Examination of Witnesses (Questions 580
- 599)
THURSDAY 16 FEBRUARY 2006
RT HON
JANE KENNEDY
MP, MS ROSIE
WINTERTON MP, DR
FELICITY HARVEY
AND MR
BEN DYSON
Q580 Mr Burstow: Just to expand it
beyond dentistry, is that the rationalisation of the position
that would apply to all of the health care charges that we currently
have within the NHS?
Ms Winterton: There are those
considerations, yes. I think there are those considerations that
if this has been something that, as I have said, successive governments
have looked at, I am sure—
Jane Kennedy: But there are other
charges which you face. If you go to hospital, to park your car
you very often, these days, pay a car-parking fee. These are valuable
sources of revenue—but they are not just a valuable source
of revenue: they also help hospitals manage space, which is at
a premium, around the hospital; they help them manage the flows
of traffic—and I think it is perfectly legitimate way in
which—
Q581 Mr Burstow: We are coming on
to car-park charges a bit later, so I am not going to trample
on that ground, but I do want to ask one other question. It is
this: If we did start with a blank piece of paper and the question
was being asked: "We have to raise one billion pounds of
revenue from the operations of the NHS, and currently we are trying
to raise that through charging people with life-threatening conditions,
by charging for access to their medicines and, in some cases,
for their dentistry, would it be appropriate to consider switching,
for example, a much greater emphasis on to the hotel cost sides
of the NHS (the cost of being accommodated, the costs of, as we
are seeing increasingly, the introduction of the telephone service)?"
the provision of those sorts of services is nothing to do with
the direct treatment and health of the individual but is the hotel
and accommodation costs, is that not a more legitimate area to
look into to raise revenue, rather than directly on the provision
of health care?
Jane Kennedy: Certainly if you
were comparing it to prescription charges, I do not necessarily
agree with that. If you have to go into hospital and you have
to go into hospital for treatment, I do not think you should be
charged for the care that you receive and the hospital services
that you receive. I think if there are enhancements, that is perhaps
a different matter—and we will come on to talk about the
telephone services and the TV services that are provided—but
I think it is important to remember on the prescription charging
scheme, for example, if we are dealing with that, that the payment
for that is income based. And, whilst there are anomalies in the
scheme, those people who cannot afford to pay or who are on the
margins of affordability are exempt from payment and they are
not prevented from getting access to their medicines. It is only
those people who are in a position to be able to pay who we ask
to contribute to the cost—and they do not pay the full cost:
the prescription charge is a contribution to the cost of the medicine.
Ms Winterton: I think it is a
balance between ensuring that the people who might be deterred
because of the cost are protected. Certainly the evidence in the
dental field (what people say and surveys that have been carried
out) it is not charging which prevents people going to a dentist.
I think it is about getting that balance right, between saying
that if there is a contribution that is going to be made, let
us make sure that we protect the people who might be deterred
from going by things such as the low-income scheme or in certain
instances in introducing these prepayment certificates.
Q582 Mr Burstow: I think Howard is
going to ask some more about that in a minute. I just want to
end with this issue of dentistry one more time, and particularly
the question of the provision of dentures, which is something
that I raised with the minister at the session we had with you
back in January. It is this concern we have had put to us both
by Citizens Advice and Age Concern, that, for as many as 45% of
older people who have no natural teeth, the issue of having access
to dentures is very important to them in terms of their health
and welfare. At the moment, with the new scheme, there is an increase
in the amount that an individual will have to pay for replacing
dentures that are needing replacement simply because of wear and
tear which is higher than in the situation where someone has lost
their dentures, where they are only going to have to pay 30% of
the new highest rate. If they got to the point where they are
no longer any good through wear and tear, they are seeing an increase
from about £100 to £189, so that is directly increasing
the cost, potentially increasing the incentive either to carry
on using very inadequate and unsatisfactory worn out dentures
or not to have anything at all.
