Select Committee on Health Written Evidence

Memorandum submitted by Which? (CP 17)



  NHS patient charges can act as a barrier to people getting the care or treatment they need, when they need it. They can also cause people to defer treatment which can result in higher long-term costs to the NHS.

  The burden of charges often falls heaviest on those who have the poorest health despite significant numbers of people being exempt from paying charges. Low income exemptions are confusing and many people do not know whether they are exempt from charges or not.

  The proposed new system of NHS dental charges will bring greater simplicity and transparency, but it will not overcome all the problems associated with the current charge system. Proposed charges for bands 2 and 3 are still too high. We also suggest that the oral health assessment should be free of charge.

  The growth in charges for hotel facilities and non-clinical services, including parking, is worrying. While the costs of providing such services should not be met from NHS funds, they should not be used as a source of income generation.

  Travel costs, including parking charges, will be increasingly important with changes in the way healthcare is provided in the NHS. We suggest various reforms to ensure these do not act as a barrier to people seeking or receiving treatment.

  A fundamental review of exemptions should be undertaken to ensure greater consistency and fairness, and to eradicate the historical anomalies between different types of NHS charges and the groups of patients that are exempt from charges. This should be based primarily on clinical considerations, and ensure that no-one is precluded from treatment because of low-income.

  Abolition of all patient charges will require either significant additional investment or take money from other areas of NHS care. In the cash-limited NHS, it is questionable whether this is the best use of money. A thorough cost-benefit analysis is needed to assess whether the costs of removing NHS dental and prescription charges will be off-set by healthcare gains for individual patients and across the NHS as well as savings of administration costs. This should include assessments from the patient's perspective as well as strict economic or clinical considerations.

  Other approaches may help overcome some of the problems caused by charges. For example, adopting a maximum charge payable in any one 12-month period at a level no greater than the current pre-payment certificate. In order to aid budgeting, it should be possible for people to make these payments on a monthly as well as quarterly or annual basis.


  1.  Which?, formerly known as Consumers' Association, is an independent, not-for-profit consumer organisation with around 700,000 members. Based in the UK, it is the largest consumer organisation in Europe. Entirely independent of government and industry, we are funded through the sale of our Which? range of consumer magazines and books, and Drug and Therapeutics Bulletin—our publication for healthcare professionals.

  2.  We campaign on a wide range of issues of importance to consumers, one of which is health. Our health campaign aims to ensure all consumers have access to safe, high-quality and patient-focused healthcare whenever and wherever they need it, together with the necessary information and support to be able to make informed decisions about their healthcare. This aim is supported through consumer and health policy research.

  3.  In compiling this memorandum, we have drawn particularly on our work on dentistry. Which? was a member of the Department of Health working group on NHS dentistry patient charges.

Are charges for treatments, including prescriptions, dentistry and optical services, and charges for hospital services equitable and appropriate?

  4.  It is undeniable that charges for NHS treatments act as a deterrent or prevent some people getting treatment when they needed it. This is despite significant groups of people who are exempt from paying charges. Evidence from the Commonwealth Fund comparative study of five countries (including the UK)[87] indicates that 4% of people failed to fill a prescription or skipped a dose because of cost, rising to 6% for those with below average incomes. While these figures are much lower than for other countries in the study (probably as a result of exemptions), they still represent a worrying number of people who are unable to take required medication because of its cost. For dentistry, the figures are even more concerning. Twenty-one per cent of people had not seen a dentist even though they needed dental care because of cost, rising to 24% for people with below-average income.

  5.  This research confirms findings from NACAB (now known as Citizen's Advice) in its 2001 study of NHS charges, which found prescription, dental and optical charges all acted as barriers to people getting treatment.[88]

  6.  Delaying treatment or failing to seek early or preventive treatments can often result in the need for more extensive and more expensive interventions at a later date. For example, a person with asthma who chooses only to obtain the prescription for medicines that bring immediate relief for their condition, is much more likely to experience crises that require emergency intervention, and in some cases hospitalisation. Thus, for the want of £6.50, the individual patient experiences much poorer long-term management of their condition and the NHS bears significantly higher costs.

