Select Committee on Health Written Evidence

Memorandum submitted by Macmillan Cancer Relief (CP 23)


  Patients who undertake regular visits to hospital for cancer treatment should be exempt from hospital parking charges.

  Department of Health guidance on parking should be more prescriptive and should instruct hospitals to offer exemptions to specified groups of patients, including cancer patients who travel regularly to hospital.

  All patients travelling to hospital for regular cancer treatment should have their travel costs reimbursed through the Hospital Travel Costs Scheme (HTCS) on a non-means tested basis.

  Compliance with Departmental guidance on HTCS should be seen as a "must-do" requirement and not an optional extra. All hospital trusts should be routinely informing patients about HTCS and local parking concessions through posters and appointment letters. We urge the Committee to ask the Department of Health to outline the action it intends to take to ensure that trusts comply with this guidance.

  Patients undergoing treatment for cancer should be exempt from prescription charges for life-saving cancer drugs or for drugs and treatments to control the debilitating side effects of treatment. Terminally ill patients receiving palliative care at home should be exempt from prescription charges.

  The Disability Living Allowance (DLA) and Attendance Allowance (AA) hospital downrating rules should be relaxed in recognition of the additional costs, including phone and TV charges, incurred by hospital in-patients.

  Before treatment commences patients should be routinely advised about the range of charges and expenses they are likely to incur during the course of their treatment.

  All cancer patients should be offered specialist benefit advice at diagnosis and at key points in the patient journey. Referral mechanisms should be built into care pathways so that patients are given advice about the right benefits and concessions at the right time.


  2.1  Macmillan Cancer Relief helps people who are living with cancer. Each and every day over 600 people in England are told they have cancer. More than one million people in the UK today have had a cancer diagnosis, and more than one in three will be diagnosed at some time in their life. As well as taking action today to support people from the moment they suspect they have cancer, Macmillan is shaping the future of cancer care. Our increasing range of services, including our Macmillan nurses, doctors and other health and social care professionals, cancer care centres, cancer information, practical help at home and help with money, is funded entirely through the generosity of our supporters.

  2.2  Macmillan welcomes the opportunity to contribute to the Health Committee's Inquiry into Co-payments and NHS Charges. In November 2004 Macmillan launched the Better Deal campaign to highlight the financial costs of cancer. The evidence about hospital travel and parking policies in this submission is taken from studies commissioned as part of the campaign and from the personal stories of cancer patients who have contacted us after hearing about the campaign.

  2.3  Financial worries are a major source of stress for patients. Over three quarters (77%) of respondents to a survey of the CancerVOICES network said they had incurred extra costs as a result of cancer.[29] Patients typically incur a wide range of additional expenses including hospital travel and parking, domestic duties, prescription charges, childcare costs, clothing (due to weight loss/gain), wigs, complementary therapies, and diet supplements. In 2004 our Macmillan Grants service provided financial assistance to 17,102 people affected by cancer and this year we expect to support over 20,000 people. To date this year we have assisted 2,411 people with hospital travel costs (including parking costs), 753 people with hospital visiting costs, and 174 people with prescription charges.


3.1  Hospital parking charges

  3.1.1  Parking charges at NHS hospitals have become an increasingly important source of revenue since hospital car parks ceased to be Crown properties in the 1980s. One hospital trust source told the Health Service Journal that their trust raises more than £250,000 a year from parking charges: "Charging is a big money-maker for trusts. In the last five or six years, trusts have cottoned on to the revenue potential of charging for car parks and turned it into a tax on health".[30] Hospital parking charges in England are not regulated by the Department of Health (DH). In 2003 then health minister John Hutton said: "It is a matter for individual hospitals to decide whether or not to charge for car parking and the cost of such charges in the light of local circumstances".[31]

  3.1.2  Macmillan's 2005 report Free at the point of delivery? is the most comprehensive survey to date of hospital parking charges in the UK.4 Between June 2004 and January 2005 Macmillan conducted a telephone audit of 285 of the 292 UK hospitals that have cancer centres or cancer units. In England, information was collected from 227 of the 229 hospitals providing cancer services. The data from the audit was analysed by Dr Foster Ltd and the key findings about parking charges were: [32]

