Select Committee on Health Written Evidence


Memorandum submitted by Citizens Advice (CP 20)

INTRODUCTION

  Citizens Advice welcomes the opportunity to submit evidence to the Health Committee's inquiry into co-payments and charges in the NHS. In recent years there has been a significant increase in CAB outreach work in health settings and bureaux now provide advice in over 1,000 GP surgeries and hospitals, as well as delivering the independent Complaints Advocacy Service in six of the nine Government health regions.

  The impact of health charges is a long-standing concern for CAB clients and we estimate that around 20% of the 73,000 health problems which bureaux deal with every year relate to health charges. In 2001 we published an evidence report Unhealthy Charges, detailing the problems raised and our recommendations for reform. Regrettably, with the exception of Wales, there has been little progress on tackling these issues since then, despite the significant reforms and additional investment which has taken place in the NHS over this period, and despite the government's explicit agenda to reduce health inequalities. We are therefore very pleased that the Committee is now undertaking this inquiry.

  In our 2001 report we concluded that many people faced financial difficulty in accessing the health care they needed because of the impact of health charges. Bureaux working in health settings reported advising clients who had not had their teeth or eyes checked for years because of anxiety about charges, and a MORI survey we commissioned for the report indicated that as many as 750,000 people in England and Wales were failing to get their prescriptions dispensed because of the cost.

ARE HEALTH CHARGES EQUITABLE AND APPROPRIATE?

  Health charges are not equitable because they inevitably impact most on people in poor health, many of whom may already be struggling to manage on a reduced income because of their health. There are also inequities across health charges, in relation to entitlement to exemptions. For example:

    —  People aged over 60 are entitled to free prescriptions but must pay for any dental care.

    —  They are also entitled to free eye tests but not dental check ups, despite the valuable role of the latter in identifying oral cancer.

    —  There is no medical rationale for the limited number of diseases which entitle patients to exemptions. Whilst people suffering from diabetes are entitled to free prescriptions, other life-threatening illnesses such as cancer and heart disease which are the subject of National Service Frameworks are not included.

    —  In relation to income, there are huge inequities in entitlement to exemption from charges depending on whether or not someone is in work. A person in work and in receipt of Working Tax Credit including a disability element is exempt from all health charges if their gross annual income does not exceed £15,050 (this equates to £289 per week). On the other hand if they then become unable to work because of ill health and their income drops, they will nevertheless lose entitlement to free prescriptions if their income exceeds their income support entitlement plus half the value of a prescription charge. For a single person aged 25 or over and not entitled to any premium, this is £56.20 plus £3.25=£59.45 per week.

  Below we examine CAB evidence of the problems patients face with the current system of NHS charges, and then consider the remaining issues raised by the Inquiry in the light of that evidence.

PRESCRIPTIONS

  Around 80% of prescriptions are dispensed free of charge. However, 80% of people aged between 18 and 60 have to pay prescription charges. The affordability of prescription charges has long been the key concern identified by bureaux. There are two key problems here.

  Firstly there is no tapered help with charges as incomes rise above the level entitling the person to free prescriptions, as there is with dentistry and optical vouchers. Historically the reason for this was presumably that prescription charges were so small that the added complexity which tapered help would cause was not considered necessary. This argument no longer stands, given that a person can easily leave a doctor's surgery with three items on a prescription, and face a charge of £19.50. Affordability problems can be compounded for patients with long term health problems where GPs seek to avoid wastage of medicines by writing prescriptions for shorter periods—a practice which is encouraged by the Department of Health but which can have considerable financial implications for patients:

    A CAB in Surrey reported the case of a client who needed a repeat prescription and is not eligible for assistance with charges. He used to be issued a prescription for six months but this has been reduced to two months, tripling the prescription charges. The GP has told him this is in order to cut down on wastage.

  Secondly the mechanism for helping heavy prescription users cap their expenditure—the pre-payment prescription certificate (PPC)—is not designed to help people on low incomes, who are not be able to afford the upfront charge of £33.90 for four months or £93.20 for 12 months. Citizens Advice has argued that the way to overcome this problem would be to include the PPC into the low income scheme so that it is priced on a sliding scale depending on a person's income.

