ANNEX 1: HEALTH COMMITTEE VISIT TO WALES
8 February 2006
Meeting with Dr Brian Gibbons, Minister for Health
and Social Services
The Minister discussed the abolition of the prescription
charge in Wales and a number of areas of relevance to the NHS
Charges inquiry.
Prescriptions
Abolition of the prescription charge was a manifesto
commitment, and was not backed up by a significant body of evidence.
A phased approach was taken to ensure affordability
and allow health officials to identify and manage the effects
of abolition on patient behaviour. The charge is currently £4
per item but is due to drop to £3 in April 2006. It will
be abolished in 2007. No change in patient behaviour has been
observed to date, but the Minister reported that modellers expect
a change with the upcoming fall in price, such as increased demand
for medicines, and patients seeking prescriptions for over-the-counter
(OTC) drugs.
Changes to the exemption list had Lib-Dem support
but it was decided to "keep it clean and simple" and
abolish the charge altogether.
The First Minister was reportedly keen on abolishing
the prescription charge in order to remove a disincentive for
patients to return to work.
Dentistry
More people are registered with an NHS dentist in
Wales (55-60%) compared to England (48%), with figures approaching
75% in Swansea.
The dental contract in Wales is similar to the English
version, but the band levels are lower. A note subsequently provided
by the Minister's office detailed the main differences between
the new English and Welsh dental contracts:
The main differences are as follows:
- Over the course of a year dentists
will be expected to provide a certain number of courses of treatment
weighted by their complexity. However, this will be 10% fewer
(5% in England) than the courses of treatment carried out in the
test period, while the dentist will still receive 100% value of
the contract. There is also a tolerance level of 5% in Wales (4%
in England) associated with the level of activity before this
triggers a discussion between the dentist and the Local Health
Board.
- Additional differences in Wales are the way in
which Vocational Training and Clinical Audit and Peer Review will
be handled and it is the intention that it will remain centrally
funded and administered in Wales and not form part of the new
dental contract value as proposed in England. This has the full
support of the Welsh Central Assessment Panel, the Welsh General
Practitioner Committee, and the Department of Dental Postgraduate
Education.
Dental Charges
The new dental charge band levels in Wales (English
levels in brackets) are:
Band 1 - £12.00 (£15.50)
Band 2 - £39.00 (£42.40)
Band 3 - £177.00 (£189.00)
Current differences between Wales and England in
the categories of patients' exempt from dental charges will continue
as now i.e. those under 25 years of age and 60 and over are entitled
to a free check up in Wales but not in England.
Eye tests
Some ophthalmic initiatives have been introduced
in Wales:
- Wales Eye Initiative—screening
of at-risk groups, such as those with sight in only one eye, those
with retinitis pigmentosa and people whose family origins are
Black African, Black Caribbean, Indian, Pakistani and Bangladeshi
- Primary Eye Acute Referral Scheme—this
scheme allows rapid referral of specific patients by GPs.
Exemptions to the sight test charge are more generous
than in England (under-25s are exempt, as for dental charges and
the prescription charge), but there are no eye tests in schools.
Other considerations—parking, bedside telephones
A similar situation to that of England is in place
for car parking, in that each Trust must make its own arrangements.
There is also a similar situation for bedside telephones.
The Minister felt that additional help for people
visiting patients in hospital was unlikely.
Meeting with ex-chairs of Health and Social Services
Committee
The Chairman and Dr Taylor met with Kirsty Williams
(Lib-Dem, Chair 2001-03), David Melding (Conservative, Chair 2003-05)
and Rhodri Glyn Thomas (Plaid Cymru, Chair 2005-date)
The prescription charge
Revision of the list of medical exemptions for the
prescription charge was suggested in a motion put forward by the
Liberal Democrats. Ms Williams admitted that a revised list might
significantly increase the number of exemptions. She thought that
the Labour party had decided to trump her proposals for a revised
list by proposing total abolition. Mr Morgan said Plaid Cymru
supported extension of the list but not total abolition of the
charge. Mr Melding stated that those with an adequate income should
pay for their prescriptions, and that the exemption list should
have been expanded. He did not believe that abolishing the prescription
charge was worth the cost.
