Memorandum submitted by the Department
of Health (CP 1)
PRESCRIPTION CHARGES
BACKGROUND
1. When the National Health Service was
established in July 1948 the principle was to provide healthcare
for all based on need, not on the ability to pay, except where
regulations provide otherwise. Initially, the prescription charge
was introduced in 1952 based on a charge per form. In 1956 a charge
per item prescribed was introduced. The charge was abolished in
1965 and re-introduced in 1968. The categories of exemption are
fundamentally unchanged since their introduction in 1968.
2. Government policy in England is that
entitlement to help with prescription charges is based on the
principle that those who can afford to contribute should do so,
while those who are likely to have difficulty in paying should
be protected.
3. The legal basis of the current arrangements
is derived from sections 77, 83A and Schedule 12 to the NHS Act
1977 and in the National Health Service (Charges for Drugs and
Appliances) Regulations 2000 and the National Health Service (Travel
Expenses and Remission of Charges) Regulations 2003.
4. Charging arrangements are a devolved
matter and arrangements in the rest of the UK are a matter for
the Devolved Administrations.
CHARGES
5. A charge is payable for each item prescribed
(ie the NHS medicine or appliance prescribed by a GP or other
authorised prescriber) or quantity dispensed unless the patient
is entitled to free prescriptions. The charge, as of 1 April 2005,
is £6.50. Categories of exemption from the prescription charge
can be grouped as follows:
— Type of item prescribed. For example,
contraceptives or treatment for a sexually transmissible infection.
— Method of delivery; for example to
an in-patient or supplied and administered by a GP.
A detailed list is in annex 1.
6. People who hold a valid Prescription
Prepayment Certificate (PPC) do not pay a further charge at the
point of dispensing. A PPC costs £33.90 for four months and
£93.20 for 12 months, for an unlimited number of items. This
means that patients can obtain as many items as they need for
less than £2 per week. It also means that the threshold number
of items where it is cheaper to buy the PPC is six items for four
months and 15 items for 12 months supply.
7. The current arrangements mean that around
50% of the population are exempt from prescription charges and
around 87% of prescription items are dispensed free of charge.
As a consequence of the current arrangements, a charge was paid
for only 8.4% of prescription items, and 4.7% of prescriptions
were charged at the reduced PPC rates.
IN RESPECT
OF THE
ISSUES RAISED
BY THE
COMMITTEE
Are prescription charges equitable and appropriate?
8. The charge, and fees for PPCs, have been
increased over time by varying amounts. Between 1979 and 1998
the charge rose from 20p to £5.80. Since 1998 the charge
has increased by 10p each year. This increase has been below the
rate of inflation. The level at which income based entitlement
to free prescription begins has been increased by the same percentage
as increases in Income Support.
9. In 2004, to assist those just above the
Low Income Scheme (LIS) limits the cut off entitlement to free
prescriptions via the NHS low income scheme was extended to patients
whose income exceeded their requirements by up to 50% of prescription
charge, currently £3.25.
10. For 2004 (the latest year for which
statistics are available) the average net ingredient cost of a
non-exempt item was £14.32 when the prescription charge from
April that year was £6.40.
What is the optimal level of charges?
11. The prescription charge is a flat rate
fee. This ensures that:
— patients know exactly what the cost
of the medication will be before they get the prescription dispensed.
They do not have to worry about whether they will be faced with
a variable price at the point of supply;
— there is equity between patients
at all levels of income;
— patients can receive the medication
that they require and that those requiring more expensive medication
are not penalised.
12. For those that do have to pay prescription
charges the PPC was introduced to reduce the expense of multiple
prescriptions. A PPC holder may obtain as many items as are prescribed
(with an average of 46 items per head per annum dispensed in 2004-05)
at a cost to the patient of less than £2.00 per week.
13. A 12 month PPC thereby effectively provides
a maximum cost ceiling, currently set at £93.20. Similar
arrangements operate in other EU countries that operate schemes
setting an annual limit on the amount of prescription charges
an individual may be required to pay.
WHETHER THE
SYSTEM OF
CHARGES IS
SUFFICIENTLY TRANSPARENT
14. The basic charge is transparent in that
each item attracts the current £6.50 charge.
