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CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 815-iii House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
Thursday 9 February 2006 DR LESTER ELLMAN, DR MAUREEN BAKER, MRS LYNN HANSFORD and MR DAVID CARTWRIGHT
MR DEREK LEWIS, DAME GILL MORGAN and MS MAGGIE ELLIOT MR BERNIE HURN and MR MIKE HALL Evidence heard in Public Questions 299 - 530
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 9 February 2006 Members present Mr Kevin Barron, in the Chair Mr David Amess Charlotte Atkins Mr Ronnie Campbell Jim Dowd Anne Milton Mike Penning Dr Howard Stoate Dr Richard Taylor ________________ Witnesses: Dr Lester Ellman, Chairman of the General Dental Practice Committee, British Dental Association, Dr Maureen Baker, Honorary Secretary of Council, Royal College of General Practitioners, Mrs Lynn Hansford, Chairman, Association of Optometrists, and Mr David Cartwright, President of the College of Optometrists and Director of Professional Services for Boots, College of Optometrists, gave evidence. Q299 Chairman: Good morning, ladies and gentlemen. May I welcome you to what is now our third evidence session in relation to the inquiry we are doing on NHS charges. I wonder if I could ask you to introduce yourselves for the record and say what organisation you represent. Dr Baker: I am Maureen Baker. I am the Honorary Secretary of the Royal College of GPs. Dr Ellman: I am Lester Ellman. I am the Chair of the General Dental Practice Committee of the BDA. Mr Cartwright: Good morning. I am David Cartwright, an optometrist with Boots Opticians and also President of the College of Optometrists. Mrs Hansford: I am Lynn Hansford. I am an independent optometrist and I am the Chairman of the Association of Optometrists. Q300 Chairman: I want to ask a general question to all of you about NHS charges. Do you think charges deter patients from seeking the services that you provide? We had evidence last week from the CAB saying that they believe people do make choices on occasions about what they can and cannot afford if they have more than one prescription to pay for. Do you think that is the case? Dr Baker: Yes, I do think that is the case. We have heard, particularly from pharmacist colleagues, of patients bringing in a prescription and saying, "I'll have that one but I'll not have that one", or, "I'll come back next week and get that one". I am sure that it does happen, yes. Dr Ellman: Certainly in dentistry the patient's choice range is now huge and a lot of them do opt to take choices that are not within the standard framework of the NHS. That is because there are a lot of things out there which are not covered by the NHS. Mr Cartwright: I think in optical services it is slightly different in that we do not have charges, so a patient does not come in and pay something. What happens is if they are eligible for an eye examination they have a voucher which should cover the cost of spectacles. I think the issue is that people are not deterred by the charges, but perhaps they are not adequately aware of what is on offer. Mrs Hansford: I would agree with David. Q301 Chairman: I think in general terms we are saying it is probably the prescription charges that may deter people from taking them up. Is there any particular area of concern in relation to that or do you think it is across the board? People on low incomes are exempt from prescription charges so why do we have this type of problem? Dr Baker: If someone has an acute illness and they have not been on regular prescriptions and so they have not paid their 'season ticket', so they have to pay for each item, and they come along and they are prescribed a number of items that relate to that particular acute illness, then three or four prescriptions soon mount up. Yes, people on low incomes are exempt, but if you are just over the threshold then it can be quite a hit if you are not expecting it and so it can have an effect. Q302 Chairman: Has the Royal College ever done any studies of this as opposed to the anecdotal things we hear about of people not being able to afford four prescriptions? Dr Baker: Not to my knowledge. Q303 Chairman: So we have no evidence base for this? Dr Baker: No. Q304 Chairman: We just think that it happens and pharmacists say that it does. Dr Baker: That is right. Q305 Chairman: Dr Ellman, in your evidence you talk about the widening gap in the dental health of the population. Why is this? Dr Ellman: It is very difficult to answer directly and say we have got absolute evidence of why it is. There is no doubt that some socio-economic groups particularly are more at risk and that some priorities are given in different directions by different people, and there are some cultural differences too. If you have not grown up in a culture of looking after your teeth and regarding that aspect of your healthcare as being particularly important then it tends to lapse to some extent and you only seek emergency care when there is some problem. So there is that widening gap. A tiny bit is related to the people who are not in the supported group but who are on the threshold of being who may find charges inhibitive to them. I have no evidence for that. I worked in inner-city Manchester for 30 years and I ran a practice there and we have certainly got some of that, but I cannot identify it entirely. Q306 Chairman: Is there any conclusive evidence that suggests that those who do not consult dentists early on for check-ups can end up costing the NHS more in the long run as it were? Dr Ellman: That must be so. I am not sure that we have done any studies on it directly. If you take the simple evidence that if you can get to the problem that the patient has before it becomes a major problem and moves on - because dental disease is progressive - then obviously it has got to be less expensive in the long run. I am not sure it is entirely as simple as that, but that is a fair estimate. Q307 Chairman: Has your Association argued with government that that is what you ought to be doing when you have been looking at issues around a new contract and things like that? Dr Ellman: We have talked in terms of prevention as being something that we would very much like to see heavily espoused by the new contract. Q308 Chairman: Is the same true for patients who delay or avoid having sight tests, that in the end it could be that there would be increased costs because of that delay to the National Health Service? Mr Cartwright: Yes, it is. If you take many of the common eye conditions, if they are diagnosed early and are treated they will not lead to visual loss in the future. For instance, glaucoma would be a good example where the patient is not immediately aware that their vision or the visual film might be getting worse until it is often too late to treat. So it is essential to diagnose that early and treat it early and that would lead to savings later on in the ongoing care of that patient. There is some evidence from the University of York to say that about 10% of falls in the elderly are due to visual disability, much of which is preventable and that costs about £250 million a year. Q309 Chairman: The elderly are not charged for sight tests any longer, are they? Mr Cartwright: That is correct. Q310 Chairman: It is the deterrence of the NHS charges that we would like to look at, where that shows that because of these charges people do not go along for eye tests and consequently it costs more money in the long run. Do you think York may have looked at that? Mrs Hansford: There is no evidence that the cost of eye care does put people off going. When free eye examinations were introduced for the over-60s there was not a huge increase in the uptake of eye examinations; it stayed pretty stable. That would indicate that it is not a deterrent for people to come and have their eyes tested. What it is is they do not understand because there is not enough publicity about the importance of good vision and how good vision can maintain your independence and make sure that you function properly through your life. Q311 Anne Milton: The evidence about elderly people falling over because they do not see well I have heard before. Dr Ellman, could you give me an example in dentistry of what will cost more if you do not get it treated early? Dr Ellman: If you leave a tooth which has decayed it may well progress into requiring more extensive treatment like root canal therapy which is a lot more expensive than a simple filling restoration, and that is not uncommon. If it does not particularly hurt at the beginning and they do not seek help, although they may know it is there, then it may well progress and become a much larger problem and the restoration may be much more difficult. Q312 Anne Milton: I am no expert, but it feels as though if dentistry does not treat you early then you just end up having your teeth out. Do you see what I mean? Dr Ellman: I do not, sorry. Q313 Anne Milton: By not treating a dental problem early there is a limit to how much it can cost you in the long run. In your example about root canal work, if you take the tooth out it costs money --- Dr Ellman: Under the current system there is a limit to what the patient can pay, but that does not limit what the NHS will have to pay, it is merely a limit to the patient charge. Similarly, even in the new system which the Government is introducing in April, although there will be a capped ceiling on what the patient's charge would be, in fact it will cost the NHS more because it will take the dentist's time away from being able to treat other patients just because it is a more expensive and time-consuming procedure. Q314 Dr Stoate: I think what Anne is trying to say is that if you do not get an optical test done you can go blind and that can have huge consequences. If you do not get your teeth fixed the worst that can happen is you lose your teeth. Are we saying there is more that can happen to you than losing your teeth and, if so, what? Dr Ellman: Obviously losing your teeth is now a social stigma in this country to a large extent. Q315 Dr Stoate: What is the big deal with losing your teeth? Dr Ellman: You have got to have dentures replaced regularly. Q316 Dr Stoate: Are there chronic long-term health implications apart from losing your teeth? Dr Ellman: Not once they have been taken out! Q317 Chairman: I want to ask the optometrists about young children. When I was at school I used to have eye tests. They may not have been that scientific, but I do remember having an eye test at school. That has stopped now. Do you think that is a disadvantage? Mr Cartwright: Certainly in my view there should be a more universal screening programme for children before the age of eight because if you catch something before the age of eight you have a chance of treating it, but if it is after the age of eight you cannot. Children under-19 in full-time education are eligible for an NHS examination. Q318 Chairman: How many of them take it up? Mr Cartwright: Out of 11.7 million NHS examinations 2.5 million would be children. Chairman: We do not know what the population of under-16s is at any one time. Q319 Mike Penning: Perhaps you could let us now. Mrs Hansford: In an ideal world all children should have their eyes examined before they start school because the formative years, as David said, are up to age eight, so you need to detect any developmental problems before that time and the earlier the better because the earlier you pick it up the more easily you can deal with it and the better the outcome at the end. You wear spectacles and so you understand that if you cannot see properly you do not perform properly. It really is important that all children, in order to reach their educational potential, ought to be able to see properly at all times. So we would really feel that that would be a major health benefit. Chairman: A member of my family has just found out at 14-years old that they have got a sight deficiency. I think that may have been picked up earlier if it had happened to me as a child. Q320 Dr Stoate: I am surprised that you are so benign about your age of eight because in my experience as a GP, if you do not diagnose strabismus before the age of 18 months you are never going to get binocular vision and that in itself is quite a handicap. Eight is far too late if you are going to diagnose a squint. Mrs Hansford: I would agree with you. Eight is the cut-off time. Q321 Dr Stoate: It is much too late by eight. Mrs Hansford: You could pick them up at four. Q322 Dr Stoate: Four is too late. Mrs Hansford: It is too late. A child with a strabismus like you are speaking of most parents would be aware of. Q323 Dr Stoate: I would like to put on the record that I am a Fellow of the Royal College of GPs and a former College examiner. Dr Baker, we have had a lot of anecdotal evidence that prescription charges put patients off receiving treatment. Is there any concrete evidence that prescription charges affect the way that GPs treat their patients? Dr Baker: I am not aware of any literature that would provide that evidence, but that is not to say it is not there. I try to keep up particularly with the health inequalities issues. We can certainly ask our Information Services Department to see if there is anything that relates to that question. I personally am not aware of any studies that have looked at that specifically. Q324 Dr Stoate: If your Information Services Department does have any evidence, I would be very grateful if you would submit it to us because we need to have a good evidence base if we are going to make a sensible report to Government. Dr Baker: We did have a publication by our health inequalities group called "Hard Lives" which is an overall look at some health inequalities issues. I would certainly be happy to send that on and I can make a specific request around the literature regarding charging and deterring people from treatment. Q325 Dr Stoate: Obviously everyone resents paying charges. What we need to know is how much of people's reluctance to pay is just simply resentment at having to pay for what ought to be a free service and how much of it is because they are having a genuine hardship effect. We need to have some evidence for that if possible. Dr Baker: The evidence we will find for you if it is there. In my own experience as a GP, I have people say to me, "Don't prescribe me this and this because I cannot afford it". Q326 Dr Stoate: I am sure that happens. What we need to try and gauge is a measure of how prevalent that is. I want to move on to non-emergency transport. Do you think that the cost of transport for people to get to hospitals and to clinics can affect the way they access the service? Dr Baker: Yes, I do. In fact, the Royal College of GPs is currently writing a paper with colleagues in the Royal College of Physicians and we are looking at the best way in which generalists and specialists can work together so that patients can get the best access to treatment. That is one of the issues that have come up. We have been hearing of cases where people may have a number of chronic conditions and they attend outpatient clinics for that, but because of a number of factors, ie they are more ill, they are poor and they either rely on public transport or it is a question of can they drive, can they park, do they pay parking charges, people default from ongoing treatment for those chronic conditions and that leads to poorer outcomes for important chronic conditions. Q327 Dr Stoate: Do you have any evidence you could submit on exactly how prevalent that is? Dr Baker: Again, I am not aware of any evidence. We are looking to see what there is in terms of referencing this paper. If we find specific references we can send that to you and I would be also be very happy to send the paper to the Committee once that has been launched. Dr Stoate: Thank you very much. Q328 Charlotte Atkins: Dr Ellman, what are your main criticisms of the new system of dental charges and what do you think will be the impact on the uptake of treatment? Dr Ellman: The impact on patient behaviour is absolutely unknown. This is one of the biggest problems we have. The problem that arises from that is you cannot then model the system to make sure that it brings in the appropriate amount of money. The remit of the Cayton committee[1] that looked at it was that it should bring in the same proportion of money as the current system does. The current system brings in about £487 million out of a total spend of £1.8 billion, so it is about 28%. What we do not know is when you change charging regimes as drastically and dramatically as this particular change is happening what that will do to patient attendance and patterns and nobody else can tell you. The bits that we do not like about the charging are the massive steps which are difficult for patients to get their heads round. For one simple filling they move from a band of £15.50 to £42.40. I do not know what the patient is going to say about that. They may opt to get additional treatment done or they may save it for some time. Q329 Charlotte Atkins: What you are saying is that patients may wait until they have more than one pain in their mouth to ensure that they fit nicely into the middle band as opposed to just missing the first band, is it not? Dr Ellman: It is a possibility. I have no handle on this. I have no way of knowing what patients will actually do. Some will progress as they have always progressed but many will be unsure. Q330 Charlotte Atkins: Is the new contract going to be profitable for dentists or are a lot of dentists going to go down the completely private route? Dr Ellman: There is some evidence from the plan providers particularly, because they are the people who have people signed up, that quite a number of dentists are moving outside the NHS because they do not see the reforms being satisfactory for their particular practice. How workable it is remains to be seen. I know that the Department of Health is fairly confident that they think they have got it right, but a lot of my colleagues are confident they have not. The one really big item that is missing is the drive towards prevention. I think the drive towards prevention is the one that I would really like to have seen in place. That is there as a token more than as a positive driver. Q331 Charlotte Atkins: So by going private they think they could do more preventative work, do they? Dr Ellman: Most dentists who go private do not go private just for the income. They go private to allow them to spend time to produce the quality of dentistry they think they want to produce and they feel patients deserve. The two things do go together. The new system does not really provide them with that time and it does not provide them with a generation towards a quality of service and a quality of outcome which we all want. The intangible factor is that of job satisfaction and that is one that dentists do not get when they are pushed really hard in terms of a lack of time to deal with patients. So when you get the average dentist out there working on the NHS seeing 40 patients a day, they do not feel that they can form a good working relationship