    —  92% of hospitals in England charged patients for parking;

    —  Parking charges are more prevalent in English hospitals than in the rest of the UK—53% of hospitals in Wales, 20% of hospitals in Northern Ireland and 6% of hospitals in Scotland charged patients for parking;

    —  Hourly rates in English hospitals ranged from 30p to £4.00 an hour, with an average hourly rate of £1.22;

    —  Charges for 24-hour stays in English hospitals ranged from 50p to £30 a day, with an average charge of £5.67 a day;

    —  Six out of 10 hospitals (59%) that charged patients for parking did not provide concessions for cancer patients.

  3.1.3  Macmillan believes that charging patients for parking when they are attending hospital for potentially life-saving cancer treatment is inappropriate and morally unjustifiable. Firstly, cancer patients in particular are penalised by parking charges because they need to make multiple trips to hospital for chemotherapy and radiotherapy. Secondly, the changing nature of cancer treatment means that patients are increasingly receiving these treatments not as in-patients but as outpatients. Four out of five patients receive radiotherapy treatment as outpatients. Finally, the unsuitability and unreliability of public transport and hospital transport means that cancer patients have no alternative but to travel to hospital by car.

  3.1.4  In order to explore the travel problems faced by cancer patients, Macmillan commissioned Opinion Leader Research to conduct patient focus groups.[33] The findings from the focus groups highlighted the number of hospital visits that cancer patients are having to make:

    —  Outpatient radiotherapy involves daily round trips to hospital, five days a week, for up to six weeks;

    —  Outpatient chemotherapy commonly involves two-three journeys to hospital a week but the length of time spent in hospital is longer than for radiotherapy sessions, with chemotherapy patients often having to park for a whole day;

    —  Patients who took part in the focus groups undertook on average 20-30 round trips to hospital for radiotherapy treatment alone, with some patients making up to 50 visits;

    —  Adding in repeat visits for diagnostic tests, consultant appointments, and follow-up appointments, patients made an average of 60 hospital visits throughout the duration their treatment with the number of visits ranging from 30 to 120;

  The following cases illustrate the cumulative cost of parking charges for cancer patients.

Carol, Breast Cancer Patient, Bristol

  After having surgery to remove the tumour, Carol had to travel to Bristol Royal Infirmary to receive radiotherapy and chemotherapy treatment, every day (Monday to Friday) for five weeks. Car parking costs £1.50 for a two hour stay. A course of treatment lasting five weeks has cost her an estimated £162.50 in parking charges.

Sally, Leukemia Patient in her early Thirties, West Midlands

  Sally was diagnosed with acute lymphoblastic leukaemia just before Christmas 2004, and has been undergoing high-dose treatment—about 10 types of chemo and radiotherapy—at Birmingham Heartlands Hospital. She had an autograft (stem cell/bone marrow support) in July. She and her husband spent £8 a day (£2 an hour) parking there every day for five weeks—a total of £280 over a five week period.

AC, Breast Cancer Patient in her Forties

  "Since my diagnosis in May 2001 I have spent over £500 on hospital car parking at various hospitals."

  3.1.5  Most of the patients who participated in the focus groups had opted to travel to hospital by car because of the unsuitability and unreliability of public transport and hospital transport. Patients undergoing courses of chemotherapy and radiotherapy commonly experience side effects such as extreme fatigue, nausea, diarrhoea and neutropenia (a condition which makes patients prone to infection). Consequently these patients are unable to use either public transport or non-emergency ambulances. Patients regularly complain that the non-emergency Patient Transport Service (PTS) is unreliable and involves long waits and lengthy ambulance journeys as other patients are picked up or dropped off along the way. The availability of volunteer driver services, which are better suited to the needs of cancer patients, is patchy and the capacity of such schemes can be limited due to the shortage of volunteers. The following quotes from focus group participants illustrate these problems:

  "Sometimes you don't make it to the bottom of the driveway before you throw up. I was ill. I was terrible, I was sick the whole way home, every single time. There's no way I could have got on a train."

