Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 113 - 119)



  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 difficult 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 effect 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 offer 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 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 staffing, 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 effectively, 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 afford 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 effectively 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 different 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 difference 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 hearing-aid 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 difference 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 difficulty, what we are suggesting on the basis of the status quo is that only people who can afford to pay £2,000 will be able to 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 effectively, 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 off 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 different levels of intensity which are subject to individual choice. Although core services  will be tax-funded, there will be many supplementary services at different 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 different 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 difficulty 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 suffering. 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 suffer 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 suffering, 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 different 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 Office 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.

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