Select Committee on Health Third Report


6  ALTERNATIVE CHARGING SYSTEMS

95. It is evident that charges cause problems, particularly for those patients on low income who are not exempt. The system of charges and exemptions, particularly as it applies to prescriptions, is full of anomalies. Here we consider the options for change, including:

  • Improvements to the current charging system for prescriptions, dentistry and sight tests and non-clinical charges, such as car parking and telephone charges, but with no major changes;
  • Modernisation of the list of medical exemptions to prescription charges;
  • A major reform of the prescription charge;
  • Abolition of charges; and
  • Introduction of a different set of charges.

Improvements to the current regime with no major changes

96. Patients do suffer under the existing system, but there is a case for maintaining it while making a number of relatively minor improvements that would alleviate some of the difficulties and could be implemented quickly. Any major change in the charging system would bring resistance from losers: both those who would have to pay new charges and those who would lose their exemption status. We were informed that improvements could be made in respect of:

Some of these changes, for example to car parking and bedside telephones, could also be made in connection with more substantial reforms discussed later in the chapter.

THE PRESCRIPTION PREPAYMENT CERTIFICATE

97. A monthly Prescription Prepayment Certificate (PPC) was proposed at a level of about £10 a month. This change would assist poorer patients who cannot afford the upfront payments for quarterly and annual PPC certificates. In addition, Citizens Advice suggested that patients receiving limited financial help through the NHS Low Income Scheme (LIS) should be able to buy a reduced price PPC.[147] This would allow those with an HC3 certificate to have reductions in the price of prescriptions. There would be some additional administrative costs associated with introducing a monthly or reduced price PPC and a small loss of revenue in providing a reduced price PPC.

98. An annual cap on prescriptions was proposed by the RPSGB and Dr Harrison from the Kings Fund.[148] Such a system is in place in Sweden, Ireland and Denmark. This proposal would mean that patients need not make the relatively high up-front payment for a PPC. It would also benefit patients who unexpectedly require large numbers of prescribed items. Dr Schafheutle of the DUPP suggested that those with a chronic disease that is normally well-controlled would gain from such a scheme:

    For [asthma patients] who are feeling generally well and who pick up their inhalers every six weeks getting a [PPC] is just not worth their while. They do not know when they are going to have an infection that may require antibiotics and when… they may need another course of antibiotics or they may need a course of steroids. These individual charges add up very quickly. There is no way for them to go back and say, "Over the last four months I have paid out far more than this £30".[149]

99. If the annual cap were set at the same level as the annual PPC the cost in terms of lost payments would be small. However, the cap could be difficult to administer. It may require a sophisticated IT system to keep track of payments made, but the NHS IT system is years away from completion. The Swedish system appears to be well-accepted and efficient, but part of the reason it runs so smoothly is because all medicines are dispensed by the same company—the state-owned pharmacy, Apoteket. Pharmacies in this country are owned by many different companies and standardising the systems to accommodate an annual cap could be complicated and costly.

100. In the absence of sophisticated IT, it would be necessary for patients to use the same pharmacist. This would be consistent with the Government's policy of increasing the role of pharmacists in healthcare, laid down in the new pharmacy contract. According to Mr Darracott:

    It would seem to be entirely consistent with that policy that people are encouraged to use the same pharmacy over and over again because that is the way the relationship builds up…[150]

Others may not view this possibility so favourably, particularly in a country where people are so mobile.

DENTISTRY

101. We received little evidence about the level of dental charges for specific treatments. The main exception was the cost of dentures that need to be replaced due to 'wear and tear'. The cost has fallen since the introduction of the new contract but is still £189 (dentures that are broken are charged at a lower price) which, according to Age Concern, might lead people to hang on to old dentures longer than they should.[151]

102. The main concerns raised about the new contract during our inquiry related to its effect on the amount of NHS work dentists would be willing to undertake and whether there were sufficient incentives in the contract for dentists to undertake preventative work. The two concerns are related: dentists had hoped the new contract would allow them to escape the 'drill and fill treadmill' but claim that it has not; as a result they claim to be disillusioned and inclined to reduce their NHS work. Dentists also note that the price of some preventative treatments, such as applying sealants to rear molars, has increased.

