Examination of Witnesses (Questions 220
- 239)
THURSDAY 2 FEBRUARY 2006
MS PAULINE
THOMPSON, MS
LIZ PHELPS
AND MR
MARTIN RATHFELDER
Q220 Dr Taylor: Is there an argument
that the very rich who are elderly should not get these exemptions?
Ms Thompson: The problem is then
that you are going to bring in means-testing and, as soon as you
start bringing in means-testing, you get the whole problem of
people who are entitled but not applying because they do not understand
the system. You have already said that it is a labyrinthine system
of means-testing for healthcare costs. Quite often it is a means-test
for a one-off cost, so people think, "Oh well, I can't face
filling in this 16-page form for a possible, very small charge",
but of course the other thing that is not looked at and has not
been looked at so far this morning is that actually people do
not just have one-off costs. Overall, older people with multiple
needs will have to travel to hospital, they will have their dental
appointment, they will probably wear glasses, they might need
a hearing aid, so, by the time you have added it all up, you are
into quite large costs, but on each individual occasion with the
problem of actually working through the system, then quite often
you have to pay and get a refund, and that is another complication.
Q221 Dr Taylor: We are coming on
to the other bits, but would you agree with the previous witnesses,
I think it was the witness from the King's Fund, who said that
really the only way to increase the amount of money is from general
taxation as being the only fair way?
Ms Thompson: Well, we have got
a free National Health Service, so you can either do that through
taxation or rejigging, the Government deciding how one is spending
the money and whether or not more should go into the NHS, so there
are two issues there.
Q222 Dr Stoate: Let's talk about
the travel scheme for people who are able to claim travel costs
back. At the moment, we have found out, only people attending
hospital are entitled to claim on the scheme, but, with the Government's
latest policy to move more care out into the community, does that
not seem wrong and is there any way of improving it?
Ms Thompson: Paragraph 6.67 of
the White Paper sort of points in slightly the right direction
because it does actually say that they are going to extend the
patient transport service to where it was traditionally provided
in hospital and they are also going to extend the eligibility
for the Hospital Travel Costs Scheme to include people who are
referred by a healthcare professional for treatment in a primary
care setting. Now, I noticed in the last set of evidence that
there was quite a lot of discussion about the Travel Costs Scheme
and how very complicated it is and I think this will need quite
a lot of unravelling as to exactly how good or bad it will actually
be. Who is the healthcare professional who is referring for treatment
in a primary care setting? People self-select to go and see their
GP, so does that mean to say they would not get the Travel Costs
Scheme for their first, initial appointment and it would only
be after the doctor says, "I'll need to see you back here
in four weeks' time"? There are going to be all sorts of
issues around that which I have not had time to look at, but I
would just say that this is on the cards, but how limited it will
be and how much it will actually meet what is needed is another
matter.
Ms Phelps: I think there are two
other aspects of that which really are important. One is what
we have been raising in relation to access to dentistry which
is a huge issue and, whilst we keep our fingers crossed that everything
will be rosy after 1 April, I think in the real world we do not
expect that to happen. We have long been arguing that, if the
PCTs cannot deliver dentistry in the local community, then at
least there should be help through the Travel Costs Scheme for
people on low incomes who actually have to make journeys of 30
or 50 miles because our evidence shows that that is one of the
main reasons people have not been taking up any dentistry that
they can get hold of from the NHS, that they cannot afford to
get there, so there is that issue. Also completely forgotten is
the issue of the costs for visitors to hospitals which is completely
outside the scheme and the only help that is available is through
the Social Fund. Again if you compare that with the Assisted Visitors
Scheme for prisoners under the Low Income Scheme, they can get
help every two weeks for a visit, yet you might have an elderly
person who is long-term in hospital and her health is very much
affected by the fact that she cannot get visits from her spouse
because he cannot afford it. Those are exactly the kind of cases
we are getting in bureaux which are really heart-rending and they
cannot be right.
Ms Thompson: I think there is
another issue and that is that we have not talked about people
who are getting continuing NHS care in nursing homes, yet they
cannot actually access the hospital transport scheme for patients
to be visited in those situations.
Q223 Dr Stoate: Is it the case at
the moment that, if someone is sent by their GP to hospital for
an X-ray or a blood test, they are eligible for the scheme at
the current time?
Mr Rathfelder: No, because that
is not care under the care of the consultant.
Q224 Dr Stoate: That is what I want
to clarify.
Mr Rathfelder: If I can amplify
that point, I think what we do not want is for people to come
and see you in your surgery simply so you can authorise transport
at the cost of £4 or whatever it might be in your locality.
That does not seem a very good use of a clinician's time. The
Social Exclusion Unit report on transport, I thought, was very
good, but the Department of Health do not seem to be in the least
bit interested in implementing it.
Q225 Dr Stoate: So you would recommend
a thorough review of the system?
Mr Rathfelder: Yes, because it
has got to take into account the money that is spent on the patient
transport service at the same time which at present is officially
regarded as providing transport for people for whom it is clinically
necessary, but that does not convey any real meaning to me. If
you are sending your patient to hospital, it is clinically necessary,
I imagine, in your judgment that they should go there. If they
cannot afford it, then are they entitled to the patient transport
system? It is not an ambulance service.