  A CAB in Wiltshire reported a couple in their 50s and in poor health who were both in receipt of incapacity benefit. They were not therefore entitled to free prescriptions and were paying over £30 each in prescription charges. They would find it hard to raise the one-off sum to buy two PPCs. The bureau calculated that had they not worked and paid national insurance contributions entitling them to incapacity benefit, they would in fact have been better off now on a weekly basis as they would receive full housing and council tax benefit and free prescriptions.

  An easement on help with prescription charges was introduced from April 2004 in response to CAB lobbying. Prior to that date, people on incapacity benefit could find themselves floated on or off entitlement to free prescriptions just because of the differential rate at which means-tested and non-means tested benefits were uprated in a particular year. From April 2004, the regulations were amended to allow entitlement to free prescriptions via the low income scheme where a person's income is within IS entitlement plus half the value of a prescription charge. This has been effective in ending the problem facing this client group, as long as they claim under the low income scheme. However, many people continue to fall through the net because they have failed to claim for this means-tested help. It is also not well suited to cases where people need urgent unplanned access to prescriptions:

    A CAB in Lancashire reported the case of a client who was moved from income support to incapacity benefit following a week in hospital as a result of a heart attack. The client found himself having to pay £12 in prescription charges in one week and had to take out a crisis loan to cover the costs. The client was very distressed that whilst he is on incapacity benefit he is not automatically entitled to free prescriptions and that he has to go through the process of completing a HC1 form.

    A CAB in Cambridgeshire reported the case of a client who is not automatically entitled to free prescriptions as her incapacity benefit is more than her income support entitlement. The client was not aware that she could claim help via the HC1 form on low income grounds. The client has been going without prescriptions because she cannot afford them.

  In other cases, clients, particularly if they are in receipt of incapacity benefit, have wrongly assumed that they were entitled to free prescriptions. This can result in patients facing accusations of fraud, penalty charges and even threatened prosecution. This is despite the fact that it seems probable that the vast majority are cases of error rather than deliberate fraud, and where the underlying problem is one of poverty. Moreover there is no formal means of appeal against such a decision.

  The penalty charge is five times the charge that the client should have paid, up to a maximum of £100. The client will also be asked to pay the original charge itself. If the client does not prove her/his entitlement to help with health costs, and she/he does not pay the amount stated in the penalty charge notice, the NHS may take court action to recover the debt. The penalty charge is increased by 50% of the penalty charge if she/he does not pay within 28 days of the date the penalty charge notice is sent.

    A CAB in Wales reported the case of a client who is on incapacity benefit and disability living allowance and therefore does not receive automatic entitlement to free prescriptions. He had claimed free prescriptions on low-income grounds but his HC2 had expired. He has mental health problems which affect his motivation, and he suffers from depression. He therefore has trouble keeping his HC2 up to date. The client reported ticking the "income support" box on his prescriptions to get them free and is now subject to proceedings for false exemption claims.

    A CAB in Greater Manchester reported the case of a client who signed a prescription form stating he was in receipt of income support when in fact he received incapacity benefit. The client did not pay the first penalty within the time limit and as a result the penalty was increased by 50%. The client was very worried about the threat of court proceedings and so contacted the relevant authority to request an appeal. He was told this was not possible but he managed to negotiate a repayment of £5 per month. He only has his incapacity benefit from which to pay this, and the nature of his condition means that he has no immediate prospects of finding work.

  There is evidence that some health professionals may also be confused about entitlement to free prescriptions and therefore give wrong advice. Pharmacists in particular are in a key position to help patients complete the back of the prescription form, especially if they have difficulty with reading English. It is therefore of serious concern if, as a result of poor advice, such a vulnerable patient group then faces harsh enforcement measures.

    A CAB in Gloucestershire reported the case of a client who does not speak English. She does not work so the pharmacist assumed she was eligible for free prescriptions. The client has now been fined £32 as well as £6.40 for the prescription charge. This has created humiliation and upset.