15. The various arrangements currently in
place were introduced to ensure that a wide range of patients
would either have entitlement to free NHS medicines or an easement
of the amount that they would have to pay by using a PPC. The
rate of uptake by benefit claimants and those on low income indicates
a widespread understanding by these patients of their entitlements.
What criteria should determine who should pay
and who should be exempt?
16. The following addresses the various
types of exemptions:
Age related
Medication needs increase disproportionately
with age whilst at the same time income usually decreases. When
charges were re-introduced in 1968, free prescriptions matched
the retirement age for men and women at that time (ie aged 65
and over).
Children under school leaving age are also exempt
as access to medication should not depend on the parents' ability
to pay. From 1988 those children who stay in education until they
are 19 also receive free prescriptions.
Medical condition
The current arrangements for exemption on the
grounds of specified medical conditions have been in place since
1968. The medical conditions qualifying for exemption were agreed
in discussion with the BMA. The list of these conditions contains
some readily identifiable permanent medical conditions which automatically
called for continuous life long (and in most cases replacement)
therapy. A person exempt on medical grounds was, and is, entitled
to all medication free to avoid doctors needing to specify which
medication should be dispensed free; that means that someone with,
say, myxoedema (underactive thyroid) can have free prescriptions
for, say, gout, heart disease, peptic ulcer, varicose ulcer and
anything else as well.
Pregnant women and nursing mothers are also exempt
from prescription charges if they hold an exemption certificate.
This is to protect the health of the unborn child and the nursing
mother. The exemption is provided regardless of the mother's income.
Income related
Those who are likely to have difficulty in paying
charges may qualify for exemptions which take two forms:
(1) There is an automatic entitlement to
help with health costs for some who therefore do not have to complete
a separate claim form. This is called "Passporting"
and applies to people receiving some state benefits eg Income
Support. "In work" benefits, such as Tax Credits and
its predecessors have entitled recipients to free prescriptions,
latterly if their total income is below a specified threshold.
People receiving Incapacity Benefit or Disability Living Allowance
are not "Passported" because these benefits are not
income related but they can make a National Health Service Low
Income Scheme claim.
(2) The National Health Service Low Income
Scheme (LIS) provides income related help for people who are not
exempt nor automatically entitled to remission of NHS charges.
The scheme covers help with NHS prescription and dental charges,
wigs and fabric supports, entitlement to NHS sight tests and optical
vouchers and payment of travel expenses to receive NHS treatment.
The LIS provides full help whereby a qualifying
patient will not pay any charges. However, those with a slightly
higher income may receive partial help with health costs. The
extent of any help is based on a comparison between a person's
resources and requirements at the date a claim is received by
the PPA or the date the charge was paid if a refund is claimed.
There is a ceiling based on capital and the calculation is referenced
to income support arrangements with "needs" being equivalent
to the income support applicable plus full housing costs and council
tax payable.
Type of item prescribed
Where treatment is desirable on public health
grounds (eg vaccination and treatment of Sexually Transmissible
Infections) then it is provided free of charge.
Contraceptives prescribed for women are also
free of charge. This ensures that women are able to take responsibility
for their own reproductive health irrespective of ability to pay.
Method of Delivery
Charges are not made where a need to pay could
impede the delivery of urgent treatment. Accordingly, treatment
in or at hospital, including medication administered at the hospital,
is free. Medication to take away is subject to the normal charging
arrangements.
How should relevant patients be made more aware
of their eligibility for exemption from charges?
17. The Department has an annual budget
of £416K for England held by the Prescription Pricing Authority
(PPA) from which it funds a range of posters and leaflets aimed
at informing people about how they may obtain help with health
costs. All material is provided free on request by phoning the
DH publication orderline or by phoning the PPA helpline. The PPA
also regularly send mailouts to stakeholders to advise them of
changes. Further promotional activities are carried out by the
PPA including holding roadshows in shopping malls, broadcasting
information over local radio networks, taking part in conferences
and training days for professionals and placing advertisements
in appropriate free and paid publications.