Ms Winterton: I think there are
a number of issues here. I am not sure of the actual figures of
people who have no teeth at all.
Q583 Mr Burstow: The figure we have
had supplied as evidence is up to 45% of older adults.
Ms Winterton: I would look at
whether that is people who actually have no teeth. I understood
that the figures for people who have no teeth is relatively small
and that it is more likely that dentures are for partial dentures,
in which case you look at the figure in the higher band, band
3, of £189. Within that band would be included not only preventative
health advice but looking at the other teeth, checking up any
fillings, any other work that needed to be done, so the whole
course of treatment including replacement dentures, would be included
in that. That is a cut, from £384, which was the maximum
you could pay previously, down to £189. The reason we made
that top band much cheaper than it had been before—and Age
Concern were particularly pleased that we made that change—was
because older people do tend to require more treatment and they
do tend to be at the higher end of the payment spectrum—as
is the case, as well, with people on lower incomes. We had to
strike that balance. Within the system that we have established,
there will be some winners and losers, but, overall—and
I think that is why the scheme has been welcomed by groups representing
older people—we have been able to lower that higher price.
Also, referring to your point about the 30%, there is actually
no difference in the current system. I know we have had this exchange
before, but, effectively, if somebody loses their dentures, there
is a decision made that it is probably through no fault of their
own—one would hope that people do not go around throwing
their dentures in a fit of pique or something—and they only
have to pay 30% of the replacement costs. We can have arguments
about whether that is the right thing or the wrong thing, but
it is an attempt, I think, to be fair in the assumption that people
are not being careless with them or just being irresponsible.
It is a judgment. But we have kept the system as it is at the
moment, because some people would think it was rather mean to
have taken it away.
Q584 Dr Stoate: I would like to explore
some alternative ways to raise revenue from the NHS. Jane, you
mentioned that you were not in favour at all of hotel charges
for hospital patients—and I have to say I entirely agree
with that. As I understand it you are not having any plans to
introduce hotel charges. But, as a GP, if I have an elderly person
recovering from a chest infection and I have decided that person
can no longer manage in the community and really needs some sort
of residential care, if I send that person into hospital they
do not pay anything at all; if I send that person into a respite
home or social services care home they may well have to pay for
that care. What is the logic in saying to that elderly person,
"If I get you into the geriatric unit down the road it will
be free; if I get you into the old folks' home down the road you
may have to pay for some of those charges—not the nursing
element but the hotel charges." Where is the logic of charging
hotel charges for nursing home patients and no hotel charges for
hospital patients for the same condition?
Jane Kennedy: Again, it comes
back to the same argument we have been having, which is that when
you have a system and you consider a reform of that nature, you
consider the pros and cons of the proposal, and you have to determine
where in your list of priorities for reform and change such a
proposal fits. The costs of such a proposal would be very significant.
Our view has been that we have other priorities that we will use
the revenue that we have, which is finite—
Q585 Dr Stoate: I have no problem
with your views on priorities of finance, and I entirely accept
that the NHS needs to raise money from somewhere to develop and
to improve services. I take issue with whether this is the right
way. Are there not alternative ways that could be found to raise
precisely the same amount of money? Can we not come up with alternative
ways? Have other countries not come up with alternative ways that
look fairer than ours? If that is the case, why are we not pursuing
those alternatives?
Jane Kennedy: I would be interested
to see the examples that the Committee might have of alternative
ways of raising revenue. In the circumstances that we are in at
the moment, our view has been that we should not make that change.
I am aware that it has been something that has been hotly debated:
it was debated very much at the last general election and it has
been something that we have considered, but consistently, having
considered it, we have taken the view that it is not a high enough
priority for us to believe we need to do something about.
Q586 Dr Stoate: I have this nagging
feeling about unfairness and I hate unfairness. I will give you
another very simple example. I have two patients in my surgery:
one has an under-active thyroid, one has an over-active thyroid,
they both have throat infections. I say to patient (a) with the
under-active thyroid, "Here's your fee prescription"
and I say to patient (b) with an over-active thyroid, "You've
got to go and pay £6.50 for that prescription," despite
the fact that neither condition has anything to do with their
thyroid disease and the patients are in all other respect identical.