    A CAB in Sheffield reported the case of a client who is illiterate and on incapacity benefit and disability living allowance. His pharmacist had been ticking the income support section of his prescription forms and getting the client to sign. The client thought he was entitled to free prescriptions and had been receiving them free for years. The client has now received two penalty charges for prescriptions and is paying off one at £10 per month. The client is concerned that there may be more penalty charges in the pipeline.

DENTAL CHARGES

  Dental charges work very differently from prescription charges. For example people over 60 are not exempt from charges, and tapered help is available with dental charges under the Low Income Scheme. Historically the main problem has been the very high level of many charges. In England patients pay 80% of the cost of a course of treatment up to a maximum of £384. Thus those with the highest oral health needs are severely penalised and many more are likely to be put off seeking treatment for fear of the possible health. Our 2001 report included a survey of clients which found that that 44% of people registered with an NHS dentist found the charges difficult to afford, rising to 75% among patients charged £200 or over. People with poor oral health can find themselves facing huge bills over a period of time:

    A CAB in London reported a client who had been charged some £5,000 over the last five years for successive courses of treatment including crowns, fillings, extractions, bridges and false teeth plates to try to address serious dental problems. All have proved ineffective and he has lost several teeth and been left with an uneven bite which means he often damages his cheek when eating. He was advised by hospital consultants that the only effective long term remedy was dental implants but these were not available on the NHS because of the cost. The client therefore wrote to the Health Minister who replied that in fact implants are available on the NHS: the consultant should make the case to the PCT which would decide whether to fund the procedure. In the event he has been refused and is now pursuing a formal complaint.

  From April 2006 however, there will be significant changes to dental charging necessitated by the reform of the dental contract. There is therefore currently a key opportunity to reform dental charges and ensure they are both equitable and appropriate for the new patient-centred NHS.

  Citizens Advice was pleased to be represented on the Department of Health Working Party which worked up proposals for this reform. Regrettably radical reform such as exempting older people from charges altogether or reducing the percentage of the patient contribution were ruled out by the terms of reference which required that any revised scheme should raise the same level of income from charges as is currently the case. However, there was the opportunity to develop a system which was more transparent and where the maximum charge is significantly reduced. The Working Party proposed moving from the current system of over 400 individual items of dental treatment, with a maximum charge of £384, to a system of three Bands, the costs of which should be weighted so as to give greater protection to those with highest dental needs.

  We are, however, concerned that the 2006-07 rates for the Bands (£15.50, £42.40 and £189) are significantly higher for Bands 2 and 3 than would have been predicted by uprating the illustrative figures which the Working Party proposed based on the 2003-04 take (£15, £27 and £130). It appears that there has been a shift in the Department's language—from requiring patient charges to raise the same level of income (£485 million at 2003-04 rates) as under the existing scheme (as was the remit of the working group) to requiring them to raise the same proportion (£645 million at 2006-07 rates) of the significantly increased funding which will be required under the new contract.

  We regret that the opportunity has not been taken to reduce the very high percentage (80%) of treatment fees currently paid by patients, by ensuring that the income raised from charges did not increase by more than inflation as a result of the shift to the new contract. By not taking this approach, patient charges overall will have increased faster than patients' incomes and will therefore become less affordable. People with poor dental health and with incomes only just above the level for help through the NHS low income scheme will be particularly affected.

  In contrast, dentists have received undertakings regarding the protection of their incomes in the early years of the new contract.

  People requiring dentures, who will mainly be older people on fixed incomes, appear to be among the losers under the reforms. Patients requiring replacement dentures due simply to wear and tear, may find the charge more than doubles. Currently the cost for a partial denture ranges from £61.85 to £97.50. Under the new scheme, the charge from April 2006 will be £189. Indeed the BDA has suggested that there may in future be little difference between NHS and private charges for such procedures.

  In our response to the consultation, Citizens Advice urged the Department to reconsider the proposed levels of charges, particularly for the higher Bands, and at least ensure that people requiring replacement dentures, who will overwhelmingly be older people on fixed incomes, are not penalised by the reforms. We also argued that future increases in dental charges should be determined having regard to the levels at which patients' incomes rise, and therefore do not exceed the level of general inflation.