18. In addition to the above:
(1) Jobcentre Plus offices also hold supplies
of the information leaflet and the claim forms for the NHS LIS;
(2) Hospitals, dentists, opticians, doctors
and pharmacists are all encouraged to keep supplies of leaflets
available for patients and to display posters. Two major supermarkets
now hold supplies of the "quickguide";
(3) The Department has a contract with the
Waiting Room Information Service which supplies stocks of leaflets
to participating GP surgeries; and
(4) New materials have been developed working
with NUS and NACAB.
Whether charges should be abolished?
19. Abolition or an increase in exemptions
could increase GP appointments if patients opt to seek medication
rather than practise self-care such as healthy activities or modifying
diet. The revenue from prescription charges and PPC fees also
provides a valuable contribution to the National Health Service.
Abolition would increase GPs' workload, increase the Drugs Bill
and cost the NHS of some £430 million in lost income (before
taking into account extra drugs expenditure).
DENTAL PATIENT CHARGES
BACKGROUND
20. Charges for dental treatment were introduced
in 1951 since which time they have been periodically revised:
eight times between 1952-79, and 20 times between 1980-2003. Dental
charges rose annually each year between 1991-2000.
21. Dental charges became a significant
part of the total cost of treatment when they were raised to 75%
of the cost of treatment and extended to dental examinations (not
just treatment) in 1989; in 1993 the proportion rose to 80%.
KEY FACTS
— Dental patient charges apply to adults
but not to children, pregnant women, people on income support
or those who receive care in a hospital out-patients or from the
Community Dental (salaried) service.
— Dental patient charges account for
approximately one-third—about £630 million—of
overall expenditure on NHS dentistry.
— The current maximum charge is £384.
From April 2006, the maximum charge for a course of treatment
will be £189.
REFORM OF
DENTISTRY
22. Primary care dental services are about
to undergo the most significant reform since the General Dental
Services were established in 1948. From next April PCTs will have
resources for dentistry devolved to them and will locally commission
services via the new General Dental Services (GDS) and Personal
Dental Services (PDS) contracts. Dentists will be paid for a contracted
level of activity over the course of a year and not for each individual
course of treatment (item of service) performed.
23. This reform requires changes to the
system of patient charges, which are currently linked to the individual
fees paid to dentists. There are currently 400 different patient
charges reflecting the various items of service. The Department
has taken this opportunity to produce a much simpler and more
transparent system of charges. The proposed new system is based
on the recommendations of a working party chaired by Harry Cayton,
National Director for Patients and the Public. The working party
included representatives from the British Dental Association,
Consumers Association, Dental Practice Board and other stakeholders.
Over the summer, the Department carried out a 12 week formal consultation
on a simplified three banded system of patient charges, based
on the working group's recommendations. The three bands of charges
correspond to the three bands of courses of dental treatment,
which will in future be used to gauge the level of service provided
by a dentist over the course of a year.
24. The proposed three charging bands (which
have been uprated since the consultation to reflect inflation)
will considerably simplify a system which the public currently
find very hard to understand:
(1) band 1 (£15.50) for a preventative
course of treatment (which might include an examination, a scale
and polish and x-ray and preventative advice);
(2) band 2 (£42.40) for dental interventions
(fillings or restorative treatment);
(3) band 3 (£189.00) complex treatments
including dental appliances.
25. Regulations covering the new charges
were placed before both Houses of Parliament in November for agreement
by affirmative resolution during December. The regulations include
amendments to take account of some specific concerns raised during
consultation (eg a 70% reduction in the charge for repair of dentures
or other appliances).
26. The consultation responses confirmed
broad support for simplifying the current system of dental charges.
Consumer representative organisations broadly supported the reforms,
whilst expressing some concerns about the level of charges, particularly
for Band 3. The British Dental Association (despite having been
represented on the working party) raised a number of concerns,
including the lack of testing. Other responses showed strong support
for overhauling the current system, but no single common view
about how best to do this. Many of the responses indicated a need
for the Department to undertake further work to explain the new
charging system to patients and the public, and work on a public
communications programme is now underway.
