Memorandum submitted by the Socialist
Health Association (CP 9)
The Socialist Health Association was founded
in 1930 to campaign for a National Health Service and is affiliated
to the Labour Party. We are a membership organisation with members
who work in and use the NHS. This submission is made on behalf
of the Association.
We believe the NHS should be organized in such
a way as to minimize disparities in quality of service between
the socially excluded and the most advantaged sections of society.
Ideally it should be organized in such a way that all such disparities
disappear.
We have campaigned for many years for a free
health service without any charges. We are very willing to give
oral evidence to the committee.
1. Whether charges for treatments, including
prescriptions, dentistry and optical services; and hospital services
(such as telephone and TV use and car parking) are equitable and
appropriate?
As Aneurin Bevan said in the debate about the
introduction of prescription charges in December 1949: "The
proposal to have a charge up to 1s. creates no administrative
difficulty at all. The administrative difficulties arise out of
the necessity of exemption." It is apparent from the debate
at that time that charges were imposed primarily as a method to
restrict demand. It is not clear to us why it is still thought
necessary to restrict demand specifically for medication prescribed
outside hospital, wigs and trusses, dentistry and spectacles,
but only for poorer people of working age. Since we established
the National Institute for Clinical Excellence there are criteria
for the prescription of medication and other treatments. It is
difficult to see what positive role these charges play.
"What evidence is there that user charges,
known to health economists as co-payments, have the selective
effects on consultation rates required to restrain over-use, even
if that were a real problem? Obviously user charges discourage
use, but economists have good evidence that consulting behaviour
has little elasticity. Poor people will give higher spending priority
to consulting a doctor than to food, if they believe medical advice
is needed.[62]
The effect of user charges is simply to reduce all consultations
across the board, regardless of the nature of the problems that
prompt them. The effect is selective only for those with lowest
incomes, least able to afford them, but most likely to be sick.[63]
In the early years of the African AIDS pandemic, user charges
were imposed at state-funded Sexually Transmitted Disease (STD)
clinics in Kenya on advice from the World Bank and as a precondition
for international aid. Consultation rates fell by 60%.[64]
Public care systems have collapsed throughout Africa: no money,
no treatment.[65]
User charges are advocated not to promote more
rational behaviour, but to shift public behaviour `corrupted'
by experience of a free public service back to a `normal' commercial
pattern."[66]
2. What is the optimal level of charges?
In our view zero is a proper level of charge
for treatment or services which are clinically required. If a
treatment or service is not clinically required then we would
not consider that it should be within the scope of the NHS and
charges might properly be made.
3. Whether the system of charges is sufficiently
transparent?
The Director of the SHA worked for ten years
as a Welfare Rights Officer in a large teaching hospital giving
advice to patients and their families. He can give evidence that
the Hospital Travel Costs Scheme in particular is not understood
by those who are intended to benefit from it or those who administer
it. In many hospitals determined efforts are made to prevent patients
from claiming the help with fares to which they are entitled.
The offices concerned are hidden away in obscure parts of the
hospital, there is no publicity given to the scheme and the offices
are often closed at times when patients would reasonably want
to access them.[67]
Although the research upon this work was based is now dated we
have reason to believe that little has changed.
There are particular problems with the cost
of taxi fares. Many hospitals refuse to pay for taxis. The official
guidance on this point states:
"In a few cases, where there is no alternative
(for example, in cases where patients have restricted mobility,
or public transport is not available for all or part of the journey),
patients may have to use a taxi or volunteer car service for the
whole or part of their journey."[68]
This does not correspond with the law, which states:
"The amount of any NHS travel expenses to
which a person is entitled under these Regulations—
(a) must be calculated by reference to the cost
of travelling by the cheapest means of transport which is reasonable
having regard to the person's age, medical condition and any other
relevant circumstances;"[69]
It seems to us perfectly reasonable that patients
should attend hospital using a taxi, and indeed that they should
be encouraged to use taxis, which are a form of public transport,
rather than use their own vehicles for which car parking provision
should be (but rarely is) made.
4. What criteria should determine who should
pay and who should be exempt?
