Select Committee on Health Written Evidence

Memorandum submitted by Age Concern (CP 14)


  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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