  The Department has now published its conclusions. There has been no reduction to Bands 2 and 3; in fact all Bands have been increased slightly above the levels quoted in the consultation paper. The only concession made in response to our concerns, is that the charges for replacement dentures as a result of loss or damage will be 30% of the Band 3 charge. However this does not apply to replacements for other reasons such as wear and tear, although the cost of the work involved would presumably be the same. The Department has also failed to make any commitment regarding future increases in dental charges.

OPTICAL CHARGES

  The system for charging for optical services represents yet another approach to charging. Here the service is basically delivered privately, but help is provided for people on low incomes through a complex system of vouchers. The main problem reported by bureaux is that clients can find that, even if they are entitled to the maximum voucher, there can be a significant shortfall between the value of their voucher and the cost of the glasses. Opticians are not required to provide glasses within the voucher value and for many people, shopping around is not an option, either because they have health or mobility difficulties or because they live in a rural area where accessible alternatives are few.

    A CAB in Hampshire reported a woman in her 70s and in receipt of pension credit whose voucher only covered around one quarter of the cost of her glasses. She had to use her savings to pay for the remainder. She commented that if she had not had savings, she would have had to do without.

    A CAB in Berkshire reported the case of a client in receipt of incapacity benefit who faced a bill of £350 for glasses with the complex lenses she required. The NHS partial voucher only entitled her to £60. The client could not afford to pay the balance and so was unable to get the spectacles she needed.

    A CAB in Yorkshire reported a client with poor eyesight as a result of diabetes. He is in receipt of income support and therefore entitled to a full voucher. However the voucher was for only £54, leaving the client to find a further £130 from his benefit income.

HELP WITH TRANSPORT COSTS

  Where patients require health care which is not available in their local area, the costs of travel can be a major barrier to accessing health care for people on low incomes. Some help with hospital travel costs is available through the Low Income Scheme. CAB evidence has long demonstrated a range of failings both in terms of the scope of the help available and the complexity of the claiming process.

  A key problem is the fact that help is only available with costs to hospitals, despite the direction of NHS policy to transfer more health care to primary care settings. In some cases however, patients' medical conditions prevent them from accessing even local facilities without incurring travel costs:

    A CAB in Kent reported a case of a client in receipt of Pension Credit (guarantee) who has an ulcerated leg having to travel by taxi each week to her GP surgery to have her dressing changed. If this treatment was undertaken in the hospital she could reclaim the cost but as this takes place in a GP surgery she is offered no assistance with costs. The bureau reported that the travel costs make up 7% of the client's weekly income, placing her under immense financial strain.

  In other cases there is no local primary care provision and patients have to travel. This is particularly the case in relation to NHS dentistry because of the longstanding access problems. Bureaux regularly report that clients are unable to travel the lengthy journey to their nearest available NHS dentist. Earlier in the year we conducted a brief survey of people accessing the CAB website for advice on any issue. 62% of those who had not been able to access a dentist said that the reason was that the only available NHS dentist was too distant or expensive to travel to. We therefore raised with the Department whether help with travel costs could not be extended to NHS dentists to help cope with the problem. However we were told that Primary Care Trusts would be commissioning local services so that this would not be necessary.

  Whilst a local service is obviously the preferable option, we remain concerned that it may not be possible to deliver this in the near future, and meanwhile people on low incomes, who are least able to afford private dentistry, are facing additional barriers in accessing NHS dental services.

  A further problem is that help with transport costs does not extend to people visiting relatives in hospital. For them, the only help available is through the community care grant element of the social fund, which is budget limited and only available to people on income support levels of income. Where patients are in hospital for lengthy periods this lack of support can be particularly hard.

    A CAB in the North West reported that a client who has a 14-month year old child in hospital with spinal muscular dystrophy has faced continuous problems in receiving help with travel costs. The child is in hospital on a long-term basis, having not left hospital since birth. The client reports that he has to get two buses to see his daughter, and on some days is unable due to lack of money, causing distress to the client and his daughter. The client has applied to the social fund on numerous occasions but has repeatedly had his claim turned down.