103. To address these concerns dentists want the contract to provide incentives to undertake preventative work such as advice to patients (for example about flossing). Preventative care of this kind should attract specific 'units of dental activity' (the reference for how activity and payment are determined). Preventative work is important and so is a motivated workforce that wants to work for the NHS. It seems only sensible to reward behaviour we want to encourage.

104. However, since the contract only came into force in April 2006, it is difficult as yet to judge its effect. There must be also some scepticism about some of the dentists' claims: is there no time to talk to patients about flossing and even other aspects of oral hygiene during a consultation?

SIGHT TESTS

105. Information collected before and after the sight test fee was introduced in 1988 shows that numbers of sight tests carried out fell after the charge was introduced. Moreover, a high percentage of the population do not have regular tests; however, we received little evidence that the cost of such tests deter people from seeking them.

106. Opticians' groups and the Minister thought there were more important priorities, in particular better tests with more emphasis on detecting eye disease and the need to encourage groups at risk of eye disease to undergo sight tests. The new Scottish NHS eye examination is, according to the opticians groups who gave evidence to the Committee, more flexible to the needs of the individual patient and does not necessarily involve refraction tests for spectacles/lenses. The Welsh Eye Care Initiative and Primary Eye Acute Referral Scheme target groups at risk of eye disease and allow rapid referral of specific patients by GPs, respectively.

107. The Committee did not receive information from patient groups or others about these schemes and it is therefore difficult to gauge the benefits (and difficulties) of introducing them to England. The opticians' groups estimated that it would cost £90 million to introduce the Scottish sight test to England. We do not yet know how successful the Scottish test has been in reducing eye disease.

108. While we did not receive many complaints about the cost of sight tests, Citizens Advice was concerned about the cost of glasses, particularly those with complex lenses.[152] The NHS provides vouchers to people on Income Support and the Low Income Scheme, but one-third of opticians do not sell glasses within the voucher value. In rural areas with few opticians, this may present a problem.

109. The Department of Health could encourage or compel opticians to carry a range of spectacles within the maximum NHS voucher value. There would be a number of objections to compulsion, both practical and in principle, not least that some opticians find there is no demand for cheaper glasses.

BENEFITS

110. Patients not in receipt of Income Support, Income-based Jobseeker's Allowance or Pension Credit but on low incomes may apply for financial assistance with health charges and other costs through the NHS Low Income Scheme (LIS). The application form (the HC1) for the LIS is poorly written and very complicated. A simpler form written in clear English which is easier to fill in would be of great benefit.

111. Citizens Advice argued that there was no need for most patients to complete the HC1 form. It pointed out that those eligible for the LIS could be identified during application for other benefits, such as Incapacity Benefit. Jobcentre Plus increasingly identifies applicants' circumstances and establishes entitlement to benefits through a single telephone call. The LIS could be included:

112. This approach would require the Department of Work and Pensions (DWP) to have a key role and the Department of Health and the DWP to work closely together.

113. The Prescription Pricing Authority runs a helpline and encourages doctors' surgeries to carry leaflets containing information on help with health charges. The BDA and RPSGB said their members felt it was their job to ensure patients knew about possible financial assistance. The RPSGB produces a card available at pharmacies to promote knowledge of benefits.

114. Nevertheless, several witnesses, including the Socialist Health Association, Age Concern and professional groups stressed that patients often did not know about their entitlement to assistance with health charges. Ministers agreed that this was the case.

115. Witnesses suggested that information about assistance with health charges, and exemption from charges, should be better advertised within GP and dental surgeries, pharmacies, opticians and hospitals.[154]

TRANSPORT

Car Parking

116. There were many complaints about the cost of car-parking. Witnesses made a number of proposals, including nationally imposed limits on charges and concessions to particular groups, such as cancer patients.[155] Some hospitals offer exemption or 'season tickets' for frequent attendees to park at a reduced rate; it was suggested that all should be instructed to do so, and to inform patients better of such concessions.

117. Limits to charges would obviously benefit patients. They would also reduce a potential deterrent to increasing use of day treatment and patient choice. On the other hand, revenue forgone by lower charges would have to be found from other sources, either from NHS funds or, if concessions are made for some patients, by increasing charges for others. If NHS funds are spent, other services will have to suffer. To what extent should money spent on care be reduced to lower parking charges?

