Examination of Witnesses (Questions 240
- 259)
THURSDAY 2 FEBRUARY 2006
MS PAULINE
THOMPSON, MS
LIZ PHELPS
AND MR
MARTIN RATHFELDER
Q240 Mr Campbell: Yes.
Ms Phelps: I think it is the bit
that confuses people most partly because it sort of works the
other way round. Instead of telling you how much you have to pay,
it tells you how much help you get, so people get very confused
about it in the first place, but the real problem with it is that
there is no guarantee that you can actually get glasses within
the cost of that voucher. It seems that in one part of the world
the Department of Health fixes the cost of the voucher, and this
is for people on Income Support on the lowest incomes, and in
another part of the world opticians are deciding what the cost
of glasses is and it is never road-tested properly. So particularly
if you are living in a rural area where you cannot shop around
so easily, you could well find that your local optician just does
not provide them within the voucher value and you have got to
find the difference which then immediately brings you below the
Income Support level. You may then decide maybe, "I can't
afford to go to the optician's at all" and this leads to
all the other health inequalities we have seen. We have suggested
that that has to be joined up better and that, if opticians are
dispensing through the NHS system, they should be under an obligation
to provide glasses within the cost of vouchers.
Q241 Mr Burstow: That has partly
answered a question I was going to ask about the voucher system
and how we can set the value in a way which is more sensible,
and joining up the two parts of the system would make some sense.
Are there any other points you would like to make to us about
how we can set the appropriate principles when it comes to setting
the value for spectacles and vouchers?
Ms Phelps: I know the Department
of Health does sit down and talk about this with the optical profession,
but so often when you get these semi-privatised systems, what
you end up with is a shortfall because the market does not actually
deliver what perhaps was the initial intention, so we have to
find a way of joining that up. The other thing we were considering
is that maybe NHS Direct should, in the same way as it can now
direct you, in theory, to your nearest local dentist, also be
able to direct you to the optician who can provide glasses within
the voucher value. It would also make the Department of Health
much more aware of exactly where those were.
Q242 Mr Burstow: That sounds like
a useful suggestion. Pauline, do you have anything else to add
on this particular point?
Ms Thompson: I was just thinking,
and this is just off the cuff, about the use of NHS Direct because
one of the big problems we have with the Low Income Scheme in
general is the amount of time it takes to fill the forms in and
how complicated it is, so when you are actually looking at the
costs of running the scheme, it falls very much on social services
and any sort of organisation that offers welfare rights advice,
so Age Concern, all the voluntary organisations, are spending
a lot of time helping people fill these forms in when really they
could be doing better things. If the Department of Health is going
to continue having these charges, should they not have responsibility
also to take on the costs of actually helping people fill in the
forms and perhaps do this over the phone, although that will not
work for everybody. It does seem quite strange, and again it is
partly mentioned in the White Paper, that more and more GP practices
are being encouraged to get welfare benefits advisers in. In fact
there has been some research done by Liverpool University and
the CAB about how getting benefits advice and an increase in income
did actually improve people's mental health and well-being and
they have done a longitudinal study looking 12 months later at
the people who actually did benefit from the benefits advice.
Therefore, you have one arm suggesting that you need more and
more people to give benefits advice to the well-being agenda and
then, on the other arm, charging.
Q243 Mr Burstow: So, as a sort of
general conclusion from what we have heard so far today, would
it be fair to say that there are some issues here about how Department
of Health objectives and DWP objectives are met and whether they
are actually properly aligned?
Ms Phelps: Yes, and I think the
DWP is moving very much towards the kind of idea of not having
to claim for each benefit separately, but pulling those together.
If you look at HC1, a lot of the questions, they exactly mirror
those of other means-tested benefits, so you should not require
people to go through that whole thing.
Ms Thompson: It should be a single
assessment process as well.
Ms Phelps: Exactly, it should
be brought into that, but that means more joining up between the
Department of Health and the DWP.
Mr Rathfelder: But the DWP makes
assessments of the take-up of the various benefits and regards
getting people to take up what they are supposedly entitled to
as valuable. I have not seen all your evidence, but I have not
seen any sign that the Department of Health has made any estimate
of the take-up of the Low Income Scheme and how many of the people
who are supposedly entitled to it either know it, know anything
about it or take advantage of it.
Q244 Mr Burstow: Well, we will have
the Minister before us at some point and you may have helped us
tip them off that we might want to ask that question.
Ms Phelps: What we find particularly
hard in that context is that then you can be penalised in the
context of not actually having maximised take-up.