It sounds like a DirectLine advert, but the fact is that that
literally does happen. That is just unfair and there has to be
a way of reducing unfairness at that level.
Jane Kennedy: As I have said,
the anomalies in this system are clear. The benefits have changed
over time and for those who are entitled to relief from prescription
charging the definitions have changed over time. Wherever we have
made those changes, the intention has been to preserve an existing
entitlement; it has never been to take one away. Where there is
a possibility of extending or increasing entitlement to free prescriptions,
we do have to balance the needs of those patients who might benefit
from that, against those who would lose as a result, and there
would always be some who would—not necessarily if we were
to deal with prescription charges in the way that you should,
not just around prescription charges, but somewhere else in the
health service there would be a cost that would have to be made.
Q587 Dr Stoate: I accept that, but,
to tie you down a bit, I gather you did not answer the beginning
of my question—I have been reminded by the advisers—on
alternative countries. Have you looked at alternative countries?
If so, which ones, and, if not, why not? I would like to know
about the work the Department has done on alternative structures,
because there are plenty of good examples from across the world
that you could have looked at. Are there any you have looked at,
and, if so, what have you found? If you have not looked at them,
why not?
Jane Kennedy: We have looked at
others. We have obviously been following developments in the two
devolved administrations. We have looked at Ireland and the experience
in Ireland. Looking through my notes, if you will allow me, we
have looked at the system in Germany, and in Italy, where the
systems are regionally based and regionally determined. We have
looked at the system in France, in Spain—right across Europe—in
Sweden, Denmark, Finland and the Netherlands. We have tended to
look across Europe for comparators.
Q588 Chairman: What have you learned
from those comparators?
Jane Kennedy: There are quite
a variety of ways in which they system operates. If you look at
Italy, as I have said it is a regionally based system and the
amount that is charged is charged per pack of medicines and not
per prescription item. Some regions do not have any charge at
all but all regions do pay a degree . . . I will get you the detail.
Dr Harvey: They pay the difference
between the reference price and the actual price, because they
have reference pricing.
Jane Kennedy: It is similar in
France. In Spain they have, quite interestingly, different
systems depending on whether you are a civil servant or not—which
I found intriguing. I see some interest from the advisers at that.
Those who are chronically sick in Spain do pay a maximum charge.
The equivalent in the UK would be about £1.80, but, again,
that is around the definition of illness. We can provide you with
this sort of detail if it would help.
Q589 Dr Stoate: It would be helpful.
There is written evidence that the BMA suggested a nominal charge,
say, of £1 for everybody except children. Do you have a response
to the BMA's suggestion?
Jane Kennedy: Again, you would
be withdrawing an entitlement from a large number of people to
achieve that. I would want to look at the findings of this Committee
and to look at the recommendations that the Committee makes, but
our view is that a review of that nature would produce as many
people who would be discontent with the outcome as those who would
be pleased with it. So we would have some concerns.
Q590 Chairman: I accept that entirely,
that you would have a situation where, if you were to restrict
somebody with a long-term condition just to have free prescriptions
for that condition, they would have to pay—and that would
be a simple change—for other conditions that came along,
but that is taking unfairness out of the system as most people
would see it. There cannot be anything wrong with that, can there?
Jane Kennedy: Again, it depends
how you define long-term condition. You would be extending exemptions
in some areas which would have cost implications, and if we were
extending it in some areas and trying to do it in a way which
was cost neutral you have other areas which would face an increase
or a loss of entitlement or the costs would be borne somewhere
else within the health service. We keep coming back to that point.
We have not been able to find a solution which protects current
entitlement and does not bring about a significant cost to the
health service.
Ms Winterton: Chairman, I can
also send some information about dentistry in other countries.