118. There is also an objection in principle to nationally imposed rules about the cost of car parking. While national guidance on car parking is issued, the Government argues that:

    …it is neither practical nor helpful to issue national blanket guidelines on car parking charges on NHS premises setting, for example, maximum levels or requiring free parking to be available for certain categories of user.[156]

The provision of parking spaces and the level of charges is the decision of individual NHS trusts. It is difficult to see how the same regime might apply in Central London and rural Shropshire.

119. Dame Gill Morgan of the NHS Confederation implied that the problem of the high cost of car parking might be eased because trusts would start to build new car parks (for which they would not charge) as a means of attracting patients to particular hospitals just as supermarkets attract shoppers:

    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….[157]

    Knowing they have got guaranteed car parking when they come…is going to be a massive competitive advantage for organisations, much more direct and understandable than any other clinical indicators that hospitals will present.[158]

We questioned the Minister, Jane Kennedy, about this possibility. She replied that car parking was, "a service for patients" rather than, "a draw".[159]

Assistance with transport costs

120. As a result of the poor location of many medical facilities and lack of public transport many patients without access to a car face severe transport problems. Patient choice will require more travel and its transport implications are being examined by the Department. Hospital mergers will also increase the need to travel but the impact of more care in the community may reduce this need for patients.

121. The non-emergency Patient Transport Service (PTS) provides transport to patients unable to reach hospital by other means. It is a slow method of travelling. Macmillan criticised the PTS; it was "unreliable and involves long waits and lengthy ambulance journeys as other patients are picked up or dropped off along the way".[160]

122. The Hospital Travel Costs Scheme (HTCS) provides financial assistance for patients who do not have a medical need for ambulance transport but who cannot meet the cost of travel to hospital.

123. The recent white paper Our health, our care, our say, indicated that the HTCS would be extended to include some primary care facilities, but would exclude dental surgeries and initial appointments with GPs. Witnesses pressed for the speedy implementation of the policy and for extension to a wide range of primary facilities; for example, the scheme should cover eligible patients receiving minor surgery in primary care facilities or those undergoing complex dental work. However, such proposals have financial implications which would be significant if a large range of primary care facilities were included in the HTCS.

124. The NHS Confederation thought more could be done to inform patients about the HTCS.[161] In 2003 the Social Exclusion Unit recommended that the Department "develop options" for information and advice on accessing healthcare facilities, such as a "one-stop shop" for patients (and healthcare staff, welfare organisations etc), to review transport options, and book transport if patients are eligible for help,[162] but its recommendations have not yet been acted upon.

125. Several organisations, including the Disability Alliance, Mind and Citizens Advice, thought it unfair that prison visitors received help with transport costs while those wishing to visit sick relatives did not.[163] Patient escorts may be covered by the existing HTCS, but hospital visitors are not. Money is available through discretionary payments from a Social Fund for certain categories of people such as those visiting their children, or relatives receiving long-term care. However, while the costs are a difficulty for some low-income patients, extension of the scheme to cover a large number of visitors would be expensive and might not be the best use of funds.

BEDSIDE TELEPHONES

126. The high cost of incoming calls to patients' bedside units was blamed by an Ofcom investigation on a "complex web of Government policy and agreements between the providers and the NHS".[164] Since the providers were not found to be entirely at fault by Ofcom, there is a case for the Department to provide public funds to reduce the costs of calls.

127. Another solution is to make use of the extensive facilities the bedside units can provide. Some hospitals have used the units for more than the provision of telephony, television and radio; this begs the question why others are not following their lead. Patientline told us:

    The great opportunity, we believe… is to extend the use of these systems for the purposes for which they were originally designed and selected so that the benefits extend well beyond those of patient entertainment and communication.[165]

This is a desirable solution but the need to generate more revenues should not be the main determinant of whether the additional available facilities are used.

