House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Memorandum submitted by Mind (CP 19)

1. INFORMATION ABOUT MIND

Mind is one of the leading mental health charities in England and Wales.

Mind's vision is of a society that promotes and protects good mental health for all, and that treats people with experience of mental distress fairly, positively, and with respect.

The needs and experiences of people with mental distress drive our work and we make sure their voice is heard by those who influence change.

Our independence gives us the freedom to stand up and speak out on the real issues that affect daily lives.

We provide information and support, campaign to improve policy and attitudes and, in partnership with independent local Mind associations, develop local services.

We do all this to make it possible for people who experience mental distress to live full lives, and play their full part in society.

Being informed, diversity, partnership, integrity and determination are the values underpinning Mind's work.

Mind would like to make the following comments in respect of the Committee's inquiry into co-payments and charges in the NHS.

2. ARE CHARGES FOR PRESCRIPTIONS EQUITABLE AND APPROPRIATE?

Mind believes the current system of prescription charging is out of date and does not address the health needs of the population, especially those on low incomes. It is inequitable and inappropriate as it discriminates against people who experience mental distress.

The Wanless Report (2002) [53]states some of the issues clearly:

"The system of free prescription in the United Kingdom is illogical, irrational and works against the principles of the National Health Service."

In particular, the current system discriminates against people with ongoing mental health conditions who are on low incomes, but whose incomes are above the threshold for exemption.

This is compounded by the current Department of Health advice (based on cost rather than patient preference) to prescribe for periods of a maximum of one month at a time. For people who take medication long-term, and who may in the past have been prescribed this on a three-monthly basis, their costs are trebled by having to renew their prescription three times more often. This is in addition to the inconvenience to the person concerned and the costs to the NHS caused by the renewal process. In addition, some people may be prescribed medication eg antidepressants for one week at a time, meaning the costs become substantial.

Mind recommends that Department of Health advice be reviewed to recommend that the length of prescription offered should depend on the needs and wishes of the patient and the prescriber's view of what is most suitable based on clinical rather than cost factors.

3. WHAT CRITERIA SHOULD DETERMINE WHO SHOULD PAY AND WHO SHOULD BE EXEMPT?

Mind believes prescriptions should be free to all.

If this is not introduced and a system of exemptions is retained, all those on low incomes should be exempt. However, the current system means there is a cut-off point for people who are on low incomes but who have an income of a few pounds over the limit, meaning they are required to pay the full amount. The system of exempting some people receiving Child Tax Credit or Working Tax Credit is welcome, but this does not cover all those on low incomes, for example some people on Incapacity Benefit. The criteria need to be revised to ensure all those on low incomes can receive the treatment they need.

In addition, Mind believes that all those with a long-term condition requiring medical care or treatment, including recurring conditions, should be exempt from prescription charges. The criteria for this should ensure that people experiencing mental health problems are included. However, we believe the current system of listing specific conditions for exemption results in inequality and exemptions should be based on the duration of the condition and the need for care or treatment rather than the specific diagnosis given.

3.1 The importance of free prescriptions for people experiencing mental distress

Many people take medication on a long-term basis in order to help maintain their mental health. However, mental ill-health requiring ongoing treatment is not currently listed as a condition entitling exemption from prescription charges. Treatment for mental health problems may consist of a number of different types of medication prescribed concurrently. In addition, the side-effects associated with some medication used to treat mental health problems often mean that further medication is required to counteract or mitigate these effects.

Furthermore, people with mental health problems are more likely than the general population to also have poor physical health. The Disability Rights Commission inquiry into the physical health of people with mental health problems or learning disabilities has found that people with a diagnosis of schizophrenia or bi-polar disorder are more likely to have ischaemic heart disease, stroke or hypertension than the general population[54]. This means that they may require a relatively high number of prescriptions for medication to maintain their mental and physical health. The National Association of Citizens Advice Bureaux's "Unhealthy Charges" report (2001)[55] found evidence that some people have to make choices between medications as they cannot afford the prescription charges for all the medications recommended for them.

Although pre-payment certificates are available for those currently receiving high numbers of prescriptions, the cost of these is prohibitive as many people on low incomes cannot afford the initial outlay for these, either for the four-monthly or annual certificate.

Enabling people who experience mental health problems to receive their medication free of charge will mean they can be assured of receiving the medication they need when they need it, without the anxiety of wondering whether they can afford it, or what they have to go without in order to pay for it. It would have the further benefit of helping to address the physical health inequalities experienced by people with mental health problems.

3.2 Right to free aftercare under Section 117 of the Mental Heath Act

People discharged from section 3 Mental Health Act treatment are entitled to free aftercare, including exemption from prescription charges for that care, under the Act. However, there are anomalies and inconsistencies within the system as many of those eligible are not aware of this, resulting in some paying for their prescriptions while others do not. In addition, only medication which is required for the person's mental health treatment is exempt, despite the fact that the person may also need to take a number of other medications (see above). There may be confusion as to which is exempt and which is not, especially if medication is frequently changed.

People who have not been formally "sectioned" under the Mental Health Act do not receive section 117 aftercare and are not entitled to free prescriptions upon discharge. This includes people who have either accepted treatment voluntarily or who are detained in hospital as "informal" patients,—that is, they are compliant but lack capacity to consent to treatment (known as "Bournewood" patients). This anomaly needs to be addressed.