27. In publishing the revised charges regulations,
the Department has emphasised the following key points:
(1) the new system reduces a complex system
of over 400 patient charges to only three charges;
(2) the maximum charge for patients will
reduce from £384 to £183—the Consumers Association
and others have welcomed this move;
(3) on average, the costs for NHS patients
will be no greater than now (in real terms) and may in fact be
lower. Under the new NICE guidelines on recall intervals for routine
dental consultations, which end the current practice of routine
six monthly visits, dentists will use their clinical judgement
to recall patients at intervals of between three months and two
years. This is expected to reduce the average frequency of patient
visits, which in turn should free up time for dentists to see
a greater range of patients and reduce the average cost per patient.
IN RESPECT
OF THE
ISSUES RAISED
BY THE
COMMITTEE
Are dental charges equitable and appropriate?
28. Charges for dental services have existed
since 1951, and we believe they are a fair way of raising important
revenue that supports the provision of dental services. Public
opinion surveys do not cite cost of NHS treatment as a significant
reason affecting take-up of NHS dentistry. The most recent Healthcare
Commission survey (2003) indicated that, of those patients who
had not been to an NHS dentist in the last year, the more important
factors influencing their decision were the perception that they
did not need to go to the dentist; access to NHS dental services
(which the Department has since been tackling through a £250
million programme of investment and workforce expansion); preference
for using a private dentist; fear of going to the dentist; and
other factors. We have, however, used the opportunity of the forthcoming
dental reforms to design a new patient system that will be fairer
and more transparent.
What is the optimal level of charges?
29. Charges for dentistry have traditionally
reflected a percentage of the overall cost of an item of treatment.
But the over 400 charges which the previous system generated led
to confusion in the public, compounded by some patients paying
privately for treatment and not being clear where NHS payment
ends and private payment begins. The new system is designed to
raise the same overall level of charge income (as a proportion
of gross expenditure on NHS dental services), but with much greater
clarity for patients as to what they will pay for an overall course
of treatment.
Whether the system of charges is sufficiently
transparent?
30. The simplified three band system of
patient charges will make it easier for patients to understand
the cost of treatment. With 400 current items of service it is
very difficult for patients to understand what they are paying
for on the NHS, and even more so when this is combined with private
treatment. Patients generally welcome the opportunity to have
"mixed" NHS and private treatments from the same dentists.
However, this makes it all the more important to ensure that patients
understand both the cost of proposed NHS treatments and the cost
of any proposed private treatment. The new arrangements will greatly
increase transparency in this respect.
ELIGIBILITY FOR NHS OPTICAL SERVICES
BACKGROUND
31. Until 1989 everybody was entitled to
an NHS-funded sight test. From 1989, eligibility was restricted
to children, people on low income or those suffering from or predisposed
to certain eye diseases. In 1999, the Government reintroduced
NHS-funded sight tests for people over 60.
32. There is no system of NHS charges for
optical services. Rather, eligibility for free, NHS-funded sight
tests is targeted at children, older people, those with or at
risk of eye disease, and people on low incomes. There are similar,
though not identical, eligibility arrangements (set out below)
for optical vouchers, which patients can use to contribute to
the costs of buying glasses or contact lenses.
33. The groups eligible for free sight tests
are as follows:
— those under 16 years of age;
— students in full time education aged
between 16 and 19;
— individuals on low incomes including
those receiving Income Support, Jobseeker's Allowance and Pension
Credit Guarantee Credits;
— individuals diagnosed as having,
or being at risk of, glaucoma; and
34. Opticians who provide a NHS sight test
currently receive a fee of £18.39 per test. This rate is
negotiated with representatives of optometrists and ophthalmic
medical practitioners.
35. The Health Bill removes current restrictions
on who PCTs may contract with to provide NHS funded sight tests,
subject to contracts ensuring safeguards and quality and the use
of qualified and registered optometrists and ophthalmic medical
practitioners to undertake clinical work. The Bill also creates
a more robust framework for commissioning similar to other parts
of primary care and which allows for commissioning of enhanced
services locally.
36. The Health Bill removes some current
restrictions on who may provide NHS funded sight tests. At present,
only optometrists, ophthalmic medical practitioners and corporate
bodies registered with the General Optical Council may contract
directly with Primary Care Trusts to provide sight tests. Businesses
owned by dispensing opticians or by lay people (if they are not
registered with the General Optical Council) can only provide
services by arranging for one of their employees (ie an individual
optometrist or ophthalmic medical practitioner) to enter into
an agreement with the Primary Care Trust to be the contractor.