NHS Dental Charges

  7.  In the case of dentistry, the financial burden of NHS treatment currently often falls hardest on those with the greatest needs, especially those with low-incomes, but who are above the low-income threshold for exemptions. This is particularly concerning given the close correlation between poor dental health and socio-economic status. And because people aged over 60 years are not automatically exempt from dental charges, many who fall into this group are older people living on limited, fixed incomes.

  8.  The current dental charge regime is extremely complex and grossly opaque, and acts as a real disincentive for many people to seeking treatment. Additionally, the actual level of charges that patients pay can be very high (80% of the cost of treatment up to a maximum of £384 for a course of treatment). Many people put off going to the dentist by the fears of what any treatment might cost.

  9.  Which? research conducted earlier this year shows that dental charges act as a major barrier to many consumers receiving care and treatment. Seven per cent of people who had not visited the dentist in the last year were put off by the cost of treatment and 58% of people agreed with the statement that dentistry costs too much even if it's provided by the NHS.[89] Additionally, many of the stories from consumers left on our website as part of our dentistry campaign, illustrated the real problems many people face meeting the costs of NHS dentistry. Our research and information from consumers paint a picture of people deferring visiting a dentist until it is unavoidable, often resulting in a failure to seek the regular preventive care that is essential to improving oral health.

  10.  As a member of the DH working group on NHS dental patient charges, Which? has contributed to the development of the new system of patient charges that will be introduced in England from April 2006. We believe this new system of patient charges is a significant improvement to the current charge regime. We have particularly welcomed the reduction in the maximum charge now payable for a course of NHS treatment to just less than half the current charge (from £384 to £189). Additionally, the three-band system offers much-needed simplicity and greater clarity so that patients will know in advance what they have to pay for their care. It will also be much clearer when people are receiving private treatment and when it is NHS.

  11.  Although the new system of NHS patient dental charges is much improved, it is not ideal. In formulating the proposals for the new system, the DH working group was required to work within the strictures of ensuring the new charge regime generated the same levels of income as is currently raised by the existing regime (£0.5-0.6 billion pa). This requirement has determined the levels at which the charges are set. It also precluded making dental check-ups or the oral health assessment free as is being done in Scotland and Wales.

  12.  Which? has argued that the band charges for levels 2 and 3 are too high, and Band 3 should be set at about £125-130. In our response to the DH consultation on the new system of dental patient charges, we also argued that including repair and replacement of dentures or orthodontic appliances in Band 3 would cause significant hardship, with many people, including older people on fixed incomes, paying significantly more under the new system. While inevitably some people will pay less under the new system and some more, we are pleased that the Government has responded to our concerns in its final scheme for patient dental charges.

Travel costs, and parking and other charges

  13.  In addition to NHS prescription, dental, optical and other charges, the costs of travel, including parking charges, are becoming an increasingly important additional financial burden for patients that can seriously affect access to care. Problems are particularly acute for patients who require long courses of treatment such as physiotherapy, chemotherapy or radiotherapy, or who have low incomes. These charges are of increasing importance as more care is provided on an out-patient or day-care basis, and services are rationalised or centralised on single sites. Additionally, roll-out of patient choice across the NHS will mean more people are likely to travel to receive treatment.

  14.  As with all charges, the burden of these costs falls heaviest on those who are sickest or who have low-incomes. In our recent report Which Choice? Health[90], we highlighted the impact of travel costs on limiting the choices of people, particularly those on low incomes or living in rural areas, and the need for assistance with travel costs to ensure they are not disadvantaged in their choice of treatment options because of the cost of getting there.

  15.  Help with travel costs is available for people on low-incomes but is only provided to attend a hospital or other facility for NHS treatment under the care of a consultant. As more treatment is provided outside hospital, many of these clinics or facilities are not covered by the current scheme, which can again limit access to treatment for some of the sickest and most vulnerable people. This has been a particular problem for people needing dental treatment who have to travel many miles to receive care because of the difficulties in securing NHS dental treatment locally. We suggest that the current scheme to provide financial help with travel to hospital should be extended to cover types of treatment that are provided in non-hospital settings and are not under the care of a consultant.

