Examination of Witnesses (Questions 420
THURSDAY 9 FEBRUARY 2006
Q420 Anne Milton: And, in doing so,
they cross-subsidise the service for the people who need it?
Ms Elliot: Yes.
Dame Gill Morgan: I suppose the
other thing we should point out is that these sorts of services
have been available by independent midwifery practices for a long
time. What is unusual about it is offering that sort of independent
service within an NHS hospital and, therefore, using the money
to cross-subsidise, and that is unusual.
Q421 Anne Milton: Are you comfortable
with it, Gill? You look wary. I can see wariness on your face.
Dame Gill Morgan: I think this
is right at the cusp of some real challenge and I am not really
sure how comfortable I feel about it because I feel, I think,
a little bit like you. There is a real benefit if you get additional
resources in to boost the services which is why I feel comfortable
about private services provided within the NHS because that money
has always gone back into the NHS and I suspect, if this had been
presented as a private service, I would have had no difficulty
whatsoever. In one way, you could present it as a private service
if you are quite comfortable about it, but I think the way that
it is presented leaves me personally feeling slightly uneasy,
but that is a personal view, not an organisational view.
Q422 Chairman: Could you just answer
this: how different is this payment in principle from a payment
for a prescription charge?
Dame Gill Morgan: I think the
thing that is different about this is partly the scale, but I
also think this is about the choices individual people can make
to have something which, as I say, could have been presented as
private and I would see it as fundamentally different from a prescription
charge. I think part of this and the discomfort is just the presentational
issues for someone who is used to the way the NHS has traditionally
worked. The prescription charge is different. That is a payment
that everybody contributes to, so it is a different sort of thing
for me. Briefly, while we are on prescriptions because I know
that is not the purpose of today, but I know you have been wrestling
with what evidence there is about how many people fail to use
prescription charges, I have brought with me a paper from a Commonwealth
survey which compared the UK with five countries which gives some
answers around prescription and dentistry. I will leave that for
Q423 Chairman: You do not then see
a prescription charge as being a part-payment for getting a service
from the NHS? Is that what you are saying?
Dame Gill Morgan: It is a co-payment,
but it is a different co-payment because it is really focused
the other way round and it has so many exclusions to it. My personal
view again about prescription charges is that we are not very
sophisticated about how we apply them, so we do not think about
what we are trying to achieve as a policy context and I do not
think we have fundamentally thought about the challenge of where
we are today with expensive drugs. One of the things we have been
thinking about internally which we have not sort of launched for
a wider public is what I have seen in other countries which is
that, if you want to make drugs available to everybody on an equity
basis, but you also want to offer some choice for people, what
other countries do is make generic drugs free and then only charge
a co-payment if somebody wants a branded drug. For example, if
you take a drug used to make you pass water, the generic name
is furosemide which would be free with no prescription charge,
but some people, however, like the branded name, Lasix, because
it comes in a green colour and they like that, so you are charged
for the branded name and, in that way, you drive two policies,
one being equity and the other being the issue that we want more
Q424 Dr Stoate: I have a couple of
very serious points I want to raise. You say it is not a two-tier
service and you also say you are just giving reassurance, yet,
according to the newspapers, and I have given the articles to
the Clerk to look at, they are not just getting reassurance, but
what they are getting is one-to-one ante-natal classes and they
are getting practice birthing sessions on a one-to-one basis.
That is not about just giving reassurance over the phone 24 hours
a day; that is about a completely separate type of service which
is not available, except to the 25 people who have got clinical
need, unless you have got 4,000 quid. That is the reality surely.
Ms Elliot: First of all, I cannot
comment on what the newspapers have said.
Q425 Dr Stoate: They are wrong, are
they, the newspapers? The £4,000 does not include the birthing
classes, the practice sessions and the one-to-one ante-natal sessions?
That is not what is happening?
Ms Elliot: First of all, other
women that we actually give care to do actually receive that type
of care throughout the one-to-one midwifery service, so we do
have a service that actually gives exactly the same type of care,
the only difference being that they do not get one named midwife
throughout the whole of their care.
Q426 Dr Stoate: Well, that is not
what is being said in the papers. It is specific women being interviewed
and I want to know whether these newspaper stories in fact are
true. The women being interviewed are saying, "It's marvellous.
I get ante-natal classes with one or two couples only, instead
of the 30 I would get otherwise, and I have got this practice
birthing session where the whole thing is done in practice on
a one-to-one basis". Is that not happening?
Ms Elliot: That happens within
the Jentle Midwifery Scheme absolutely.
Q427 Dr Stoate: Right, so that is
what they are getting for their £4,000 and not just reassurance
over the phone.
Ms Elliot: Yes, but that actually
goes back to the fact that that is a want and not a need and that
is what they are paying for.
Q428 Dr Stoate: But what I am trying
to say is that that is a two-tier service. They are getting something
which is completely unavailable to women who are not paying £4,000.
Ms Elliot: It is unavailable to
those women, but the women that are not paying £4,000 receive
an absolute high level of care that is acceptable and within the
Q429 Dr Stoate: But not within the
NSF. The NSF standards only reach those people who pay.
Ms Elliot: Yes, but then you could
go on then and add on separate things which women actually pay
for that are not available within the NHS.