The Health Bill will remove this cumbersome arrangement and allow
for direct contracts with these practice owners, provided that
those undertaking the clinical work are qualified, registered
optometrists or ophthalmic medical practitioners on a PCT's "performers
list". This will make it more straightforward for a range
of providers to enter NHS service provision and will help sustain
and promote choice for patients.
37. The Bill also creates an integrated
legal framework within which Primary Care Trusts can commission
enhanced ophthalmic services. This will support PCTs, where appropriate,
in increasing work undertaken in primary care, reducing inappropriate
referrals to hospital and enhancing the role of primary care professionals
in diagnosing and managing eye conditions. The Department is currently
sponsoring a number of NHS pilots that involve expanding the role
of primary care professionals in managing low vision, glaucoma
and age-related macular degeneration.
38. Subject to the Bill becoming law and
being implemented, we envisage the sight testing service operating
like the General Ophthalmic Service (GOS) system now. Eligibility
for NHS funded sight tests will be maintained for all those currently
eligible. Contractors will (as now) be able to establish themselves
in areas and have a contract with the NHS provided they meet agreed
national criteria. Patients will be able to choose the GOS contractor
who provides their NHS funded sight test. We also envisage continuing,
as now, to have a centrally negotiated sight test fee. NHS sight
testing will, we anticipate, continue as a demand led service
with consistent standards across the country and patient choice
of the practitioner who they wish to go to for their NHS funded
sight test.
39. Patients who have received a NHS sight
test, and who need glasses or contact lenses to correct their
eyesight, receive a prescription showing the required strength
and type of glasses or contact lenses. Eligible patients also
receive an NHS optical voucher, which they can use to meet (in
whole or in part) the cost of these glasses or contact lenses.
Eligibility for optical vouchers is primarily targeted towards
children and people on low incomes. There are eight voucher bands,
each to a set value according to the strength and type of the
prescription. The current voucher values vary from £32.90-£181.40.
We recognise that the higher an individual's prescription the
more the glasses will cost. This is why the higher the prescription
the more financial help an individual would get with costs. The
optician who dispenses the glasses or contact lenses redeems the
value of the voucher from their local Primary Care Trust.
40. The groups eligible for optical vouchers
are:
— those under 16 years of age;
— students in full time education aged
between 16 and 19;
— individuals who have been prescribed
complex lenses; and
— individuals on low incomes including
those receiving Income Support, Jobseeker's Allowance and Pension
Credit Guarantee Credits.
IN RESPECT
OF THE
ISSUES RAISED
BY THE
COMMITTEE
Are funding arrangements equitable and appropriate?
41. These arrangements are designed to provide
support to people most at risk from eye disease or who might otherwise
be discouraged on financial grounds from having their eyes examined.
Eligibility for optical vouchers relates predominantly to income
and is targeted on those who might have most difficulty in purchasing
glasses or contact lenses.
42. Vouchers provide eligible patients with
flexibility in respect of which glasses or lenses to choose. They
allow patients to top up the voucher value (if they wish) to buy
a more expensive pair of glasses or lenses.
Whether the system of charges is sufficiently
transparent?
43. The conditions for entitlement are simple
and straightforward and are designed to minimise any possible
abuse of the system.
44. For example, sight tests are recommended
every year for persons over 60 years of age. Further tests within
any year are not free of charge unless the optometrist or ophthalmic
medical practitioner is satisfied that the sight test is necessary.
These arrangements prevent individuals from seeking a sight test
for which there they do not have a clinical need unless they are
willing to pay privately.
What is the optimal level of funding?
45. There are no central limits on expenditure
on NHS sight tests or optical vouchers. Expenditure is demand-led,
in the sense that it is driven by the numbers of eligible patients
who visit their optician for NHS-funded sight tests and the numbers
of optical vouchers issued as a result of these sight tests. The
number of NHS funded sight tests increased by 3.1% from 2003-04
to 2004-05.