Q591 Chairman: We would greatly appreciate
that if you could do that. Could I ask both of you, while on this
issue: a crude interpretation would be, "We are going to
keep it like this because it has been like this for 50 years,
other than this three year blip, on prescription charges"
but that is not a rule of thumb, that you look at the NHS and
say, "We're going to leave it like that because it has been
like that for 50 years," is it? It is far from it, is it
not? You are looking at other areas that you would probably like
to change before NHS charges.
Jane Kennedy: That is the key,
and in the end that has been how we have determined our approach
to it.
Ms Winterton: There is also an
issue in dental care as well. People very often, at the moment,
mix NHS care with cosmetic care. There have been a lot of changes
that, in a sense, even further complicate that particular system.
We have tried to make it clearer to people what they can get on
the NHS, with the charge that goes with that, and what they are
then charged for privately on top of that. But it has been a growing,
if you like, mixed economy in terms of dental care.
Jane Kennedy: One more point,
where we are having that general discussion, just to reiterate:
the numbers of prescriptions that are now exempt from payment
is 87%. Of the 13% for which charges are raised, about 5% are
now paid under the prepayment certificate, so there is a maximum
that is paid in any one year on that. We have improved the low-income
scheme and the PPA, the authority who administer the scheme, are
looking at introducing monthly payments which would ease the burden
on those who do have to pay.
Q592 Charlotte Atkins: For the 13%
who do pay, what is the Government's policy? Is it to raise charges
in line with inflation or to keep the income from the charges
at generally the same proportion of the NHS budget?
Jane Kennedy: Our policy has been
to have a nominal increase, almost, in prescription charges since
we were elected in 1997. Year on year it has only gone up by 10p
per year. The view that we have taken is that to abolish them
would be too big a step, but we acknowledge the burden that it
can be for those at the margins, just above the low-income scheme
level and so on. We have accepted, overall, the contribution that
prescription charges costs are making is reducing.
Q593 Charlotte Atkins: Basically,
the answer to that question is neither—neither to keep it
in line with inflation, nor as a proportion of the NHS budget.
I understood that in reviewing the system of NHS dentistry charges
the new system was required to raise the same proportion of funds
as the old one. Is that correct?
Jane Kennedy: Yes.
Ms Winterton: Yes.
Q594 Charlotte Atkins: Therefore,
did you decide how this new banded charging system would affect
patient behaviour, because we have heard in a previous inquiry,
when we were talking to you, Rosie, that people are predicting
that patient behaviour will change and that they will store up
treatments, get into a higher band, get greater value for money.
When you were looking at that did you make those predictions?
Ms Winterton: What we looked at
in terms of the new charging system and the relationship between
patient behaviour is that, because of the reform system and because
of the changes in the NICE guidelines, which mean that instead
of going back every six months, if the dentist decides that somebody
does not need to come back within six months but could wait maybe
one or two years, then the patient behaviour, the patient pattern,
if you like, changes. I do challenge this idea that people are
going to store up their fillings to get into different bands,
frankly.
Q595 Charlotte Atkins: Everyone loves
a bargain!
Ms Winterton: I find it very difficult
to think that people would say, "If I hang on six months
to get another filling, I can get that one in the same band."