There was reportedly no debate on the funding needed
to cover abolishing the prescription charge. The move was funded
by the Welsh Assembly Government (WAG) as a whole. The move will
cost £32 million, which represents 10-15% of the total drugs
budget. A nominal charge per prescription was not considered.
Mr Morgan stressed that chronic illness impacts on
earning ability and that individuals need to be protected from
perverse incentives against returning to work after illness. The
cost of prescriptions make a big difference to those on low incomes
and workers have to pay the charge while the unemployed, or those
unable to work due to incapacity, are more likely to receive free
prescriptions. He added that levels of illnesses such as asthma
and chronic obstructive pulmonary disease are much higher in Wales
than elsewhere in the UK.
The current and ex-Chairs agreed that the evidence
base for abolition of the prescription charge was very weak, and
that little was known about the possible health benefits. Ms Williams,
Mr Melding and Mr Morgan all expressed concerns relating to how
the situation will be monitored, the possible increase in demand
for prescriptions for OTC medicines, and the "hassle"
that GPs may face as a result.
"Health tourism", whereby English patients
try to have their prescriptions dispensed in Wales to avoid the
prescription charge, is not a major problem yet.
Dental and ophthalmic issues
Both the Tory and Lib-Dem Members said they would
rationalise those eligible for NHS dental care, to include older
adults as well as children. The Lib-Dems would increase the number
of patients exempt from paying dental charges and the fee for
the NHS sight test to include greater numbers of at-risk patients.
The current and ex-Chairs reported that many dentists
are not happy with the new contract, and some are leaving the
NHS to work privately. There are problems of access to NHS dentists,
as well as retention of dentists. However, the percentage of the
population registered with an NHS dentist has changed very little
in recent years.
Meeting with Ann Lloyd, Head of Health & Social
Services Department, and John Sweeney, Director of Community,
Primary Care & Health Services Policy Directorate
The Welsh health officials made three main points
regarding the abolition of the prescription charge:
- The evidence base for the move
was not available at the time the decision was taken
- It was too difficult to modernise the exemption
list
- Abolition supports the shift towards increased
use of primary care.
The officials gave the Committee some background
to the decision to abolish the prescription charge. The WAG agreed
that unless they attacked ill-health, inequality and lack of access
to care they would never "climb the mountain" of health
problems in Wales. There was a feeling that unless something was
done, health inequalities would never improve, and abolishing
the prescription charge was seen as one way of addressing this
problem. Previously, it was very common for patients not to fill
their prescriptions.
The Health and Social Services Department expects
the fall in the prescription charge to £3 in April 2006 to
increase demand for medicines. There is to be a public education
campaign to limit this demand, to appeal to individuals' better
nature and encourage them not to abuse the system. The officials
stated that abolishing the prescription charge was not at the
top of their list of priorities at the time.
No studies were commissioned to the look at the problem
before the bill to abolish the prescription charge was passed,
however, the policy on prescriptions and charging is to be examined
over the next 5 years by the All Wales Strategy Group. This research
was commissioned by the Welsh Health and Social Services Department
to evaluate any change in prescribing patterns and changes in
uptake of medicines. The officials hope that this work will yield
evidence that, in an ideal world, should have been available before
it was decided to abolish the prescription charge.
The research described above will inform work on
a reduced formulary that is also under way in Gwent. If doctors
are only able to prescribe free of charge from a set list of medicines,
this will limit expenditure on some (possibly expensive or OTC)
medicines.
Ms Lloyd pointed out the connection between abolishing
the prescription charge and the push towards increasing the availability
of health services within primary care. Providing free prescriptions
removes a barrier to patients being treated outside hospitals
(where prescriptions are free already).
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