  "We were able to get an ambulance . . . but it takes it about 5 hours to get there and 5 hours to get back. It would have been alright to get there but no way could I have sat in it coming back because you feel so nauseous."

  "I just stood and waited on the bus. I must have stayed an hour and a half waiting on a bus and I'd just had radiotherapy."

  The Department for Transport estimates that 1.4 million people miss, turn down or simply choose not to seek medical help because of transport problems.[34] However, missing an appointment is not an option for cancer patients for whom treatment may literally be a matter of life and death. Charging cancer patients for parking when they have no alternative but to travel to hospital by car is effectively a tax on illness. If the NHS wants to avoid the charge that it is profiting from sick and vulnerable patients it should ensure that specific groups of patients are exempted from charges.

Recommendation: Macmillan Recommends that Patients who Undertake Regular Visits to Hospital for Cancer Treatment should be Exempt from Parking Charges.

3.2  Prescription charges

  3.2.1  Cancer patients who are not receiving in-patient treatment may be liable to pay for prescriptions for a wide range of drugs and treatments. The prescriptions required by cancer patients are mainly for drugs to counteract the side effects of treatment (nausea, fatigue, etc.). However, some patients who are prescribed cancer drugs such as tamoxifen or oral chemotherapy agents may also be liable for prescription charges. A list of the range of drugs and treatments for which cancer patients might incur prescription charges can be found at Appendix 1.

  3.2.2  As radiotherapy and chemotherapy treatment is increasingly being delivered on an outpatient or day surgery basis, it is becoming more and more common for cancer patients to incur charges for prescriptions. Nearly one in five respondents (17%) to Macmillan's survey of the CancerVOICES network said that prescription charges were one of the extra expenses they had incurred since being diagnosed with cancer.[35] One in six respondents to a recent Macmillan survey of 50 breast cancer patients said that prescription charges were their single biggest expense.[36] Most of the patients who took part in the focus groups conducted by Opinion Leader Research for Macmillan said that the cost of multiple prescriptions was a major concern.[37] The following examples illustrate the costs incurred by patients:

LC, Breast Cancer Patient in her Fifties

  She took Tamoxifen and other drugs for three years. Her bi-monthly prescription would, at the current rate (£6.50 per item for 18 prescriptions), cost £117 in total. In addition she also had to pay a monthly prescription charge for anti-depressants and for sleeping tablets.

DB, Breast Cancer Patient in her Fifties

  During treatment DB was prescribed a number of items including steroids, relaxants, anti-sickness medication, and constipation medication. Each fortnight she was spending £24 on prescribed items an, over a period of six months she spent approximately £288 in total. When she finished treatment she was prescribed tamoxifen.

AC, Breast Cancer Patient in her Forties

  Although AC didn't have to take Tamoxifen she took a whole host of other drugs as a result of her cancer ie painkillers, anti-depressants, anti-nausea medication, medication for constipation. She had five items each month, which at current rates would cost £32.50 each month.

PJ, Ovarian Cancer Patient in her Sixties

  She was given prescriptions to combat the side-effects of her treatment. "It's unfair that you have to pay for medication to counteract the side-effects of your treatment, it doesn't even dawn on you that you may need to do that", she said.

  Recommendation: Patients undergoing treatment for cancer should be exempt from prescription charges for life-saving cancer drugs or for drugs to control the debilitating side effects of treatment. Terminally ill patients receiving palliative care at home should also be exempt from prescription charges.

3.3  Television and telephone charges

  3.3.1  Cancer patients who took part in the focus groups conducted by Opinion Leader Research reported a range of costs incurred by hospital in-patients, notably food and drink, magazines, TV rental and telephone calls. Several participants were "highly critical of the premium rate charged for calls into the hospital to the bedside phone".[38] Television rental and phone charges were among the most commonly cited costs incurred by cancer patients according to benefit advisers in our recent Access Denied report.[39] The study explored benefit advisers" perceptions of the problems faced by cancer patients in accessing disability benefits. In-depth interviews were conducted with 17 cancer-specialist advisers who work in Macmillan-funded advice services which provide advice and support to over 10,000 cancer patients a year.