Do you know what I mean? It is an argument that people make. I
find it quite a curious assumption, because I do think that if
people were in that bad a position there would be assistance given
through the various schemes. The Committee may have a different
view, but I just find it a bit bizarre that people would behave
like that. I also think that when a person goes for their initial
examination under the new system, within one cost, they can have
a check-up, they can have a scale and polish, they can have preventative
advice and they can have, if necessary, x-rays as well all within
that first band. If the dentist were to say (and Ben may correct
me if I am wrong here), "Look, there is an immediate filling
but there is one that will need a little bit of attention within
two or three months", then that would count as a course of
treatment. If the dentist says, "This is what is clinically
necessary", then it can extend over that time. I would challenge
some of the assumptions that are being made about patient behaviour,
but I would say that there are differences in the way the system
will operate, and the charging system was meant to take into account
some of those changes, but overall the system was designed, frankly,
just to be simpler for patients to understand, because too many
times—and I think I have said this before—constituents
have come to me and said, "That NHS is terrible. I have just
paid a thousand pounds to have my teeth done." I say, "No,
you have not, because all you can pay on the NHS, as is it stands
at the moment, is £384. You should go back to your dentist
and say, `Wait a minute. What have I paid for on the NHS and what
have I paid for privately?'" This system means that there
are only three possible payments that people can make, and the
dentist, under our regulations, has to make absolutely clear what
is NHS and what is private. I think that that is a good change
for patients and also, frankly, the system is less complicated
for dentists.
Q596 Charlotte Atkins: That is great
if you can find an NHS dentist to apply those charges. What the
Committee would be concerned about is to make sure that the charges
were not operating against a preventative dentistry system, to
actually encourage people (which is difficult anyway) to go to
a dentist for preventative work. That is the important thing,
to make sure that charges do not get in the way of that. Did you
consider that when you were drawing up the new system?
Ms Winterton: Absolutely. You
will notice, I am sure, that within the first band there is an
allowance for preventative work. If you move into the second band,
the first band comes with you. You are not paying one charge of
£15.50 and then another charge of £42.50. It is all
encompassed, and so preventative work is allowed for. In terms
of the contract itself in saying that the number of treatments
can be reduced by 5%, the level of activity, that again is to
take into account preventative work. I think there is a wider
issue, though, about the whole reforms when it comes to preventative/public
health work that, as we allow local commissioning within some
of the schemes that are already working, it does allow dentists
to be able to do more work, for example in schools, giving oral
health advice. I have visited Newham recently which, extraordinarily,
has an incredibly low rate of registration but NHS dentists who
are longing for people to come through the door, and what the
primary care trust has decided to do is to use some of them to
go out into schools to say, "Please come and register with
a dentist. This is why you should do it", and at the same
time is able to give some oral health advice. Under the new system
there is much more flexibility about allowing that kind of work
to take place.
Q597 Mr Burstow: I would like to
come on to the way in which different policies interact with each
other, particularly the very clear policy direction that came
from the White Paper about a greater emphasis on community-based
treatment. This is going mean that more patients who currently
receive free medicines in hospitals will in future have to pay
for them. Is that reasonable?
Jane Kennedy: We will want to
look at that. Clearly it is going to be something we are going
to be looking at as we take forward the work and the development
of the White Paper. There will be implications for other areas
of cost as well, including travel costs, as we allow people to
choose where they are being treated, so all of this field is under
review.
Q598 Mr Burstow: So that we are clear,
is there a time line to which that review is working, and when
might decisions be made as a result of such a review?
Jane Kennedy: The development
of the services that we said we would want to encourage in the
White Paper will be taken forward over the coming months and years,
and the impact of those services upon patients, and particularly,
as you say, if they are being prescribed more frequently
by GPs performing different roles than they are at the moment
or even by pharmacists, then we will want to ensure that they
are not disadvantaged.
Q599 Mr Burstow: The danger, of course,
is that there is never a clear point where a decision is absolutely
necessary, because each part of the NHS will reconfigure and rearrange
its services at different paces, and so there will never be a
point where the whole of the NHS has got to where you want it
to be, certainly not in the next few years, and yet this must
have, on a locality by locality basis, impacts on the way in which
the current prescription policy and exemptions will operate, meaning
that some people who hitherto were getting their treatment in
hospital may suddenly find themselves confronted with the fact
that what was originally free simply because they were in a building,
because they are now in their home taking the medication, they
are having to pay for it.
Jane Kennedy: These are issues
that we are keeping closely under review as we take forward the
work in developing the services. We will want to ensure that,
as we are seeking to improve the services that people receive
by delivering it more locally, that they are not disadvantaged
in the way that you have said.
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