  16.  The creep of local authority controlled parking zones and introduction of the congestion charge for Central London, sometimes means the operation of parking charges is outside the control of the NHS facility where care is provided. However, these all add additional elements to the cost of being sick and getting treatment, and it should be possible to recoup under the scheme for help with travel to hospital.

  17.  Where such charges are levied by an NHS facility, they should not be used as a means of income generation. However, the cost of maintaining parking facilities should not take money from a trust's money for service provision.

  18.  Some hospitals already give exemption to parking charges for people requiring long-term, essential treatment, in addition to those who have a blue badge, disabled parking permit. We suggest that where hospitals charge for parking they should give priority to people receiving treatment at the hospital and introduce permits to allow those who need to travel by private transport, because of their health or clinical needs, to park for free while they receive treatment or attend appointments.

  19.  The creeping introduction of charges for other amenities such as TV and telephone use is a worrying trend. Again we suggest that such schemes should not be used as a means of income generation for trusts, however neither should their provision detract from clinical services. We note that OFCOM is undertaking an investigation of telephone charges levied by Patientline, and await the outcome of this.

Exemptions from charges

  20.  Although for most types of NHS patient charges there are various exemption categories intended to ensure that particularly vulnerable groups are not prevented from seeking or receiving treatment by its cost, current exemptions are rife with anomalies and inconsistencies. As such, they can be inequitable and very confusing for patients. For example:

    —  People aged over 60 are not automatically exempt from dental charges but are from prescription charges.

    —  People aged over 60 and some high risk groups receive free eye tests but not dental check-ups.

    —  People with diabetes are exempt from all prescription charges, irrespective of whether they are associated with managing their condition or not. However, those who suffer from cystic fibrosis are not; similarly people with asthma or who need life-long essential medication following an organ transplant are not.

    —  Additionally, exemptions on the basis of low-income are extremely complex and often very difficult for consumers to understand whether or not they are exempt from charges.

  21.  The list of those groups that are exempt from charges has evolved historically but has not kept pace with recent medical developments or population changes. For example, until fairly recently few people with cystic fibrosis survived into adulthood, but now many are paying for prescription medicines that are vital for life. Similarly, the blanket exemption for people with diabetes was made at a time when incidence of the disease was much lower than it currently is, and is forecast to be in the future. And with the planned increase in the pension age for women to 65, and the talk of increasing this still further for both men and women in the future, there is little rationale for continuance of the current exemption for prescription charges for people over 60 years.

  22.  Which? suggests the over-riding basis for exemption for any charges should be clinical need. Additionally, no-one should be prevented from receiving treatment because of low income. We recommend that there should be a systematic and radical review of the exemption categories to eradicate anomalies and inequalities and to ensure that charges do not prevent people with low incomes or significant healthcare needs seeking or accessing both preventative care and essential treatment.

  23.  Lessons from the review of dental charges suggests that this will not be an easy task and removing exemption status from groups that already have it is likely to be unpopular. However, the growing numbers of people who likely to be eligible for free prescriptions suggests that this is likely to become an increasing burden on the NHS that takes resources from other much-needed services. More and creative ways of looking at this issue are needed, particularly if groups of patients who are not currently exempt from charges, but need life-sustaining medication are to be given exemption status. For example, should exemption from charges be limited only to those prescription items that are needed to manage the condition that grants exemption status?

  24.  We suggest that there should also be greater consistency between exemption categories for prescription, dental and optical charges to facilitate better consumer understanding. Particular attention should be given to the exemption categories for dental charges to afford greater consistency with prescription and optical charges. This should include examining whether there are certain groups of people who are clinically-disposed to greater risks of poor dental health.

How should charges be set?

  25.  Which? suggests that where NHS patient charges exist they should be based on the following principles:

    —  Transparency and simplicity.

