Examination of Witnesses (Questions 480
- 494)
THURSDAY 9 FEBRUARY 2006
MR DEREK
LEWIS, DAME
GILL MORGAN
AND MS
MAGGIE ELLIOT
Q480 Dr Taylor: We have heard rumours
that there are problems with free prescriptions in A&E.
Dame Gill Morgan: I have not heard
anything about problems with free prescriptions in A&E.
Q481 Dr Taylor: One really important
argument in favour of abolition to me seems to be that with the
greater shift of patients from inpatient care to outpatient care
and care in the community, even chemotherapy for cancers and things
like that, some very deserving patients are losing the free prescriptions
from hospital care and are having to pick them up with outpatient
care. Is that not going against the whole of the White Paper's
aim and is that not an extra strong reason for abolition?
Dame Gill Morgan: It depends.
There are different ways of funding those. What a significant
number of hospitals do is buy the package which provides the free
prescription and the home therapy so that people are still treated
as an outreach from hospital, in which case those drugs are not
charged through an NHS prescription. It is provided in the same
way it would be provided if you were admitted as an inpatient
on that oncology ward.
Q482 Dr Taylor: Is that widely known?
Dame Gill Morgan: It varies from
drug to drug. Obviously, if it is a drug that you can take orally
then you may be in a different position, but what we are trying
to do is take more of the infusions of cancer drugs into people's
homes because if you are feeling pretty rotten, you are feeling
pretty sick, you are better off feeling pretty rotten and sick
in your own home and having care provided in your own home, but
it is outreach.
Q483 Dr Taylor: It was oral agents
I was talking about because there are more and more chemotherapy
agents transferring from intravenous to oral.
Dame Gill Morgan: Yes, but you
are again in the position that if you are going to do that, and
particularly through a GP's prescription, the GP has to feel comfortable
and competent about using those drugs, and therefore it depends
whatever shared protocols are developed locally. For many of the
more complicated drugs I think it is quite appropriate if GPs
say, "We are not prepared to be part of a share-care protocol",
and therefore the care is still provided as hospital care even
though it is provided on an outpatient basis.
Q484 Dr Taylor: Correct me if I am
wrong but if a consultant gives an outpatient prescription to
an outpatient, that still calls for a charge, does it not?
Dame Gill Morgan: It depends on
how it is prescribed. A lot of outpatient prescriptions are still
taken within the hospital and people still come in to take some
of the therapy. If they are on continuous oral treatment that
would be prescribed as a script either by the consultant or by
the GP who will continue that. There is a range, depending on
whether it an oral type of therapy or whether it is maintenance.
It is much more complicated because where in the system you will
come depends on the drug, the disease, the stage and a whole set
of things.
Q485 Dr Taylor: So do you not think
the Welsh Assembly is right to aim to abolish prescription charges
entirely as this is raising extra complications?
Dame Gill Morgan: Again, this
is a personal view; I have never tested it with the members, but
my personal view is that if we did not have prescription charges
that would help because we have some costs. The downside of that
is that we would have to find some way of getting that money into
the NHS in some other way and then you have got a political debate
about whether it should be taxation based.
Dr Taylor: I am not asking now but could
we have a written note of other ways of raising £450 million?
Q486 Chairman: Last week's answer
was general taxation by most of the witnesses. We are not at that
stage of the inquiry.
Dame Gill Morgan: Exactly.
Jim Dowd: Could you give us the next
set of lottery numbers as well?
Q487 Chairman: I would just like
to say one thing on what you have said about this issue that inpatients
normally would not pay for any charges, and that is the potential
inequity. I asked this question last week and it did not seem
that it was true, that people can be discharged from hospital
with a month's supply of something where other people would have
to pay or they would have to pay in different circumstances. Is
that inequitable, do you think? I know it is people being kind
but is it inequitable?
Dame Gill Morgan: It probably
is inequitable but you would have to look at what the conditions
and the types of reasons were and I have no knowledge about who
would get a month's prescription free and who would not, so I
would only be guessing. I have not got any evidence on that. One
thing I should also say about Patientline, because I do think
it is important to look at the other bit, which is what the patients
say about this, is that the surveys that have been done show that
88% of patients really love these things, and certainly have found
the availability of a bedside personal phone of great benefit
to them. There is very high patient satisfaction and, you are
quite right: this is a problem outside the hospital and for relatives
rather than for patients. The patients like it and value it.