with those patients, they have not got the time to encourage prevention to take place and that is a continual reinforcement process. Q332 Charlotte Atkins: If they want to get off the drill-and-fill treadmill, would not the best way of doing that be by increasing the input of fluoridation in terms of particularly young people's health? Dr Ellman: The scientific evidence is that fluoridation makes a massive impact particularly on young people's dental health, yes, but this has issues that you know a lot more about in this House than I know about it to do with the resistance to it. That is not in my gift but it is there. Q333 Charlotte Atkins: What is your view about the issue of dentists who are requiring parents to go private while they treat their children on the NHS? I understand under the new contract that will not be acceptable. Dr Ellman: I have no evidence that this actually happens. I am not denying that it does. Q334 Charlotte Atkins: You should see my postbag in that case because I can assure you it does. Dr Ellman: I will take your evidence. I think it is wrong that patients are treated in that way. It is not something we do in our own practice. You could say we only treat adults privately and we will happily take your children on the NHS, but I do not think one should be a condition of the other. I find that unacceptable. Q335 Charlotte Atkins: Is it not difficult to separate that? You could have a dentist saying, "I don't make it conditional", but we know some say on a nod and a wink, "I will not take your children unless you go on Denplan", or some other private system and it is very difficult to prove one way or the other, is it not? Dr Ellman: I would imagine it is. Q336 Charlotte Atkins: If you heard that some of your members were going down this route you would condemn them for that, would you? Dr Ellman: I think we would want to advise them not to do so. Q337 Charlotte Atkins: Mr Cartwright, based on what I hear and see from your own evidence, you are concerned about the cross-subsidy to sight test fees from people who require spectacles, is that right? Mr Cartwright: That is correct, yes. Q338 Charlotte Atkins: Is that because you think that the present sight fee does not cover the extensive sight test that most optometrists embark on? Mr Cartwright: The current sight test paid for by the NHS, which is £18.39, does not cover the real cost of providing that examination, which is around £37. There is this cross-subsidy from the sale of spectacles and contact lenses which in effect is a tax in some ways on the wearer of spectacles who is then paying for part of that examination. Q339 Charlotte Atkins: Just because you have a sight test at one particular practice does not mean you cannot take that sight test off and go and buy your spectacles somewhere else, is that right? Mr Cartwright: That is correct. Q340 Charlotte Atkins: In the future you could have a basic sight test, a medium one and one that is far more expensive. Could you have a different level of sight test and follow-on care in the future? Mr Cartwright: Absolutely. The optical profession has published its view of what could be done in the future where there was a much wider role for optometrists in providing that essential eye examination. The role of the optometrist could be expanded within that to some extent, but then we would also have an additional service where the optometrist is effectively the first port of call for anybody who has a problem with their eyes. So if it is a red eye conjunctivitis then that would go to the optometrist and the vast majority of cases the optometrist would be able to treat. We could also have glaucoma monitoring and diabetic monitoring where the optometrist should be fully engaged as well. If optometry was doing that those services would be remunerated at a realistic level. Q341 Charlotte Atkins: Would it make sense to offer a differential service to different people depending on age and general health? At the moment you have a standard sight test that everybody who comes through the door has, although I have been very impressed by some of the sight tests I have been offered because they seem incredibly extensive. In fact, they normally convince you you are blind and you are so relieved by the end of it that you are not that you are willing to accept anything! Mr Cartwright: Over the last ten years the diagnostic tests that are available have expanded quite markedly and optometrists are involved in that. At the moment there is this cross-subsidy and actually it would be something that the Government is missing out on in not taking advantage of that resource that is available to free up resource elsewhere. Q342 Charlotte Atkins: What do you think the future for the sight test should be? What would you recommend? Mr Cartwright: We would recommend that we should have an expanded eye examination as an essential service that is available in all areas. Q343 Charlotte Atkins: So that you are pulling in youngsters who at the moment are not getting that full cover? Mr Cartwright: Certainly there should be a much greater awareness of the importance of eye examinations and eye health and preventative eye care. There would then be optometrists being in effect the GP for eye services. So any eye condition would initially come to the optometrist for diagnosis and monitoring to decide what it is and to potentially treat and then we would also be engaged locally in glaucoma schemes, diabetic retinopathy monitoring schemes, the treatment of age related macular degeneration or the diagnosis of age related macular degeneration and advice and guidance there. Q344 Charlotte Atkins: The Department does not seem to think that the sight fee itself really matters because it is negotiated in a competitive framework. What is your view about that? Mr Cartwright: Absolutely not. The cross-subsidy is not a good example where the one who wears spectacles then has to pay for part of the eye examination for somebody who potentially has not got to wear spectacles, so there is a hidden cost to that third party. Q345 Charlotte Atkins: The other issue is to do with the NHS voucher and the fact that many practices do not seem to stock spectacles which are fully covered by an NHS voucher. Does that mean that a number of people either do not come for a sight test or they decide that they will not buy a pair of spectacles simply because they cannot afford the gap between the voucher and the cost of the spectacles? Mr Cartwright: Two-thirds of optical practices do supply spectacles like the single vision or bifocals or the two pairs covered by the cost of the voucher. There is not any evidence - that does not mean to say that it definitely does not happen - to say that people are deterred from an eye examination or from coming along to an optical practice because of the cost of spectacles. There needs to be greater awareness of the fact that people can come along that are eligible for an eye examination and that it is an important part of monitoring for eye conditions which if found early can be treated, but in two-thirds of practices the voucher will cover the cost of the spectacles. Q346 Mike Penning: Dr Ellman, I was astonished to hear you were not aware of this blackmailing which is going on within dentists about how you cannot keep your children on the NHS unless you go private yourself. Not only is that an issue for my constituents, but my dentist wrote to me (obviously he does not realise I sit on this Committee) saying that if I wanted to stay with him I had to go private and my children would get NHS services if I stayed. Are you saying you have never heard of this before? Dr Ellman: I said I have no evidence that that is happening. You are giving me some. Can I just correct the position that your dentist seems to have taken which says he will happily treat your children on the NHS but you must go private? He did not use that as a lever. Q347 Mike Penning: He did. He said he would remove me from his list as an NHS patient unless I went private. Dr Ellman: He did not say he would not treat your children on the NHS unless you go private. Q348 Mike Penning: Yes, he did. Dr Ellman: In that case, I am sorry, I would not agree with that. Q349 Mike Penning: I will supply you with that letter. Are you for the contract? Are you happy with it? Are you going to sign the contract that is being offered to you or are you going to reject it? Dr Ellman: I do not have powers to reject on behalf of the dentists. Q350 Mike Penning: But you are going to advise them on whether it is good or bad for them. Dr Ellman: Yes, we do advise them. We have just said that at the present time this contract is an absolute mess. That was in our press release the other day. The contract needs to be looked at in a much more serious manner than it has been looked at because there are serious flaws in it. Q351 Mike Penning: If they do not change the flaws you are going to advise your members not --- Dr Ellman: They will probably have to live with it because quite a lot of our practitioners on two grounds want to remain within the NHS. One is that they are in areas where to move outside the NHS would be inappropriate and the other is that a lot of dentists are actually wedded to the concept of the NHS; that is what they want to do. Those who move away rarely do it on grounds of the economics of the situation, but rather the fact that job satisfaction of spending longer with patients, has been removed.[2] Q352 Mike Penning: NHS dentistry could not survive without your members being fully involved in that. If your members said "No, we're not happy with his contract" the Government would have to look again, would they not? Dr Ellman: They would, you are quite right. Unfortunately dentists do not work that way. They are independent contractors and the word independent comes to the fore. Q353 Chairman: Do dentists take a collective view through your Association on issues like new contracts? Do they have a vote? Dr Ellman: No. We do not do that because we did not negotiate the contract; it was imposed on us.[3] It is a Department of Health contract that has been pushed forward. All we have done is talk about it, advise them and chip away at some of the things that are wrong. Some of the things that are still wrong make it a very disadvantageous contract in some respects. Q354 Chairman: As an Association representing dentists you have not negotiated the new contract with the Department like the BMA negotiated with the new GP contract, have you? Dr Ellman: That is correct. Q355 Chairman: You have not done that and therefore you do not have a collective view on whether it is good or not. Dr Ellman: It may have been done previously but it has not been done on this occasion. Chairman: I hope my two colleagues will be able to send you information about this other issue and then you can respond to that.[4] I am sure we would appreciate that during the course of our inquiry. We are going to move back now to vouchers for glasses. Q356 Mr Campbell: Citizens Advice told us that they had evidence that a lot of people who go for an eye test cannot afford to pay the difference between the voucher and the price of the glasses. What is your take on that? Is the voucher system wrong? Do they need to increase that or take it away altogether? Mrs Hansford: As David said, two-thirds of optical practices in the UK offer spectacles within the voucher value. I think you will always be able to find people who fall outside that or who perhaps have not understood it. When I read that I did feel that perhaps we need to work with Age Concern and the CAB to see if we cannot resolve that. It sounds like it is small pockets of a problem. What you have to understand is there is no such thing as an NHS pair of glasses anymore. What happens is that all spectacles are provided as a private contract and the Department of Health provide a voucher to help people who are on low incomes towards the cost of a private pair of spectacles. It is up to the patient to decide what spectacles they want to buy, whether they want to buy a budget pair or a more expensive pair. Maybe there are misunderstandings about whether there are cheaper pairs available, I would not know and it is difficult to talk about specific cases. There is plenty of opportunity to buy spectacles within the voucher value. Q357 Mr Campbell: There must be a big difference between the worth of the voucher and the price of the glasses. Mrs Hansford: There can be. If you buy a pair of spectacles like I am wearing there will be a huge difference between the voucher value and the spectacles. You would expect me to be wearing top of the range spectacles, would you not? If I had a voucher it would make a very small dent in the cost of this pair of glasses, but I did not have to choose this pair of glasses, I could have chosen a budget pair and I could have had a pair of bifocals instead of a pair of varifocals, but that is my choice. One of the strengths of the optical market is that it has complete and utter patient choice. There are no restrictions to the optical market whatsoever. You can have ten optical practices in a row in a street. Whilst that is very uncomfortable for us sometimes as business people, it is a driver for excellence. If you have got lots of competition you have to be good to make sure that you keep your head above water and that your business is a success. Q358 Mr Campbell: Would it not be better to do away with the voucher system and have an income cut-off rather than a voucher system and give them a good pair of glasses? Mrs Hansford: I do not understand what you mean. Q359 Mr Campbell: So instead of having a voucher system they would have to declare if they are on Income Support or low wages. Would that not be a better system, where the Government would give them a good pair of glasses rather than the budget pair? Mrs Hansford: But a budget pair does not mean it is a bad pair of glasses, it just means that it is not a designer pair of glasses. Q360 Mr Campbell: A lot of people would not wear a budget pair. They may say, "I'm not going to pay the difference just for a budget pair of glasses, but if I had a bit more money I would go for a good pair". Even the poor want to have glasses like my own. Mrs Hansford: There is plenty of selection in spectacles. Q361 Mr Campbell: I do not know about that. I go to my optician's and I look at the little case with the budget pairs and there are only about 12 pairs in there. Mr Cartwright: It is a fact that two-thirds of practices will provide spectacles of the voucher value, so at no extra cost at all and with a range of spectacles. We are not going back to the old NHS days of brown or black glasses where there was a badge of poverty --- Mr Campbell: There is not a great choice. I have looked at them when I have been in there. For the best glasses there are three or four cases. Q362 Jim Dowd: Go to another optician, Ronnie! Mr Cartwright: I beg to differ because it is a very competitive market and there is choice, so people will be able to go in and there will be a number of frames that are available for that person. Q363 Mr Campbell: I have not got a problem with that. My point is about the difference between the voucher they get and the price of the good glasses. I am talking about poor people on Income Support getting a good pair of glasses. Mr Cartwright: These would still be good glasses, they would be good lenses and they would still be backed by that professional service. There is no difference in the offering to the patient. Anne Milton: My child has worn glasses since he was 18-months old and I have never paid for them. The choice has been fantastic. I live in Surrey and if there was any way of going to the opticians where you did not have to pay for glasses it would be there, but in fact every optician has distributed them. They are fantastic glasses. You are using the words good and bad prejudicially and it is not fair. If you want a Giorgio Armani pair of glasses you are going to have to pay for it like you would a suit. Mr Campbell: The voucher system only applies to some frames. Anne Milton: And they are absolutely fine. Mr Campbell: They should go beyond that. Q364 Chairman: Maybe you should have that debate in a private session. Would the issue of the value of the voucher be the difference in this debate? Mrs Hansford: There is not any such thing as free glasses and then the next pair of glasses cost you £200. You might pay £5, £10 or £15 to have something a little bit better. We are not talking about huge amounts of money to have a bigger choice. You can spend a lot of money on spectacles just the same as you can spend a lot money on a suit, but you can also get an off-the-peg suit that is perfectly reasonable, that can be thrown in the washing machine and look good for years that you do not pay a lot of money for, and you can have a pair of glasses that you do not pay a lot of money for that look perfectly good and do the job. Mr Campbell: A good pair of glasses costs about £100. Chairman: This is a very interesting but anecdotal debate in many ways. I would like to move on now. Q365 Mr Amess: Chairman, just for a moment I want to join in the free-for-all and go completely off the script. About 45 minutes ago we had this interesting exchange between Dr Ellman and my two colleagues about what happens when you neglect your teeth, what is the ultimate effect of it and all the rest of it. Surely you end up with dentures. Not everyone is successful in wearing dentures. You need teeth to eat and chew your food. You cannot just sit there sucking boiled sweets all day. I would have thought you could even die through it. Never mind your remark about the aesthetic result, I would have thought it was very, very important that you keep your own teeth. Dr Ellman: There is no doubt whatsoever that in today's world more and more and more people wish to retain their teeth for as long as they live and that is where the additional expenditure will come in. If their teeth are taken out and they wear dentures then that will reduce that effect to some extent. Q366 Mr Amess: Believe it or not, I am trying to help you with the answers. Dentists no longer pull out teeth unnecessarily. They do everything they can to save them. Let us come on to the opticians and the national service framework. Mrs Hansford: We never pull out eyes! Q367 Mr Amess: In your written evidence you say that General Optical Services are "not underpinned by a national service framework for improving health in the optical field". Obviously you feel that this is a big issue. Given that it is a big issue and given that there are all these different contractors, there is certainly some resistance as a result of the charges. Why is it so important, and how could you achieve this national service framework in practice? Mrs Hansford: That is all laid out in this document that I waved around when David was talking. We did present this document to Rosie Winterton in the autumn of last year and it does lay out our vision of the future for primary eye care and David did explain it in quite a lot of detail, ie the essential service, the additional services and the