Select Committee on Health Third Report


1  INTRODUCTION

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.[1] 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.[2] 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]

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.[4] The Government also wants to improve preventative healthcare, yet charging for a dental check-up means people are less likely to attend.[5] 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 revenue.[6]

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 transparent
  • 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.[7] 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.[8] 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]

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

2   See Chapter 3 for details Back

3   NHS Plan. July 2000: http://www.dh.gov.uk/assetRoot/04/05/57/83/04055783.pdf  Back

4   Q 282 (Mind) Back

5   See Chapter 3 for details Back

6   Ev 94 Volume II Back

7   Health Committee, Second Report of Session 1993-1994, Priority Setting in the NHS: The NHS Drugs Budget, HC 80-I Back

8   See Annex 1 Back

9   See Annex 2 Back


 
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Prepared 18 July 2006