  This help compares unfavourably with that available to family members of prisoners, who are entitled to help with travel costs under the low income scheme for up to 26 visits per year.

  The payment system can also cause problems. Despite the Department of Health guidance stating that providers should ensure that clients are able to obtain travel cost refunds at all times, a number of clients have experienced problems with this.

    A CAB in Lancashire reported the case of a client who has difficulty claiming payment as a result of the Bursars office shutting at 4 pm. Making the claim by post could take up to anywhere between two weeks to one month which would result in the client getting into debt in other areas.

  Many of these problems were recognised by the Social Exclusion Unit (SEU) in its February 2003 report Making the connections: final report on transport and social exclusion (Chapter 11). That report estimated that each year 3% of or 1.4 million people miss, turn down or simply choose not to seek healthcare because of transport problems. These percentages are doubled for those in the most deprived wards or in car-less households, and more over-75s find access to hospital difficult than any other age group.

  The SEU report made a number of clear Government commitments—that new guidance would widen eligibility to the Patient Transport Service to include primary care facilities and to include circumstances such as inadequate public transport or where patients are on a low income, that greater help should be extended to visitors, and that there should be a "one stop shop" to provide advice and information on help with travel to health care facilities. We would be concerned if any of these proposals replaced the entitlement to help through the Hospital Travel Costs Scheme, rather than being used to extend patient choice. However, our main concern is that it is now nearly three years since the SEU report was published and yet little appears to have changed on the ground.

  This is despite the fact that patient choice of providers is a key element of the Government's planned health reforms. In the patient choice pilots, free transport was provided and it was clear that this was a key element in ensuring equity of patient participation. Yet despite this, the Government has recently announced that in the national roll out, free transport will only be provided for those already entitled under existing schemes.

  This is a missed opportunity which we believe will have serious implications for the equity of the patient choice agenda.

CAR PARKING AND OTHER CHARGES

  Bureaux are increasingly reporting client concerns over the very high car parking charges which some hospitals impose. In many cases patients may have no choice but to use car transport, if they live in a rural area, if there is inadequate public transport or if they have serious mobility problems. And there is of course no help available with these costs. Even blue badge holders are not necessarily exempt from charges.

  Problems are compounded because patients have no control over how long a visit will be required:

    A CAB in south London reported a client who attended A&E on the advice of her GP, following an accident to her foot. The car park charge was £3.75 for the first two hours and £7.50 thereafter. She was 10 minutes over the two hour period and therefore had to pay the higher charge. She also questioned the fact that charges were reduced to £1 per hour after 6 pm. Had she known, she could have postponed her trip til then, but that would have been a busier time for A&E.

  ICAS bureaux also report the resentment felt by patients pursuing an NHS complaint who need to attend the hospital for a meeting regarding their complaint. It adds insult to injury that they then have to face high car parking charges in order to pursue their complaint, especially as no financial compensation is available through the complaints process.

  There is also growing concern regarding the very high cost of telephone charges to hospital in-patients. Where friends and family are unable to visit, either because of the inadequacy of the financial help provided or because they themselves are unable to travel, telephone contact becomes an important means of contact.

    A CAB in Essex reported that people wishing to telephone patients were being charged 49p per minute at peak time and 39p off-peak. The bureau commented that this compared poorly with advertised rates to USA of 3p per minute.

    A CAB in Gloucestershire reported a client who is disabled and had been unable to travel to visit her husband in hospital. The husband, who is blind and therefore found it difficult to dial out, was depressed and in need of support from his wife. The client received a telephone bill for nearly £1,200 for calls to the hospital number. There had been no indication that the calls would be more expensive than the normal rate. The Trust's position is that they have to make the line rental self-financing.

  We welcome the fact that Ofcom is currently investigating the prices charged to people making telephone calls to hospital patients.

WHAT IS THE OPTIMAL LEVEL OF CHARGES? SHOULD CHARGES BE ABOLISHED?