  3.3.2  The following case studies illustrate the impact of charges for phones, televisions and the Patientline communications system (which combines telephone, television, email and internet access).

PJ, Whose Sister had Bowel Cancer

  PJ's sister was treated at St Thomas' in London. PJ spent £53 in total calling her sister on Patientline and, consequently, her monthly telephone bill more than doubled. It cost 39p a minute off peak and 49p a minute at peak rate but as she says "when someone is ill there is no peak or off peak". For patients to call out the charge was 10p a minute while TV rental cost her sister £3.50 for 24 hrs—but she would only want to watch a couple of programmes so this worked out to be very expensive. She says that her sister was in hospital for three weeks and had no choice but to use Patientline. "It's like grave robbing, they're making a profit out of other people's misery", said PJ.

PW, Breast Cancer Patient in her Thirties

  "[Patientline] cost me a fortune, but I had to use it as I have a young daughter who I needed to keep in contact with and make arrangements for". In relation to TV charges she said "I had no choice but to pay to use the TV. I was stuck in bed, it was difficult to move, and the TV was the only entertainment. I never expected I'd have to pay for the privilege"

AC, Breast Cancer Patient in her Forties

  She had to pay a deposit for the TV and £5 a day hire. AC said that it "added up to quite a bit but you don't really have much choice, you have to pass the time somehow".

  3.3.3  Disability Living Allowance (DLA) and Attendance Allowance (AA) are the main benefits for meeting the extra costs of disability. However these benefits are withdrawn for adults after 28 days spent in hospital—either in one continuous spell or separate spells linked together by periods of less than 28 days (the so-called "linking rule"). Currently, other social security benefits are downrated after 52 weeks though, as the Chancellor announced in the March 2005 Budget, the hospital downrating rules will be scrapped altogether from April 2006 for all benefits except DLA and AA. In a 2003 parliamentary debate Maria Eagle MP, then Parliamentary Under-Secretary of State for Work and Pensions, explained the rationale behind the DLA/AA in-patient rules: "All in-patients' disability-related needs are met by the national health service. That is where the rule against overlapping provision comes in, and that is why DLA and AA are withdrawn".[40] However, as our evidence shows, in-patients incur a range of extra costs including charges levied by NHS hospitals for phone and television use. These are not frivolous types of expenditure but essential to ensure the emotional well-being of patients undergoing treatment for cancer.

  Recommendation: The DLA and AA downrating rules should be relaxed in recognition of the additional costs, including phone and TV charges, incurred by hospital in-patients.

3.4  The hidden costs of travel

  3.4.1  Although hospital travel costs may not appear to be NHS charges, Macmillan believes that these hidden treatment costs should also be regarded as co-payments. As we have explained in para 3.1.5 above, cancer patients have no alternative but to travel to hospital on a regular basis for treatment. The delivery of chemotherapy and radiotherapy on an outpatient basis means that cancer patients incur quite substantial travel costs during their course of their treatment. Patients who took part in the Opinion Leader Research focus groups spent £380 on average on travel and parking charges with costs ranging from £25 to £848.[41]

  3.4.2  The NHS is making considerable savings by delivering treatment on an outpatient or day surgery basis. An influential NHS Modernisation Agency document which urged hospitals to make day surgery rather than in-patient treatment the norm, estimated that trusts could save £200 a day as a result.[42] A hospital can therefore save £6,000 by delivering a six week course of radiotherapy on an outpatient basis. Whilst we are in favour of hospitals delivering treatment in more cost-effective ways, this should not be achieved by shifting the financial burden onto patients in the form of travel and parking charges. The NHS is supposed to be free at the point of delivery and therefore we strongly believe that these hidden costs of treatment should not be borne by patients undergoing treatment for serious and life-threatening diseases like cancer. We would like to see the NHS take a more holistic approach to the issue of financial efficiency. If hospitals are introducing new ways of delivering treatment which free up in-patient beds, the financial implications for patients should always be considered. In the case of outpatient cancer treatment we would like to see some of the considerable savings that trusts are making reinvested into helping patients with travel costs.

