting
the concepts behind the Bill and eligibility to access, we are
happy with the concept of that being helpful but we have a big
caveat about that, which is we keep hearing figures postulated
about how much money the NHS spends on patients who have no right
of access, but in fact there is no fact on this. We do think it
is very important that we actually understand just how much money
the NHS is spending inappropriately and how much it could save
or otherwise recover, because the cost of the bureaucracy of introducing
this system in terms of health alone could be greatly in excess
of that, so that major overall caveat should be in place. The
question of putting things on the face of the Bill is actually
quite important. It seems to us, however, that what we need to
make certain of is that the provision of services to those most
at need is exempt from the requirement to have the eligibility
card with them at the time rather than how that is achieved. It
is the outcome that we are most concerned about and we are concerned
about that in terms of two different areas. It is both the way
in which you describe the care that is excluded, that is emergency
care and immediately necessary care or care for certain infectious
diseases. We have a very real concern about what those definitions
mean. Secondly, there are groups of particularly vulnerable people
who might find it difficult to have with them cards at the right
time at which they need to access services. So you are looking
at a medical model of need and, secondly, a modelling of vulnerable
people. If that can be encompassed on the face of the Bill to
protect those then that would be fine, but we are equally happy
with a system that protects that even if it is not on the face
of the Bill.
Q820 Mr Singh: When you are talking
about vulnerable people, would you include people with mental
health problems in that?
Dr Nathanson: People with mental
health problems or those who just find it difficult to be sufficiently
organised to have documents with them, who are frightened of the
system, and that will happen particularly with people who have
mental health problems but it could happen at different times
in people's lives when they face other major crises, when they
are feeling particularly vulnerable and it will also happen for
more people as they become more elderly.
Q821 Mr Singh: You mentioned costs
to the Health Service of this system and I was intrigued by that
because I cannot see what those costs are. Is it not a simple
matter of somebody going along when the ID system is operating
and presenting their ID card? Where is the bureaucracy cost in
that?
Dr Nathanson: The question then
is, who is going to test it? Who is going to make sure that it
is that person's card? What is the process for that? For example,
if we are talking about biometric data that has to be accessed
every time services are accessed and particularly perhaps hospital
services in, `are they emergency situations or not', then you
could say that we might have to have biometric readers in many
different places and, at the moment, those are quite expensive
pieces of kit. So, that is one of the costs. The second is that
you actually have to have people in place to chase up those who
have had care because the care is needed but perhaps not covered
under the immediately necessary and therefore they are not eligible
for free care and you have to chase them to get the money back.
Clearly, there are some hospitals, for example, in the UK where
there may be substantial amounts of care offered to people who
have no right of eligibility for the NHS and who already have
systems in place to chase that and who may get quite good recovery
of significant sums. But, for many other units, it might be so
rare that to have somebody in place and machinery in place may
be a complete waste of money and it is that balance that concerns
us.
Q822 Mr Singh: I know that you are
particularly concerned about GPs policing access to healthcare
and certainly smaller practices or single practitioners; do you
think that is going to be a particular problem?
Dr Chisholm: I think that certainly
as far as general practitioners are concerned, they would be concerned
about the workload implications of any system and, if it is relatively
simple and non-bureaucratic as a way of proving entitlement, then
I think that general practitioners are broadly supportive of the
approach that those who are entitled to receive NHS care should
be enabled to receive that care and those who are not entitled
should not receive care at public expense. I do think there are
issues about the simplicity of the system and I think that, as
far as general practice is concerned, I would like to distinguish
between the steps that might be taken when a patient is seeking
to register with a practice and what they do each time they receive
care. Our preference would be that they would establish their
entitlement at the time of registration with special and appropriate
arrangements being made for the frail, the vulnerable, those lacking
capacity and those with mental health problems in order that they
are not denied the care they need purely because they are finding
problems with the system. I would like to make that distinction
between registering with a practice and the routine need to prove
entitlement each time that a patient is seen. I think also there
are issues about checking the biometric data. I think there is
a world of difference between, let us say, a receptionist checking
a card and a photograph on a card compared with the need to check
fingerprints or check iris data or whatever, which clearly would
have significant workload implications and also significant implications
in terms of cost to the public purse.