Q245 Mr Burstow: I think that point
has been very clearly made to us today and certainly it is something
I think we would want to come back to with other witnesses later.
Can I come on to some specific services because really in a way
that is the best way to understand how the system is working and
how it might not work in the future. In the evidence we have had
from Age Concern, there was a reference to the new structure of
dental charges and how that will be inequitable for older people.
I wondered, Pauline Thompson, if you could say a bit more about
how that actually is so.
Ms Thompson: We are obviously
very concerned about dental charges because we have got loads
of evidence about the problems that older people have with their
oral health, and again it is all part of the Well-being Agenda,
that it is really important. The fact that people do actually
have to pay for their dental check-ups and then, once they have
had their dental check-ups, I know we have got new charges and
some of the worries have been slightly alleviated by the fact
that the cost of replacement of lost or damaged dentures, they
are making it slightly lower, but we do still have the question
of what is going to happen to the people who just have wear and
tear on their dentures and whether they are going to be expected
to find £189 for this. I think really our big problem is
that there are real problems with dental health, we know that
dental health can actually affect people very severely, even to
the extent of malnutrition, yet we are still not looking at whether
or not we are putting barriers, well, we are putting barriers
to people having good oral health.
Q246 Mr Burstow: On this point about
wellbeing and malnutrition being potential consequences of this
particular policy, how well grounded is that in terms of evidence?
Are we talking anecdotes here or actual research?
Ms Thompson: No. There has been
quite a lot of research on gerontology, meeting the challenges
of oral health for older people.[1]
Q247 Mr Burstow: Perhaps references
could be passed on to us so we can look at that. Can I ask Ms
Phelps from Citizens Advice, last week I asked a question about
dentures of Rosie Winterton, the minister responsible, about this
apparent anomaly that 30% of the highest band will be charged
where they have lost or damaged their dentures but they pay the
full whack of £189 if they just happen to have had their
dentures for a very long time and it is wear and tear. The Minister
said there had been no change to the system. Has there been a
change to the system in terms of how much people are paying and
could you say a bit more about that?
Ms Phelps: Yes. For my sins, I
was on the Harry Cayton group that looked at this. To start off
with, given the health inequalities agenda it is very sad that
the Government did set in the terms of reference of that group
that they had to create the same amount of charged revenue as
under the existing scheme, although compared to other European
countries it is very high with people having to pay 80% of the
cost, so a huge percentage of the charges. The new system has
to deliver the same. There seems to have been a slight change
in the language over time because the brief of the group was to
develop a system which would deliver the same level of charges.
We assumed that meant—working on 2003-04 figures—with
inflation only up to what would happen in April, but in reality
what appears to have happened is the new dental contract has proved
to be much more expensive than under the old system and the Department
has decided it wants to raise the same percentage of take from
charges as under the previous scheme. In fact, we are going to
see a very significant increase in the amount of revenue that
comes from charges post-April, which I think is another example
of where policy is not being led by trying to tackle health inequalities,
it is being led somewhere else in the agenda. What has happened
in the end is bands two and three are significantly higher than
the Cayton group hoped would have happened, particularly band
three at £189. If you look at the cost now of a partial denture,
there has always been help with replacement, if you break it or
lose and that has not changed. But if you are an older person
who has had your dentures for a long time and they are not working
properly any more, I am told that currently that will cost about
£100 to get a new partial denture and under the new scheme
that is going to be £189.
Q248 Mr Burstow: So there is a change,
they are going to be paying more.
Ms Phelps: We knew that moving
from however many it was to three bands would mean that there
will be some gainers and some losers but what we do not know is
where some of those big losers will be. It is a question of guessing,
the Department has not been clear for which groups or in which
situations it will cause the biggest losses. It struck me straight
away that the partial denture was one concern.
Q249 Mr Burstow: Maybe we need to
return to that again when we have the Minister. Can I ask Age
Concern about free eyesight tests for the over-60s. What is the
evidence for an improvement in people's health as a result of
that? Is there any evidence?
Ms Thompson: I cannot honestly
say. One would sincerely hope that by having a free test you are
encouraging people to go along and are not putting a barrier to
them having a test where other conditions might well be picked
up. I think that there is that problem and across the board it
is really important, it is part of health. You have chosen some
things that you are charged for and some where it is free.
Q250 Dr Naysmith: Can we move to
another service that is regarded sometimes as a bit of a Cinderella
in the National Health Service, and that is chiropody, which is
mentioned in the Age Concern evidence they submitted to us. Particularly
you talked about the service being free in theory but patients
are charged by default for these services. Could you expand on
what you mean by that?
