Examination of Witnesses (Questions 40
- 59)
THURSDAY 19 JANUARY 2006
DR FELICITY
HARVEY, MR
MIKE BROWNLEE,
DR BARRY
COCKCROFT, MR
BEN DYSON
AND MR
ROB SMITH
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 affordability
as being the criterion, if you really are concerned with affordability
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 affordability 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.
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-off 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 differences, not why people who
can well afford to pay for the prescriptions get them free and
some people who cannot really afford 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 non-residential 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 suffering 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 suffering 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 suffering
from those conditions or any other conditions are already exempt
through another basis. It is a very difficult 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 effective.
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 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 affected 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 effect. Do you
think that will have a significant impact on the dental health
of particularly those groups which find dental charges hard to
afford?
Dr Cockcroft: I think the contract
will have a significant impact on the way services are delivered.
The service was effectively 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 different 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 difficult 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 difficulties
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 difficulty
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
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 difficulty in people differentiating 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
difference 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 x-rays, and, in the case of a partial
denture, any other treatment that the patient needs on the rest
of the mouth.
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