Q823 David Winnick: Is this a problem
at the moment regarding registration? If someone comes along to
a GP surgery to register, surely there are certain checks which
already occur.
Dr Chisholm: In general, people
register in one of two ways: they either bring along their medical
card or they do not and, if they do not, then another form is
filled in which relies on them providing information about their
name, address and date of birth. The checking is then done by
the primary care organisation so, in England, the primary care
trust, and the equivalent organisations in the other three countries,
rather than the checking being done by the primary healthcare
team. Doctors and their staff do not actually themselves take
any steps to confirm that an individual is living where they say
they are living.
Q824 David Winnick: It is not really
their job, is it?
Dr Chisholm: No, it is not their
job and obviously the patient has a vested interest in giving
the address in that although most care is now premises based,
if they are requiring a home visit, it is helpful if the address
matches up.
Dr Nathanson: One of the key issues
as well is the concept that, when patients register with general
practices, very often, people do not move to a new area and think
`where is the GP?' and go and register, possibly with the exception
of mothers with young children who are more likely to. Many others
only register when they suddenly need care, when they are acutely
ill and, in those circumstances of course, doctors would usually
provide the care, if it were necessary, while the process of the
checks are going on.
Q825 Mr Singh: Maybe we are making
a mountain out of a molehill. If a person's rights or entitlements
are established when a person first registers with a GP, then,
if the GP is referring them for medical treatment to hospital,
the GP could confirm that person's entitlement. So, there does
not need to be another check at the hospital level. The only real
issue would be emergency care in terms of hospitals.
Dr Nathanson: Yes except of course
that very often people go to hospitals in situations which are
not necessarily full emergencies but are this `somewhere in between'
state being dealt with in primary care. In other words, whether
it is an appropriate or inappropriate use of the hospitals, that
is where people will get some of their care and they may not have
been registered with a GP. It is particularly likely of course
that people will go to hospitals for care which a GP could provide
if they are not registered, so that is both transient populations
but also populations who just have not got round to registering.
That may even be increasing with the difficulty of recruiting
more people into primary care at the moment. So, yes, for the
patient who is registered with a GP if the check is done at registration,
it is not a problem in terms of access to the types of secondary
care which would be excluded from the emergency provisions, that
is the elective care. That would all be covered in the one check.
The problem is the person who turns up at hospital needing urgent-ish
care, as it were, and it does take us into this long and complex
problem of how you would model what is immediately necessary care,
which is quite important.
Q826 Mr Singh: Would it not be better,
rather than trying to deal with these issues through legislation,
to deal with them through codes of practice which can be tested
and improved and tested and improved?
Dr Nathanson: Absolutely and one
of the things we are doing at the moment is that we are talking
already to both the health departments and to the Home Office
about the ways in which we would want to see a system work, whether
by codes of practice or regulation or in whatever way it is set
up because we think it is very important that the system which
is designed to protect the public purse from inappropriate use
does not in fact damage the health either of individuals or of
the public more generally.
Q827 Mrs Curtis-Thomas: I understand
when you say that the costs associated with people who access
medical services when they have no entitlement to do so is not
known. This Committee knows that we have a number of people in
this country who have accessed the country illegally and are working
illegally and presumably they also seek health services as and
when the need arises. So, perhaps the problem is significant.
I just want some clarification from you because I think what I
am hearing is that doctors have a reluctance per se in
asking people for identification and is that true and, moreover,
would there be an attempt, for instance, if somebody presents
with a medical health problem, to retrospectively ensure that
that individual was in fact eligible for health services? I hear
you talking about significant parts of the population being exempted
and then the presumption is that they will not be checked either
because their condition makes them not automatically the excluded
special interest group.
