Memorandum submitted by Age Concern (CP
14)
INTRODUCTION
1. Age Concern welcomes the opportunity
to provide evidence to the Health Select Committee on co-payments
and charges in the NHS. Age Concern England (the National Council
on Ageing) brings together Age Concern organisations working at
a local level and 100 national bodies, including charities, professional
bodies and representational groups with an interest in older people
and ageing issues. Through our national information line, which
receives 225,000 telephone and postal enquiries a year, and the
information services offered by local Age Concern organisations,
we are in day to day contact with older people and their concerns.
1.1 The subject of co-payments and charges
in the NHS is a matter of great importance to older people who
are the majority users of NHS services. Two thirds of general
and acute hospital beds are used by people aged 65 and over (National
Service Framework for Older People, Department of Health, 2001).
In 2003-04 people aged 65 and over accounted for approximately
47% of the NHS Hospital and Community Health Services budget (Departmental
Report, Department of Health, 2005). Older people are thus likely
to be the group most adversely affected by the charges. As the
committee stated in its press releases the rationale behind many
of these co-payments is unclear in a system that is "free
at the point of use". In addition to the national charging
scheme for certain aspects of the NHS there is evidence of a growth
in locally imposed charges to raise revenue for the particular
NHS Trust, in particular for car parking which can have adverse
effects on the ability of older people to access services or create
additional anxiety.
2. Are charges equitable or appropriate?
2.1 It is questionable whether any charges
for NHS health services are appropriate. Charges may well work
against the prevention and well being agenda, and may contribute
to the continuing widening of the health inequalities gap. The
Government has continued to voice its commitment to an NHS which
is free at the point of delivery, with access based on need rather
than the ability to pay. There does not seem to be any clear reconciliation
of this commitment with the policy of charges for some aspects
of care. Health charges inevitably impact most on those in poor
health, and the links between poor health and low income have
been well researched and demonstrated.
2.2 Within the system there seems to be
no logic as to which services are exempt from charges and which
are not. The fact that, for older people, eye tests are free yet
dental check ups are not appears to have no rationale. (Indeed
the only rationale 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). The low income scheme is complex and
contains some anomalies by which people in work are able to access
free services at a far higher income than those who are not working
(which of course is the position for the majority of older people).
3. National charging issues.
3.1 Dental charges. Age Concern has recently
responded to the consultation on changes to charges for dental
treatment; the Department of Health has now published it's the
outcome of the consultation. Almost half of all older people do
not access any form of dental care and among the major contributory
factors are the actual cost or the fear of the cost, as well as
the difficulty in finding an NHS dentist. Good oral health is
particularly important for older people as it is essential to
enable individuals to eat, speak and socialise without discomfort
or embarrassment. There is clear evidence of links between poor
oral health and malnutrition. In spite of the Government emphasising
the importance of oral health in public health terms (Choosing
Health—making healthy choices easier, Department of Health,
2004), unlike Wales and Scotland there has been no commitment
made to introduce free dental check-ups for older people. Indeed
the proposals for changes to dental charges introduces a more
expensive charge for a basic check-up which is hard to reconcile
with the objectives of increasing emphasis on preventive dental
care and removing the deterrent for those with poor oral health
from seeking treatment because of cost.
3.2 We were extremely concerned that the
original proposal was that all replacement dentures would attract
the highest of the three bands of charges (£183). Although
we are pleased that in response to consultation that the Government
has in part listened to these concerns and set the price of replacement
for loss and damage at 30% of the highest band (now £189),
we are still worried that for replacement due to wear and tear
the cost will be £189. This would clearly disproportionately
affect older people of whom some 40-45% over 65 have no natural
teeth, possibly in part due to dental practices in their younger
days. We are still concerned that such a high charge might lead
some older people to carry on using damaged dentures or none at
all which could have a devastating affect on their health and
well being. The Government states that the regulations remain
unchanged to allow the Secretary of State to determine no charge
in cases of hardship or on the grounds that the loss or damage
did not entirely result from lack of care by the individual. It
is very important that all information given about charges make
it very clear that there is this Secretary of State discretion
and in what circumstances it might be considered.
