Examination of Witnesses (Questions 559
- 579)
THURSDAY 16 FEBRUARY 2006
RT HON
JANE KENNEDY
MP, MS ROSIE
WINTERTON MP, DR
FELICITY HARVEY
AND MR
BEN DYSON
Q559 Chairman: I was going to say
welcome back—I think three of you have been in front of
us just a few weeks ago—but good morning anyway. I wonder
if I could just ask you to introduce yourselves for the record,
please.
Mr Dyson: I am Ben Dyson. I am
Head of Dental and Ophthalmic Services at the Department of Health.
Ms Winterton: Rosie Winterton,
Minister of State at the Department of Health.
Jane Kennedy: Jane Kennedy, Minster
of State, Department of Health.
Dr Harvey: Felicity Harvey, Head
of Medicines, Pharmacy and Industry Group within the Department
of Health.
Q560 Chairman: Thank you very much.
Welcome to the fourth session of our investigation into NHS charges.
You have probably heard this quote on many occasions before. Lord
Lipsey, the Social Market Foundation described NHS charges as
a "dog's dinner lacking any basis in fairness or logic".
One of the areas, of course, is the issue that the prescription
charges exemptions have not been properly reviewed since 1968.
The officials told us when they came in that this was for historical
reasons, as it were. Does historical inertia justify maintaining
a system that is unfair and clearly is not working? Many witnesses
have told us that in the last few weeks.
Jane Kennedy: For the avoidance
of any doubt on this, we are very firmly of the view that charges
and prescription charges are a valuable and legitimate source
of revenue for the National Health Service. We have sought to
develop a system in which those people who can afford to pay are
required to contribute, but those people who cannot afford to
pay are exempt—and many other people in fact who could afford
to pay are also exempt. We know the way in which prescription
charges have arisen—and you will have heard a lot of evidence
about that—and they are part and parcel of the way in which
we manage the health service and they are a valuable source of
resources. Probably the areas of exemption and the changes that
we have been making to the low-income scheme and to the prepayment
certificate scheme have been areas in which we have been able
to help people on the margins.
Chairman: You will look into that a little
bit further.
Q561 Dr Stoate: As a brief supplementary
on that, Minister you said that you felt he principle was right
that people who could afford to pay should be made to pay—and
I do not entirely disagree with that principle—but if that
is the case why do they not simply remove the mildly illogical
exemptions for people, for example, with under-active thyroid
compared with those with an over-active thyroid, or exemptions
for people who need oral medication for their diabetes as compared
with people who do not need oral medication for their diabetes?
If you simply want to base it on ability to pay, why have any
exemptions at all for those rather arcane conditions, which do
not bear much relationship to modern medicine?
Jane Kennedy: Because to abolish
exemptions would have cost implications. If we were to have a
different set of exemptions, there would be some conditions that
we may determine were not suitable to be exempt.
Q562 Dr Stoate: Why have exemptions
at all? Why not simply reduce the cost, say, to a fiver and remove
all the exemptions? At least it would be a level playing field
for all medical conditions. I am not saying you should do that
but what is wrong with that?
Jane Kennedy: We reviewed prescription
charges through the CSR 1998. We looked at the prescription charging
system and, having looked at it, decided that we would not make
changes to it. We were not the first government to have done that:
since they were introduced, they have been looked at many times,
and on each occasion it has been concluded that, whilst there
are anomalies in the system—and we accept that—the
system we have is probably best left as it is. There will always
be groups of patients who feel that their condition should be
exempt. I hear the point you are making, but every time we do
that there is a cost implication.
Q563 Dr Stoate: Minister, you said
that it is your view that things should be left alone. You are
probably fairly unique in thinking that, because all the witnesses
we have heard from, either orally or in writing, feel the system
should not be left alone. If you are saying that it should be,
I have to say that you are in the minority with that view.
Jane Kennedy: Yes. Probably. I
have found the preparation for this inquiry, and the requirement,
as you do prepare, to look at the system, very useful. We will
look at the recommendations the Select Committee brings forward
and we will consider those carefully, but I get representations
from patients with a whole range of different conditions who believe
they should be exempt from prescription charges, and if you took
that route you would effectively abolish prescription charges.
Dr Stoate: I appreciate that.
Q564 Chairman: On that, Minister,
we had a witness last week, a young adult now, who is a cystic
fibrosis sufferer. Twenty-five years ago, when the list was drawn
up about long-term conditions, it would have been the case that
people with cystic fibrosis would not have survived childhood
and consequently there would never have been a question of them
having to pay what are multiple prescription costs for their particular
condition. It seems completely unfair that that particular case
has not been reviewed. It seems that a system that cannot review
that—because medical science is moving on—has something
wrong with it. But you think it is best left alone.