  Recommendation: All patients travelling to hospital for regular cancer treatment should have their travel costs reimbursed through the Hospital Travel Costs Scheme on a non-means tested basis.


  4.1  As we have said earlier, Macmillan believes that parking charges and prescription charges for patients undergoing cancer treatment are morally unjustifiable.


  5.1  Hospital car parking charges appear to be reasonably well advertised on hospital websites. However, as our Free at the Point of Delivery? report shows, patients are not being routinely informed about parking discounts or about the Hospital Travel Costs Scheme (HTCS) under which parking charges can be reimbursed for patients on benefits/low income (see para 7.1 below).

  5.2  While prescription charges might be reasonably transparent, patients are not always warned at the start of their treatment that they might incur such expenses nor are they routinely advised about pre-payment certificates, which reduce the cost of repeat prescriptions as the following examples illustrate:

PW, Breast Cancer Patient in her Thirties

  She hasn't ever been told about pre-payment certificates. She saw a sign in the chemist about it but doesn't think it would be cost effective for her. She never expected that she would have to pay for drugs after her treatment, she says it's "extra money from my pocket, another extra expense when cancer had already meant my income was reduced."

AC, Breast Cancer Patient in her Forties

  Despite having to spend over £30 a month on prescriptions she was never told about pre-payment certificates—she found out about these herself. "It was really daunting to fork out all this money when I was so ill", she said. She was never told that she would have to pay for all of this medication after she finished treatment.

  5.3  Although Patientline leaflets detailing the charges are available on hospital wards, relatives and carers are not always warned about the cost to the caller of phoning the patient in hospital. PW, a breast cancer patient in her thirties, told us that relatives and friends "weren't aware that the charges would be so high". PJ, whose sister had breast cancer, said that each time she called the Patientline telephone system there was an introduction of at least a minute before she could dial the patient's extension which she could not skip. Often her sister would turn her phone off as she felt too ill to speak and did not want to be disturbed but there was no way for PJ to find this out until she had got past the recorded message and dialled the number, by which time the call may have cost £1 or more.

Recommendation: Before Treatment Commences Patients should be Routinely Advised about the Range of Charges and Expenses they are likely to Incur during the Course of their Treatment.


  6.1  Department of Health (DH) guidance on car parking charges advises hospitals to "consider" concessions for certain patient groups but does not specify which patients should be granted concessions. [43]By contrast, the equivalent Scottish Executive Health Department guidance specifically suggests that "consideration should be given to providing concessions to certain categories of patient (for example "patients attending regularly for dialysis or radiotherapy)".[44] The consequence of the Department of Health's laissez faire approach to parking charges in England is a postcode lottery of charges and local concessions. A reanalysis of our hospital audit data found that only four in 10 hospitals (42%) with cancer centres provide free parking for certain cancer patients.[45] Appendix 2 illustrates the variations in practice.

  Recommendation: Macmillan recommends that Department of Health guidance on parking should be more prescriptive and should instruct hospitals to offer exemptions to specified groups of patients, including cancer patients who regularly travel to hospital.

  6.2  The current system of medical exemptions from prescription charges, which was drawn up in 1968, is outdated and riddled with anomalies. 30 years ago cancer patients were much more likely to be treated in hospital and die from the disease. Consequently, prescription charges were not such a big issue for cancer patients. Today, as a result of more effective treatments, improved survival rates and the shift from in-patient to outpatient treatment, cancer patients increasingly find themselves liable for prescription charges often for long periods of time. This trend is set to continue as oral chemotherapy becomes more widely employed. Patients can purchase pre-payment certificates and may be eligible for free prescriptions if they are in receipt of certain means-tested benefits or if they satisfy the NHS Low Income Scheme means test. However, Macmillan wants cancer patients to be eligible for free prescriptions without having to undergo a means test. As we have argued earlier, cancer patients should not have to pay for cancer drugs or drugs and treatments to control symptoms.