3.3 Optical charges. The voucher system
is complex and in most cases leaves a large shortfall between
the cost of glasses and the value of the voucher. Currently vouchers
normally only cover a fraction of the cost of the cheapest pair
of glasses that can be bought at most opticians. Some older people
need more than one pair of glasses and it is often not made clear
that a voucher can be given for each pair. Although the value
of the voucher affects all people on a low income, older people
are less likely to be able to shop around to find the cheapest
pair. The cost and difficulty of shopping around in rural areas
where there is less choice of optician is another factor. We are
concerned that some older people, if they have to pay more than
their voucher covers, might decide to do without glasses (or not
change them as frequently as changes to their eyesight demand),
thus possibly putting themselves at risk of falls, or a highly
diminished quality of life because they cannot see properly. Opticians
are not required to have a selection of glasses within the voucher
price, and this is something the committee may wish to consider
as a recommendation. Age Concern recommends that there should
be a review of the value of vouchers to ensure that they meet
the costs of buying an appropriate pair of glasses and that these
levels should be kept under regular review.
4. Local charges.
4.1 Car parking. We are very pleased that
the Select Committee has raised this as an issue as it is one
that is causing increasing concern to older people. Many rely
on getting to hospital by car if they have difficulty managing
public transport, or live in rural areas where public transport
is not available. As older people are unable to access the mobility
component of Disabled Living Allowance, they are further disadvantaged
as older people do not have their mobility needs recognised by
any payments to help. The way car parking charges are imposed
varies enormously between hospitals bringing in yet another post-code
lottery to the NHS, in this case without even a possibility of
challenge through the courts or via the Ombudsman. Some hospitals
have a limited period where there is no charge to enable setting
down or for quick visits. Others impose a charge from the start
with charges going up in half hour or hourly intervals. The price
can vary hugely with some hospitals charging more than the local
charges for parking for shopping. Often individuals only find
the cost of parking at the hospital when they arrive as no information
has been given in the appointment letter. We are also very concerned
that any remissions schemes are not generally known about and
are idiosyncratic to the hospital.
4.2 The issues around car parking that particularly
have been brought to Age Concern's attention are:
— The lack of disabled parking
places forcing people to use the main (charged for) car park.
Even though there may be a remission using the blue badge scheme,
often the offices that deal with this are a long walk from the
car park;
— In one area the high costs of
hospital parking (£2 per hour up to £10) has meant that
the local neighbourhood is affected to the extent that the local
authority has brought in a controlled parking scheme around the
hospital—this in an area where it is difficult to get to
the hospital on public transport;
— Where an older person requires
an ambulance the carer is often not allowed to travel with the
patient, even where the carer is needed at the hospital to help
the patient dress and undress, to go to the toilet, or to transfer
from wheelchair to examination couch. The carer has to make their
own way to the hospital most often by car and park in the car
park. Because ambulances collect patients at any time prior to
the appointment to fit with their schedule, parking can be for
some hours. For instance we have an example of a patient being
pick up a 8.45 am for 10.45 am appointment meaning that the carer
was parked for two hours longer than necessary to meet the convenience
of the ambulance service, and being charged more for each hour
parked;
— Where car parks charge for different
time periods individuals are, to some extent, paying for the inefficiency
of the hospital. For instance, in a recent example brought to
our attention, a routine blood test took over an hour because
of the long queue meaning that the patient had to pay more for
parking even though the test only took about five minutes;
— Where carers (especially spousal/family
carers with terminally ill spouses) need to park, perhaps for
long times, the parking charges can be a deterrent if they are
on a low income and thus could deprive a person of being able
to spend time at this highly emotional period.
4.3 Age Concern recommends that there should
be a national review of car parking charges to ascertain the rates
being charged; what profit is being made; what people's views
are of parking charges and what problems are experienced; what
exemptions are made and how this is communicated to the patient
and their carers; and that there should be national guidance on
car park charging for NHS facilities.
4.4 Bedside phones. Age Concern receives
some queries about the cost of some bedside phones which we understand
are charged at a premium rate. Although we appreciate a bedside
phone aids communication, the charges impact heavily on older
people, as they have replaced the "telephone trolley".
Older people are more likely to have mobility problems which mean
they cannot get to a public phone. For those ringing patients
in hospitals it is not always made clear that this may have a
higher cost than a normal call. We have had a complaint from one
older person ringing his wife in hospital that he only realised
the high cost when he received his phone bill. Since older people
are more likely to have difficulty visiting relatives in hospital
and therefore may rely on telephone contact to keep in touch,
they are disproportionately affected by these high charges.
5. Other costs.
5.1 Although the Health Committee is looking
at NHS charges there are number of "hidden" costs which
severely impact on older people. These arise from instances where
the NHS fails to provide a comprehensive or fully accessible health
service.