Jane Kennedy: If we were to review
it and look at the medical exemptions—but if we were to
do it from the point of view of staying cost neutral overall—as
I say, you would have to take some conditions out and put others
in, and we have taken the view from the outset, when we first
reviewed it, that actually the contribution that prescription
charges makes to the health service is a valuable one. We
have other priorities that we would rather spend the resource
on than giving relief in particular cases like this.
Q565 Dr Stoate: But even were it
cost neutral, you could still come up with a system that was considered
to be fairer. The suggestion I have made, for example, of reducing
the overall prescription charge for each item but removing some
of the exemptions, would be cost neutral, but at least it would
be a more level playing field if we are really trying to stick
to the principle that those who can afford to pay should pay.
At the moment, that is not the case.
Jane Kennedy: It will be interesting
to see what your formula is, Dr Stoate. We will have a look at
that.
Q566 Mr Burstow: Could I pick up
on this issue of reviews. With the current scheme of exemptions,
1968, various written answers that I have seen on this refer back
to the CSR as being one of the reviews that took place. When the
Committee took evidence from officials a few weeks ago, we were
rather given the impression that there had not been a major, if
you like, root and branch examination of the scheme at all. Can
you tell me a little bit more about how thorough the examination
of the scheme was when the CSR review took place?
Jane Kennedy: I cannot go into
detail but it was a serious examination of the scheme. It
was determined that, if we were to begin, for example, to review
the list of medical exemptions, you would generate as many losers
as winners.
Ms Winterton: I can add to that.
During the evidence it was said that ministers had looked at it,
and I did used to have responsibility for this area. I think,
frankly, that every minister who comes in then gets the postbags
of letters from people saying why can this condition, that condition,
the other condition not be added to it? Because medical science
has changed, and, as you said, Chairman, people with cystic fibrosis
are living longer, and there are other conditions, some cancer
conditions, that are almost long-term conditions now as opposed
to killers. It is something that I think ministers look at. As
Jane Kennedy has said, one of the issues is that within that there
will always be losers. People who have had an expectation, and
perhaps for 20 or 30 years have received medication, if all the
exemptions were removed would lose that. That is obviously something
that I am sure the Committee would want to consider.
Q567 Mr Burstow: Just to be clear,
it is one thing to have a look at; it is another thing to issue
instructions to officials to come up with workable options along
the lines that Dr Stoate has put forward that will enable you
to make a judgment as to whether or not there are better ways
of achieving your objectives than the current 1968 exemption scheme.
Have you done that, and had specific options looked at and costed?
Ms Winterton: That was, I believe,
the 1998 review.
Jane Kennedy: As I have said,
there are anomalies in the current system, but it was difficult
to make a case for removing exemption from one group of patients
(however we do it) and extending it to another group.
Q568 Chairman: What about when somebody
has a long-term condition which they are given a free prescription
for, but then something else in their health crops up—which
it could potentially in all of us—and they get a free prescription
for that which is nothing to do with their long-term condition?
It is hardly fair, is it?
Jane Kennedy: As I have said,
there are anomalies and it is not the perfect system. I mean,
87% of prescriptions are exempt from charges and that has increased
since 1997. The cost of prescriptions has been increasing by 10p
a year since 1997, and, therefore, in comparison to inflation,
the increases have been much lower than inflation. The numbers
of people who are helped by the low-income scheme and who now
use the prepayment certificate approach are increasing—or,
rather, the numbers being helped by the low-income scheme are
not, but we believe they are being exempted by other means. We
have been seeking to improve the current system without going
through the wholesale root and branch review that members of the
Committee clearly think it requires, because we believe that by
doing that we will create as much upset and disquiet as we would
satisfy.
Chairman: That leads very well into our
visit last week to a devolved assembly and what they are doing
and the wonders of having devolved powers in the United Kingdom
now. Richard.
Q569 Dr Taylor: Thank you very much.
We really heard exactly the same argument from the people in Cardiff
leading to the diametrically opposite conclusion. Because they
told us that any review would simply lead to a different set of
anomalies and complications—which is really exactly what
you have said—but from that they took the jump and said
the only fair thing to do is to abolish the charges, which they
are working on at the moment. Obviously it is going to cost them
less, but, proportionately, we worked it out and it is about the
same—so their proportion is about the same as the £450
million in England. It is very, very hard, I think, to argue it
your way round. You are attacking it at the margin: prepayment
certificates, the low-income scheme. Do you not really think the
only fair thing is to abolish and then work desperately on how
we can make the £450 million with a different route?
Jane Kennedy: Frankly, no, because
we have higher priorities for the health budget. That is the answer.
Q570 Dr Taylor: Absolutely.
Jane Kennedy: In the end, both
the Welsh Assembly and we have come to similar conclusions, if
you like, in terms of the evidence that we have been giving to
you, but we have taken different decisions as a result of that.