Q430 Dr Stoate: What I am trying
to get at very simply is that they are paying for a service which
they cannot get on the NHS if they have not got the money.
Ms Elliot: Yes, but then nobody
gets those services on the NHS. It is not something that is available.
There is not another scheme that provides one midwife total care
within the NHS. That is not available.
Q431 Dr Stoate: You are right, but
it is an NHS service which is only available to those who have
got £4,000 over and above the ordinary NHS standard.
Ms Elliot: It is not an NHS service.
Q432 Dr Stoate: Well, you have just
said that it is part of the NHS.
Ms Elliot: No, the women who are
in our one-to-one midwifery service actually receive a very similar
service, but these women pay for extra things which are not clinical
need. They are things that they want, not things that they need.
Q433 Dr Stoate: Okay, I will leave
it there. You have said that you seem to support or seem to have
some sympathy for a scheme whereby, if you want a generic drug,
you get it for free, but not if you want the branded drug. What
is the difference then if I were to say to a schizophrenic, "You
can have largactyl or Chlorpromazine for free, but, if you want
Olanzapine, one of the typical anti-psychotics, it is going to
cost you 50 quid"? Would that not be the same thing?
Dame Gill Morgan: No, I do not
think it would because there you are not comparing like with like
because the more modern anti-psychotics are clinically more effective
and they have been shown by NICE to be. It is not like for like
and that, to me, is fundamentally different.
Q434 Dr Stoate: Why is that fundamentally
different? What is the difference between saying that the basic
NHS midwifery service is okay, but not up the NSF standards, whereas,
if you are going to pay £4,000, you can have the NSF standard
because that is not like for like either?
Dame Gill Morgan: Well, that is
where you go back to where I think, if this is presented as a
completely private scheme, which is what the NHS has already been
allowed to do, it would not be causing some of this heartache
as it does sit right in this middle bit and the NHS has been allowed,
even in Barbara Castle's day, to provide some private practice.
I think part of the issue here, which is why there is so much
interest in it, is that it is stirring up this question of how
far you mix private work with public work on the same ward and
you get the benefits accruing to the NHS, and that is very difficult.
Q435 Dr Stoate: Are we not just going
straight down a slippery slope? Okay, you could argue that the
new anti-psychotics are clinically different from the old anti-psychotics,
though other people might not necessarily agree with that, and
maybe the anti-psychotics are not a very good example, but maybe
we could come up with many other examples, and I am sure it would
not take me long to come up with other examples, where a drug
might be okay, but actually there is a "rather better one"
and NICE might think it is a rather more sophisticated drug, and
it does not make that much difference, but you can have that if
you pay for it. Is that not the same thing and how far would you
Dame Gill Morgan: Some countries
have done that of course. If you go to New Zealand, that is the
way they have handled their prescribing costs. I am not advocating
that because I think there is a duty to use the best, and most
appropriate, drug and that is what NICE gives us. It gives us
a view about what is the best drug to use at a particular time.
However, within that, there is a great difference between the
generic version of the drug and the branded version of the drug
when things come off patent and the cost difference can be absolutely
phenomenal. Now, it seems to me that that is not the same because
you would not be withdrawing a service from people, you would
actually be putting in a top-up for people who wanted a particular
branded version rather than the generic. Now, I have not done
any modelling and I am not presenting this as a hypothesis of
what we should do, but what I am trying to suggest is that we
could be looking at some of these charges in different ways and
then maybe both ways of bringing some resource in because, when
you add up all the charges that come into the NHS, it is a significant
contribution to the running costs of the NHS, but we could be
doing it in a way which does not actually compromise equity and
which does not actually compromise another policy which is to
get actually more generics prescribed. It is a suggestion that
we need to begin to think differently about it rather than the
way we have always thought about it.
Q436 Dr Taylor: We are coming back
to prescription charges later, but I am afraid I wanted to talk
to Maggie a little bit more because, when we did an inquiry on
midwifery in the last session, it came absolutely clearly out
that why mums like midwife-led birth centres is because they have
a very high chance of having one-to-one care from the same midwife
throughout. Now, I have to say that I think it is entirely wrong,
and I hope the Committee will say it is entirely wrong, to do
it the way you are doing it because these people are in fact getting
private care at half price. What does it cost to have a baby privately,
to have the whole shooting match privately? How much does it cost?
Ms Elliot: Well, between £4,000
and £5,000 with a private obstetrician, depending on the
service they have, whether they have a caesarean section or not,
Q437 Dr Taylor: So they can have
a baby privately for £4,000 or £5,000 and they can come
into the NHS unit and pay £4,000?
Ms Elliot: Actually I need to
take advice on that.
Q438 Dr Taylor: It strikes me that
this is cut-price private medicine.
Ms Elliot: Sorry, depending on
the actual service, it is £7,000 to £8,000.
Q439 Dr Taylor: In a hospital like
Queen Charlotte's, your delivery will be high-class, so you do
not need to pay to make sure that you get the right obstetrician
to do it. What you do need to pay for is the superb comfort of
having the same midwife all the time, so here you are giving people
who can afford it a better class of care, and I hope the Committee
will come out and say that it is entirely wrong without somebody
having to take it to court to prove that it is wrong.
Ms Elliot: It is not