Dr Nathanson: We are not saying
that they should be exempted but we are saying that if people
who are clearly particularly vulnerable at that time or even permanently
arrive needing to access care and do not have an entitlement card
with them, then the presumption must be to treat them if that
care is needed. That is not to say that you should say that these
people would never have cards because there may be other very
distinct advantages to that card. The issue about cost is an important
one and there is ongoing research to try to find out just how
much use is made of the NHS in its various forms, as it were,
by people who are not strictly entitled to it by a number of bits
and pieces of research. Looking particularly at secondary care,
in secondary care, most hospitals, particularly those with the
more transient populations or in areas where there are more likely
to be or it is thought that there are more people who have no
eligibility, already have systems in place for doing this. For
example, areas where there is a large tourist population. Hospitals
have long had a system when people access care of finding out
if they are eligible and billing them if they are not and recovering
most of the money—it is a majority, as we understand it,
that is recovered in that way. There are other areas where they
probably do not see more than the most minute number and it may
actually be not cost effective to chase those. That is not saying
that they would not want to if they could but we have to again
make sure that the bureaucracy does not cost more than the money
it is meant to recover. In terms of care, it does take us always
back to this issue about how you define the care that is needed
and, in a sense, what we are looking at here is a medical modelling
which is what we would prefer to find because, if you have the
right modelling for care, it relieves a lot of our concerns about
the processes because it means that people who are vulnerable
because they are acutely ill for whatever reason will get the
care that is necessary and we would actually argue that it is
necessary not just on humanitarian grounds but that it probably
makes good economic sense as well.
Q828 Mrs Curtis-Thomas: So, you would
argue for exclusion for those? Even if they were not covered by
identity, they should still have access to free care?
Dr Nathanson: If people need care,
they must receive it.
Q829 Mrs Curtis-Thomas: So, you are
saying that?
Dr Nathanson: Yes. Let me give
you an example and the kind of example we would look at is that
of somebody who has been an asylum seeker and who has now been
denied permission to stay and are waiting to leave the country.
They no longer have access, they are not eligible to full NHS
care. We are not suggesting, for example, that people in that
situation will be put on an NHS waiting list for a hip replacement,
that would be inappropriate, but let us suppose that that individual
has insulin-dependent diabetes and they have no money and they
cannot afford to pay for the insulin prescription. We could end
up in the daft situation where they go into a coma because they
are not getting their insulin, they are admitted to hospital and
they get the full emergency treatment which they would get even
though they are not eligible for other care because emergency
care would be provided. They get better, they get sent home with
a small supply of insulin; they run out of that, they cannot afford
to buy any more, they again decline until they are in a coma and
again are in emergency treatment which costs a lot of money whereas
ongoing provision of free insulin would cost us almost nothing.
It is that kind of model that we are concerned about. What is
emergency and immediately necessary care? Antenatal care, care
for somebody with a number of very serious medical conditions
but where they are not going to die tomorrow if we do not give
them care immediately, so it may not be immediately necessary,
but the cost in terms of their health problems and potentially
the cost to us as we have to deal with them when they become emergencies
could be substantial and we just think that that is a grouping
that needs to be looked at very carefully.
Q830 David Winnick: It might be considered
as common humanity.
Dr Nathanson: Indeed, but one
could also say that it does make economic sense as well which
is always a good backup for common humanity!
Dr Chisholm: Essentially, we are
asking for sensitivity and discretion in the application of the
system in two particular areas: one of them is in relation to
vulnerable patients where the system ought to exercise sensitivity
and discretion in deciding whether care is provided if they are,
because of their vulnerability, finding problems in producing
or dealing with the bureaucracy of the system. The other area
where sensitivity and discretion is required is in the areas that
Dr Nathanson has been describing, the borderline between emergency
and immediately necessary care and care that is not so defined,
and I think that allowing some sensible discretion there is going
to be wise in order to prevent the very problems that have been
described.
Q831 Mr Prosser: Dr Nathanson, I
just want to pursue the same theme a little further. All of us
would give sympathy to the cases you have given and, if nothing
else, we want commonsense written into the Bill but how would
you actually write those sorts of sensitivities and those sorts
of discretions into the Bill? Can you look at other legislation
with respect to the duties and limitations that the medical profession
carry out where there are clauses and the draftsmen have come
up with remedies which provide you with the comfort you want and
that we all want?
Dr Nathanson: I think, sadly,
we have not found anything in any legislation that gives this
kind of protection, but there are some examples that we can look
at in regulations that have come out of legislation that gives
a degree of this and that is the sort of thing we would like.