128. It has been suggested that providers had encouraged hospitals to maintain the ban on mobile telephones so that bedside telephones would be used. Ofcom raised the question, but did not draw any conclusions. It is claimed that mobile phones disturb other patients and staff and because of their cameras can breach patients' privacy. On the other hand, in many circumstances the sensible and sensitive use of a mobile phone would inconvenience no one. Should all patients and their friends and relatives suffer because a minority were inconsiderate? We did not receive any evidence that mobile telephones interfere with the operation of medical equipment.

Modernisation of the medical exemption list

129. Many witnesses called for the medical exemption list to be changed to include their particular condition. The many anomalies in the medical exemption list, for example the fact that some individuals with long-term debilitating conditions are exempt while others with equally serious illnesses are not, makes the modernisation of the list an eminently sensible suggestion in principle.

130. There are, however, problems arising from the proposal. The first is, as Department of Health officials told us, "where would you draw the line?".[166] Modernisation of the list of medical exemptions, while pleasing groups newly included, would doubtless result in a some groups who thought they should be exempt continuing to pay the charge.

131. If most groups with a claim to exemption were included in the list of exemptions, the increase in the number of free prescriptions would lead to a considerable loss of income. Ministers saw this as a powerful reason for leaving well alone. In Wales the likelihood that modernisation would lead to so many exemptions was one of the reasons for the abolition of prescription charges.[167]

132. We tried unsuccessfully to find out what the cost of modernising the list might be. We were told by officials that no large-scale review of the list of conditions exempt from the prescription charge had ever taken place. We asked the Department to estimate the cost of modernisation but we were told that when this had been considered during the 1998 CSR the costs had been difficult to establish.

133. It would be possible to reduce the amount of revenue lost by requiring exempt patients to pay for prescriptions that are not related to the exempted condition. At present, some patients with long term conditions are exempt from paying for any prescription, however unrelated to their long term condition. War disablement pensioners, however, are only exempt for prescriptions related to their disability. It should be possible to extend this to other patient groups although it would be complicated in some cases (for instance, diabetics are more likely to suffer other conditions such as hypertension and it would be difficult to distinguish between medicines that treat the main condition and those for unrelated illnesses).

A major reform of the prescription charge

A LOWER CHARGE WITH FEWER EXEMPTIONS

134. Another option would be to make more radical changes to the prescription charge. One possibility, recommended by our predecessor Committee in 1994, is "a lower charge and fewer categories of exemption".[168] A lower charge would be of particular help to those poorer working people who currently pay for their prescriptions. The amount of revenue raised would depend on the level of the charge and the extent of exemptions. Sweden, for example, has virtually no exemptions to charges for prescriptions.[169]

135. The Social Market Foundation proposed ending exemptions for expectant and nursing mothers and older adults who are not on low incomes. It stated:

    Older people who can afford it are expected to pay a proportion towards the costs of their social care, so it seems illogical that prescription costs are excluded.[170]

This principle could be extended so that the only exemptions were income-related.

136. In its written evidence the BMA suggested the removal of all exemptions and the introduction of a low flat-rate fee. It argued that such a low fee was unlikely to prevent anyone from seeking healthcare or obtaining prescription items:

    … for example a £1 payment that every patient would pay per prescription or item, with no exceptions. This might mitigate against inappropriate use of the exemption status (ie: for over the counter medicines) but be low enough to ensure that those on low incomes or on multiple medication could still afford it.[171]

137. Such a system would also increase the revenue to the Exchequer. As part of the 1998 Comprehensive Spending Review, the Department investigated a flat-rate charge of £1 with no exemptions. It found that this would produce an extra £120 million in revenue. In 2004, 686 million prescribed items were dispensed[172]; a charge of £1 per item would therefore raise £686 million (currently £427 million is raised), if no exemptions were made. If children were exempted, income would drop by around £42 million since 6% of prescribed items are for children.

138. There is likely to be opposition to these proposals from groups that are currently exempt. Witnesses raised other concerns. Dr Harrison of the Kings Fund thought they would be complicated and expensive to administer, although this seems unlikely given that the system would in principle be the same as that currently in use. It is possible that even a low charge of £1 might deter some people and be a hardship for those on low incomes.

REFERENCE PRICING

139. The Social Market Foundation proposed a new system for prescription charges, "which would link the charge to the therapeutic value of the medicine".[173] One way of doing this would be to introduce reference pricing, whereby patients are charged different fees according to which medicine they choose to use within a specific drug class.