  7.1  Department of Health guidance to hospital trusts specifically states that "notices about the HTCS should be displayed in all patient areas" and that "provider units should ensure that they provide details of the HTCS and of local transport and concessionary fare arrangements with appointment or admission letters".[46] However our hospital audit shows that this guidance is not being implemented. We asked cancer nurses and information postholders in cancer centres/units how the HTCS and local parking concessions were promoted in their hospitals and found that:

Promotion of HTCS

    —  48% of health professionals in England either did not know how the scheme was promoted or else said it was not promoted;

    —  Only one in five respondents in England (19%) said that their hospital was promoting the scheme through posters, website, appointment letters or at first appointment;

    —  34% of respondents in England said that patients were informed by word of mouth alone;

    —  Only 7% of respondents who knew if the HTCS was being promoted (UK-wide) said it was advertised in appointment letters, while 21% said it was promoted through posters.

Promotion of Parking Discounts

    —  Parking concessions varied from hospital to hospital—some hospitals provided free parking for cancer patients while others offered discounted rates;

    —  Only 9% of hospitals promote parking discounts by leaflets and less than one in five (18%) promoted through posters. The most common method of promoting parking discounts for cancer patients was word of mouth;

    —  Hospitals do not always promote parking discounts. As one respondent told us "In theory there's a service people can apply for to get parking for £3 a day, but in reality it's not openly offered, advertised or discussed".

  7.2  A 2001 Audit Commission report found that the Hospital Travel Costs Scheme (HTCS) was not well publicised.[47] Four years since that report was published it is clear that little progress has been made and that some hospitals are deliberately not advertising the scheme. One respondent told us that "Transport and parking issues are not highlighted to patients because the area is too problematic". Another said that her hospital did not promote the HTCS because too many patients would claim travel costs and the hospital did not have sufficient funds to cover this (even though Primary Care Trusts reimburse hospitals for HTCS expenditure). It is unacceptable that some hospitals, either deliberately or through omission, are not advising patients of their statutory entitlement to financial help under the HTCS.

Recommendation: Macmillan Believes that Compliance with Departmental Guidance on HTCS should be seen as a "Must-Do" Requirement and not an Optional Extra. All Hospital Trusts should be routinely Informing Patients about HTCS and Local Parking Concessions through Posters and Appointment Letters. We urge the Committee to ask the Department of Health to outline the Action it intends to take to ensure that Trusts Comply with this Guidance.

  7.2  We would also like to know what progress the Department of Health is making in implementing the recommendations in the 2003 Social Exclusion Unit report Making the Connections.[48] The SEU recommended that the Department of Health should develop options to provide information and advice on getting to healthcare facilities and book transport where appropriate. One idea floated by the SEU was the development of a "one-stop shop" service which would provide advice to patients on transport options and arrange patient transport. However, to date, we have seen no evidence that the Department has acted on this recommendation.

  7.3  Macmillan wants a much more systematic approach to advising patients about the full range of concessions and benefits to which they might be entitled. The NHS is very poor at informing patients about financial concessions and benefits. A recent National Audit Office report found that 77% of cancer patients were not given information about financial benefits.[49] However, simply giving patients written information is not sufficient. Patients also need help to interpret complex information about benefits and concessions and support to negotiate the benefits maze.

Recommendation: Macmillan wants to see all Cancer Patients offered Specialist Benefit Advice at Diagnosis and at Key Points in the Patient Journey. Referral Mechanisms should be built into Care Pathways so that Patients are given Advice about the Right Benefits and Concessions at the Right Time.


  8.1  Macmillan's primary concern is to ensure that cancer patients do not have to pay for the "privilege" of undergoing cancer treatment. Therefore we support any reform which means that cancer patients do not have to pay for travel, parking charges or prescriptions.

  8.2  It could be argued that foregoing revenue from car park charges means redirecting money away from other front line hospital services. We think this argument is disingenuous. Firstly, we believe that the failure to consider the impact of charges on repeat visitors amounts to poor planning. Secondly, as we have said earlier 42% of hospitals with cancer centres provide free car parking for certain cancer patients. If these hospitals can provide front line services without having to levy parking charges on cancer patients then we can see no good reason why all other hospitals cannot do the same.


