Memorandum submitted by Mind (CP 19)
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
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
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charging is out of date and does not address the health needs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
The Wanless Report (2002) 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
3. WHAT CRITERIA
Mind believes prescriptions should be free to
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
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.
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)
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
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
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
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.
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.
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
6. OTHER ISSUES:
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"
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.
6 December 2005
53 Wanless, D (2002) Securing our future health:
Taking a long-term view, London, HM Treasury. Back
Disability Rights Commission (2005), Interim Report of a Formal
Investigation into Health Inequalities. Back
National Association of Citizens Advice Bureaux (2001) Unhealthy
Charges, London, NACAB. Back
Mind (2003) The Hidden Costs of Mental Health, London,