140. Under such a system, one medicine within a given class is designated as the most suitable—using both clinical and cost-effectiveness measures—and is used as a reference. The cost of this drug is automatically covered by any co-payment scheme. If patients decide to use a different, more expensive, medicine, they pay the difference in cost. If a clinician judges that the reference drug is unsuitable, the patient may receive a more costly alternative at no extra charge.

141. Such schemes are in place in Denmark, Finland and parts of Canada and have been shown to reduce costs without any negative effect on health.[174] According to Profs Light and Lexchin, reference pricing,

    …encourage[s] patients to use the most cost-effective drug available for their condition…Thus co-pays serve to keep overall costs down, yet support clinically appropriate prescribing.[175]

142. We received little evidence on the subject of reference-pricing but it seems likely that it would be complicated to administer and would require work to determine which drug should be the reference and on what basis, and at what level, alternative medicines should be charged.

Abolition of charges

143. A simpler proposal, which was the preferred option of several witnesses, is the abolition of health charges. Abolition would ensure that no one was deterred from seeking treatment. It was, furthermore, argued that it was illogical to charge people for drugs, dental protection and eye tests when other medical procedures are free.[176]

144. Witnesses pointed out that the reasons for charges are historical, as officials from the Department of Health admitted. If we did not have the present system of charges we would not introduce it now. Age Concern told us:

    …the only rationale [for the fact that older people pay for dentistry] offered in the recent Department of Health consultation on dental fees was that there have been dental charges in place since 1951—that is usually the argument made for change and modernisation.[177]

145. The arguments put against abolition were as follows. First, the abolition of all health charges should not be seen as a cure-all for the current problems; more people might go to the dentist and the optician, but it is far from clear that charges are the main reason why large numbers of people do not regularly visit them now. Secondly, it is likely that demand would rise following abolition and some of the increased demand might be "extravagant", in the words of Attlee. If all charges were abolished, it might be necessary to introduce some other way of restricting demand, particularly for prescriptions. Finally and most importantly, if all charges were abolished, an extra £1 billion would be required for the NHS budget; if demand rose following abolition, as might be expected given the experience in Italy, the cost could be significantly greater. Even if £1 billion could be afforded, should it be a priority?

146. Could there be a way of off-setting the lost revenue? There is, as we have seen, anecdotal evidence that doctors too readily prescribe OTC medicines to patients who get free prescriptions and do not always prescribe the cheapest, most effective drug.[178] The introduction of a limited formulary listing which medicines can be prescribed routinely for which conditions could address this problem. Formularies are used effectively in hospitals and a formulary for general practitioners is being developed in Wales. Such a system would curtail the prescription of drugs that are available cheaply from pharmacists. Ministers were interested in this possibility; Jane Kennedy said she wanted to consider the idea:

    I want to give some thought to what you are saying. It would be quite a major step…It would be interesting to see if the Welsh Assembly finally does take that step.[179]

147. A limited NHS formulary could also be combined with a system of reference pricing, as described in the previous section. Such a scheme is in place in Australia, where the state pays the cost of medicines listed on an agreed formulary minus a contribution from patients.[180] Medicines included in this formulary have been considered according to effectiveness and cost and have been compared to other available therapies. Patients who want, for example, branded rather than generic drugs can obtain them, but must pay the difference in price.[181] Local examples of formularies exist in England; a good example is in place at University College London Hospitals trust, where medicines are included on the list only after information on drug efficacy, safety and cost are considered by a dedicated committee.[182] If well organised and regularly revised, such a formulary would encourage prescription of the best medicines, in terms of both clinical and cost-effectiveness. Ensuring that the list remain current would be a challenge, however.