5.2 Transport. In developing our response
for the White Paper on community health and social care a consistent
theme raised in focus groups was concern about the costs and availability
of transport to travel for health care. Lack of NHS dentists can
mean much longer journeys for older people to access the nearest
NHS service. Only travel to hospital comes under the NHS travel
scheme, but over the years more services have been transferred
to primary care settings for which no financial help is given.
For those older people who cannot access public transport, it
can mean a considerable cost if a taxi is required. We receive
many complaints about the difficulty in obtaining home visits
by GPs and other health professionals. Increasingly patients are
expected to make the journey to their surgery. In the focus groups
we held, this was particularly raised by older carers and those
living in rural communities—the costs involved in arranging
transport for a GP consultation were considerable.
5.3 We have commented above on the problems
of visiting patients in hospital caused by car parking charges,
and we are also concerned that the cost of transport can be a
major deterrent for older people visiting relatives. For those
on pension credit it may be possible to get some help via the
social fund, but this entails yet another claim to the DWP adding
an additional stress.
5.4 The problems of transport to health facilities
have been highlighted for some time. Age Concern London's report
"A Helicopter would be nice" (2001) outlined
many of the problems that older people in a city area experience.
Some of these problems are compounded in rural areas. In 2003
the Social Exclusion Unit made a number of recommendations regarding
transport to health facilities Making the connections: final report
on transport and social exclusion. It is extremely disappointing
that so far none of these have been taken forward.
5.5 Chiropody. This is one of the services
about which Age Concern receives the most queries and concerns
from older people. Although the NHS does not impose charges, failure
to commission an adequate service to meet population health needs
results in charging by default. Chiropody services have the potential
to maintain mobility and therefore secure independence for older
people. Many NHS chiropody services have been reduced by tightening
eligibility criteria so that only people with "high level"
foot health needs (such as some people with diabetes) are able
to access the service. This practice is continuing as a way of
managing financial deficits. Where chiropody services are available,
waiting lists for treatment are often very long. We have recommended
in a submission to the White Paper consultation that a maximum
wait for chiropody services should be imposed in line with that
proposed for waiting times for other health services.
5.6 The picture is one of significant variation
across the country and it is not possible to reconcile this variation
with different levels of foot health need. It is clear that in
many parts of the country the NHS is failing to provide a comprehensive
foot health service. The consequence is that many older people
are faced with the stark choice of paying for private care, or
receiving no care at all. Although some voluntary organizations
such as Age Concern have tried to fill that gap through developing
toe nail cutting services, there can still be costs to cover the
running of the service. In a recent adjournment debate (28 November
2005) the cut back in podiatry services in the London Borough
of Havering was discussed, and a case mentioned where a constituent
had to choose between meeting the costs of eating or having her
toe nails cut. Another Age Concern has reported to us that financial
difficulties in the local PCT has meant a severe tightening in
the eligibility criteria for people to access chiropody services,
with the result that even people who are blind or have severe
arthritis can no longer have an NHS chiropodist. Age Concern recommends
that there should be national standards on eligibility for NHS
funded chiropody and that consideration should be given to how
the policy of `choice' could be made to work in this area (given
that there is not a workforce shortage).
5.7 Dental care. We have highlighted above
the fact of poor access to an NHS dentist for many older people
and the implications of this for health and well-being. The distances
many would need to travel in order to visit an NHS dentist often
makes this an unrealistic option. In these circumstances the existence
of NHS charges or help with health costs becomes irrelevant. The
lack of a comprehensive NHS dental service forces many older people
to choose to either pay for private dental care or not to have
any care at all. Age Concern has received anxious enquiries from
older people whose dentist has decided to stop providing NHS care
- the people concerned, on low fixed incomes, are unable to see
any way in which they could afford either dental insurance or
the costs of private care as it arises. A survey undertaken by
one Age Concern found that the main reason why older people had
a private dentist was because of a change of practice from NHS
to private by their own dentist.
6. Transparency of charges and exemptions.
6.1 Not only are charges complex (hence
the consultation to try to simplify dental charges), but the system
of getting help with charges seems designed to confuse and put
people off applying for help. The fact that the leaflet HC11 "Help
with Health Costs" on the Department of Health website
runs to 77 pages indicates the level of complexity with the contents
list alone running to three pages. This leaflet does not even
attempt to explain the "low income scheme" merely referring
the person to form HC1. This is perhaps not surprising given that
the rules for qualifying on the low income scheme require the
completion of a form similar to that of income support/pension
credit.