We would like to see doctors working with Government departments
to write regulations which are sensible and which do not undermine
the Bill but in fact bring into it this humanity which would actually
make it work and which will actually, I think, significantly reduce
people's fears, certainly in terms of the health area.
Q832 Mr Prosser: Do you think it
should be widened to other vulnerable people, people who are addicted
to alcohol or to drugs, people with chaotic lives?
Dr Nathanson: I think we would
want to see in the regulations the ability to act flexibly for
those people. The difficulty is, do you want to prescribe it very
precisely because for many people say with drug dependencies including
alcohol dependency, for much of their life, they are not living
in such a chaotic state that they could not use the system as
it is designed, but there may be times in their lives when they
cannot produce the right evidence of identity and they may be
the people who are, at that time in their lives, moving away from
where they had previously been registered and that is where again
there is this issue of having some flexibility to treat in the
hope of returning them to a state where they can then cooperate
with the requirements of the regulations or of the law.
Q833 Mr Prosser: Is it not the case
that, even at the moment under whatever regulations and limitations
persist now, every day GPs in the surgeries and consultants are
using commonsense and applying discretion in a humane way and
in a sensible way?
Dr Nathanson: Yes, absolutely,
and, in talking to colleagues last week, we were given examples
of the way in which somebody working in an accident and emergency
unit would say to somebody who was not eligible for NHS treatment,
"No, that is not something that would require free treatment.
That is not something where your illness/medical condition is
such that it would be an emergency or something immediately necessary"
and in fact they find when saying this to the patient that they
say, "You are the fourth hospital that has told me this;
maybe I should try giving up getting access to this" because
there is clearly a consistency. In fact, I think there is remarkable
consistency on most patients. There will be occasional patients
on whom two doctors might slightly disagree but it would be rare.
Q834 Mr Prosser: Mr Phillips, in
your evidence, you talk about being able to convince all communities
that the new potential ID cards will not disadvantage them or
discriminate against them etc. Do you want to amplify on that
now that you have seen the draft Bill?
Mr Phillips: Yes. I think there
are a few simple points here. First of all, there is a pretty
profound lack of evidence about the potential impact on different
ethnic groups and communities in this country. One of the first
things that we notice is that we still have not yet had a proper
race impact assessment on the proposal and we think that would
be an important thing at this stage plus, were there to be a move
to a compulsory scheme, that would also need a separate impact
assessment. Secondly, there is the issue of perception in that,
whether or not the proposal is favoured, it will certainly without
any doubt cause some anxiety amongst many minority communities
in this country. There is some evidence from the Home Office's
own survey on this with the focus groups and so on and they are
questions which are still unanswered. For example, foreign nationals
who might be the first category to carry them compulsorily and
that in itself raises a question but the issue is, who is a foreign
national? Some people who have lived here for 30 years are still
foreign nationals and you might have situations in which two people
in a house out of seven are compelled to carry identity cards.
The third point that I want to make particularly in relation to
minority communities is that there is a question which you have
to some extent been hinting at which is what is on the card. To
what extent it is an entitlement card and to what extent it is
truly an identification card because there is a point at which,
with certain kinds of information, there ceases to be an identity
card and becomes, from the point of view of some minority communities
anyway, an immigration status card and that in itself potentially
creates some substantial issues.
Q835 Mr Prosser: Do you have any
way of addressing that in the Bill? Have you given any thought
to a form of words which would address those concerns or would
you want separate regulation outside of the Bill?
Mr Phillips: The first thing would
have to be, as I said, a proper impact assessment but, in relation
to the Bill itself, I think that the most important thing would
be to establish that there would be minimal information on this
card. There are issues about what would be on the register and
so on. We think, for example, for a whole variety of reasons,
anything that goes beyond purely biometric information becomes
a problem. It is one thing to have a card which identifies you
but a card which moves into the arena of discretion raises a number
of things. Once you are into entitlement, what then happens, and
we know—and I can elaborate on this if you wish—from
other experiences is that what tends to happen, with the best
will in the world, is that those who have to do the checks will
apply a differential filter as to who they ask to produce the
card. So, at the moment you have a piece of information which
can be demanded which might differentiate by ethnicity and so
on, then you create a different sort of problem. One other point
which perhaps is not quite so obvious but is one that I think
will be raised by a number of communities is the issue about the
cost of change of information and keeping the information up to
date. If you are going to be fined £1,000 or whatever it
might be if you do not keep your information up to date, this
will undoubtedly have a differential impact on different kinds
of communities particularly, for example, the 100,000 or more
gypsies and travellers in this country who are not settled. If
there is an address on the card and they have to keep this up
to date every time they move, we can begin to see chaos, catastrophe
and all sorts of problems there. I think that the summary is,
first of all, let us understand exactly what might happen and
there are techniques by which we can do that before we get into
passing legislation but, secondly, in the legislation, I think
any pressure or anything that will reduce the amount of information
held on the card to that which is essentially biometric, which
by the way could include ethnicity, is helpful.