Ms Thompson: There is some evidence
which we have just picked up, a report, and some government figures.
Initial contacts with chiropodists have fallen from over 960,000
in 1996-97 to 769,000 in 2003-04, so that is nearly 200,000 less
people who are being seen by chiropodists at a time when we have
got more older people. It is because chiropody services have largely
been withdrawn and their eligibility criteria are becoming much
higher. We have got evidence from some of our local Age Concerns
that even people with really severe arthritis who are blind cannot
access chiropody services, they have to go and have their toenails
cut and feet looked at either by a private chiropodist or local
Age Concerns who in some areas are picking up the lower end, the
toenail cutting service but, again, it is a cost to us to provide
this service and sometimes we have to pass it on to the individuals.
It is really charging by any other name. Basically, how much is
chiropody part of the Health Service and how much is it health,
how much is it social care. It is back to the old bath syndrome:
when is toenail cutting a health service or a social service?
One of our Age Concerns has been very concerned because they have
done a huge tightening of the criteria and they feel that older
people should not be put in the undignified position of having
to plead for basic foot care. They had a case where somebody could
not afford to go to a chiropodist and they ended up pleading with
the health authority to go to the NHS chiropodist. They also,
quite rightly I think, say it is a short-sighted policy because
money might be saved initially but not in the long-term. We did
a document some years ago called On your Feet but I think
we would have to call it Off your Feet now because things
have got so much worse. In her letter she ended up saying: "If
the people who make decisions could come face-to-face with some
of the toenails we have seen they might change their mind".
It is really charging by stealth.
Q251 Dr Naysmith: Certainly it is
something where I imagine most MPs around this table have had
a similar experience to me where you get people coming and saying,
"We used to have our toenails clipped and now we do not".
In my constituency, which spans two different primary care trusts
and two different local authorities, there are a number of ways
of dealing with that situation. You are right. I had a case two
years ago where the health authority, after exchanging letters,
said, "Has the person concerned asked her neighbour if he
will cut her nails?" Within the area people recognise what
you have just said, that you can prevent much more serious illness
by clipping nails and doing minor foot care.
Ms Thompson: A bit of help at
the right time. We are always saying it.
Dr Naysmith: So that is a hidden charge
that we have identified.
Q252 Jim Dowd: I want to return to
Paul's question about the effect of removing the cost of eye tests.
All of you individually have cited the deterrent effect of charges
generally. Why is it possible to calculate that but not the beneficial
effect of the removal of charges?
Ms Phelps: Certainly from our
point of view we see people come in the door who say, "I
did not get my prescription" and the MORI work we did showed
750,000 people had not got their prescriptions dispensed in the
previous year. We see that bit of it. We see other people driven
to below poverty level paying them. The health impact, certainly
in terms of prescriptions, is I would assume it is a given that
if a health professional has decided that person needs that drug
and they do not take it, to my mind that is enough, is it not?
Q253 Jim Dowd: I am asking you .
Ms Phelps: To measure the health
outcome would not be something that we would be able to do around
this table, you would have to do it further down the line. As
Pauline said, the nearest bit is the evidence we got on the impact
of just having CAB advice in GPs' surgeries and how that led to
a reduction in prescriptions. Yes, it is possible.
Mr Rathfelder: Does this not take
us further towards what is the essential point of charging? When
charges were first introduced they were clearly designed to reduce
the consumption of medication but that no longer seems to be an
objective of the present Government. Certainly in Manchester they
are encouraging GPs to prescribe more in order to reduce other
costs. It makes no sense to continue with charges. What may make
sense is a more refined argument about what the National Health
Service ought to be providing. The decision should not be made
by individual patients who can or cannot afford £6.25 or
whatever it is to have their teeth, toenails or whatever other
part of the body is not included looked after. We have a system
now for evaluating the cost-effectiveness of interventions and
that was not in existence in 1950 or in 1968 when we had charges.
We should have NICE investigating the cost-effectiveness of chiropody,
eye tests, dental tests and deciding whether they are worth doing,
not rationing them by paying for them.
Chairman: I think you have answered Richard's
next question.
Q254 Dr Taylor: That is a very interesting
point as to what the NHS ought to be providing because it raises
the whole question of healthcare rationing which is something
that I personally feel we should be facing up to. My question
is the really huge question: if each one of you started with a
blank piece of paper what would you have on it as ways of raising
the money that has got to be raised other than these charges that
we have been talking about? Everybody wants to abolish prescription
charges but we have got to raise the £450 million they make.