  9.1. Macmillan believes that an investigation of the punitive impact of NHS charges and co-payments is long overdue. We would like to give oral evidence to the Committee. Considered in isolation each charge or co-payment may not appear particularly onerous, but when these costs are added up the financial impact of cancer on patients' lives can be very substantial. Moreover, many patients find themselves having to meet these additional costs at precisely the same time that household income may be depleted through loss of earnings. In a recent Macmillan survey one in four breast cancer patients said they had to cut back on food shopping or bought cheaper food (28%).[50] A recent survey by CancerBACUP found that 39% of working age cancer patients had experienced "significant financial difficulties' as a result of cancer.[51] NHS charges and co-payments represent a significant component of these additional costs and it is vital that action is taken to relieve the financial burden on cancer patients.

Duleep Allirajah

Senior Policy Analyst

Macmillan Cancer Relief

December 2005

29   Macmillan survey of CancerVOICES network (2003-unpublished). CancerVOICES is a network of people affected by cancer that is supported by Macmillan. Back

30   Health Service Journal Special Report, No walk in the park: how trusts manage their car parking, 16 September 2004. Back

31   House of Commons Written Answers, 28 April 2003, Col 278W. Back

32   Allirajah D, Herbst K, Morgan L, Free at the Point of Delivery? Exposing the hidden cost of hospital travel and parking for cancer patients, Macmillan Cancer Relief in association with Dr Foster Ltd (2005). Back

33   Opinion Leader Research (June 2005), Macmillan Cancer Relief Better Deal Costs. The findings from this study were published in Allirajah et al Free at the Point of Delivery? (2005). Back

34   Department for Transport (DfT), Accessibility of local services and facilities (2002). Back

35   Macmillan survey of CancerVOICES network (2003-unpublished). Back

36   Can you afford to have breast cancer? Macmillan Cancer Relief press release, 26 October 2005. Back

37   Opinion Leader Research (June 2005), Macmillan Cancer Relief Better Deal Costs. The findings from this study were published in Allirajah et al Free at the Point of Delivery? (2005). Back

38   Opinion Leader Research (June 2005), Macmillan Cancer Relief Better Deal Costs. The findings from this study were published in Allirajah et al Free at the Point of Delivery? (2005). Back

39   Miller S, Access Denied: Benefits advisers' perceptions of the problems cancer patients face when claiming Disability Living Allowance and Attendance Allowance, Macmillan Cancer Relief (2005). Back

40   House of Commons Hansard, 25 March 2003, Col 27WH. Back

41   Opinion Leader Research (June 2005), Macmillan Cancer Relief Better Deal Costs. The findings from this study were published in Allirajah et al Free at the Point of Delivery? (2005). Back

42   NHS Modernisation Agency, 10 High Impact Changes for service improvement and delivery: a guide for NHS leaders (September 2004). Back

43   Department of Health, Income Generation-Car parking charges: A guide to implementation (1996). Back

44   Scottish Executive Health Department, Guidance on hospital car park charging, NHS HDL(2004) (April 2004). Back

45   In November 2005 Macmillan re-analysed the hospital audit data and found that 18 out of 42 hospitals with cancer centres (42%) provide free parking for radiotherapy or chemotherapy patients or both. Back

46   18 Department of Health, The hospital travel costs scheme (published on the DH website). Back

47   See Audit Commission, Going Places: Taking people to and from education, social services and healthcare (2001) and NACAB, Unhealthy Charges: CAB evidence on the impact of health charges (2001). Back

48   Social Exclusion Unit, Making the Connections: Final Report on Transport and Social Exclusion 2003. Back

49   National Audit Office, Tackling Cancer: Improving the Patient Journey February 2005. Back

50   Can you afford to have breast cancer? Macmillan Cancer Relief press release, 26 October 2005. Back

51   CancerBACUP, Work and Cancer: How cancer affects working lives (2005). Back

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