Q488 Chairman: Could I move on to
this issue we were talking about earlier on the change in treatment,
the acute sector coming out into the community in terms of people's
homes? The other change in pattern that we have had very much
in the last few years is people going in now for things like day
surgery or even for day chemotherapy treatment where at one time
they would have been an inpatient. With regard to travel costs,
do you feel that there is a burden there because of the changing
pattern of treatment that people have in the Health Service?
Dame Gill Morgan: Again, we have
never surveyed our members about it but I can talk about a personal
position, which is that certainly, when we looked at travel costs
in a health authority I was involved in, we exempted people who
had to come for chemotherapy, for renal dialysis or for repeated
issues. There were no patient transport charges for any of those
patients and there were also no car parking charges for those
patients because it was recognised that those things were a great
burden if you were routinely coming to a hospital or needing care,
which is quite different than if you go once in a while.
Q489 Chairman: In terms of the assistance
people can get with travel costs, are you happy that people get
to know about these schemes or with the take-up of these schemes?
Dame Gill Morgan: Yes. Certainly
one of the most interesting debates which generated most discussion
at a local level was about patient transport because patients
were very well aware of the issues. It is widely advertised in
the majority of hospitals. Again, I do not think we have been
quite as imaginative about patient transport as a service as we
might have been, so one of the things that some authorities have
done is get joint agreements with local government because local
government are paying for lots of patient transport, particularly
to bring children into special schools and things like that, and
in many places there is no connection between the transport plans
of all the different organisations, so you have vehicles sitting
unused during the day somewhere but another service is using them
elsewhere. Quite a lot of health organisations, particularly in
rural areas, have funded co-ordination schemes jointly with local
government to begin to look at how you get a much more sensible
use of something which is very important in rural areas.
Q490 Chairman: Should hospitals be
encouraged to see car parking as a means of raising revenue?
Dame Gill Morgan: I understand
why hospitals have gone down that route. Very many hospitals have
gone down that route because they are centrally sited and, as
you have picked up in one of your other discussions, large numbers
of people on the street use hospital car parks to avoid paying
council charges. I think we are at a point of real change because
if you look at why patients choose hospitals, uniformly towards
the top of the list is car parking, so I am now aware of a number
of hospitals which are not only reducing their car parking costs
and fees but are also taking their staff out to park and ride
schemes so that the whole of the car parking on site, other than
for night staff or unsocial hours, is available to patients. If
you want to market your hospital the things that patients will
go on is accessibility, car parking and availability, and then
one or two clinical indicators, but it is the car parking which
is the biggest drive. I think we are going to see a change and
more hospitals making car parking free because that will be a
competitive edge for them. I think we are at a point now where
we are going to see a significant change.
Q491 Jim Dowd: Representing an inner
London seat, as I do, even there the issue of car parking is important
though the transport links to, say, Lewisham or King's are very
good. At Lewisham there was a period when it was free and it was
being used by commuters from Kent to access Catford and then coming
here. This is my point: if we remove charges how do you stop (a)
that recurring or (b) all the spaces being consumed by staff?
Dame Gill Morgan: Exactly, and
that is why some of the charges have come in. What you would have
to do is have some system for people who are recurrent. You could
issue a pass when an outpatient invitation was sent. There are
ways you can begin to think about handling it differently, but
most people are not yet at the stage of thinking about that because
they are not yet thinking, "What are we going to do to get
the competitive advantage?". Once that is on the agenda,
as it already is for foundation trusts, I think you are going
to see a massive change in car parking.
Q492 Jim Dowd: So what you are saying
is that if you just abandoned car parking charges and left it
as a free-for-all that would have no administrative cost, whereas
if you abandoned charges but still had a managed system that would
just add to the overheads of the trust, would it not?