Q226 Jim Dowd: But that is not it.
It is for people who are deemed to have a medical condition which
makes public transport unsuitable.
Mr Rathfelder: Well, most of them
do go by the patient transport system simply because they are
old and frail actually. Why is public transport unsuitable
for old, frail people?
Q227 Jim Dowd: For the same reason
you get off the Congestion Charge if you want to go to St Thomas's,
for example. If the clinician says that you are unfit to use public
transport, you are—
Mr Rathfelder: So we all have
to go and see our doctor so that he can certify us as being incapable
of going on a bus?
Q228 Dr Stoate: Does it have any
effect, negative or positive, on people who are housebound? Are
they in any way disadvantaged or advantaged by the current scheme?
Ms Thompson: One of the problems
we come across is where people who are housebound, and I am not
only talking about the Hospital Travel Costs Scheme here, but
the patient transport service, and, because they are housebound,
they need to have the patient transport service and it, therefore,
makes appointments very, very long in hospital. You are talking
about pretty ill people and, because the ambulance will come and
pick them up at whatever time it suits the ambulance, quite often
that is two or three hours earlier than the actual appointment,
so the person is then sitting in a waiting room for that length
of time to actually get seen and then quite often they have to
wait another hour, so it is a day trip basically if you are using
the ambulances.
Q229 Anne Milton: Pauline, hospital
car parking charges for the elderly, how great a burden do you
think they are?
Ms Thompson: We are getting increasing
numbers of phone calls from our local Age Concerns about it and
from people directly. It is probably not to the same level as
perhaps the Macmillan evidence will be, but people do often have
more than one condition, so they go into hospital for one condition
one day and within the same week they can go to hospital to see
another person, so overall it does actually start to mount up.
Because many people cannot use public transport, then they are
using their cars to drive themselves, but more often than not
relying on friends and family to drive them, so then that person
has to park in the car park. We are beginning to find that the
charges really are going up and it does seem to be a revenue-raising
system for hospitals. Also, the more inefficient the hospital
is, the more you are likely to be charged because, if you are
there and your outpatients appointment is at such-and-such a time,
but you actually wait two hours, you are then paying extra for
the hospital's inefficiency which obviously does not go down very
well, so it is actually much more of a problem and we have been
getting more and more phone calls about it over the last few years.
Q230 Anne Milton: I think the difficulty
with saying that people can or cannot use public transport, probably
the truth is that everybody can, but it is just that it will be
deeply unpleasant and unacceptable. That would be my feeling.
At what point can you not use public transport?
Ms Thompson: Many people cannot
use public transport. They might have a back problem, so they
cannot actually go and stand at the bus stop. They might have
difficulty in getting on the bus. The buses do not always go to
where you want and you might have to have several changes on the
bus, so you might actually be talking of making a journey which
by car would be about 10/15/20 minutes into a journey of an hour
or an hour and a half. That in itself for older people, who might
not have a huge amount of energy and who are, by nature, ill because
they are going to hospital, I think it is quite impractical for
some of them to use buses and probably the majority.
Q231 Anne Milton: I am not actually
disagreeing with you. I am saying it is a bit of a nonsense to
talk about it because it is terribly area-dependent. A bus in
a rural area is a completely different prospect from a bus in
the middle of London.
Ms Thompson: Yes, but some people
would just have absolute difficulty in using a bus.
Mr Rathfelder: There are particular
problems for people with sick children where of course the patient
is not the person who is paying the costs. People who have a number
of children who may not have anywhere to leave those other children
may have to take the entire family to hospital. People with severely
disabled children, certainly in Manchester when I was working
there, had consultants often in six different hospitals and would
spend their entire lives trekking from one place to another to
see Mr So-and-so for one organ and Mr So-and-so for a different
organ. I had a terrible case of a Somali man with a child with
dislocated hips and he was expected to take this child in plaster
on a bus, then change in the middle of Manchester, walk across
the middle of Manchester from one bus station to another bus station
and the hospital would not pay for a taxi for him and, although
they accepted that he was eligible for the Hospital Costs Travel
Scheme, they would only pay his bus fare. I thought that was cruel
and inhumane.
Q232 Anne Milton: Should we pay the
childcare costs then, do you think?
Mr Rathfelder: Well, it would
be more sensible than dragging all these other children into the
hospital.
Q233 Anne Milton: Pauline, do you
think we should be building car parks at hospitals to help with
transport and letting people have it free?
Ms Thompson: Quite a few hospitals
do actually have them and I know in London it is different, but
a lot of hospitals do have fairly large car parks, though there
is always a problem about how many disabled parking places there
are. Certainly I think that hospitals need to take cognisance
of the fact that many patients are old and are not going to easily
be able to get there, so you, therefore, do have to think of it
in the round. Again in the White Paper it does very specifically
look at local transport in general which is welcome to actually
get some joined-up thinking between local transport and the Department
of Health, but I do not see how you can avoid car parking in the
current system. Okay, I think we are going to raise some new issues
when we go to the idea of more surgery care and again I think
they are going to need to address that issue because quite often
surgeries will not necessarily have adequate parking nearby, so
it actually in some way could compound the problems initially
while people think about how they are going to access the surgery
if they need to come by car.