  We have taken these two questions together as we consider it difficult to justify any charges given firstly the basic principle that the NHS is free at the point of delivery, secondly the well-established links between health and poverty, and thirdly the Government's clear objective to end health inequalities. The main arguments against charging are well known:[6]

    —  They are inequitable because, for those above the "low income levels" (which are set at a very low level), the charges impact most on the worst off and on those who have most need of treatment.

    —  They may be cost ineffective to the health service if they result in deferred treatment.

    —  They involve significant administrative costs in terms of collection, anti-fraud measures, and the promotion and administration of full and partial exemption schemes.

    —  They are not required in order to prevent unnecessary use of health resources since access to these is already controlled by health professionals.

  It is therefore difficult to make any comment about what would be an optimal level of charges. What is however clear, is that if charges are to remain, they must be set and uprated having regard to their affordability for patients, not in order to raise a certain level of revenue, as appears to the case in relation to the recent proposals on dental charges.

  In relation to prescriptions a priority must be to reform the PPC in order to ensure that heavy prescription users on low incomes can benefit from this budgeting tool.

  In relation to optical charges, there is a need to establish a mechanism to ensure that glasses within the value of the NHS vouchers are available from all opticians providing NHS treatment.

IS THE SYSTEM OF CHARGES SUFFICIENTLY TRANSPARENT?

  The answer to this question must be no. Health charges have developed in an ad hoc way, with different mechanisms and different exemptions applying across the various charges, as has been outlined above. The result is anything but transparent, as is evidenced by the fact that the Department of Health leaflet helped with health costs (HC11) runs to 77 pages and the claim form HC1 has 16 pages of questions and four pages of notes.

  Patients are frequently confused by the fact that they may be exempt from some charges and not others and that exemptions may be made on grounds of income, or age, or medical condition, and these vary across the charges. The system for optical vouchers is particularly obscure, and patients often assume the figure given is the amount they have to pay, not the amount by which their charge is reduced.

  The result is that bureaux regularly report clients who have missed out on the help they are entitled to. We are not aware that the Department has made any estimate of the extent of this problem. It is also highly likely that people already socially excluded, who are in any event likely to have greater health needs, will be the greatest losers.

WHAT CRITERIA SHOULD DETERMINE WHO SHOULD PAY AND WHO SHOULD NOT?

  The underlying principles must be to ensure that:

    —  No one is prevented from accessing healthcare, or indeed from benefiting from the planned choice agenda, because of financial difficulties. Income-related help must be the first priority.

    —  The scheme supports rather than undermines the health inequalities agenda. This would suggest weighting charges away from those with highest health needs.

    —  The system is simple, transparent and easy to claim. This would suggest maximising exemptions and passporting from other benefits (for example housing, council tax and disability benefits), and ensuring similar rules apply across the different charges.

  There would also be a need for transitional protection in any reform to ensure no-one lost out at the point of change.

HOW SHOULD PATIENTS BE MADE MORE AWARE OF THEIR ELIGIBILITY FOR EXEMPTION FROM CHARGES?

  There is currently a chronic lack of information and advice for patients at the places and times when that advice is needed. Whilst the Government has seen for example the promotion of benefit take up as a key means of tackling pensioner poverty, there seems to have been no parallel recognition that promoting take-up of the available help with health charges—both exemptions and the low income scheme—should be a key plank in efforts to tackle health inequalities.

  Part of the problem is that the Department of Health is not able to require GPs, dentists, pharmacists and opticians to even display posters or hold claim forms, despite the fact that they are undoubtedly best placed to promote take-up. This could be addressed by making such requirement part of the contract with these professions for the provision of NHS services. It is also regrettable that the HC1 is not downloadable from the Department's website, as is the case for DWP benefits such as income support, housing benefit and disability living allowance.

  More generally, there is a need to develop greater links with DWP so that the promotion of help with health costs is fully integrated into other benefit take-up work.

Liz Phelps

Citizens Advice

December 2005






6   See for example Eversley, J and Sheppard, C, Thinking the Unthinkable: the case against charges in primary health care, Health Matters, 1998. Back


 
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