Memorandum submitted by Citizens Advice
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.
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
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.
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 periodsa 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 expenditurethe 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 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
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
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 languagefrom
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
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.
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
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
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.
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
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
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
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
The SEU report made a number of clear Government
commitmentsthat 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
This is a missed opportunity which we believe
will have serious implications for the equity of the patient choice
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
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.
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:
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
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
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.
The underlying principles must be to ensure
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
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 chargesboth exemptions
and the low income schemeshould 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.
6 See for example Eversley, J and Sheppard,
C, Thinking the Unthinkable: the case against charges in primary
health care, Health Matters, 1998. Back