Introduction of a different set of charges

148. A further option is to abolish some or all existing charges but replace them with a new set of charges. Ideally such charges would encourage desirable behaviour and not deter people from seeking treatment as the present system does. Professor Smith, of York University, sent us a memorandum arguing for a major reform. His proposals were:

149. Professor Smith argued that some degree of healthcare rationing was inevitable. He proposed the provision of a "core package" of essential care free of charge to everyone. 'Extra' services would then be defined and charges levied for these procedures or treatments:

The private sector, as well as the NHS, could provide services that are additional to core clinical treatment for a fee. This already happens for treatment no longer available on the NHS, such as the cosmetic procedures performed by the Foundation Skin Clinic in Harrogate. Simplyhealth stated:

    …there are no markets or services of any kind in any area of our lives where we can all have the very best of everything all the time, how and where we want it. This is not the case with food or shelter or education. It is unreasonable therefore to expect it of healthcare, it is not possible.[184]

150. Ministers may be considering something similar. At a meeting of the Liaison Committee last year, the Prime Minister suggested that co-payments in certain non-core areas of public services should be looked at.[185] Jane Kennedy told us that although she was opposed to healthcare rationing:

    What we have been discussing this morning is where on the edge of that definition it might be possible for NHS organisations and others, and indeed the state, to raise resources by charging. That is the debate that we are having today and we will continue to have, I am sure.[186]

151. A range of charges are employed in other European countries to promote the better use of services. In Sweden, patients are charged for each outpatient visit (to a nurse, GP or specialist, and for each visit to A&E), and pay a 'hotel' charge for inpatient stays. Patients are encouraged to visit the appropriate healthcare professional by different levels of charges; thus, it costs less to see a nurse than a consultant and therefore patients are less likely to use the services of a specialist in the first instance. Patients pay around £6 to see a nurse, £9-10 to see a GP and £17-20 to see a specialist. It costs about £10 to go to A&E. Swedish patients also pay for dentistry and medication.

152. There are few exemptions to charges. Instead, expense is mitigated by the use of an annual cap on payment for outpatient care, and pharmaceuticals. The annual cost ceiling is £66 for outpatient care. Inpatient care is capped at £6 per day, but there in no annual limit. For medicines, each patient (or all the children in a family together) does not pay more than £134 per year. Co-payments have been in place in Sweden since the 1970s and generate approximately 3% of total healthcare resources.

153. There are similar charges in the rest of Europe. In Germany, from 2004, there has been a €10 charge for the first appointment with a doctor in each three month period, up to an income-related maximum. In France, from January 2005, patients have been charged €1 for each consultation, intervention and test. French adults not suffering a long term illness are charged a fee for consulting a specialist without the endorsement of a 'gatekeeper' physician. Introducing a charge of £1 to see a GP here would raise £200 million, in gross terms, if appointment rates remained stable.[187]

154. Establishing a core package of free NHS services and adopting a "European" system of charges of the type used in Sweden (including access charges and hotel charges) would have advantages. It is better to be clear about what is funded for free and what is not. Otherwise, according to Professor Smith, it is probable that we will have to:

    …reduce the scope and quality of the NHS by stealth, and reduce the widespread support for tax funding of the NHS, an outcome that cannot be to the general public good.[188]

155. "European" style charges could persuade patients to use the NHS more appropriately. Every year, 15 million GP and practice nurse appointments are missed and patients do not attend one in 10 hospital appointments.[189] Missed GP appointments cost the NHS over £162 million annually[190] and missed hospital appointments cost £680 million.[191] A survey of 683 GP surgeries by the group Developing Patient Partnerships (DPP) found that two-thirds of respondents would support charging patients who did not attend or cancel their appointment.[192]

156. If charges of this type were introduced it would be possible to abolish existing charges on medicines and dentistry and make sight tests free. Thus charges which discouraged bad behaviour (failing to turn up for appointments) would replace the current charges on medicines, dentistry and sight tests which adversely affect healthcare.

157. On the other hand, the introduction of "European" style charges would also have disadvantages:

  • major changes would be made to raise what is in the context of the total NHS budget a relatively small sum;
  • they could be complicated and costly to administer; and
  • they could put people on low incomes off seeking healthcare.

158. If the aim of the new charges is to replace all existing charges, they will need to raise £1billion net which is only a little more than 1% of the NHS budget. Is it worth a radical overhaul with all the disruption involved for such a sum? Modest access charges would be unlikely to bring in large sums: Swedish charges raise 3% of the budget but that includes charges for pharmaceuticals.