Dame Gill Morgan: Indeed, but
if it gives you a competitive advantage, and that is why I am
linking it with patient choice and people choosing where to go,
that is offset by extra patients who will come to you, because
knowing they have got guaranteed car parking when they come, and
patients go to hospitals when they are ill, is going to be a massive
competitive advantage for organisations, much more direct and
understandable than any other clinical indicators that hospitals
will present. It will be car parking right up there, I think.
The other issue which I think is really interesting about car
parking and why a lot of organisations have had to charge for
car parking is that in a number of cities in particular there
have been planning rules which have not allowed hospitals to build
or to have sufficient car parking spaces because of the impact
on roads. I have even heard councillors say things like, "We
cannot possibly have extra car parking spaces because it will
encourage more people to travel to the hospital", and I have
sat on the other side of the desk saying, "Actually, we want
people to come to the hospital when they need the treatment".
There is another side to this, which is that in many hospitals
car parking places are in real shortage and a scarce amenity,
which is why people are looking at off-placing their staff and
having park and ride schemes. There are now some interesting models
of people who are thinking of new ways of putting in multi-storey
car parks which are actually very cheap in capital terms and very
safe, but it would boost the car parking availability for patients,
and I think we will see more drives to get those sorts of issues
in, which will bring some conflict in terms of planning rules.
Q493 Mr Amess: I think you have probably
already answered the question, but obviously it is very tough
on patients who have to go back regularly for treatment. Could
you just articulate what the case is for a voucher system?
Dame Gill Morgan: I am aware of
hospitals where people going for chemotherapy or renal treatment
have special car parks with barriers and they issue a card for
people to come in so that you actually have the access for the
treatment. I think again that that is a sort of interim stage
between completely moving to a complex administrative system and
charges, and people already do that sort of thing but it varies
because every organisation will be in a different context in the
environment and therefore what you might want to do in an inner
city area is going to be fundamentally different from what you
might want to do in a rural area.
Q494 Mr Amess: In addition to the
midwifery service apparently a dermatology clinic will soon be
opened by Harrogate District NHS Foundation Trust. NHS patients
will be able to pay the trust to remove moles and warts, to screen
moles or—and I think this is very interesting—to have
Botox injections to reduce heavy sweating. Perhaps the Labour
leader would take advantage of that when he takes off his jacket.
Can you think of any extra non-clinical services that might be
made available in hospitals in the future? Are we going to be
sitting round having a séance?
Dame Gill Morgan: That one I think
is very simple. That is a private service providing the things
that NHS patients no longer have access to because most organisations
have reduced the availability of purely cosmetic therapy. What
the hospital is doing is filling a niche and providing a competitive
private service for patients who just want to come to the hospital.
In terms of other things you might want to charge for, the sorts
of things I think people might be interested in, if you assume
that the NHS has to provide treatment and therapies that work
and have been demonstrated to work, and this will be contentious
and we will probably get more comments about this than the rest
of the things I have said, you might want to say complementary
therapies. There is no evidence for the majority of complementary
therapies. Therefore you could very well see people offering complementary
therapies and charging for them within an NHS setting. The reality
is that for things like cancer therapy, HIV care, a lot of those
services already provide complementary therapy as part of an overall
holistic package for people, and you could see that you might
want to offer that sort of thing. The other opportunity I think
is around things like hotel type facilities. If you went to the
private sector you would be offered a wine list, a better menu.
You could begin to see charges being raised in that sort of way,
none of which would actually impact on the clinical care of other
people. I think it would be very difficult to offer a wine list
within an NHS hospital because of the problems we have with alcohol
but it is those sorts of extra things, you could say. In the States
they call it jacuzzi competition because a lot of the hospitals
compete by having en-suite jacuzzis which are better than the
en-suite showers and you get into that sort of thing which people
start to charge for, which are not clinical and they do not impact
on the clinical care you get. That is the sort of area I think
people will be looking at.
Mr Amess: Thank you. That is very interesting.
Chairman: I would like to thank you all
and particularly you, Maggie, for answering our questions earlier
and helping us in this inquiry, and hopefully in the next few
months we will have an inquiry so that you can see if your evidence
this morning has influenced us in any way. We will have to wait
and see about these issues. Thank you.
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