It is a question of how you prioritise and that is why the Welsh
Assembly have made that decision.
Q571 Dr Taylor: Another really dramatic
suggestion they were looking at in Wales was getting a Welsh national
formulary. We have the British National Formulary at the
moment which is absolutely superb, but what we need and what they
were looking at in Wales is a sort of breakdown of that into the
drugs that the NHS would pay for—probably leaving out some
of the ones that it would not, because there were perfectly effective
alternatives. Could you see anything like that happening here,
a review to produce a national formulary of the drugs that would
be afforded by the NHS?
Jane Kennedy: As Rosie says, the
National Institute for Health and Clinical Excellence performs
that role for new medicines and for treatments. You are saying
that we should look at the way that the national formulary works
and use that. It would be interesting. I want to think about it.
Q572 Dr Taylor: NICE is superb, as
fast as it can go on new medicines, but really I am looking at
everything that is in the BNF. Should there be a limitation
on some of those, for which there are alternatives that are perhaps
cheaper?
Jane Kennedy: I do not know if
Felicity has a view on that.
Dr Harvey: I think the BNF
includes all licensed drugs.
Q573 Dr Taylor: Absolutely.
Dr Harvey: In terms of paying
for licensed drugs, a doctor, as you well know, can prescribe
any licensed drug and, indeed, any unlicensed drug. In fact, as
soon as a new drug comes on the market and has been licensed,
then they can be prescribed. There is no wait for reimbursement
agreements, because that happens automatically through the PPRS.
Q574 Dr Taylor: I am getting at an
examination of this very basic right of a doctor to prescribe
absolutely anything that is in the BNF regardless of price
if there is a cheaper alternative.
Dr Harvey: I think that has always
been a matter of clinical freedom based on the clinician's decision
as to what medication is required for a particular patient.
Q575 Dr Taylor: Have we not got to
the point, because the financial problems are so intense in so
many places, where this form of health care rationing has to be
considered?—however politically dangerous it is.
Jane Kennedy: I want to give some
thought to what you are saying. It would be quite a major step.
Q576 Dr Taylor: I know.
Jane Kennedy: It would be interesting
to see if the Welsh Assembly finally does take that step. I would
be reluctant to consider such a step at this stage, but I want
to think about what the Committee has got to say.
Dr Taylor: Thank you.
Q577 Mr Burstow: Before I come on
to my question, with reference to the 1998 review it would be
very helpful if we could possibly have a note which sets out the
options that were considered; the costings, if any, that were
done; and the conclusions that were reached. We know the main
conclusion—the conclusion was not to change it—but
it would be very helpful., if possible to have a note on that.
Is that okay?
Jane Kennedy: Yes.
Q578 Mr Burstow: Thank you. We have
been exploring this and in the opening statement from Jane Kennedy
we have had some sense of it, but what is the point of health
charges? What criteria guide the Government's policy? We have
heard raising revenue is seen as a good purpose. Is that one of
the reasons? We have heard it is. Is it also, though, to limit
demand for services?
Ms Winterton: Could I come in
here, Chairman? Going back to your previous quote from Lord Lipsey,
I have to say that the system we had of dental charges, for example,
was extremely complicated for dentists and for patients: 400 different
items of service. In the reforms, we have tried to take that down
to a much simpler system, but, of course, in undertaking that
review, obviously the questions arose as to whether you should
have any system of charging at all. Certainly, in the dental field,
since 1951 there have always been charges for dental work. We
wanted to see a system that was much simpler. As I say, if you
say, "Should we have this system at all?" you do then
have to look at the revenue implications of taking that away,
which in the dental service would be about £600 million.
Again, as Jane Kennedy has said, when you are reviewing this,
those are the kinds of issues you go back to. During the course
of the review of dental charges, we did say, "Well, this
is something which has existed for a long time"—and
I think successive governments, frankly, have looked at and decided
it is, in a sense, inbuilt now in these areas. There might be
all kinds of reasons why you would consider taking it away, but
you would then have to look at the revenue coming from elsewhere,
so, overall, I suppose one would go back to the original 1951
decision to introduce it. Once you have got there, then the considerations
that govern changing the system obviously come into play, and
some of those are the amount of revenue that is collected from
that.
Q579 Mr Burstow: To summarise, the
reason we are doing it is because we have always done it that
way.
Ms Winterton: If you are looking
at it and you are reviewing it, as we did with the dental charges—and
of course it crosses your mind: Do you reverse what has been happening
for 50 years?—you have to be realistic and say, "This
is something that has gone on for 50 years. People to a certain
extent do accept it." And if you look at comparisons with
other countries, I think we spend more in public money on dentistry
than any other of a comparable nature. You have to say, given
all those circumstances, given the history, in particular, of
dentistry and charging, do you want to take it away and find the
money from elsewhere?
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