159. A new system of charges would require hospitals and GPs' practices to collect access and hotel charges. We were told that collection is straightforward and causes few difficulties in Sweden, but is unlikely to be as easy in England. In Sweden, the system is well-established; here it would be new and it is likely that neither hospitals nor GPs would welcome having to collect the charges. We were told that in Sweden patients were sent a bill for their time in hospital and pay it. A similar response could not necessarily be expected in England.

160. Even in Sweden charges create some problems for those on low incomes. Charges to see clinicians discourage some people from seeking health advice or treatment. A recent large-scale study showed that of Swedish people with "financial difficulties", over one-third refrained from seeing a doctor compared to around 10% of the group as a whole.[193] A survey by the Swedish National Board of Health & Welfare in 1999 found that around 3% of the Swedish population avoided using healthcare due to charges. The figure would probably be higher in England since the same survey concluded that 4% of Swedes did not fill prescriptions or buy medicines, and 15% did not seek dental care[194] whereas the comparable English figures are 6% and 24%.


147   Q 238 Back

148   Qq 165, 204 Back

149   Q 159 Back

150   Q 204 Back

151   Q 245 Back

152   Q 240, Ev 31 Volume II Back

153   Ev 137 Volume III Back

154   Q 235 Back

155   Ev 50-59 Volume II [Macmillan] Back

156   Ev 9 Volume II Back

157   Q 490 Back

158   Q 492 Back

159   Q 677 Back

160   Ev 52 Volume III Back

161   Q 489 Back

162   Chapter 11, Access to Healthcare, in Office of the Deputy Prime Minister Social Exclusion Unit, Making the Connections: Final Report on Transport and Social Exclusion. February 2003 Back

163   Ev 43, Ev 61, Ev 32 all Volume III Back

164   Ofcom, Ofcom Own-initiative investigation into the price of making telephone calls to hospital patients, A case closure document issued by the Office of Communications, CW/00844/06/05, 18 January 2006 Back

165   Q 455 Back

166   Q 35 Back

167   See Annex 1 Back

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

169   See Annex 2 Back

170   Ev 83 Volume II Back

171   Ev 28 Volume II Back

172   Department of Health 2004. Prescription Cost Analysis, England Back

173   Ev 83 Volume II Back

174   Ev 95 Volume II Back

175   Ev 94 Volume II Back

176   Qq 213, 255 Back

177   Ev 11 Volume II Back

178   But we do not know how extensive this problem is Back

179   Qq 575-576 Back

180   Most people pay a charge of up to £11.90 and 'concession card' holders (mainly those on low incomes) pay approximately £1.90. See www.health.gov.au for details Back

181   See www.health.gov.au for details Back

182   See page 42. Health Committee, Fourth Report of Session 2004-05, The Influence of the Pharmaceutical Industry, HC 42-I Back

183   Ev 157 Volume III Back

184   Ev 139 Volume III Back

185   Oral Evidence taken before the Liaison Committee on Tuesday 3 February 2004, Q 140

Mr McFall:…Could I ask you the general question: are higher user fees going to have to make a major contribution to increasing funding for public services from now on?

Mr Blair:…No, in the sense that those that are funded by general taxation, the schools and the National Health Service, will continue to be so. However, on the other hand, our tuition fee policy is an example. Congestion charging is another example. I think there is an issue for the long term about how-not for those, as I say, core public services that have traditionally been funded under general taxation but for other issues, like skills-we look at issues to do with co-payment Back

186   Q 702 Back

187   Source: House of Commons Library. Not printed Back

188   Ev 158 Volume III Back

189   Research conducted in 2004 by the Institute of Healthcare Management and the charity Developing Patient Partnerships Back

190   Institute of Healthcare Management, 2004 Back

191   Source: Grant Shapps MP. Full data not printed. Reported in the Daily Telegraph, 8 May 2006  Back

192   DPP survey data from GP practices throughout the UK, August 2005. 683 practices were included in the survey; there was no indication of which staff members responded Back

193   This study included 70,000 participants and was conducted by the Swedish National Institute of Public Health Back

194   Swedish National Board of Health & Welfare, 1999. These are only lower than in England, where 6% of patients do not fill prescriptions and 24% do not seek dental care for financial reasons Back


 
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