1. It is often said that the NHS is paid for by taxation
and therefore free at the point of use. There are various ways
in which the NHS is not free. Personal nursing care (defined by
the NHS as 'social care') is a massive financial burden on the
elderly. Some clinical
interventions such as cosmetic surgery are undertaken in
the NHS only in limited circumstances. Some patients must pay
for their prescriptions, regardless of whether the medicine is
for a life-threatening illness or mild pain relief. Similarly,
some may also pay for dental care and sight tests. Some charges
were first introduced over 50 years ago.
2. Charges have been criticised for many years. Studies
have shown that charges reduce the uptake of prescribed medicines,
which can have an adverse effect on health outcomes.
The Government's own NHS Plan states that, "charges
are inequitable in two respects: they increase the proportion
of funding from the unhealthy, old and poor compared with the
healthy, young and wealthy,
[they] risk worsening access
to health care by the poor".
3. The current system of charges may also undermine
important health and social care policies. The Government wants
to reduce social exclusion, yet charges may deter people from
returning to work. The
Government also wants to improve preventative healthcare, yet
charging for a dental check-up means people are less likely to
attend. As Professors
Donald Light and Joel Lexchin stated:
Every study we know of done in Europe or North
America documents again and again over the past 15 years that
co-payments and other charges contradict the goals of a good health
care system, harm patients, save little money, and generate little
4. The consequences of charges are mitigated by exemptions,
which cover children and patients over 60, patients with specific
medical conditions, hospital patients (for the prescription charge)
and groups that are in receipt of certain benefits. However, the
medical exemptions to the prescription charge have not changed
for 40 years and do not take changed practice and treatments into
account. Income-related exemption can involve a complex application
process and must be renewed annually. Charges also create a harsh
poverty trap for those just above the threshold. More fundamentally,
no easily understood principle underlies the complex set of exemptions.
5. In view of these concerns, we decided to look
at healthcare charges to determine whether they have a place within
an NHS which claims to be free at its point of use, or whether
the resources could be better raised elsewhere. In October 2005,
we announced the following inquiry:
The NHS makes charges for certain treatments,
for example prescriptions, dentistry and optical services and
for certain amenities, for example for television and telephone
use and for car parking at some hospitals. These charges (sometimes
known as co-payments) have not been systematically or thoroughly
examined for many years. Their rationale is unclear. Patients
are often unaware of the rules surrounding charges and of exemptions.
Accordingly the Health Committee has decided to undertake an inquiry
into the subject with the following terms of reference:
Whether charges for:
- Treatments, including prescriptions, dentistry
and optical services; and
- Hospital services (such as telephone and TV use
and car parking) are equitable and appropriate.
- What is the optimal level of charges?
- Whether the system of charges is sufficiently
- What criteria should determine who should pay
and who should be exempt?
- How should relevant patients be made more aware
of their eligibility for exemption from charges?
- Whether charges should be abolished.
6. The Health Committee last examined charges in
1994, in its report Priority setting in the NHS: the NHS drugs
budget. It recommended lower prescription charges and fewer
exemptions. Here we
consider this recommendation again, as well as other options including
the abolition of the prescription charge, which will soon take
effect in Wales.
7. We also consider the issue of fees from first
principles. What is the purpose of charges? Are medicines and
dental and ophthalmic services the most suitable areas of healthcare
for which to levy a charge? What else could the NHS charge for
which would minimise the adverse effects on health?
8. As part of the inquiry, we made two visits. In
February, we went to the National Assembly for Wales in Cardiff,
where we had the opportunity to discuss the effects of phasing
out the prescription charge, as well as different policies in
dental services. We had useful meetings with the Welsh Minister
for Health, Dr Brian Gibbons; with the current and previous Chairs
of our counterpart Committee, Rhodri Glyn Thomas, David Melding,
and Kirsty Williams; and with officials from the Department for
Health and Social Services.
Our visit to Sweden in March gave us the chance to study a health
system where patients make a larger financial contribution through
a range of fees, including hotel charges for staying in hospital
and a charge for visiting a clinician.
9. We held four oral evidence sessions. We heard
from Ministers and officials from the Department of Health, professional
associations, Royal Colleges, health professionals, think-tanks,
academics, medical charities and private companies working in
the healthcare sector. We were particularly impressed by the evidence
given by Ms Lynsey Beswick, an "Expert Patient Adviser"
with the Cystic Fibrosis Trust which vividly highlighted the problems
that charges might cause patients.
10. We are very grateful to our Specialist Advisers,
Professor John Mohan of Southampton University and Professor Nick
Bosanquet of Imperial College London, for their expert guidance
and help throughout the inquiry.
1 Health Committee, Sixth Report of Session 2004-05,
NHS Continuing Care, HC 399-I Back
See Chapter 3 for details Back
NHS Plan. July 2000: http://www.dh.gov.uk/assetRoot/04/05/57/83/04055783.pdf
Q 282 (Mind) Back
See Chapter 3 for details Back
Ev 94 Volume II Back
Health Committee, Second Report of Session 1993-1994, Priority
Setting in the NHS: The NHS Drugs Budget, HC 80-I Back
See Annex 1 Back
See Annex 2 Back