Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 40 - 59)



  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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