Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 420 - 439)



  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 you.

  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 generics prescribed.

  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 NHS.

  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 take it?

  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, whether—

  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—

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