enhanced service. It is pretty much the same as we have in Wales. My practice is in Wales. You are probably aware that we have enhanced primary eye care in Wales where we provide an acute referral scheme which is in effect a triaging system and where patients with eye problems can come to the optometrist. About two-thirds of the practitioners in Wales are accredited to deliver those charges. There is the Low Vision Scheme and other things like that. We feel quite strongly that there ought to be a national service framework and a publicity campaign so that everybody understands the importance of vision. If you speak to anybody about the importance of vision and they think about it for more than ten seconds, it is obvious that you cannot function unless you can see properly, but it is never a thought that is prominent in people's mind. The children's NSF does not mention eye care for children and the older people's NSF does not mention eye care for older people and yet when I say that you think that is mad. If we had an NSF for vision so that everybody understood the importance of vision, the importance of eye care, seeing well and detecting eye disease early, then I think that would be a huge health gain for patients and for the NHS as a whole. Q368 Mr Amess: If this were to be effective you would systematically have to monitor the situation. How would you get the information across to the public and private sector? What would be the mechanism to make this national service framework a reality? Mr Cartwright: We are currently about to embark on negotiating the new GOS contract and we would propose that the essential services, the additional and enhanced services within that and they should be properly funded. Much of this would go through the Department of Health. We would have payments and all that sort of information would be there. Is that the sort of things you are thinking of? Q369 Mr Amess: Given that there is public and private provision, how would you collect it all? How would you get everyone to agree? You are suggesting that the Department controls the thing overall. There seems to be a bit of a contradiction. Mr Cartwright: If we were thinking about awareness and if we had a framework - and they do exist in some areas of the country and Wales is a good example - where a patient who has an eye problem is going to their GP but then they no longer go to their GP but to an optometrist locally then that actually would raise awareness very quickly that if I have got a problem with my eyes I will go to my optometrist. At a GP's surgery you would be able to go to see the optometrist. When you ring up for an appointment and they ask you what it is about, you would say it is to do with your eyes and you would be referred to the optometrist. We do not need to talk to every GP, although that might be a useful thing to do, but if that was a nationally set framework which was set centrally and then PCTs were picking that up then that would happen naturally. Mr Amess: The Committee will reflect on your evidence. I think Boots is splendid! Q370 Jim Dowd: It is a German company that has just bought them! Mr Cartwright: It is Italian. Q371 Jim Dowd: I want to raise the comparatively recent development of people being able to buy glasses off the rack from supermarkets. I just wondered what your view of that was. Mr Cartwright: Supermarkets have entered the market and it is very competitive. In the supermarkets it is a registered practice so you will have an optometrist or a professionally qualified person there to help. Q372 Jim Dowd: I am not talking about that, I am talking about the fact they are on the shelves alongside any other product. What is the percentage of people buying glasses without professional guidance? Mr Cartwright: This has been there for 20 years and I think at the time the profession was thinking if that was appropriate. There is also unregistered spectacle dispensing. Both of those have regulation behind them. If it is a readymade pair of readers and it is to correct presbyopia, that is glasses for near work, you should not be able to go in and buy them for driving for instance. There would be an age limit set so that children cannot go and buy these to correct their distance vision. It is acceptable if there is background regulation. Also, for unregistered dispensing, so somebody can set up without the professional service, the regulation says that there has got to be a prescription dated within two years. There has got to be measurements taken. I think it is acceptable if there is some background to it. Q373 Jim Dowd: But there is not. They are just on racks. People go in and pick up a pair and they go to the cashier and that is it. Mrs Hansford: That is why we need the national service framework. Q374 Jim Dowd: I was asking your view about that as a practice. Mr Cartwright: It certainly has its dangers because in a lot of places there will be responsible promotional material with it saying an eye examination is important and you should do that every two years, so that would be a responsible way of doing it. There are some places where you can just go and buy them. You can imagine that for somebody whose sight is failing they may think, "I'll just go and get myself a slightly stronger pair of glasses", and actually they have got a medical problem and they should be going to have their eyes examined to correct that. Q375 Jim Dowd: So the supermarkets should adopt a more responsible and active role, is that what you are saying? Mr Cartwright: It would be unfair to pick on supermarkets. There are some places where you can just go and buy readymade reading spectacles. The important point is to raise awareness so that people think, "Okay, I can get these, but I need to make sure they are right for me and I need to back that up with an eye examination". Mrs Hansford: There is a lot of evidence to show that people who buy 'ready readers' are quite often buying them as a backup pair to their prescription pair. So they have had their eyes examined and they have bought their prescription specs. That may not be every case. Q376 Mike Penning: When you are in the opticians having your eye test they give you the prescription and they try and sell you glasses while you are there, but if you get out the door like I did you can buy them elsewhere for £10. Mrs Hansford: As long as you have had your eye examination and as long as you are buying a pair of reading glasses that suit you that is not a problem. Q377 Jim Dowd: I bought a pair in Sainsbury's largely because I could not read the label on something I was going to buy and thought they would help. Mrs Hansford: As long as you went and had your eyes examined by the optometrist the next day that would not be a problem. Q378 Jim Dowd: I have not. Mrs Hansford: Well, you need to. How do you know you have not got glaucoma? Jim Dowd: You are right. Q379 Dr Taylor: I am going to follow the rather rumbustious precedent of not sticking to the script certainly for the moment. I am really quite staggered to hear that the BDA has not expressed a collective view about the contract because I really thought it had.[5] Are local dental committees affiliated to you? They are part of you, are they not? Dr Ellman: No, they are not. They are statutory bodies that represent the profession locally and present the views and they are there to assist primary care trusts and the like in formulating policy and dealing with things on the ground. They are not dissociated from us but they are not part of the British Dental Association. Q380 Dr Taylor: The Birmingham Local Dental Committee is convinced that the BDA has really given up and is really trying to persuade local dental committees to make the best of a bad job, even actively advising members to convert to private dentistry. Does that accord with what you have heard? Dr Ellman: Yes, indeed. I am aware of what Birmingham LDC has done. Q381 Dr Taylor: We went to Wales yesterday and we were told by the minister that they had made distinct changes to the dental contract in Wales which made it more acceptable to the Welsh dentists. Do you know about that? Dr Ellman: I am not familiar with the details of the changes in Wales. I am aware that they are making differences between England and Wales, but I am not entirely sure that I understand all the nuances of it so I cannot comment.[6] Q382 Dr Taylor: Let us come on now to help and information that is available to patients. Firstly, Dr Ellman, in your written evidence you have said, "as with many co-payments in the NHS exemptions are absolute. Consequently there will be a large proportion of the population on the cusp of exemption criteria." Have you any idea what could be done to help these sorts of people? Dr Ellman: It is really a matter for government. It is possible to work on the basis of a partial subsidy in relation to the income level that is there and therefore in a way means tested. You could support it in stages. Q383 Dr Taylor: Would you like us to put that sort of suggestion forward? Dr Ellman: I have no reason not to. It would be very helpful for many who are on the lower economic scale but not supported by benefits of any sort. Q384 Dr Taylor: Can I just clarify some detail about the actual charging. Have I got it right that you pay £42 for one filling and, if you have ten fillings, you pay exactly the same? Dr Ellman: Yes, £42.40 is the current ----- Q385 Dr Taylor: So one filling is exactly the same? Dr Ellman: Yes, it will be. That is exactly how it works. Q386 Dr Taylor: Surely, if patients know about that, as we have rather been hinting before, they are going to delay and have a few fillings to get their money's worth rather than just pay the 42 quid for one and then go back and pay another 42 quid for another? Dr Ellman: Yes, that is a possibility. I have no idea. I suppose, to some extent, it depends on how difficult the problem is. If it is causing you acute distress, then you are obviously going to seek help straightaway. Q387 Dr Taylor: Before I come to the others, how are you setting about letting people know, and really it is supposed to be a simple banding system, but, if one crown costs you the same as several crowns, one tooth on a denture the same as a whole denture, how are you setting about explaining it to people? Is it your job to explain to the person in the chair how much it is going to cost? How do you set about that? Dr Ellman: We put out some advice leaflets for dentists to help them explain the charges and the changes to the patients, so we have gone in that direction. That has only recently been published and it is actually on the BDA's website now, together with a poster that they can download and put in the waiting room, which explains as simply as we can what the changes will mean for patients, so we have done that. Dentists are aware of what is going on and most of them do explain to their patients what is involved.[7] Q388 Dr Taylor: Again, in your evidence, you draw attention to the document Help With Health Costs, and, as other people have told us, and I forget how many pages it is, but it is terribly complex. Dr Ellman: Yes. Q389 Dr Taylor: You say here that you want to go out with your own paper. Is this what you have actually done already? Dr Ellman: No, we are not allowed to. Sorry, are you referring to that form that you can claim on?[8] Q390 Dr Taylor: I am referring to HC11, Help With Health Costs. Dr Ellman: That is a big form that is published by the Department of Health, I think, which means that, if you are on a low income, but not on Jobseekers Allowance or one of these benefits, it will allow you to claim the money or the support from the relevant authority. That is a big, complex document, as you rightly say. We would like that simplified because it makes it very difficult for patients to deal with and some, I am sure, are deterred by the fact that it is a big jargony form. Q391 Dr Taylor: So, and this is really to everybody, should we be suggesting that that document is sort of fragmented into separate documents for each particular service? Obviously the dentists would say yes. Dr Ellman: I think it is the same document for every service, is it not, that applies? I am not sure. Q392 Dr Taylor: I rather imagined, although, I have to admit, I have not seen it, that it actually explained details of the charges. Dr Ellman: No, it does not. It is a form that is used for you to claim repayments or payments of the dental charges in this particular instance. Q393 Dr Taylor: So how are you and the others trying to draw patients' attention to the range of costs? Is it your job to tell them what it is going to cost? Mr Cartwright: If I could pick this up for optics, many practices have this sort of leaflet which is a guide to NHS entitlements because we are slightly different in that we do not have charges, we have entitlements. Practices would also have posters, saying what the entitlements are and on the PCT, primary care trust, visit, they will pick the ophthalmic advice and will pick that up if there is not one there and say, "Well, you should have one. You should have leaflets", and staff would be aware of that as well. Q394 Dr Taylor: So you would accept that it is a part of your role to hand out the information? Mr Cartwright: Certainly, and we do so, yes. Dr Ellman: We do likewise. Dr Baker: Anyone who has been to a GP surgery will know there are racks and racks of leaflets and there are normally leaflets explaining prescription charges available for people to pick up. Q395 Mr Campbell: Back to the opticians again, I have a thing about opticians! Scotland and Wales have introduced a new eye test examination. Basically can it come here? Can it come to England and how much will it cost? Mr Cartwright: We would certainly be delighted if it were to come here or a very similar sort of system and I think it can come here. That would be part of what the general ophthalmic services review should be about. We would need to look at the cost and I think certainly it would cost more, but I think, if that was looked at in terms of the then value in terms of the longer-term savings, that would clearly make the case for that sort of system coming here. Mrs Hansford: Someone has just whispered in my ear that, if the Scottish scheme were introduced in England, it would cost £92 million according to the Department of Health. Q396 Mr Campbell: So that is a lot of money. Mrs Hansford: In NHS terms, it is a drop in the ocean. Q397 Mr Campbell: A drop in the ocean of course, yes. Mr Cartwright: I think, if we were saying that the current expenditure is £350 million and that includes vouchers and eye examinations, and I think we had a figure of nearly £2 billion earlier, you can replace teeth, but not eyes. Q398 Mr Campbell: Are you getting more money for better tests? Mr Cartwright: There is a wider range of services, yes. Q399 Mr Campbell: And of course available to all? Mr Cartwright: Yes. Mrs Hansford: I wanted to interject when we were talking about patients travelling to hospital and paying car parking fees. Of course the beauty of an optometrist delivering services in the community is that there are no car parking fees, there are no hospital trips, there is no transport because they can get on the bus, they can walk round the corner and the optometrist is there. That is one of the benefits of delivering more optometric services in optometric practices. It is an under-used resource. Mr Campbell: I will have to get on my bike then! Q400 Chairman: I have just one more question to you about the issue of domiciliary eye tests when we were talking earlier about elderly people falling and everything else and sort of the added cost to the NHS for that. What is the current position with domiciliary eye tests? Mr Cartwright: Domiciliary eye examinations are available, and there are many practices who do them and some companies which specialise in domiciliary eye care. I believe that one of the issues there is that there is a fee for the first patient and then a lower fee for subsequent patients. There should be a higher fee for the first and second patients and then perhaps a tail-off, whereas it happens at the moment after just one patient. Q401 Chairman: If you had this National Service Framework which was mentioned earlier, obviously issues like that would be in there and hopefully would be accepted throughout the UK. Could I move on to Dr Ellman. You advocate an automatic, free oral health risk assessment programme which I would have thought, in terms of last week's White Paper, was something that the Government would be interested in looking at. What are actually the costs and benefits of such an initiative like that? Has it been costed in any way? Dr Ellman: Not as far as I am aware, but it has not been developed properly yet either.[9] There is an outline being developed, but there is no IT system to support it currently. A full oral health assessment has been used by other people in private plans, for instance, to give guidance to get a full picture of somebody's oral health, not just the fillings, but the whole picture. That would be beneficial because you could see and again you could do the one thing we have never really done much of in dentistry and that is to measure the health gain, the effects in terms of what we do. We know what the immediate effects are, but we do not know the long-term effects. It would also enable patients to be encouraged along the prevention route by doing oral health scores, so you would know exactly where you were in terms of relationship. This has been trialled outside the NHS by Denplan actually who did it as part of one of their schemes with a fair degree of success, so I think we are not reinventing the wheel from that viewpoint. Q402 Chairman: Have you got reports from Denplan on that which perhaps the Committee could look at? Dr Ellman: I can try and ask them if they could supply us with some for you. I have not any. Q403 Chairman: The other thing I would just like to ask you, Dr Ellman, was not really about NHS charges, but it does come into what you have just said there to some extent. It is this issue of fluoridation of the public water supply. What is the BDA's position on that? Dr Ellman: Absolutely solidly in favour. We ran a massive campaign here at Parliament for that some 18 months ago and that was very successful. The BDA is very much in favour of that and the science is very much in favour of that. There are entrenched views in the different directions, but there we are.