Q836 Mr Prosser: As you know, for
the last two years or so, people who have been making asylum claims
in the country have already been provided with an identity card
which is called an ARC card which has a biometric chip on it.
Has the introduction of that card made it easier for asylum seekers
by proving their identity very clearly and precisely or has it
caused some of the problems which we have heard about not necessarily
in today's evidence but the general sort of evidence and critiques
about identity cards?
Mr Phillips: The upside of the
ARC is that it has, I think in many circumstances, made it simpler
and quicker for people to identify themselves and therefore in
relation to, for example, illegal working, this is a plus. However,
I think that there is an issue that arises which is to do with
the updating of the system, which we have some anecdotal evidence
of in relation to the ARC, the application registration card,
which is that we know that, if people have to continually update
their cards, especially if they are not entirely settled and so
on, there are all kinds of real practical and organisational difficulties
that gives rise to and, yet again, we have the issue about the
£1,000 civil penalty for not updating. This again comes into
play here. So, the signal from the ARC is that it may make things
quicker but, in terms of the proposal that is made in the Bill,
it could create difficulties which are quite severe for some ethnic
groups.
Q837 Bob Russell: Six months ago,
the Home Secretary announced the award of contracts to run the
NHS care record scheme which will provide all 50 NHS million patients
with an individual electronic NHS carer card which will detail
key treatments and care within either the Health Service or social
card. Do we need an identity card as well or should that information
be put on the identity card?
Dr Nathanson: There are several
points here. The first is that this is a grand scheme and we are
all hoping that it will work because there are huge advantages
to all of us in having a single electronic health record. It is
the classic thing where you are knocked down by a bus when you
are nowhere near home and they need to know whether you have allergies,
whether you are under any other medical treatment and so on.
Q838 Bob Russell: Would the individual
have that card?
Dr Nathanson: The individual under
the NHS scheme will not have a card at the moment on which there
will be health information, so there are key questions here about
how you will identify that the patient here is the person to whom
this record applies, although there will be a standard NHS number
applying to each individual. At the moment, there is not a single
NHS number, just to make life complicated, and we actually potentially
have different numbers, particularly if you move north and south
of the border with Scotland, but there are moves to simplify that.
This is one of the things that has been recognised for many years.
Also, if you go into one hospital, those notes will never get
to another hospital. So, it is linking all of that together. One
could very cynically say, name a major public sector scheme's
computerisation that has worked flawlessly, but that is because
I am terribly cynical about this. There are real issues of potential
good from this. The benefits of an ID card in relation to that
might be if the majority of people normally always carried an
identity card. Then, when they are knocked down by the bus in
another city, it would be the card that identified them, that
fed into the machine in the hospital to which they are taken and
that brought up the key things on their records and that could
potentially be advantageous but I think we are very many years
away from that at the moment.
Dr Chisholm: There are other reasons
why identity cards are being proposed and I think that it would
be inappropriate to have medical information contained on the
identity card.
Q839 Bob Russell: Why?
Dr Chisholm: Our wish is that
such information should be excluded. Why? Not least because we
would want the public to be reassured that other people who had
access to their identity card were not able to access personal
health information. I think that will be, irrespective of technological
solutions, a genuine fear in terms of public perception. I think
that, as Dr Nathanson has said, it is possible that the ID card
might in some way help to link to the electronic patient record
in terms of healthcare professionals who have a need to know information,
but I think that our preference would be basically to keep the
two systems separate and not to include medical information.
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