    —  Consistency and fairness.

    —  Affordability, particularly for those on low incomes and with the greatest clinical needs, such that charges do not act as a barrier to care.

    —  Supportive of preventive care.

    —  Ease of administration.

    —  Ease of understanding for patients.

  Additionally the costs of administering any low-income exemptions should not be so great as to negate the value of any charge income levied.

  26.  We also suggest that any annual increases in the level of charges should be limited to at most the current rate of inflation, otherwise the burden for those on fixed incomes becomes too onerous.

Should charges be abolished?

  27.  In an ideal world, there would be no charges within the NHS. However, this is not a realistic option given the limited pool of funding available for NHS care. Removing dental, optical and prescription charges would have significant financial implications for the NHS that would either require significant additional funding or would take money away from other aspects of service provision. For example, making all NHS dental care free would require, under current levels of activity, investment of a further £0.5-0.6 billion a year. Despite the healthcare benefits that would no doubt accrue together with significant savings in an administration costs, it is questionable whether this would be the best use of limited NHS resources.

  28.  In relation to prescription charges, Which? has been neutral on whether they should be abolished, arguing for the need for a proper cost-benefit analysis of the likely costs and benefits of such a scheme, both now and in the future, which takes full account of the patient's perspective as well as strict economic considerations. While over 80% are already dispensed without a charge, the costs of making all prescriptions free would be significant and likely to increase significantly in the future. The amount spent on medicines in the NHS continues to increase at a rate greater than inflation each year, and the number of average number of prescription items dispensed increases each year—13.7 in 2004 compared with 9.5 in 1994. Of particular concern is the fact that many of these medicines are never actually used.

  29.  There is a real danger that if NHS prescription charges were abolished, the drug bill might escalate out of control unless there are some limits on what types of medicine can be prescribed free. In some European countries, the level of prescription charges depends on the therapeutic level of the medicine (for example in Belgium and France) with some drugs requiring as little as a 15% co-payment while others require a full 100% payment for any drug that is not on the national list. Alternatively, in Sweden and Denmark, what patients pay towards the costs of medicines is determined by their overall annual levels of co-payments, with a set maximum limit in any 12 month period above which all medicines are free.

  30.  If NHS prescription charges are to continue, we suggest that fixing a maximum annual level of charges that patients pay would be fairer for all. This way people who are chronically ill (but are not on the exemption list) or who suffer a period of ill-health would receive help with their prescriptions. This annual limit could be set at the level no greater than the annual season ticket (pre-payment certificate) of £93.20, and people should be able to purchase this on a monthly basis as well as quarterly and annually.

  31.  In relation to dentistry other issues arise. We suggest there is little rationale why charges exist for dental care but not for other types of healthcare. For the consumer, there is very little difference between the pain and health implications of an ear infection and those of a dental infection, but for one there is no charge to see the health professional and for the other there is. While we would not argue that there should be no NHS dental charges, we do suggest that the current charge for the oral health assessment (or check up) should be abolished to encourage more people into preventive care. This could be particularly important in picking up the early stages of oral cancer.

  32.  For the future, it is likely that the costs of providing universal healthcare under the NHS will continue to rise. This is likely to lead to increased pressure to introduce new or increase existing co-payments for NHS services. What will be important in this context is to ensure that people with equal, but different clinical, needs are treated fairly and consistently what ever type of care or treatment they need. It is also vital that the short-term gains of introducing or increasing co-payment are not allowed to obscure the longer-term benefits, both for individuals and the healthcare system as a whole, of ensuring people receive early and preventive care to deal with their condition or illness.

Frances Blunden


7 December 2005

87   Commonwealth International Health Policy Survey 2004 (covering Australia, Canada, New Zealand, United Kingdom and United States) Back

88   National Association of Citizens Advice Bureau Unhealthy Charges (2001). Back

89   Which? omnibus survey of interviews conducted in-home between 12-16 January 2005 with a nationally representative sample of 1,894 GB adults aged 16+. Back

90   Which Choice? Health (July, 2005). Back

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