[10] Q404 Chairman: We have heard them over the years, but, with our new regulations in situ now, we do not know when or who is going to operate them. Could I just move back to the opticians. How do you see the new general ophthalmic services contract developing in the future, not in terms of you would like it set in the National Service Framework and everything else, as I am sure you would, but in terms of charges? Do you think there is going to be any great change? Mr Cartwright: I think, in the ideal situation, there would be eligibility, so an eye examination would be something that everybody could access. I think we have to be realistic and say that there are certain groups that are more at risk than others, such as children, elderly people, sufferers of medical conditions and those on low income, so that is absolutely right. Personally, I would then put more effort into extending the role of the optometrist to be able to deal with specific situations that would free up resource elsewhere. We have talked about where, if somebody has red eye or conjunctivitis, that would go into the optometric practice and, perhaps rather than extend eye examination eligibility to absolutely everybody, I would put some money into that side. Q405 Chairman: Well, could I thank all of you for coming along this morning. It has been quite an enjoyable session with the little bit of entertainment in the middle of it all! Thank you very much indeed and hopefully it will not be too long before we are actually reporting to Parliament in relation to this. Any further papers you have on these issues we will be more than happy to look at before we come to any firm conclusions. Mrs Hansford: Would you like us to send copies of these documents to the Committee? Chairman: Yes, indeed we would. I think David would in particular. Thank you. Witnesses: Mr Derek Lewis, Chairman, Patientline; Dame Gill Morgan, Chief Executive, NHS Confederation; and Ms Maggie Elliot, President, Royal College of Midwives, and Head, Midwifery and Women's Services, Queen Charlotte's and Chelsea Hospital, gave evidence. Q406 Chairman: Good morning. Could I welcome you to the Committee and thank you for coming along to help us with our third evidence session in looking at the issue of NHS charges. I wonder if I could just ask you to introduce yourselves and what organisations you represent. Ms Elliot: I am Maggie Elliot. I am representing the Hammersmith Hospitals NHS Trust. Dame Gill Morgan: I am Gill Morgan and I represent the NHS Confederation. Mr Lewis: Derek Lewis and I am the Chairman of Patientline. Q407 Anne Milton: My first question really is addressed to Maggie. Perhaps you could tell us a bit more about the scheme in place at Queen Charlotte's Hospital where expectant mothers can pay for NHS care. Maybe you can expand on that and tell us a little bit about why it was developed in the first place. Ms Elliot: First of all, the mothers do not pay for NHS care and we are quite clear about that. The mothers actually book in to the hospital normally first, so they actually are entitled to, and absolutely would receive, NHS care if they themselves did not choose to go private. The scheme started about two years ago or the concept was two years ago, but the actual commencement of the scheme was about 18 months ago. One particular midwife came to me very, very keen to provide 24-hour on-call service to reassure women that everything is all right and that sort of thing, so it was started as a result of that conversation. She had also been aware of a very similar, but not the same, scheme in another trust. There was a demand from women, so we looked into it fully and started. Q408 Anne Milton: So, just for the record, mothers pay for that? Ms Elliot: Mothers pay for the 24-hour on-call service that this midwife and now, since then, one and a half others actually provide which is not available to other women basically. Q409 Anne Milton: So what you are suggesting is that, if you cannot afford to pay for it, you do not get the reassurance in the middle of the night? Ms Elliot: Yes, you do, but you do not get the same person to do that. Of course the relationship builds up with that one midwife, so, as soon as the woman calls her, she knows immediately who it is, what her issues are and provides very reassuring advice or tells her to come into the hospital or whatever. Yes, other women are able to call the hospital, but they speak to either a midwife on the delivery suite or they speak to a community midwife basically. Q410 Anne Milton: There has been evidence around for years and years and years about the outcomes for women in pregnancy if they have a named midwife and certainly organisations like the NCT have been calling for that for years, so in fact your access to somebody you know is quite important when you are pregnant? Ms Elliot: It absolutely is and we would move towards that for everybody, particularly if it is part of the NSF, so it is planned for the future, but currently we do not provide the absolute midwife for that woman. The other thing of course is that the scheme has allowed us to provide this service for women with a clinical need, so, as well as this midwife and now another one and a half actually providing that service for the women who pay for it, we actually now can provide it for women with severe clinical need, and she takes on women free of charge which we would not have been able to have done if we had not actually started this scheme. Q411 Anne Milton: What would be the clinical need? Ms Elliot: It is people who may have had a very traumatic experience with their first birth, so they would come to me and I would have a conversation with them on the telephone and then I would refer them on to the Jentle Midwifery Scheme because they basically need the reassurance of one, single midwife. Q412 Anne Milton: You talk about difficult socio-economic circumstances as well. What do you mean by that? Ms Elliot: Well, that could be somebody who had a history of domestic violence. Basically anybody who needs the reassurance of a midwife who absolutely knows their history from start to finish are the people who are referred to this scheme. Q413 Anne Milton: So clinical or socio-economic, people whose pregnancy is flagged up as maybe being complicated for a number of reasons? Ms Elliot: Yes. To put this into context, because it is a pregnancy from start to finish, this is called a 'caseload', so the Jentle Midwifery Scheme have actually taken 51 women who have actually delivered with them who have actually paid. Additional to that, they have taken on an extra 25 who have not paid, and they were able to expand that number as well, but they also provide reassurance and care to other women as well. Q414 Anne Milton: Are you comfortable with it? Ms Elliot: Absolutely, yes. Q415 Anne Milton: I need to ask you that because it could be seen very much as a two-tier system. Ms Elliot: It is not a two-tier system because all women at Queen Charlotte's, I hope, have a high quality of care. These women do not actually receive a better quality of care, but they simply pay for the reassurance of one midwife and nobody else will get that. Q416 Anne Milton: You are subsidising, richer people are subsidising the needs of a group of people you have flagged up as having exceptional needs during their pregnancy? Yes? Ms Elliot: We are able to reinvest the money back into the NHS, yes. Q417 Anne Milton: Quite. Just moving on to Gill, do you think this kind of scheme will be introduced elsewhere? Dame Gill Morgan: I think the challenge for schemes like this is that they are right on the cusp between the private sector and the NHS which makes it, I think as you have been exploring, really quite difficult to know how far people will take them. We are not aware of a large number of schemes of people trying these sorts of things, but we are aware of individual organisations trying them. This is really quite different, I think, from the other one which has had a lot of publicity recently which is the dermatology clinic which is quite clearly a private service run in NHS hospitals. We have always been able to run private services in NHS hospitals and we have always been able to offer extra amenity in terms of beds and hotels right back to 1948. This is really exploring a new territory and I think we are not going to know, and this is one of the problems for organisations, quite how acceptable it is until at some point it gets tested in law because it is right at the boundary, I think, in terms of position. You will have tested it before you actually set it up, but it will be the test of whether anybody challenges it in court which will finally encourage organisations to do it. I think people will be looking at this, but not necessarily intending to go down the route at the moment. Q418 Anne Milton: Just to come back to you, Maggie, do you have any figures of the people who pay for this, how many of them have the sort of need that you would have identified? Ms Elliot: Well, first of all, anyone who had a need would have had our one-to-one midwifery service anyway, so it is actually a want absolutely rather than a need. They pay for something they want. Q419 Anne Milton: So they are paying for something they want, not something that they need? Ms Elliot: That is right. Q420 Anne Milton: And, in doing so, they cross-subsidise the service for the people who need it? Ms Elliot: Yes. Dame Gill Morgan: I suppose the other thing we should point out is that these sorts of services have been available by independent midwifery practices for a long time. What is unusual about it is offering that sort of independent service within an NHS hospital and, therefore, using the money to cross-subsidise, and that is unusual. Q421 Anne Milton: Are you comfortable with it, Gill? You look wary. I can see wariness on your face. Dame Gill Morgan: I think this is right at the cusp of some real challenge and I am not really sure how comfortable I feel about it because I feel, I think, a little bit like you. There is a real benefit if you get additional resources in to boost the services which is why I feel comfortable about private services provided within the NHS because that money has always gone back into the NHS and I suspect, if this had been presented as a private service, I would have had no difficulty whatsoever. In one way, you could present it as a private service if you are quite comfortable about it, but I think the way that it is presented leaves me personally feeling slightly uneasy, but that is a personal view, not an organisational view. Q422 Chairman: Could you just answer this: how different is this payment in principle from a payment for a prescription charge? Dame Gill Morgan: I think the thing that is different about this is partly the scale, but I also think this is about the choices individual people can make to have something which, as I say, could have been presented as private and I would see it as fundamentally different from a prescription charge. I think part of this and the discomfort is just the presentational issues for someone who is used to the way the NHS has traditionally worked. The prescription charge is different. That is a payment that everybody contributes to, so it is a different sort of thing for me. Briefly, while we are on prescriptions because I know that is not the purpose of today, but I know you have been wrestling with what evidence there is about how many people fail to use prescription charges, I have brought with me a paper from a Commonwealth survey which compared the UK with five countries which gives some answers around prescription and dentistry. I will leave that for you. Q423 Chairman: You do not then see a prescription charge as being a part-payment for getting a service from the NHS? Is that what you are saying? Dame Gill Morgan: It is a co-payment, but it is a different co-payment because it is really focused the other way round and it has so many exclusions to it. My personal view again about prescription charges is that we are not very sophisticated about how we apply them, so we do not think about what we are trying to achieve as a policy context and I do not think we have fundamentally thought about the challenge of where we are today with expensive drugs. One of the things we have been thinking about internally which we have not sort of launched for a wider public is what I have seen in other countries which is that, if you want to make drugs available to everybody on an equity basis, but you also want to offer some choice for people, what other countries do is make generic drugs free and then only charge a co-payment if somebody wants a branded drug. For example, if you take a drug used to make you pass water, the generic name is furosemide which would be free with no prescription charge, but some people, however, like the branded name, Lasix, because it comes in a green colour and they like that, so you are charged for the branded name and, in that way, you drive two policies, one being equity and the other being the issue that we want more generics prescribed. Q424 Dr Stoate: I have a couple of very serious points I want to raise. You say it is not a two-tier service and you also say you are just giving reassurance, yet, according to the newspapers, and I have given the articles to the Clerk to look at, they are not just getting reassurance, but what they are getting is one-to-one ante-natal classes and they are getting practice birthing sessions on a one-to-one basis. That is not about just giving reassurance over the phone 24 hours a day; that is about a completely separate type of service which is not available, except to the 25 people who have got clinical need, unless you have got 4,000 quid. That is the reality surely. Ms Elliot: First of all, I cannot comment on what the newspapers have said. Q425 Dr Stoate: They are wrong, are they, the newspapers? The £4,000 does not include the birthing classes, the practice sessions and the one-to-one ante-natal sessions? That is not what is happening? Ms Elliot: First of all, other women that we actually give care to do actually receive that type of care throughout the one-to-one midwifery service, so we do have a service that actually gives exactly the same type of care, the only difference being that they do not get one named midwife throughout the whole of their care. Q426 Dr Stoate: Well, that is not what is being said in the papers. It is specific women being interviewed and I want to know whether these newspaper stories in fact are true. The women being interviewed are saying, "It's marvellous. I get ante-natal classes with one or two couples only, instead of the 30 I would get otherwise, and I have got this practice birthing session where the whole thing is done in practice on a one-to-one basis". Is that not happening? Ms Elliot: That happens within the Jentle Midwifery Scheme absolutely. Q427 Dr Stoate: Right, so that is what they are getting for their £4,000 and not just reassurance over the phone. Ms Elliot: Yes, but that actually goes back to the fact that that is a want and not a need and that is what they are paying for. Q428 Dr Stoate: But what I am trying to say is that that is a two-tier service. They are getting something which is completely unavailable to women who are not paying £4,000. Ms Elliot: It is unavailable to those women, but the women that are not paying £4,000 receive an absolute high level of care that is acceptable and within the NHS. Q429 Dr Stoate: But not within the NSF. The NSF standards only reach those people who pay. Ms Elliot: Yes, but then you could go on then and add on separate things which women actually pay for that are not available within the NHS. Q430 Dr Stoate: What I am trying to get at very simply is that they are paying for a service which they cannot get on the NHS if they have not got the money. Ms Elliot: Yes, but then nobody gets those services on the NHS. It is not something that is available. There is not another scheme that provides one midwife total care within the NHS. That is not available. Q431 Dr Stoate: You are right, but it is an NHS service which is only available to those who have got £4,000 over and above the ordinary NHS standard. Ms Elliot: It is not an NHS service. Q432 Dr Stoate: Well, you have just said that it is part of the NHS. Ms Elliot: No, the women who are in our one-to-one midwifery service actually receive a very similar service, but these women pay for extra things which are not clinical need. They are things that they want, not things that they need. Q433 Dr Stoate: Okay, I will leave it there. You have said that you seem to support or seem to have some sympathy for a scheme whereby, if you want a generic drug, you get it for free, but not if you want the branded drug. What is the difference then if I were to say to a schizophrenic, "You can have largactyl or Chlorpromazine for free, but, if you want Olanzapine, one of the typical anti-psychotics, it is going to cost you 50 quid"? Would that not be the same thing? Dame Gill Morgan: No, I do not think it would because there you are not comparing like with like because the more modern anti-psychotics are clinically more effective and they have been shown by NICE to be. It is not like for like and that, to me, is fundamentally different. Q434 Dr Stoate: Why is that fundamentally different? What is the difference between saying that the basic NHS midwifery service is okay, but not up the NSF standards, whereas, if you are going to pay £4,000, you can have the NSF standard because that is not like for like either? Dame Gill Morgan: Well, that is where you go back to where I think, if this is presented as a completely private scheme, which is what the NHS has already been allowed to do, it would not be causing some of this heartache as it does sit right in this middle bit and the NHS has been allowed, even in Barbara Castle's day, to provide some private practice. I think part of the issue here, which is why there is so much interest in it, is that it is stirring up this question of how far you mix private work with public work on the same ward and you get the benefits accruing to the NHS, and that is very difficult. Q435 Dr Stoate: Are we not just going straight down a slippery slope? Okay, you could argue that the new anti-psychotics are clinically different from the old anti-psychotics, though other people might not necessarily agree with that, and maybe the anti-psychotics are not a very good example, but maybe we could come up with many other examples, and I am sure it would not take me long to come up with other examples, where a drug might be okay, but actually there is a "rather better one" and NICE might think it is a rather more sophisticated drug, and it does not make that much difference, but you can have that if you pay for it. Is that not the same thing and how far would you take it? Dame Gill Morgan: Some countries have done that of course. If you go to New Zealand, that is the way they have handled their prescribing costs. I am not advocating that because I think there is a duty to use the best, and most appropriate, drug and that is what NICE gives us. It gives us a view about what is the best drug to use at a particular time. However, within that, there is a great difference between the generic version of the drug and the branded version of the drug when things come off patent and the cost difference can be absolutely phenomenal. Now, it seems to me that that is not the same because you would not be withdrawing a service from people, you would actually be putting in a top-up for people who wanted a particular branded version rather than the generic. Now, I have not done any modelling and I am not presenting this as a hypothesis of what we should do, but what I am trying to suggest is that we could be looking at some of these charges in