6.2 Those older people who are above the
pension credit guarantee levels but who may be eligible for help
with health costs have to fill in yet another form (much of the
information required will perhaps have been given to the DWP in
an application for the savings credit, or to the local authority
to apply for council tax benefit). With the exception of people
aged 65 and over whose income is exclusively dependent on state
benefits, the certificate only lasts for 12 months and the form
therefore has to be completed on a regular basis. The DWP has
recognised that older people's means do not change regularly and
have accounted for this in setting awards of Pension Credit for
five years in the majority of cases. It would seem sensible for
the Department of Health to follow this rationale for the Low
Income Scheme and have a similar five year award for all older
people. Knowledge of the Low Income Scheme is poor and all too
often we find that older people do not have a current HC2 or 3
certificate and so are faced with having to try to get a refund,
or are put off from applying for a refund once they have paid.
6.3 For those in receipt of pension credit,
changes to the system have added to the complexity of older people
receiving the help with health costs which they are entitled to.
Older people no longer have order books which prove that they
are on pension credit, many older people do not know if they are
on the guarantee credit or just the savings credit, and as benefit
is awarded for a five year period they may well have lost their
notification letter. Few realise that they need to take it with
them to the dentist or optician or hospital. It would be an improvement
if the DWP could issue a card—similar to membership cards
for older people to carry with a clear explanation with them that
the card will be needed for dentists, opticians and hospital visits.
6.4 In addition to the complexity of the
system for claiming help with health costs, and the fact it involves
an intrusive means test often for one off payments, we are also
concerned about how little it is advertised or promoted. There
is no requirement on health professionals such as GPs, dentists
and opticians to display leaflets about getting help with health
costs. They also do not have to have copies of the forms. Age
Concern recommends that PCTs should be required to promote the
scheme through GP surgeries, dentists and opticians and a regular
supply system set up so that the most up to date leaflets are
always available to overcome the perennial problem of out of date
leaflets. Given that the costs are reported as putting people
off seeking early treatment and advice, it seems that a major
chance of helping move forward on the prevention agenda is being
missed. The Department of Health should work with the DWP to develop
joint approaches to coordinate and improve benefit take-up. There
should also be better joint working between the pension service
and local authorities with targeted campaigns designed to improve
knowledge and take-up of all benefits. Likewise support to improve
take-up should be undertaken by housing departments for those
applying for disabled facilities grants and housing benefits.
7. The optimum level of charges.
7.1 Age Concern believes that charges for health
services are not appropriate and that older people, wherever they
live, should have free and fair access to health services to promote
and maintain their physical and mental health and to treat illness.
Charges work against the Government's agenda of the prevention
of illness, and against the commitment to reduce health inequalities,
as they inevitably affect the poorest and those with the greatest
health needs. We are not aware if there has been any study on
the cost of running the low income scheme and policing the exemption
schemes. More difficult to cost but a highly important factor
is the possible later cost to the NHS caused by older people not
having treatment because of worries about charges.
8. What criteria should determine who
should pay and who should be exempt?
8.1 As stated above, Age Concern is opposed
to charges that are fundamentally at odds with the principles
of a NHS service free at the point of delivery with access based
on clinical need. If charges are to remain it is imperative that
they do not discriminate against older people. Help with costs
should be based on the principle that no one should be forced
to choose not to access health services or care because of concerns
about cost. To achieve this would require a more generous and
easily accessible system of means testing, with greater passporting
-for instance those in receipt of housing or council tax benefit
getting full help with health costs.
8.2 Equally care must be taken to ensure
that those with the highest health needs are not penalised by
charges across a range of services they require. There is currently
no way of ensuring that those people who are not eligible for
the low income scheme and who need a variety of services for which
a charge is levied, or require many hospital visits, are not having
to spend large sums of money which they cannot afford. There is
no equivalent to the pre-payment scheme for prescriptions to help
keep the costs down.
9. Conclusion.
9.1 We hope that the above helps the committee
in their inquiry. The charges which are the subject of this inquiry
currently create many problems for older people. We are particularly
worried that ad hoc local charges such as those for parking
have become a way for NHS Trusts to reduce their budgetary pressures
at the expense of the local community, with little scrutiny on
the way they are imposed or their impact on patients. We hope
that this inquiry will shed some light on this subject.
9.2 Age Concern strongly recommends the
abolition of direct charges for health care. Given that the choice
agenda will allow patients to choose to go to a private hospital
funded by the NHS, there is a strong argument that the same should
apply to primary and community based services such as chiropody
and dentistry. There should be a review of help with transport
costs to hospital and other health services such as GP and dental
practices and regulation of charges locally determined charges,
such as parking.
Pauline Thompson
Age Concern
December 2005
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