46. Levels of funding are also clearly affected
by rules on eligibility. In 1999, the Government reviewed the
eligibility rules and extended eligibility for sight tests to
those over 60. The available evidence suggests that this resulted
in a transfer of sight tests from the private sector to the NHS,
rather than any material increase in the overall number of sight
tests undertaken. This does not suggest that any further extension
in eligibility (and the associated increase in NHS funding) is
likely to affect significantly the overall number of sight tests
undertaken or the associated health outcomes.
What criteria should determine who may receive
funding and those who should not?
47. As set out above, the eligibility criteria
for NHS-funded sight tests (which in turn affect levels of NHS
expenditure on sight tests) are designed to ensure that children,
older people, other patients who are or may be predisposed to
eye disease, and those on low incomes are not discouraged from
having their sight tested. The criteria for optical vouchers are,
similarly, designed to support those who might otherwise have
difficulty buying glasses or contact lenses, either because they
are on low incomes or because they require complex lenses.
How should relevant patients be made more aware
of their eligibility for NHS optical services?
48. Information about the extensive arrangements
for providing help with NHS optical services and other health
costs are publicised in the leaflet HC11, "Are you entitled
to help with health costs?" Posters are also available for
display in optical practices and hospital out-patient departments.
Whether the current arrangements should be abolished?
49. The Department is not persuaded that
extending eligibility for NHS-funded sight tests and/or optical
vouchers would be a cost-effective use of NHS resources. As indicated
above, the evidence from the most recent extension in eligibility
(in 1999) does not suggest that further extensions would significantly
alter the overall take-up of sight tests (ie taking into account
both NHS and private sight tests).
CHARGES FOR BEDSIDE TV AND TELEPHONES
BACKGROUND
50. The NHS Plan "A Plan for Investment,
A Plan for Reform" was published in July 2000 and set out
Government Policy for investment in the NHS and for reform of
the way the NHS delivers care for patients. As part of improving
the environment in which the patient is treated and to make available
services that they take for granted at home, it was decided to
set a target for the availability of bedside televisions and telephones
in every major hospital by the end of 2004.
51. NHS Estates undertook two competitive
tender exercises (July 2000 and January 2001) and Licensed a number
of Providers to install these services in NHS Trusts. The object
being to utilise the private sector in the provision of the services
so that the installation was funded by the private sector with
the recovery of capital operating costs being met by the system
users.
52. Installation of these services went
well and at the end of 2004, bedside televisions and telephones
had been installed in 122 major hospitals (more than 400 beds)
and in 33 smaller hospitals (less than 400 beds). Over 75,000
units had been installed at that time, the NHS Plan target was
largely met.
53. The Office of Communications (OFCOM)
has opened an investigation into the provision of bedside communication
and entertainment services recently installed in NHS hospitals
under the Competition Act 1998.
54. The terms of the investigation are as
follows:
a. whether the agreements that are in place
between certain NHS Trusts and both Patientline and Premier each
infringe the Chapter I prohibition of the Competition Act 1998
("the Act") and/or Article 81 of the EC Treaty (anti-competitive
agreements); and
b. whether the prices that Patientline and
Premier each charge consumers for making calls to hospital patients
each infringe the Chapter II prohibition of the Act and/or Article
82 of the EC Treaty (abuse of a dominant position).
55. The Department of Health is co-operating
with this investigation. No further action should be taken until
the OFT publishes its conclusions.
IN RESPECT
OF THE
ISSUES RAIDED
BY THE
COMMITTEE
Why was it decided to charge patients for these
services?
56. These facilities provide additional
services to improve the patient environment, and are not related
directly to the provision of clinical care. The private providers
took the financial risk in installing and operating the systems;
they are essentially a free good to NHS Trusts. It would not have
been appropriate to divert funding for the provision of essential
clinical services to pay for televisions and telephones.
57. If patients wanted to watch TV in the
past, they had a choice of watching a communal TV in the dayroom,
free of charge, or in some cases could rent TVs to watch at the
bedside. Patients have always had to pay to make an outgoing call
from the hospital on ward payphones.
Whether charges for bedside televisions and telephones
are equitable and appropriate?
58. The Project to install the bedside televisions
and telephones was structured so that the provider chosen by the
NHS Trust would install and operate the bedside communications
at its own cost. The NHS patient is charged directly for the services
used and the contract is between the user and the provider. It
was the intention of the Project that the installation of these
services would not be a cost for NHS Trusts. Over £115 million
of private funding has been used to introduce these services into
NHS hospitals. This capital funding will of course be recouped
by the private providers over time, through the revenue streams
generated.