different ways and then maybe both ways of bringing some resource in because, when you add up all the charges that come into the NHS, it is a significant contribution to the running costs of the NHS, but we could be doing it in a way which does not actually compromise equity and which does not actually compromise another policy which is to get actually more generics prescribed. It is a suggestion that we need to begin to think differently about it rather than the way we have always thought about it. Q436 Dr Taylor: We are coming back to prescription charges later, but I am afraid I wanted to talk to Maggie a little bit more because, when we did an inquiry on midwifery in the last session, it came absolutely clearly out that why mums like midwife-led birth centres is because they have a very high chance of having one-to-one care from the same midwife throughout. Now, I have to say that I think it is entirely wrong, and I hope the Committee will say it is entirely wrong, to do it the way you are doing it because these people are in fact getting private care at half price. What does it cost to have a baby privately, to have the whole shooting match privately? How much does it cost? Ms Elliot: Well, between £4,000 and £5,000 with a private obstetrician, depending on the service they have, whether they have a caesarean section or not, whether ---- Q437 Dr Taylor: So they can have a baby privately for £4,000 or £5,000 and they can come into the NHS unit and pay £4,000? Ms Elliot: Actually I need to take advice on that. Q438 Dr Taylor: It strikes me that this is cut-price private medicine. Ms Elliot: Sorry, depending on the actual service, it is £7,000 to £8,000. Q439 Dr Taylor: In a hospital like Queen Charlotte's, your delivery will be high-class, so you do not need to pay to make sure that you get the right obstetrician to do it. What you do need to pay for is the superb comfort of having the same midwife all the time, so here you are giving people who can afford it a better class of care, and I hope the Committee will come out and say that it is entirely wrong without somebody having to take it to court to prove that it is wrong. Ms Elliot: It is not ---- Q440 Dr Taylor: Do not try and defend it! Ms Elliot: It is not a better level of care than the women on the NHS receive. Dr Taylor: Of course it is. What they want is the same midwife ---- Q441 Chairman: Let her answer the question. Ms Elliot: We do have a one-to-one midwifery scheme and that does provide a named midwife, but that midwife cannot be guaranteed, because of annual leave and because of other reasons, to provide that level of care. This midwife and now the two whole-time midwives give that guarantee to them that it will be them that actually will deliver that baby because they arrange their annual leave around those women, so they will not go on annual leave when they have got women booked, so it is a guaranteed service. The women actually want that. They want the reassurance of a midwife and it truly is not a better level than women with clinical need actually get. Dr Taylor: I think you have dug the hole deep enough. Thank you. Q442 Chairman: Obviously the individual concerned can arrange holidays in terms of days of the week, but the actual day, as I understand it, can be quite a long process in terms of hours and everything else. Ms Elliot: Yes. Q443 Chairman: Indeed on a couple of occasions I have sat through those long hours, waiting! Obviously it will disrupt that day, particularly the day of birth, for these individuals in terms of going back perhaps to their families and everything else at the times they would normally have been able to, so is there any personal gain in those individuals' income, as it were? Ms Elliot: For the midwives? Q444 Chairman: Yes. Ms Elliot: No, they receive the NHS salary. Q445 Chairman: And that is it? Ms Elliot: Yes, and of course including all of the on-call allowances that the NHS provides as well. Q446 Chairman: So they will get that whether it was somebody who had £4,000 sitting alongside them or not? That would be the same? Ms Elliot: Yes, so, whether the women are either paying for the extra services or not, the midwifes would receive exactly the same salary. Q447 Anne Milton: I would just make a comment really about when you were talking about prescribing, Gill. I think one of the issues, and where it gets very complicated, is that compliance is a big issue, so, even if there is no difference in the tablet, but I would like Lasix and I do not like that ghastly furosemide, that comes into it, and also there is the placebo effect of drugs where, if somebody perceives that Lasix will be better for them, then they are more likely to get better if they take the Lasix actually? Dame Gill Morgan: Sure. Q448 Anne Milton: But just to come back to Maggie, and I think you were given a particularly hard time by Dr Taylor actually, what these women are paying for is a guaranteed person? Ms Elliot: That is right. Q449 Anne Milton: If you believe, therefore, that they are not getting anything that they need, but it is something that they want, and I am sorry to be controversial, it is going to be said, therefore, that you are exploiting women at a very vulnerable time in their lives. Ms Elliot: There is a huge demand for this and we are turning people away all the time. Q450 Anne Milton: But I can say that it is exploiting them and encouraging them to believe, because they will believe, I would guess, that they need this. Ms Elliot: We absolutely do not advertise it in any shape, form or description. It is the women that ask for it and for a long time they have always said that they cannot provide it, but this midwife had actually had experience of a very similar scheme and knew that it worked very well, so we were asked for it. She came to me with the proposal and, I have to say, the women that actually go on to the scheme actually have to be booked with us first, so, because we are in London and there are capacity issues, we cannot take women from Timbuktu, but they actually have to be booked with us and live within our local area in order for us to accept them on to the scheme. We are currently turning a lot of women away from it because we just cannot provide the demand. Q451 Chairman: Gill, can I just ask you about this issue of purchasing beyond a generic prescription. It is a form of choice, is it not? Dame Gill Morgan: Yes. Q452 Chairman: "Choice" is the sort of buzzword now certainly in terms of patients, though I am not sure about the people who are providers who work in the Health Service. I know this is not a confederation view, but just your personal view ---- Dame Gill Morgan: This is just a discussion, yes. Q453 Chairman: Do you see choice, which has effectively a co-payment in that respect, as being something that is consistent with the NHS as it has been in the past or indeed is now or could be in the future? Dame Gill Morgan: My personal view is that, where co-payment is necessary for something which is essential, we should not be charging co-payments. That does not fit with the NHS and the ethos of the NHS, but, where this is something which is about preference, I think you could begin to explore different ways of thinking about co-payments. For example, we have always made amenity beds available where people have been able to pay an additional sum to have a private room. It seems to me that there are opportunities in that sort of zone to think differently because there is some choice and that is why some of my response to this is that it is right at the edge of things that we have always done. You could argue that having a private room, for which we charge an amenity charge, is some sort of way where you could only do it if you have got the money, it is unfair, but at the same time you know that, if the private room is needed for an individual patient for a clinical need, there will not be an amenity bed available. I just think we need to be thinking differently about some of these charges and whether there are ways that we can do it where we are not co-paying for fundamental treatment because I personally feel very strongly that that is not the ethos of the NHS or the way we should be going. Q454 Chairman: I have got in mind the situation where, if you look at the Calman-Hine report of quite a long time ago now about surgery, and cancer surgery in particular it was looking at, we had hospitals and clinicians who were identified as being better skilled at saving somebody who had to have surgery for cancer than other establishments. It would be very tempting for somebody to say, "I'd like to co-pay on the NHS to go to that hospital with that surgeon", which Calman-Hine identified where the chance of surviving that cancer is quite a few percentage points higher than not going there. What would you say to that? Dame Gill Morgan: I would find that completely unacceptable, on personal grounds. As far as our members are concerned, it would be very hard and we have never surveyed our members collectively on that, so I cannot speak on behalf of the NHS. Chairman: I understand that and it is not in our script either, but it is just something I thought I would like to test out with you. We will move on to David Lewis now. Mr Amess: Before that, poor Maggie! She has had a terrible time in this Committee and even Richard has been sticking the boot in. I am so sorry the opticians have gone because I just wanted to say to you, Maggie, that I think your glasses are splendid! I bet they were not taken off the shelf! Mr Campbell: More importantly though, how much did they cost! Q455 Mr Amess: We have with us now this morning Mr Lewis and I am sure that what the Committee would really like to know is what really went on between him, Michael Howard and Miss Widdecombe, but we are not going to pursue those matters and we are going to talk about Patientline. Now, there has been some very, very tough stuff in terms of the criticism of Patientline, huge criticism about the costs of installation when you think that, with the technology developing, they are practically giving TVs and phones away, et cetera, so I think the first thing the Committee would like you to address is how you can defend the very, very high costs of installation. Mr Lewis: Well, of course these systems are very sophisticated systems. These are not simply televisions and telephones at the bedside. When the so-called Patient Power programme, under which they are installed, was specified back in 2005 as part of the NHS Plan, what the NHS was then looking for was a device that would not only provide telephone, television, radio and so on, but would have the capability of doing a lot of other things, providing interactive services for patients at the bedside, being capable of providing access to electronic patient clinical records at the bedside for use by nurses and doctors, and being able to provide the mechanism for patients to order their food at the bedside for dietary management and so on. Therefore, the systems that have been installed are essentially a PC at every bedside and it is a specially designed PC for the hospital environment, as a result of which the cost of installation is high. It is typically about £1,750 per bed, all of which is funded by the providers who install them who additionally fund the operating costs and that involves having staff in each hospital, typically about five people in each hospital, who keep them clean, who maintain them and who look after patient needs in relation to them. That inevitably results in a substantial amount of cost being incurred. The UK is unique in that this particular type of sophisticated system is funded in this country in a way that it is not anywhere else and that is that at this point it is funded entirely through payments by patients and by their friends and relatives who make calls to patients. As you may be aware, Ofcom, which was still investigating the costs of incoming calls at the time we submitted our evidence to the Committee, has subsequently reported and has concluded that the charges for incoming calls were essentially an unavoidable consequence of the way the funding structure has been set up in the UK where the providers, as was recognised by the NHS at the time, had little choice but to recover the bulk of their costs from charges for incoming calls. The great opportunity, we believe, and we welcome the Ofcom report, is to extend the use of these systems for the purposes for which they were originally designed and selected so that the benefits extend well beyond those of patient entertainment and communication. We hope that the review group that is now being established by the Department of Health will indeed explore those further uses so that we can achieve a much more equitable spread of the cost of the systems between different users. Q456 Mr Amess: You have really sort of guessed many of my questions really, including talking about Ofcom. In terms of the volume of complaints, have you had a lot of complaints about the cost of charges not only from patients, but from Member of Parliament? Mr Lewis: I think it is important to say, first of all, that, by and large, there is a remarkably high level of satisfaction with these services on the part of patients, and the NHS itself conducted research about a year ago which indicated that 90% or thereabouts of patients were satisfied with the services that they received. There are obviously concerns about having to pay at all in the hospital environment within the NHS, but again, by and large, the majority of patients feel that the charges for television and for outgoing calls, which were deliberately capped as part of the original programme, are reasonable and they are happy to pay those. There have been complaints, and there has been quite a significant volume of complaints, about the costs of incoming calls which are set at a much higher level and which are now higher than the norm for telephone calls generally, and those complaints come from callers, friends and relatives who call patients and indeed from Member of Parliament who are reflecting the views of their constituents. Q457 Mr Amess: In terms of the technology that you have available, would you share with the Committee what other services you feel you could provide and can you try and seduce us by saying that, if you did provide these extra services, in actual fact you would be saving money for the National Health Service? Mr Lewis: A number of these services not only, in our view, would save money, but produce some significant improvements in patient care, patient satisfaction and indeed patient choice, but, with a PC at the bedside, the scope is very considerable. For example, and these are all things which are now being done, but not to the extent that we would like to see them done, there are two hospitals in the UK where patients now order their food on the system. Q458 Mr Amess: Which are those hospitals? Mr Lewis: They are in the north-east, North Tees and Hartlepool, the first two hospitals to do so. That brings a number of benefits: the information about the menu and its dietary parameters is easily available to the patient; they can order their food a very short time before the meal is actually delivered; it arrives at the right bed because they have not moved bed in the interim and that brings significant reductions in food wastage; it completely eliminates the need to print menu cards; changes to the menu can be done instantly; and it is a means of providing information about what food patients have ordered for the monitoring of their diet. In those two hospitals and the other hospitals that are now looking at it, there are some very tangible savings and clinical benefits. Q459 Mr Amess: Will you answer the direct charge though that one of the reasons your expenses are so high is that you are not getting that which you thought you would from the National Health Service and it is the poor old patient who is lumbered with these costs? Mr Lewis: I think there is an element of truth in that. When this programme was conceived, it was anticipated that things like food-ordering and access to clinical records at the bedside would be widely used and would generate a significant source of income for the providers. The development of that income has been much slower than was originally expected. Had that income developed at the pace that everyone expected at the time, we would have expected to have been able to reduce the level of incoming call charges by now. Q460 Mr Amess: Do you think the current charging agreement does actually have a viable future or do you think the whole thing is going to have to be looked at again? Mr Lewis: We believe it is viable, but unsatisfactory at present and we would very much like to see change and we hope, therefore, that this review group that is being set up by the Department of Health will, first of all, consider a wide range of options, will look at the way these services are funded in other countries which do not involve high levels of charges for incoming calls, will consider ways of encouraging other uses to the system, and also more effective operation on the boundaries between the services that the providers offer and the things that the hospital does. Our belief is that, if there is an open mind in approaching those issues, there are a number of ways in which those charges can be reduced and we very much hope that it will operate to a very tight timetable as it is not something we would like to see drift on for any great length of time and we would like it to work to conclusions within a few months so that we can actually implement some changes quickly. Q461 Mr Amess: This may be a bit difficult for you to answer, but how much money do you think would have to be generated from the National Health Service to reduce the charges to a reasonable level? Mr Lewis: It is extremely difficult to answer that question because it depends entirely on the mix of services provided and what some of the additional costs are of providing those services. We do not see a single solution to this, but we do see, if you like, there being a menu of actions which, brought together, should enable incoming call charges to be reduced to a level that callers would consider to be acceptable and would remove a number of other irritations, one of which is the need at present for the warning at the beginning of all incoming calls about the cost of those calls. Q462 Mr Amess: Finally, and you have sort of already answered this, Ofcom and the criticisms - what is it your intention to do about these criticisms? Mr Lewis: Well, I am not usually someone who would make complimentary remarks about a regulator, but they did actually, I think, do a quite thorough job to a reasonably tight timetable. Their conclusions were that the level of incoming call charges, which was the specific bit they were investigating, were a cause for concern, they were a source of complaints and they looked out of line with other telecoms charges. However, they did conclude, first of all, that the level of those charges was heavily influenced by the specifications that had been set by the NHS for these systems back in 2000: the