In addition, new mental health legislation will seek to limit the free aftercare currently provided by section 117 of the Mental Health Act to more narrowly specified forms of care and for the limited period of six weeks. Mind believes this period is too short to ensure a person receives adequate care and support after discharge.

3.3 Non-Resident Treatment Orders under new Mental Health legislation

The draft Mental Health Bill 2004 provides for compulsory treatment in the community under "non-resident treatment orders." Failure to take this medication could result in detention in hospital.

Mind opposes the principle of non-resident treatment orders. It is likely that the government would plan to make certain types of medication freely available to people receiving ordered treatment in the community. But in the absence of published draft regulations and codes, we do not have that assurance, and can only guess at the adequacy of prospective arrangements.

The new treatment orders are likely to be relatively narrow. They may require an additional application to the Mental Health Tribunal to be changed (for instance for a change in medication). Medication or other treatment might be prescribed that promotes mental health or prevents deterioration that is not within the terms of the compulsory order.

Mind therefore seeks a firm undertaking that all the medication that could be prescribed will be contained within treatment orders or alternatively that all medication prescribed to a person under a non-resident order will be free. It would be counter to natural justice to require a person to pay for medication which a tribunal had ordered them to take, and upon which their liberty therefore depends. For all the reasons explained above and by the same token, people on compulsory treatment orders should not be obliged to make invidious choices about the amount of chargeable care or treatment that they can afford when they are vulnerable and at risk of losing their freedom.

4. SHOULD PRESCRIPTION CHARGES BE ABOLISHED?

Mind believes, for the reasons we have outlined above, that prescription charges should be abolished, and that charges in other areas should be revised in order not to impact disproportionately upon people on low incomes.

5. ARE OTHER NHS CHARGES FAIR AND EQUITABLE?

5.1 Car Parking

Charges for car parking at NHS facilities are inequitable. This issue is of particular importance to people visiting a relative or friend who is in hospital over a long period of time, and is related to our comments on travel costs for visitors (see para 6.1). It is important that a person experiencing mental health problems stays in touch with their social networks, and if a friend or family member is visiting frequently and they are on a low income, the cost can become prohibitive.

A system should be established for claiming back parking charges for people who are on low incomes who are the primary visitor for someone in hospital, or if they are enabling children under 18 of the person in hospital to visit their parent, up to an agreed amount.

5.2 Televisions

There has been a move in some trusts towards the installation of bedside communication facilities including TVs which require payment for use. Mind considers these to be completely inappropriate for mental health in-patient units. Many service users currently comment that there is very little activity available in in-patient units, and the TV lounge provides a very important source of activity and also a social focus for the unit.

If bedside facilities are provided at all in mental health units, TV channels should be free of charge.

5.3 Telephones

In mental health units payphones are usually provided which require phone cards which are more expensive than domestic call rates. This is inequitable for people on low incomes. Trusts should not seek to make profit on phone calls made by patients, and should make phone cards available which are best value for money for patients.

All in-patient wards should therefore have a telephone which is available for patient use which accepts incoming calls.

6. OTHER ISSUES: NON-NHS CHARGES INCURRED IN RELATION TO NHS TREATMENT

Mind would like to add the following comments for the Committee's attention:

6.1 Visiting expenses

There are a range of costs incurred by those who experience mental ill-health or their carers which are levied by other agencies. This includes payment for travelling or overnight costs incurred by those visiting people who may be using mental health services a long distance from home, such as national specialist centres, regional secure or high secure hospitals. Currently, the only means of seeking funding for visiting costs is through application to the Social Fund, which is discretionary, limited and in some cases repayable.

In 2004, the ODPM Social Exclusion Unit published its report on mental health and social exclusion, stating the importance of social networks and support in promoting mental well-being and recovery. Ensuring people who are mental health in-patients can maintain contact with their families and friends should therefore be part of their care plan, and people on low incomes should receive financial support to enable this. The Assisted Prison Visits Scheme provides a comparable system for people visiting prisoners which could be used as a model.

6.2 Paying for treatment recommended by a GP but unavailable through the NHS

In addition, many people who experience mental distress find themselves paying for treatment which their GP or other doctor recommends, but are unable to access through the NHS such as counselling and psychotherapy.

In Mind's "Hidden Costs of Mental Health" report (2003)[56], 21% of respondents had paid for counselling or therapy prescribed by their GP. These therapies are often unavailable via the NHS due to long waiting lists, lack of NHS therapists in the area and cuts in services etc. However, they are often vital to supporting people's mental health. Many people pay for these privately despite being on low incomes, because their health would otherwise deteriorate significantly. As well as the negative impact upon their lives, this would ultimately result in increased costs to the NHS and the state generally.

Failure to provide adequate free treatments for people experiencing mental distress is a false economy. There should be recognition of the high costs incurred to people on low incomes who need access to therapies in order to maintain their mental health, as a result of the lack of adequate NHS provision.

7. ORAL EVIDENCE

Mind would be pleased to give oral evidence to the Committee on this topic if it would be helpful to the inquiry.

Moira Fraser

Mind

6 December 2005