Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 120 - 137)



  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 afford it, it would enable the service to offer 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 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 afford 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 efforts should be made to take out the charges, all efforts 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 afforded 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 different way of funding IVF treatment which again uses tax-payers' funding a different 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 tax-funded 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 offering 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 efficient 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 different 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 tariff—I do not need to tell you—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 offering 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 affluent communities where people are more likely to be able to afford 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 offers 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 off orthopaedics waiting lists and give them a bit of free physiotherapy, then they come off 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 different route.

  Q131  Dr Stoate: You have given examples of audiology and physiotherapy being possibles for co-payment, but in order to make a meaningful difference 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 difficult 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 off 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 affordable 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 afford, but perhaps there may be something we can do at the affordable end.

  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 co-payments 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 off, 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 difference 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 effectively 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 off, 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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