highly sophisticated technology; the requirement to put one of these units at every bed even though it is uneconomic; and the requirement to provide a range of free services for the NHS, such as free radio, free information services and so on. They concluded, as a consequence of that and combined with the cap that has been established on charges to patients, that the providers had very little choice other than to effectively charge these higher prices to incoming callers, and they described the charges as being the result of a "complex web of government policy and agreements". In addition to the published report ---- Q463 Mr Amess: What does that mean, do you think? Mr Lewis: I think you would probably have to ask Ofcom, but I think it relates back to the policy when the programme was set up and the way it was funded. They have published a report and they have also written to the Secretary of State with a series of recommendations, we understand, although we have not seen that letter as yet, but hope to do so as part of the work of the review party. Q464 Dr Taylor: Is it fair to say, Mr Lewis, because you have said that your system will have a computer by the bedside which would show an electronic patient record, that the relatives who are paying 49p a minute for their incoming calls are in some way subsidising the national programme for IT? Mr Lewis: Not at present because at present the usage of the system---- Q465 Dr Taylor: But it is there. Mr Lewis: Well, indeed. The usage of the system for that purpose is at present very limited. There is just one hospital, Chelsea & Westminster, which is using our system to access an electronic clinical record at the bedside, and very successfully so, so effectively ----- Q466 Dr Taylor: Does your warning message say, "Thank you very much for using this service. It is going to cost you 49p, but you are helping the NHS towards its aim of having readily available electronic patient records at the bedside"? Mr Lewis: In principle, that is a correct conclusion. We do not include that in the message for fear of lengthening it further. Q467 Jim Dowd: Because that would cost them a further 49p! We are actually talking about the kind of charges for incoming calls that people were desperate to pay ten or 15 years ago in the early days of mobile technology, but I will put that to one side. I am sure it is difficult to estimate, but what proportion of inpatients take advantage of your services? Mr Lewis: A very high proportion do. Approximately 70% of the terminals we have at the bedside at any one time have a patient registered to them and about half of those on any one day will be paying for a service or people will be paying to call them. The other half will be making use of the free services, radio, television, if they are children or have special needs, or may not be using the service on that particular day, so it does have a very high level of usage. Q468 Charlotte Atkins: You have said here that the installation costs are something up to £2,000. Given the changes in technology, is there the opportunity for these costs to come down? It seems to me that you have got something a bit like a white elephant in many situations because the full range of services which are provided in these units are not being exploited, so people are having to pay the cost of more than actually ringing Australia to access a friend or relative in hospital, and I speak with experience here, having ended up with a charge of £60 when a member of my family used your service. It seems to me that they are paying for something which is not being fully exploited. Mr Lewis: I think the answer to that is that they are not white elephants by any means. In fact our technology is regarded outside the UK as being leading edge, and hospitals in the United States, for example, are bearing the full capital costs of the magnitude you have just described in order to install these systems because they see a very wide range of benefits from them. In a US hospital there is already television and telephone there and US hospitals are paying up to £2,000 a bed in order to provide devices which will provide the full range of clinical services and other services that I have been talking about. Q469 Charlotte Atkins: But it is a white elephant if it is not being used. That is the point. It is not a white elephant in the sense that it is being used in other countries, but it is a white elephant if it is not being appropriately used and the full system is not being exploited, which means in fact, as Richard was saying, that patients' friends and relatives, by and large, because they are ringing the hospital and they are the ones that are being charged excessively, are subsidising a system which is not being appropriately used in the NHS. Mr Lewis: In that sense, I would agree with you. I think the solution to that is to ensure that they are fully used. This investment is now largely a sunk investment; it has been made and the systems are there. The challenge, I think, is to make sure that the full potential of it is used to improve patient care, to generate the sort of cost savings we were talking about, to reduce medical errors and so on, for which there is considerable potential. Q470 Charlotte Atkins: But the contract was agreed when, in 2000? Mr Lewis: The contracts were specified in 2000, yes. Q471 Charlotte Atkins: So presumably technology has now moved on and you presumably have stage two, stage three of your systems which presumably, given that the cost of computers and other technology is coming down, are not as expensive as they were back in 2000? Mr Lewis: The actual capital cost is very similar. Technology has moved on and it has become slightly more sophisticated but the core costs, which are in designing the physical hardware that goes in at the bedside and all the cabling, have not changed significantly in that period. Q472 Charlotte Atkins: And as to the people who are being exploited effectively when they ring in, are you doing any sort of analysis about what sort of people are facing these huge charges, because it seems to me that the people who are more likely to use the system are the ones who cannot visit the relative, who are ringing in as a substitute for a visit, and therefore my instinct tells me that the people who face these high charges are more likely to be the people who are less likely to be able to afford them? Mr Lewis: The evidence we have is anecdotal but it is that the people who use the service to call in do cover a very wide range of both friends and relatives. They certainly do include those who are on lower incomes and those who may not be able to make the trip into hospital and for whom it is an important means of contact, and I think that is a further compelling reason for the need to change the structure of the provision of these services to enable a reduction in those charges. Q473 Charlotte Atkins: And also, of course, because the charges come on your normal phone bill, it is quite likely that complaints will not be made direct to yourselves because it is just a nasty shock when your quarterly bill comes through the door. Mr Lewis: That is true and that is one of the reasons why the NHS has insisted and we have wanted to make sure there is a warning at the beginning of every call so that there is less risk of there being an unpleasant shock when callers receive their bill, but it is an inherent problem with this type of service. Q474 Charlotte Atkins: We all know that if you are ringing someone whom you are very worried about the likelihood of you listening very closely to that particular warning message is not going to be great. Mr Lewis: We do have five to six million people who call using Patientline systems each year and the proportion of those who get an unpleasant shock when they receive their telephone bill and are unaware of what they are being charged is quite small. Q475 Charlotte Atkins: Thank you. Gill, did you want to come in? Dame Gill Morgan: Quite a few of those complaints that come do come to individual organisations and it is one of the strands in hospitals, complaints about the charges when the bill comes in. There are a number of reasons why the NHS is not getting the functionality. The first is that when Patientline started it was an orphan project. It was an idea about improving accessibility for patients and linking into things but I do not think at the time, in the way that it was introduced into the NHS, anyone had begun to grasp these other functionalities. Where the NHS is now is that it is not quite ready to get these functionalities because they really do depend, as Richard has pointed out, on having some of the functionality from Connecting for Health universally available. That is why projects like Chelsea and Westminster, which are showing how you can begin to link these things together, saving staff time, giving patients much more information about themselves, giving much more information about individual conditions, are the model for the future. I think things will change but you have to have something to link that system in and that is not yet available uniformly across every hospital in the country. Q476 Dr Taylor: Can they look up on Google all about their illness while they are lying in bed? Mr Lewis: They can indeed. We provide internet access. Q477 Dr Taylor: Internet access as well? Dame Gill Morgan: Yes. Mr Lewis: A number of hospitals have also asked us to provide access to a variety of different information sources that they have quality control over, which may indeed include NHS Direct online. Q478 Dr Taylor: I shall be very well informed because I am going to visit one of the hospitals in the recess. Coming back to Gill and going back to prescription charges, could you tell us again what the piece of paper you have handed over tells us? Dame Gill Morgan: There was a Commonwealth Fund survey of five different countries in 2002 that asked the question had you ever not cashed a prescription or not had dental treatment, and a whole range of things, and it just showed that in the UK we had some people who had not done things because of money but it gives a comparator internationally. Q479 Dr Taylor: So it does give us a bit of fact? Dame Gill Morgan: It gives you a bit of fact, yes. Q480 Dr Taylor: We have heard rumours that there are problems with free prescriptions in A&E. Dame Gill Morgan: I have not heard anything about problems with free prescriptions in A&E. Q481 Dr Taylor: One really important argument in favour of abolition to me seems to be that with the greater shift of patients from inpatient care to outpatient care and care in the community, even chemotherapy for cancers and things like that, some very deserving patients are losing the free prescriptions from hospital care and are having to pick them up with outpatient care. Is that not going against the whole of the White Paper's aim and is that not an extra strong reason for abolition? Dame Gill Morgan: It depends. There are different ways of funding those. What a significant number of hospitals do is buy the package which provides the free prescription and the home therapy so that people are still treated as an outreach from hospital, in which case those drugs are not charged through an NHS prescription. It is provided in the same way it would be provided if you were admitted as an inpatient on that oncology ward. Q482 Dr Taylor: Is that widely known? Dame Gill Morgan: It varies from drug to drug. Obviously, if it is a drug that you can take orally then you may be in a different position, but what we are trying to do is take more of the infusions of cancer drugs into people's homes because if you are feeling pretty rotten, you are feeling pretty sick, you are better off feeling pretty rotten and sick in your own home and having care provided in your own home, but it is outreach. Q483 Dr Taylor: It was oral agents I was talking about because there are more and more chemotherapy agents transferring from intravenous to oral. Dame Gill Morgan: Yes, but you are again in the position that if you are going to do that, and particularly through a GP's prescription, the GP has to feel comfortable and competent about using those drugs, and therefore it depends whatever shared protocols are developed locally. For many of the more complicated drugs I think it is quite appropriate if GPs say, "We are not prepared to be part of a share-care protocol", and therefore the care is still provided as hospital care even though it is provided on an outpatient basis. Q484 Dr Taylor: Correct me if I am wrong but if a consultant gives an outpatient prescription to an outpatient, that still calls for a charge, does it not? Dame Gill Morgan: It depends on how it is prescribed. A lot of outpatient prescriptions are still taken within the hospital and people still come in to take some of the therapy. If they are on continuous oral treatment that would be prescribed as a script either by the consultant or by the GP who will continue that. There is a range, depending on whether it an oral type of therapy or whether it is maintenance. It is much more complicated because where in the system you will come depends on the drug, the disease, the stage and a whole set of things. Q485 Dr Taylor: So do you not think the Welsh Assembly is right to aim to abolish prescription charges entirely as this is raising extra complications? Dame Gill Morgan: Again, this is a personal view; I have never tested it with the members, but my personal view is that if we did not have prescription charges that would help because we have some costs. The downside of that is that we would have to find some way of getting that money into the NHS in some other way and then you have got a political debate about whether it should be taxation based. Dr Taylor: I am not asking now but could we have a written note of other ways of raising £450 million? Q486 Chairman: Last week's answer was general taxation by most of the witnesses. We are not at that stage of the inquiry. Dame Gill Morgan: Exactly. Jim Dowd: Could you give us the next set of lottery numbers as well? Q487 Chairman: I would just like to say one thing on what you have said about this issue that inpatients normally would not pay for any charges, and that is the potential inequity. I asked this question last week and it did not seem that it was true, that people can be discharged from hospital with a month's supply of something where other people would have to pay or they would have to pay in different circumstances. Is that inequitable, do you think? I know it is people being kind but is it inequitable? Dame Gill Morgan: It probably is inequitable but you would have to look at what the conditions and the types of reasons were and I have no knowledge about who would get a month's prescription free and who would not, so I would only be guessing. I have not got any evidence on that. One thing I should also say about Patientline, because I do think it is important to look at the other bit, which is what the patients say about this, is that the surveys that have been done show that 88% of patients really love these things, and certainly have found the availability of a bedside personal phone of great benefit to them. There is very high patient satisfaction and, you are quite right: this is a problem outside the hospital and for relatives rather than for patients. The patients like it and value it. Q488 Chairman: Could I move on to this issue we were talking about earlier on the change in treatment, the acute sector coming out into the community in terms of people's homes? The other change in pattern that we have had very much in the last few years is people going in now for things like day surgery or even for day chemotherapy treatment where at one time they would have been an inpatient. With regard to travel costs, do you feel that there is a burden there because of the changing pattern of treatment that people have in the Health Service? Dame Gill Morgan: Again, we have never surveyed our members about it but I can talk about a personal position, which is that certainly, when we looked at travel costs in a health authority I was involved in, we exempted people who had to come for chemotherapy, for renal dialysis or for repeated issues. There were no patient transport charges for any of those patients and there were also no car parking charges for those patients because it was recognised that those things were a great burden if you were routinely coming to a hospital or needing care, which is quite different than if you go once in a while. Q489 Chairman: In terms of the assistance people can get with travel costs, are you happy that people get to know about these schemes or with the take-up of these schemes? Dame Gill Morgan: Yes. Certainly one of the most interesting debates which generated most discussion at a local level was about patient transport because patients were very well aware of the issues. It is widely advertised in the majority of hospitals. Again, I do not think we have been quite as imaginative about patient transport as a service as we might have been, so one of the things that some authorities have done is get joint agreements with local government because local government are paying for lots of patient transport, particularly to bring children into special schools and things like that, and in many places there is no connection between the transport plans of all the different organisations, so you have vehicles sitting unused during the day somewhere but another service is using them elsewhere. Quite a lot of health organisations, particularly in rural areas, have funded co-ordination schemes jointly with local government to begin to look at how you get a much more sensible use of something which is very important in rural areas. Q490 Chairman: Should hospitals be encouraged to see car parking as a means of raising revenue? Dame Gill Morgan: I understand why hospitals have gone down that route. Very many hospitals have gone down that route because they are centrally sited and, as you have picked up in one of your other discussions, large numbers of people on the street use hospital car parks to avoid paying council charges. I think we are at a point of real change because if you look at why patients choose hospitals, uniformly towards the top of the list is car parking, so I am now aware of a number of hospitals which are not only reducing their car parking costs and fees but are also taking their staff out to park and ride schemes so that the whole of the car parking on site, other than for night staff or unsocial hours, is available to patients. If you want to market your hospital the things that patients will go on is accessibility, car parking and availability, and then one or two clinical indicators, but it is the car parking which is the biggest drive. I think we are going to see a change and more hospitals making car parking free because that will be a competitive edge for them. I think we are at a point now where we are going to see a significant change. Q491 Jim Dowd: Representing an inner London seat, as I do, even there the issue of car parking is important though the transport links to, say, Lewisham