What is the optimal level of charges?
59. The provision of bedside televisions
and telephones was (and is) an emerging market. NHS Estates considered
the experience of providers already in the market to assess a
reasonable measure of likely costs. The procurement process was
designed to establish the market rate for the provision of these
services by appealing to a range of applicants to make offers
against the parameters set out as part of the tender exercise.
60. Each of the suppliers offers a different
range of services and prices. The cost of TV ranges from £2.50
to £3.50 per day. The cost of outgoing telephone calls is
around 10p per minute. The cost of incoming telephone calls ranges
from 15p to 49p per minute.
Whether the system of charges is sufficiently
transparent?
61. The suppliers of the service advise
the user of the cost of the services when they apply to use the
system. In addition, incoming callers are advised at the onset
of the telephone call of the charges to be levied (apart from
HTS who do not offer this service).
What criteria should determine who should pay
and who should be exempt?
62. Private providers are responsible for
the costs of installation and ongoing operation of the services.
In order for them to realise a return on their investment the
revenue stream must provide them with an adequate return. Patients
and other users pay for the services provided.
63. All providers have offered to provide
children with free TV. Some suppliers offer discounts on TV charges
for the elderly and long stay patients. In addition, some suppliers
offer unused credits handed back by patients to be distributed,
at the discretion of ward staff, to those patients who may benefit
from the services but are not able to pay for them.
64. For patients who cannot afford or do
not wish to use the services provided, TVs usually remain in day
rooms and messages from friends and relative can be passed to
and from the nurse's station, as happened in the past.
How should relevant patients be made aware of
their eligibility for exemption from charges?
65. Under the provision of these services,
the only patients with a guaranteed exemption for charges are
children and they are advised of this as appropriate.
Whether charges should be abolished?
66. The services are provided by private
providers, most of whom have entered into 15 year contracts with
NHS Trusts. The providers are not able to operate the service
if they do not get a return on their investment. The only way
for charges to be abolished, and to retain these services in NHS
hospitals would be for the NHS to pay for the services and buy
out the remaining capital charges. There may be a number of other
options that could be considered further at a later stage.
INCOME GENERATION ACTIVITIES (INCLUDING CAR
PARKING)
BACKGROUND
67. All NHS bodies have powers to undertake
activities to increase the amount of income available to them.
It is under these powers that, for example, NHS trusts can charge
for car parking on their premises, or rent out retail units (the
gift and flower shops found in the main concourse of most hospitals).
This part of this Memorandum of Evidence provides some specific
information about car parking charges.
CAR PARKING
68. NHS trusts do not have to provide car
parking facilities on their premises. However, if they do, then
they will necessarily incur costs in terms of maintenance and
security, and even staffing depending on the particular arrangements
put in place. If no charges were made, then these unavoidable
costs would have to be found from elsewhere, at the risk of taking
funds away from patient services. Having said that, NHS trusts
are not obliged to charge for car parking, but are free to do
so within the income generation rules.
69. Thus, it is a matter for individual
Trusts to decide whether they wish to introduce such charges,
and if they do, then at what level the charge should be set, taking
into account local circumstances. Hospitals' locations differ
with regard to the amount of space available for car parking and
the pressure they face on available spaces. NHS Trusts must therefore
decide on the arrangements for car parking in the light of their
particular circumstances, including whether or not, and whom,
to charge. When making such judgements, Trusts have to consider
the needs of all users of the hospital, including consultants,
junior medical staff, nurses, other staff, patients, visitors,
emergency vehicles and others. Where spaces are limited, it may
be impossible to offer all or any of these groups free or subsidised
parking as to do so would affect the space available for others.
70. These factors have meant 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. However, as indicated above, guidance has been in place
for some years advising on the range of factors that need to be
considered if an NHS trust is thinking about introducing car parking
charges. This includes information on the different types of arrangement
that might be available, the needs of the various users, consulting
and reaching a decision, and how to manage the scheme once it
is in place.
Department of Health
7 December 2005
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