Q234 Anne Milton: And there are issues
with community hospitals which are very good and local, but you
have clearly read the White Paper in a great deal more detail
than I have at this stage, but I think they are talking about
populations of 100,000 which in rural areas is a huge geographical
spread probably.
Ms Thompson: Yes.
Q235 Mr Campbell: The Low Income
Scheme which was mentioned before, what are its weaknesses and
does it benefit those it has got to benefit? Does it benefit the
people it is supposed to?
Ms Phelps: What we do not know
is how much non-take-up of it there is, but our evidence would
suggest that that is a lot. It is highly complex and it is divorced
from the DWP benefits, so it does not benefit from being piggy-backed
in any way when you are making claims for other benefits. It is
not well advertised. Amazingly, health providers are not required
to publicise in the GP surgeries, in pharmacies, in opticians
and dentists, they are not required to display any information
about it, so it seems to me that was a missed opportunity with
the new contracts which could require that, but they do not. Then
it is very complicated and, as has been said, the leaflet runs
to 70-odd pages and the claim form runs to 16 pages, so it is
very deterring. Our evidence certainly shows that it does not
work insofar as a lot of people who should be getting help through
it are not. Perhaps the worst thing that is coming and the one
thing that we did not pick up in our 2001 report because it happened
since is this system of penalty charges which has now come into
force. That is a very harsh system. You can understand you have
got to police any system once you have built it and it is another
admin cost. But now if you so-called fraudulently claim for a
free prescription and you get caught, you are subject to five
times the prescription charge and, if you do not pay it, it doubles
in 28 days. We are finding a lot of clients caught in that system
who actually could have got free prescriptions under the Low Income
Scheme, but nobody told them or actually in some cases pharmacists
and health professionals told them wrongly. They said, "Are
you on benefits? In that case, tick that box".
Q236 Mr Campbell: That was going
to be my next question. Is there anything in the information line
that is put out to get this across?
Ms Phelps: The Department of Health
does produce publicity, there are leaflets and things, but I would
like to see all health professionals required to display this
and required to be more proactive, particularly at the point of
the pharmacy, at the point of dispensing, to pick up whether or
not people should be entitled and to help direct them towards
that. There is a lot more that could be done, but, having said
that, the system is burdensome, it is complex.
Q237 Mr Campbell: It is not very
good.
Mr Rathfelder: If it was not a
system based on the social security system but something with
a simple line which said, for example, that if your income is
under £100 a week, then you qualify, because the key information
that people need to know is whether they are poor enough to qualify,
On the Department of Health's website, there is a Frequently Asked
Question, "What is the maximum income I can receive that
would still enable me to qualify for full help?" and what
is the answer? "Each claim is assessed individually based
on the information contained in the HC1 claim form. There is no
maximum amount as it depends entirely upon the circumstances of
the individual or family", which is of course just the information
we were looking for, is it not?
Ms Phelps: It is interesting,
looking again at who is entitled to free prescriptions from that
point of view with the new Tax Credits system. It has become really
bizarre that, if you are entitled through that, if you are in
receipt of Working Tax Credit with a disability element and/or
Child Tax Credit, then you get free prescriptions up to an annual
income of £15,050 which is about £289 a week, but, if
you happen to be a single, unemployed person who is sick and on
Incapacity Benefit, then it is IS plus half the prescription charge,
which is £59.45 a week. Now, there are just huge differences
and it shows how the system has grown piecemeal and there is no
coherence to it.
Q238 Mr Campbell: You have suggested
tapering assistance to reduce the impact of the purchase of the
Pre-payment Certificate, which is another promising idea as well,
as well as greater passporting to treat benefits. Can you expand
on that?
Ms Phelps: One thing you could
do is say, "If you are entitled to a means-tested benefit,
then you get your free prescriptions", so you piggy-back
on to that and do not have two tapers for in particular, Housing
Benefit and Council Tax Benefit, which run well above Income Support
levels, and that would simplify it for a lot of people. The thing
we have said about the Pre-payment Certificate, I do not think
it would complicate it more, but it would just be to say that
you bring it into the Low Income Scheme. You would leave the system
as it is, but, if you are on a low income, your HC3 Certificate
telling you how much help you get with dentists, how much with
optical charges, et cetera, could also say, "You can get
a Prescription Pre-payment Certificate for £5, £10,
£15 or whatever". I think that is, to our mind, a much
better way than saying that you can pay for it on a monthly basis
because then you are still saying that people on low incomes have
got to pay £90-something over the year, whereas, if you actually
tapered the costs of the PPC, you would be giving people on low
incomes the same advantage that people on higher incomes have
who can afford to cap their costs.
Q239 Mr Campbell: That would be good,
I think, if that could happen. If we cannot get the charges abolished
with this Government, then obviously I think that which you have
mentioned is a better plan hopefully. You have mentioned the voucher
system just before for low-income groups. What are the pros and
cons of this voucher system?
Ms Phelps: The optical voucher?
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