or King's are very good. At Lewisham there was a period when it was free and it was being used by commuters from Kent to access Catford and then coming here. This is my point: if we remove charges how do you stop (a) that recurring or (b) all the spaces being consumed by staff? Dame Gill Morgan: Exactly, and that is why some of the charges have come in. What you would have to do is have some system for people who are recurrent. You could issue a pass when an outpatient invitation was sent. There are ways you can begin to think about handling it differently, but most people are not yet at the stage of thinking about that because they are not yet thinking, "What are we going to do to get the competitive advantage?". Once that is on the agenda, as it already is for foundation trusts, I think you are going to see a massive change in car parking. Q492 Jim Dowd: So what you are saying is that if you just abandoned car parking charges and left it as a free-for-all that would have no administrative cost, whereas if you abandoned charges but still had a managed system that would just add to the overheads of the trust, would it not? Dame Gill Morgan: Indeed, but if it gives you a competitive advantage, and that is why I am linking it with patient choice and people choosing where to go, that is offset by extra patients who will come to you, because knowing they have got guaranteed car parking when they come, and patients go to hospitals when they are ill, is going to be a massive competitive advantage for organisations, much more direct and understandable than any other clinical indicators that hospitals will present. It will be car parking right up there, I think. The other issue which I think is really interesting about car parking and why a lot of organisations have had to charge for car parking is that in a number of cities in particular there have been planning rules which have not allowed hospitals to build or to have sufficient car parking spaces because of the impact on roads. I have even heard councillors say things like, "We cannot possibly have extra car parking spaces because it will encourage more people to travel to the hospital", and I have sat on the other side of the desk saying, "Actually, we want people to come to the hospital when they need the treatment". There is another side to this, which is that in many hospitals car parking places are in real shortage and a scarce amenity, which is why people are looking at off-placing their staff and having park and ride schemes. There are now some interesting models of people who are thinking of new ways of putting in multi-storey car parks which are actually very cheap in capital terms and very safe, but it would boost the car parking availability for patients, and I think we will see more drives to get those sorts of issues in, which will bring some conflict in terms of planning rules. Q493 Mr Amess: I think you have probably already answered the question, but obviously it is very tough on patients who have to go back regularly for treatment. Could you just articulate what the case is for a voucher system? Dame Gill Morgan: I am aware of hospitals where people going for chemotherapy or renal treatment have special car parks with barriers and they issue a card for people to come in so that you actually have the access for the treatment. I think again that that is a sort of interim stage between completely moving to a complex administrative system and charges, and people already do that sort of thing but it varies because every organisation will be in a different context in the environment and therefore what you might want to do in an inner city area is going to be fundamentally different from what you might want to do in a rural area. Q494 Mr Amess: In addition to the midwifery service apparently a dermatology clinic will soon be opened by Harrogate District NHS Foundation Trust. NHS patients will be able to pay the trust to remove moles and warts, to screen moles or - and I think this is very interesting - to have Botox injections to reduce heavy sweating. Perhaps the Labour leader would take advantage of that when he takes off his jacket. Can you think of any extra non-clinical services that might be made available in hospitals in the future? Are we going to be sitting round having a séance? Dame Gill Morgan: That one I think is very simple. That is a private service providing the things that NHS patients no longer have access to because most organisations have reduced the availability of purely cosmetic therapy. What the hospital is doing is filling a niche and providing a competitive private service for patients who just want to come to the hospital. In terms of other things you might want to charge for, the sorts of things I think people might be interested in, if you assume that the NHS has to provide treatment and therapies that work and have been demonstrated to work, and this will be contentious and we will probably get more comments about this than the rest of the things I have said, you might want to say complementary therapies. There is no evidence for the majority of complementary therapies. Therefore you could very well see people offering complementary therapies and charging for them within an NHS setting. The reality is that for things like cancer therapy, HIV care, a lot of those services already provide complementary therapy as part of an overall holistic package for people, and you could see that you might want to offer that sort of thing. The other opportunity I think is around things like hotel type facilities. If you went to the private sector you would be offered a wine list, a better menu. You could begin to see charges being raised in that sort of way, none of which would actually impact on the clinical care of other people. I think it would be very difficult to offer a wine list within an NHS hospital because of the problems we have with alcohol but it is those sorts of extra things, you could say. In the States they call it jacuzzi competition because a lot of the hospitals compete by having en-suite jacuzzis which are better than the en-suite showers and you get into that sort of thing which people start to charge for, which are not clinical and they do not impact on the clinical care you get. That is the sort of area I think people will be looking at. Mr Amess: Thank you. That is very interesting. Chairman: I would like to thank you all and particularly you, Maggie, for answering our questions earlier and helping us in this inquiry, and hopefully in the next few months we will have an inquiry so that you can see if your evidence this morning has influenced us in any way. We will have to wait and see about these issues. Thank you. Witnesses: Mr Bernie Hurn, Research and Strategy Manager, Simplyhealth Group Ltd (previously HAS Group), and Mr Michael Hall, Chief Executive, Standard Life, gave evidence. Q495 Chairman: Thank you very much for coming. Could I first of all apologise for the lateness of the hour. We were expecting to be into this third session a little earlier. For the record I wonder if you could give me your names and the organisations you are from. Mr Hurn: My name is Bernie Hurn. I am the Research and Strategy Manager for the Simplyhealth Group, formerly known as HSA. Mr Hall: My name is Mike Hall. I am the Chief Executive of Standard Life Healthcare and, just for the information of the Committee, you can probably tell from the lines on my forehead that I have had 30 years' experience in healthcare, 12 of which were in the NHS and nine of which have been in the private hospital sector before moving to the insurance side. Q496 Chairman: Once again, thanks for coming along. I wonder if I could ask both of you what are the major problems that people experience with NHS charges and what proportion of the population is covered by insurance that helps them to access NHS provided services? Mr Hurn: It is a substantial proportion of the population, in the sense that today are represented here by private medical insurance, cash plans, complementary products and so on. About six and a half million people industry-wide are covered by cash plans and an even larger figure by private medical insurance. It is in excess of ten million people today and Simplyhealth represent about two and a half million lives as a mutual organisation which in essence has a public concern in that regard. What we represent is predominantly blue collar workers and these people have issues in the cash flow impacts of charges on their monthly cash flow and what we provide is a tool for smoothing that out and enabling them to access NHS services and services surrounding that. Q497 Chairman: Mr Hall? Mr Hall: As far as the private medical insurance market is concerned, there are just over 3.6 million subscribers to private medical insurance, but those 3.6 million cover a total of over 6.5 million lives, 6.57 million to be precise, which equates to about 11% of the total population. In terms of charges, my view is that because charges have been developed in a fairly piecemeal fashion over the course of the last 50 years I do not think they pass the test of fairness and equity. When I retire my understanding is that I will become entitled to free prescriptions. I do not think that passes that test. I would be more than happy to pay for my prescriptions if that meant that the money I am paying goes back into the NHS to pay for other people in a less privileged position than I. I think that fairness and equity test is difficult now to prove. There is evidence to the contrary, and I think it is difficult for people now to understand the range of charges that are now made because they themselves have not chosen to pay for those; they have been decided elsewhere. The success of our business is made up of providing services, obviously at a charge, that people want to buy and our evidence suggests that there is a willingness by people to pay charges. They may not necessarily be the ones that are currently charged for. Q498 Chairman: Would you, for instance, compensate somebody if they had prescription charges or glasses charges under your scheme? Mr Hall: We would not, no. Q499 Chairman: But you would, Mr Hurn? Mr Hurn: We do indeed, and that is 73% of what we pay out across the cash plan industry but, because we are also the largest representation within that group, we are indicative of the industry standard. About 73% of what we pay back is directly related to NHS charges, that is, dental, optical, hospital inpatient stay. The rest of that is made up in what we call POCAH, which is physiotherapy, osteopathy, chiropractic, acupuncture and homeopathy, something that the previous speakers alluded to. Those are services that people choose to access which they take responsibility for and we help them to access those services as well. What we look at is what the NHS provides, what the major impact of that is and also, being a mutual, we are driven by what our members need to create a format for access to the rest of those services. Q500 Chairman: Being a mutual, do you see trends in terms of the money that you are paying out for NHS charges? Are they reducing, are they increasing? Are there any differentials that you measure now when ten years ago it was not like that? Mr Hurn: Cash plans pre-date the NHS and have been in existence since 1922, some of them since 1895, so the premise for paying charges has existed for a very long period of time. What we see is that as Government policy is changing and NHS behaviours are changing the needs of our members and their claims behaviour changes. I will give you a couple of examples. One is dentistry and another one is that, just over a year ago when the four hours in A&E targets were introduced and people were being admitted to the ward, we saw a corresponding increase in hospital inpatient stay. What we paid for traditionally was when people used to have loss of income but these days it covers not only loss of income but also a number of the other charges that have been spoken about - telephone charges, car parking charges, so we help to mitigate the impact of those costs. Q501 Chairman: Do you expect, with this concept of out-of-hospital care, to see changes in that way, that people will not be staying in hospital as long, or indeed may not even be going in in a few years' time compared to five years ago? Mr Hurn: I think there is a difference there in that we pay for the event, not necessarily the location. We do have a hospital inpatient stay plan but we also have outpatients and day surgery, so whatever the location of that service is we will still pay for the event. We pay for what the member needs, so whenever the member accesses that within an NHS trust setting or at home or in a GP surgery, whatever the case may be in the future, we will still pay for those. Effectively what we will see is a change of location but not necessarily a huge change in behaviour. Mr Hall: My experience is that we have seen average length of stay in hospital change quite dramatically over the last decade or so from probably seven and a half to eight days, if we go back about 15 years, now down to about two and a half days and that is predicated by the growth in outpatient treatment and day case surgery. Q502 Chairman: Do you think that there is going to be any major change as far as your insuring the patient side is concerned in the future with the proposed changes that are about to take place? Mr Hall: Yes, I suspect so. Originally, because people were hospitalised for longer periods, there was an expectation that they wanted a private room with an en suite because they knew they were going to be there for some time. Given the choice most of our customers would rather not spend any more time in any hospital than they absolutely need to, so being able to be treated quickly and efficiently with good outcomes, either on an outpatient basis or as a day case, is a preference. Q503 Chairman: In the medium to long term is that a threat to your business? Mr Hurn: No. Mr Hall: No, not at all. In fact, if anything, if the move is towards more cost effective treatment in a more appropriate setting, then obviously the premiums we charge for access to that may be lower. Q504 Charlotte Atkins: Mr Hurn, we were looking at your evidence and obviously you say that payments should be affordable to all. You recommend a broadening of charges or the establishment of an affordable shared responsibility premise-based charge. I am not quite sure what that means. Can you extrapolate for me? Mr Hurn: If you put it in the context of what we do, we have people contributing to a fund of money and these are people who are employed and who tend to be blue collared workers. People have access to that fund on pre-agreed terms and therefore what they have access to they have full knowledge of and it is clear and easy to understand. This is not only driven by our values but also by the FSA, whereby we have to be fair and open to our customers, so therefore they know and realise the implications of them making a claim, not only as to what they are entitled to but also as to the impact on the rest of the group. They therefore have an understanding that there are not unlimited funds, that this is not open-ended, and an understanding of what they are entitled to as a form of responsibility to the rest of the group who are contributing to that. I do think that sometimes public perception of what the NHS entitles them to, of what the open-ended cost would be, is misguided, especially looking at future funding of the NHS and extra services being provided. It is not open-ended. There must be a realisation by people that there is only so much money that we can utilise in one way or another. I think it is part education but it is also part understanding of their behaviour that needs to be brought to people's attention. Q505 Charlotte Atkins: So you would very much favour keeping NHS charges and not going to a fully funded system out of general taxation? Mr Hurn: We think there is an existing premise for NHS charges and, as I have said, charges pre-date the NHS, but I do think we ought to look at mitigating the impact of those charges because there are a number of people in society who do presently find themselves hugely impacted by charges because they are not on certain benefits but they are not top earners in society and therefore £189 for dentistry, for instance, can make a tremendous impact on them come the end of the month. Q506 Charlotte Atkins: Would you like to make a comment, Mr Hall? Mr Hall: The issue for us goes back to the customer or, in the case of the NHS, the patient. Our view is that we should conduct research amongst the customer base, the general public. We know from research we have done that the majority of a cross-section of people we researched, and that is the general public, not our customers, favoured charging as a means of accessing better quality healthcare. There is a strong vote in favour of paying charges. Only 25% of them thought that taxation was the best way to do it so more than double that believed that having control of paying charges themselves was a better solution. The issue is that no-one actually knows what the public would value in terms of charges, which services they would pay for and under what circumstances. Our view is that any charges should be tapered. To have a position where there is a very fine line between when you pay and when you do not pay does not seem equitable to us either, so our view is that it should be tapered according to their income and their situation. It should not just be that you pay 100% or you pay nothing. Q507 Mr Campbell: In the survey that you took of the general public, are we looking at a case of, "I am prepared to pay if I can get in quickly and get my operation before everybody else"? Mr Hall: It was not the question we asked them. Q508 Mr Campbell: Why did you not ask them that because that does happen when you are paying? If somebody asked me that I would say, "Yes, I will pay for it if I can get in quick", because people have to wait a long time. Mr Hall: That may well be true, that that was the motivation for some people's answers to would they contribute. Q509 Mr Campbell: I am sure it was. Mr Hall: But that is my point, I think, about asking them what services under what conditions they would pay for, and if a more timely service was something that people would contribute to, thus raising money within the NHS to pay for improved services for everyone, that would seem to me to be a fairly equitable way of distributing those contributions. Q510 Mr Campbell: What you are saying there though is that they who can pay get it done and they who cannot have to wait and hope they get the money out to get them there. Mr Hall: The question we asked them was how they would want the issue of increasing healthcare costs to be dealt with, so it was in the context of a recognition that the cost of healthcare generally was increasing. As I say, over half of them answered in the positive, that they would deal with the increased costs of healthcare by making personal contributions. It was the increased costs of healthcare per se rather than the