"The present system of NHS charges is a
dog's dinner lacking any basis in fairness or logic" Lord
Lipsey, Social Market Foundation. In reply to this comment, made
in the SMF's report in 2003 the Department of Health said it regularly
reviewed its prescription policy. It is difficult, however, to
discern any evidence of such reviews having any influence on the
real world. The list of conditions which give exemption from prescription
charges appears to have been laid down in 1950, on the basis that
these were conditions where medication was then permanently required.
We are not aware that there has been any subsequent change. As
stated above we feel that the fairest and most efficient system
would be to abolish charges altogether. We defy the Department
to produce a fair and acceptable system of charges to replace
the present embarrassing mess.
5. How should relevant patients be made more
aware of their eligibility for exemption from charges?
If there are no charges we will not have to
worry about this matter. If there were a fair and comprehensible
system of charges and exemptions it would be much easier to explain.
The lack of awareness of exemptions, particularly in respect of
Hospital Travel Costs, acts in practice as a system of rationing
by ignorance which is perhaps the most indefensible of all rationing
systems.
6. Whether charges should be abolished?
A long series of reports have established that
charges on patients are the worst possible method of financing
a health service. These include both the NHS Plan,[70]
and the Wanless Report[71].
The National Consumer Council in 2003 pointed out that around
750,000 people in England and Wales fail to get their prescription
dispensed because of the cost and how little clarity there is
on the purpose of NHS charges.[72]
The National Association of Citizens Advice Bureaux in 2001 described
how the "fundamental contradiction at the heart of the National
Health Service is the existence of charges for essential items
such as prescriptions, dental and optical treatment, within a
service which claims to provide health care free at the point
of delivery".[73]
Further reports have described in detail the
inequitable consequences of the present system for cancer patients,[74]
and the importance of tackling travel costs effectively.[75]
In our view the development of a more complex system of healthcare
provision such as is now proposed, requires this problem to be
tackled now. Many of our members and many NHS staff have formed
the view that this government intends to privatise the NHS. If
the government wants to prove wrong those critics who assert that
the widespread introduction of charging is next on the agenda
then it would do well to sort out this mess.
"The availability of good medical care tends
to vary inversely with the need for the population served. This
inverse care law operates more completely where medical care is
most exposed to market forces, and less so where such exposure
is reduced. The market distribution of medical care is a primitive
and historically outdated social form, and any return to it would
further exaggerate the maldistribution of medical resources."
[76]
We do not accept that it is desirable to deter
the population, particularly the poorer members of it, from seeking
medical attention:
"The myth that consultations for retrospectively
diagnosed `non-illness' represent over-use or abuse is refuted
by evidence, but this has not deterred advocates of NHS `reform'
from using it as a weapon in argument. Bosanquet and Pollard confirmed
its grip on public opinion in their survey noted on p 5. Apparently
unconcerned about whether it was true, they identified it as their
best entry point for eroding persistent public support for an
inclusive NHS funded through social solidarity:
". . . almost two-thirds say that people
visit their GP when there is no real need, simply because the
service is free at point of use . . . it is the public's readiness
to concede over-use . . . that points the way forward . . . With
64% saying that there is over-use, there is a strong moral as
well as practical case for a charge . . ." [77]
There is no way that any care system can function
without the number of people consulting about worries greatly
exceeding the number whose worries eventually prove justified.
For example, rectal bleeding is an important signal of possible
bowel cancer, for which early surgery is life-saving, but it still
commonly presents too late. About 20% of adults have some rectal
bleeding each year, but less than 1% of them consult a GP, and
the proportion referred to a hospital specialist for further investigation
is ten times less even than this.[78]
For this example alone, and there are many others, there is overwhelming
evidence that patients use the NHS too little rather than too
much . . ." [79]
We urge the Government to take a bold step by
abolishing charges. If it is felt necessary to restrict demand
for NHS services then let us devise a rational way of doing so
which does not discriminate on the basis of personal wealth.
"The essence of a satisfactory health service
is that the rich and the poor are treated alike, that poverty
is not a disability, and wealth is not advantaged." [80]
Martin Rathfelder
Socialist Health Alliance
5 December 2005
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Hospital Travel Costs Scheme-Current Practice and Best Practice
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