Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 480 - 494)



  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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