issue of waiting times or waiting lists. Q511 Jim Dowd: Let us clarify that. The truth of the matter is that we all pay for healthcare. The question is, by which route. Are you saying that survey was your policy holders or the general public? Mr Hall: The general public. Q512 Jim Dowd: Just so that I am perfectly clear about this, is it a variation on the theme that people actually value more things they pay for rather than things that they get, ostensibly, for nothing? Mr Hall: I think that is a truism in life generally. One of the issues that I believe exists is that there is no notion of value currently. Q513 Jim Dowd: Why? Because the service is free at the point of use? Mr Hall: Yes. That is not an argument to say it should not be; it is an argument to say that people should have the notion of value, so when we reimburse our customers' costs, even though they do not pay, we do send them a copy of the bill so that they understand the value of the healthcare they have consumed. We have done separate research to try and ascertain the extent to which the public do understand the costs of healthcare, not just ours but in the NHS as well, and that would seem strongly to indicate that there is no notion of value. I think only about one in ten of the people we surveyed had anywhere close to the cost in the NHS of doing a hip replacement, for example. Most of those other nine were woefully low in their estimation of the total resource cost of providing that service. I think that is a problem. It is a problem that we are consuming something that we have no good notion of value about. Q514 Dr Taylor: I was going to ask you what sorts of things the public would be prepared to pay for but you have said you cannot answer that. Is one of your ideas of the open public consultation you mention in your memorandum to get at just that, what people would be prepared to pay for? Mr Hall: Absolutely. We are a strong advocate for having a system by which the public can contribute themselves to the debate in saying, "These are the things I would value, these are the things I would pay for". It must be a better system to have people contributing to the things that they think make a difference and that they would personally value rather than the current system, as I said before, which has been developed in a piecemeal way, which people do not understand and which lacks that element of equity. Q515 Dr Taylor: You mentioned that charges should be tapered. Would that be on a means tested method or how would that be? Mr Hall: I am not an expert in terms of how one would taper it but it does not seem logical to me that I could get free prescriptions and somebody else on a lower income, simply because they were not retired, could not. Likewise, it would not seem logical to me that somebody who was unemployed could get access to services at no charge, yet somebody on a low wage would have to pay the full charge rather than only part of the charge. Q516 Dr Taylor: This point has been made to us by many people. Health savings accounts: are these one of your ideas and, if so, could you tell us a little about them? Mr Hall: Yes. It is premised on a number of things. The first one is that we tend to have been a society fixated on delivering the results of ill health rather than focusing on the benefits of good health. I do not think we have a society where health and wellbeing play enough of a prominent role. I think it makes sense to find ways to incentivise people to take more responsibility for their own health and wellbeing, and that is easier said than done, of course. One of those ways, we are suggesting, could be through the notion of the health savings account, a tax efficient way, in the same way that cash ISAs are a tax efficient way of saving, that could be used in part or in whole to contribute either to the consumption of healthcare that is charged for or for other health related services that are deemed by the Department of Health or the Government to be beneficial to health and wellbeing. Whether that is gym membership, whether that is diet or other elements of exercise is not my area of expertise, but it is the notion of encouraging people to save and to spend from those tax efficient savings in that way. We also considered the concept of a health incentive card. In the same way that commercial enterprises use cards for loyalty schemes why should it not be that you could earn points on, for example, buying fruit and vegetables? That would attract points, and maybe gym membership would attract points or other things deemed to be contributing to health and wellbeing could earn points that could be redeemed either in terms of the health savings account as a cash incentive to that account or in some other way. I think at the moment there is a complete lack of incentive to address the issue of health and wellbeing or saving against the costs of healthcare. Q517 Jim Dowd: Would you get your card taken off you for going to McDonald's? Mr Hall: No, but you would get points taken off. Chairman: Thank you very much for that, Mr Hall. I am quite interested in that type of concept in terms of a potential lifestyle influence. Q518 Anne Milton: Mr Hall, the point you raise about people being unaware of the costs is very valid and the big bee in my bonnet is prescriptions, that if people were aware how much the tablets in the bottle cost (a) I think it would increase compliance because it would encourage people to finish the course and (b) they would be aware of the huge cost of some drugs that are prescribed. I wanted to ask you both about the White Paper and the use of the private and not-for-profit sectors and whether you feel that in the light of the White Paper and the mention of those things it is more or less likely that charges will start creeping in? Mr Hall: I suspect that it is inescapable that, because of the demands on healthcare and the increasing costs of delivering healthcare, charging will be with us. At the moment my understanding is that current charges accrue at something like just over a billion pounds a year. That is obviously a significant sum of money and with the changing demographics of this country and the growing elderly population I think I am right in saying that in the next 25 years the number of people over 70 is going to increase by 70%. That is a fairly frightening statistic and that debate has already started in terms of pensions but is probably under-discussed publicly in terms of the impact on healthcare. I do believe that charging in some way, shape or form, which retains those elements of fairness and equity, will be with us in the long term. I think that is likely to increase rather than reduce, and therefore I think more innovative ways of identifying what should be charged for and having a mix of other companies, whether they be not-for-profit companies or commercial private sector companies making provisions in those areas, is a reality. Q519 Anne Milton: It makes it more likely? Mr Hall: Yes. Q520 Anne Milton: Mr Hurn? Mr Hurn: I would concur, that there is a likelihood of charges coming in and that we find at the moment that the NHS reforms have seen an increase in demand. The King's Fund this morning said we are spending more money but we are not necessarily seeing a return on investment. People are going to increase demand and they have also got an increased expectation of what the NHS can deliver. Whether that is sustainable or not is probably not for this debate but poses the question then: if people want it but it is not available on the NHS would they be willing to pay for an extra service, an NHS-plus service? I do think, in view of foundation trusts having to generate an income, having to compete against practice-based commissioning, that there is a high likelihood of charges coming in. Q521 Anne Milton: So, on the premise that the demand for healthcare is infinite, which it probably is, with increasing expectations and decreasing tolerance the choices are stark. It is either increased general taxation to an infinite level - demand is infinite - or you charge? Mr Hall: That would absolutely be my opinion. It is not just the fact that everybody wants access, understandably, to the best quality healthcare but we are as consumers far better informed now on healthcare than we have probably ever been and the internet has been one of the main reasons for that. I know many doctors who find themselves presented with patients armed with printouts from the internet where they are sometimes better informed than the doctor in terms of what the latest drug or treatment is. We are seeing a huge change in that. I am sure you have probably already had evidence about some of the pharmaceutical developments and some of the new classes of drugs that are now starting to become available, of which Herseptin is just one. There are many more in the pipeline and if research shows that they are as efficacious as Herseptin is that will present even more major challenges to the whole of this country. It is not just about the NHS but also in terms of the affordability of those drugs and with a growing elderly population, and in that same time period I spoke about the 30-34 age group is going to shrink, then the balance of people paying tax to support those in retirement is going to change and that is why I think taxation alone becomes a solution that is in a cul-de-sac. Q522 Chairman: Both of you and other witnesses have criticised the current NHS charges. I think the opening shot was that the King's Fund said they were a dog's dinner in terms of how they are at the moment. You were asked earlier to tempt into areas where maybe charging should be expanded or be made more equitable and that leads on from what you have just said. Are there any areas where you would care to speculate on, say, what NHS charges would be like in ten years' time in healthcare on things that will have charges as opposed to what we know at the moment have charges? Mr Hall: I would not, actually, and the reason I would not is that I do not think I am a representative sample of the British public because of my knowledge. I would most heavily rely on undertaking that research and that debate on a much wider scale. If you fit the charges to things people are willing to pay for and would value that could take us anywhere, but if it is what people would be willing to pay for then I think that makes charging acceptable. It is really a question of how much additional resource our health services will need in the future, the willingness of people to pay for those, how they wish to pay for them and the amounts they are willing to pay. Until that research is done we will not know whether the equation balances out or whether we have a gap. Q523 Chairman: Mr Hurn, do you have a view on that? Mr Hurn: We do. It is difficult speculating into the future and it is probably not our place to do so, but it probably comes to stating what a minimum level of treatment would be and then what sits beyond that that people would like to have as, again using the phrase, an NHS-plus service, in other words that then becomes chargeable and the state would underwrite for the catastrophe, for the inability to afford, but people who can afford would then proactively look at ways of being able to afford that. This is not creating a two-tier system but a basic level of what is acceptable for everyone but the ability for people to step up should they want to and should they be able to afford to. Q524 Jim Dowd: The truth is that in ten years' time the NHS charging regime will be logical, reasonable, rational and understandable because, of course, the big event between now and then will be the publication of the report of this Committee which will deal with it all. Can I just say to Mr Hall first, how do you respond to the Government's avowed intention to put the private healthcare business out of business and what impact would that have on your business? Mr Hall: The private healthcare business has been around longer than the NHS so I do not know how realistic it is to assume that we will be out of business, but if we ever do go out of business I do not believe it will be because of the Government; it will be because of our customers. Our customers keep us in business because we deliver products and services that they want to buy and that seems to me the way in which the western world works. You stay in business for as long as you have products and services which are valued by the people who purchase them. 11% of the population value the services that we offer. We give people choice and people exercise that choice and they have done for the last 50-plus years. Q525 Jim Dowd: Regardless of the levels of performance in the National Health Service? Mr Hall: Absolutely. One of the strange things is that you cannot correlate the number of people covered by private medical insurance with the ups and downs of the NHS. I worked in the NHS in the 1970s when waiting lists were probably amongst the worst that they have ever been and that was during a period when private medical insurance saw the largest growth, not because of the waiting lists but because of the building of modern private facilities where people could get treatment. When those hospitals were completed the numbers stayed the same even when the waiting lists went down, and what we see at the moment are numbers covered by private medical insurance ever so slightly increasing, very marginally, I have to say, but at a time when we have seen the biggest decrease in waiting lists. I do not think it is possible to correlate one precisely with the other. In fact, they do not correlate. It really does come down to the perception of the public and the choices that they make. Q526 Jim Dowd: Would it be reasonable to assume that the profile of your policy holders is healthier than the average? Mr Hall: That is a very good question. If you look at the socio-economic split of people who have private medical insurance it is probably not what you would expect to see. 18% of the professional employers and managers group have private medical insurance. I think most people would probably believe that that was an awful lot higher than that. 14% of the self-employed have private medical insurance and by and large the self-employed are sole traders or are maybe employing one or two other people. If you go to the unskilled, 6% of those are covered by private medical insurance, most normally through their employer. I would say probably, taking your average of the total population, that ours would be slightly healthier but probably not by as much as one would imagine. Q527 Jim Dowd: But that is not because of anything you do. It is just a simple fact. Finally, Mr Hurn, are HSA the same people who are the shirt sponsors of Blackburn Rovers Football Club? Mr Hurn: They used to be. Q528 Jim Dowd: I do not hold that against you, by the way. In the note that I have here it says that you paid out claims of approximately £166 million in 2004 and that figure was projected to rise by something over 20% to £200 million-plus in 2005. Is the normal rate of growth, above 20%? Mr Hurn: No. We have been through a period of mergers and acquisitions which has meant that the group has grown. Q529 Jim Dowd: So that is exceptional? What would be the normal growth in payouts? Mr Hurn: The normal growth in payouts across the industry when you look at our average claims ratio will sit somewhere between 75% and 85%. That means that most of the money that comes in goes back out ----- Q530 Jim Dowd: No, I am talking about the annual change. Mr Hurn: That would be about 6%. Chairman: Simplyhealth Group Ltd does not ring a bell with me but I think HSA does and I and my wife may be covered by one of your policies. I declare that right at the end. Can I say to both of you thanks very much indeed for coming along and answering our questions. It has been a very interesting session once again this morning. All three of the sessions have been very interesting and hopefully it is going to help us to come to some conclusions on this matter. [1] Note by witness: In 2003, Harry Cayton, the Director for Patient Involvement at the Department of Health, established a working group to review patient charges. He submitted the group's report to Ministers on 31 March 2004. The report was published on 7 July 2005. The BDA were present on the committee as expert advisors and concentrated on two key issues for dentists of bad debt and missed appointments [2] Note by witness: An independent survey carried out for Doctors' and Dentists' Remuneration Review Body in 2002 looked at the reasons why dentists were turning away from NHS dentistry: about 70%said they felt rushed when treating NHS patients; around 60% said that their workload did not allow them to provide the professional standard of care with which they were comfortable; while at present 60% of dentists spend at least 90% or more of their time working in the General Dental Services, only about 16% expected to be so committed in five years' time [3] Note by witness: As a result of primary legislation-the Health and Social Care (Community Health and Standards) Act 2003-the new General Dental Services contract was outlined in this Act. The Act was an enabling act for the Department of Health to implement the contract. It was not designed as a negotiated contract between the Government and the profession. The BDA were privy to discussions with the dentistry Minister, Rosie Winterton MP and her departmental officials about the contract. The BDA constructively inputted into these discussions, but the final details of the contract lie with the Department of Health. Debate about the precise details of the contract came through secondary legislation-the National Health Service (General Dental Services contract) Regulations 2005 [4] See Ev x. The BDA has also written to Charlotte Atkins MP and Mike Penning MP to help clarify their constituency cases [5] See Ev x [6] See Ev x [7] Note by witness: As part of the National Health Service (General Dental Services contract) Regulations 2005, dentists must display an NHS-sponsored poster in their waiting rooms explaining the new dental charges regime [8] Note by witness: The BDA has produced leaflets and posters for dentists to display in their surgeries explaining the new dental charging regime and which patients are exempt from dental charges. The Department of Health have produced their own patients leaflets which build on the HC11 form [9] In 2003, the BDA produced a report, Oral Healthcare for Older People: 2020 Vision, which made a number of recommendations in this area. See Ev x [10] Note by witness: Water fluoridation is the most effective public health measure in reducing dental decay and for tackling oral health inequalities. Tooth decay is a significant problem in the UK and the dental health inequalities are widening. In socially deprived communities as many as one in three children under the age of five will have one or more decayed teeth extracted. As part of the Water Act 2004, MPs voted in favour of local communities being offered the change to decide whether they wanted targeted water fluoridation schemes in their locality |