We want to abolish the other charges but where is the money going
to come from?
Mr Rathfelder: Either we put the
money on higher rates of tax—I do not understand why people
who earn more than £100,000 should pay less per pound than
poor people do on their income—or we work out something
that we want to deter. I would put a tax on hydrogenated vegetable
oil personally.
Q255 Dr Taylor: So we increase specific
taxes on certain things. Anything else?
Mr Rathfelder: No, I think that
is enough. I do not see that there is any point in trying to raise
money through the National Health Service, that is not the point.
The whole point about the National Health Service is that it is
supposed to be free at the point of need. We can have discussions
about what it ought to be providing. Personally I have no qualms
with some things you can pay for as an optional extra, although
I do not know whether my colleagues in the Socialist Health Association
would agree with that.
Q256 Dr Stoate: I certainly would
not and I am a member of it.
Mr Rathfelder: If you are admitted
to hospital and they say, "You can have wine with your meals
but you have got to pay for it, but you can have tea for free",
that does not seem to me to be—
Dr Stoate: I think that is important
because that is a slippery slope argument. Queen Charlotte's Hospital,
which we have been looking at this morning in terms of an article,
are saying you can have a decent midwife if you pay four thousand
quid or you can have an NHS one if you do not and—
Anne Milton: No, it was not saying that.
Dr Stoate: It was not quite saying that.
Chairman: Can we leave that point until
we see the actual papers and then we will come back to that with
another set of witnesses.
Anne Milton: That needs to be challenged.
It did not say "decent".
Dr Taylor: Can we go to the other two
to get answers.
Anne Milton: That is very derogatory.
Q257 Chairman: Where does the money
come from if it is not charges?
Ms Phelps: I have to agree, I
think it has to come through general taxation. The reason for
that is I think all of us would rather pay over our lifespan according
to our means rather than face sudden large sums at a point when
we are ill when that means our income has dropped for those very
reasons. It is not the best way to do it. If you took it through
the income tax system then you could instantly make a positive
contribution to tackling poverty and ill-heath because those on
lower incomes would pay less. We know that they are likely to
be in higher health need so currently they are likely to pay more.
It supports the prevention agenda and you cut those admin costs
and penalty charges.
Ms Thompson: I can only say I
would agree with what has been said.
Q258 Mr Amess: I just want Mr Rathfelder
to clarify something. The Socialist Health Association is affiliated
to the Labour Party, so you support Labour. I have been listening
very carefully to what you have been saying. How successful are
you and have you been in influencing the Government's health policy?
Mr Rathfelder: This one or its
predecessors? We like to claim some credit for the establishment
of the National Health Service in 1945. More recently I think
this Committee has been doing a better job than we have.
Jim Dowd: So the answer is nothing.
Chairman: The answer is no comment on
that.
Q259 Mr Burstow: This comes back
to the question of drawing the line between what is free and what
is not free. Last week in the High Court a judicial review decision
in the Grogan case decided that the guidance issued by
the Department in respect of NHS continuing care was flawed. Pauline
Thompson, do you think that the framework that is long awaited,
that is being put forward as the next step to try and deal with
problems of NHS continuing care, is an answer to the criticisms
that the court made last week?
Ms Thompson: I think the judge
did say it was the local criteria that was fatally flawed but
he certainly had lots of criticisms about the Department of Health
guidance as well. It is going to be a step—it is only a
step—in that if you have one national set of criteria you
have still got lots of different people applying it and it depends
how the assessment tools are sorted out. All I can say is it really
depends. I still feel very strongly that unless we have sorted
out the registered nurse care bands and what is considered to
be incidental and ancillary nursing care then I do not think we
are going to be very much further forward. It will be very interesting
to see whether or not there is an application to appeal the case
and what happens after that.
Chairman: Can I thank you very much indeed.
Can I just say one thing: if any of you know of any study that
has been done in recent years about the actual effects on charges
due to the changes in benefits, Family Tax Credits and things
like that, I would be very appreciative if you could direct it
to us. It would be interesting to see exactly how quick or not
the Department of Health reacts to these changes in the state
benefit system. Thank you all very much indeed. I am sorry it
has gone on so long.
1 Note by witness: For example, Gerondontology,
vol 22 supplement December 2005, Meeting the Challenges of
Oral Health for Older People, A Strategic Review. Back
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