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CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 815-iv House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
Thursday 16 February 2006 MR SEAN WILLIAMS and MR DAVID STEWART RT HON
JANE KENNEDY MP, ROSIE WINTERTON MP, Evidence heard in Public Questions 531 - 708
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 16 February 2006 Members present Mr Kevin Barron, in the Chair Mr David Amess Charlotte Atkins Mr Paul Burstow Mr Ronnie Campbell Dr Howard Stoate Dr Richard Taylor ________________
Witnesses: Mr Sean Williams, Board Member and Partner for Competition, and Mr David Stewart, Director of Investigations, Ofcom, gave evidence. Q531 Chairman: Good morning. May I welcome you to the fourth evidence session we are taking in relation to our inquiry into the National Health Service charges. I wonder if I could ask you to introduce yourselves for the record and tell us the positions that you hold. Mr Williams: Thank you very much, Chairman. I am Sean Williams. I am a Board Director of Ofcom. I am also responsible for the competition group in Ofcom, which is where we enforce competition law in the communications markets. I have with me today my colleague David Stewart, who can introduce himself. Mr Stewart: My name is David Stewart, I am Ofcom's Director of Investigations, which means that I am responsible for our Competition Law Enforcement Team which conducts investigations and reaches conclusions on those Q532 Chairman: Thank you very much, again, for coming. There are no surprises as to why you are here, of course. I would just like to ask you if you could describe your concerns about the lawfulness of the contractual arrangements made between the NHS Trusts and the providers of telecommunication services to patients. We have obviously seen your letter to the Secretary of State and understand that you are hoping they are going to take some action. Could you tell us your views on this? Mr Williams: Yes, indeed. As I say, Ofcom is the competition authority in communications markets. We became aware of the consumer concerns about high charges for calls to hospital patients. We opened an investigation under competition law to see whether or not the high charges were the result of anti-competitive behaviour in breach of competition law. We found in our investigation that they were not a breach of competition law, and that the high prices which we remain concerned about were the result of the arrangements put in place by various bodies in the Government and the NHS. In particular they arise, I think, from a combination of matters of Government policy, matters related to the implementation of that policy by the NHS estates, and by the particular concession agreements and their terms which the providers have agreed with particular NHS Trusts. While we remain concerned about the high prices, our view is that it is a matter for the Government to take into consideration and is not a matter of breach of competition law in any way. Following our investigation the Government has set up a Patient Power Review Group to work with providers to provide a better solution and hopefully to address these particular problems. Q533 Chairman: Would it be fair to say that you thought it was unfair in the sense that patients' friends and relatives should be subsidising this system? Mr Williams: I would say that we remain concerned about the high prices. We think the high prices are, as I say, a result of the way the contracts and the arrangements are structured. The concession agreements and the overall framework agreement cap the charges for various services, so it is really a matter for the Department, the NHS and the providers to work out the fairest way to recover these costs, I think. Q534 Chairman: Nowadays an enormous number of people use mobile phones. There are some allegations made that pressure has been put onto NHS Trusts to maintain a mobile phone ban within their establishments. Would we get rid of this problem if that sort of ban were lifted? Mr Williams: I will bring my colleague on this one, but, in general terms, our findings were that there was nothing in the agreements as such which prevented in an inappropriate way the use of mobile phones. But it is a bit more complicated than that. Mr Stewart: The agreements between NHS Trusts and the providers reflect a general requirement in the model agreement, which is that there be a provision saying that the hospitals, to the extent that there are good clinical reasons to do so, will restrict the use of mobile phones. That is not a blanket ban on the use of mobile phones in hospitals, and, amongst other things, we looked at the way in which in a number of cases that provision had been given effect in practice. One of the things that is clear to us is that it is not a simple or straightforward issue: there are clearly some very important clinical reasons related not only to the need to give patients time undisturbed during their care but also, more recently, with the development of camera phones, some issues around patient privacy. There are some good reasons why hospitals should have and do have the right to restrict the use of mobile technology and we have suggested that one of the roles the Department might play is helping the NHS Trusts to understand their rights and responsibilities so that an effective balance can be struck. Chairman: Thank you for that. Q535 Mr Amess: Gentlemen, I might look as if I am in splendid isolation on this side this morning, but I am very much with you. Is that an Australian accent? Mr Stewart: It is. Mr Amess: Okay. Chairman: That one was not in my brief! Carry on, anyway. Q536 Mr Amess: Gentlemen, it seems to the Committee that the fact that you are having the review is pointing directly towards National Health Service incompetence. I wonder if you could answer that charge. The other thing I wanted to put to you is this: In your report you blamed high incoming call prices on "a complex web of Government policy". That is a marvellous expression. Could you also enlarge on this complex web of Government policy? Mr Williams: The complex web really has three kinds of component. The first level is Government policy, the Patient Power Programme and the aspiration in Government policy to roll out bedside communications on a national basis to all bedsides. There is then the second level, which is the NHS Trust licence, national licenses or framework agreements, which then implement that intention by means of a framework agreement that specifies the kinds of services, the functionality of these beside communications units, the prices that have to be observed or the caps on the prices that have to be observed. The third level is the specific concession agreements or contracts that the providers have agreed with particular NHS Trusts which then specify further how the particular charges for the actual services are going to be levied. It is in the interplay between those three levels of these arrangements that the result is manifest, which appears to us to be high call prices, particularly for incoming calls, which, in a sense, are necessary for the providers in order to recover the costs of these rather sophisticated units which they put in at bedsides. That is, in a sense, what the complexity is all about. I do not think we are in a position to judge whether or not it is a good implementation of a good or bad policy intention - that really is a matter for the Government - but I think it is worth the providers and the Government getting together to work out whether or not this is the most appropriate way to recover the cost of these services. Mr Stewart: I would add to that. I think it is perhaps useful to clarify that our role is as a national competition authority, and one of the things that is axiomatic in looking at someone's conduct - in this case that of the providers - under competition law, is that the conduct that is under investigation is conduct that is unilateral conduct or something for which, in effect, they can be held accountable. Once you reach the point where it is clear that is not the case, there are a number of other factors; in particular, when those factors involve Government policy, then the responsibility of the national competition authority is to stand back from using what in those circumstances is the rather blunt instrument of competition law and hand the issue of how the various interests are meant to be traded off back to the Government and back to the Department. I certainly would not agree with the assessment that we have in any way been involved in making an assessment, as Sean says, about the policy or how it has been implemented. That is certainly not the way we see our remit. Q537 Mr Amess: Thank you for rebutting that. I did say I would ask two questions, but, as we have a little bit of time, let us go for a third - and you are Australian: Has Ofcom identified funding arrangements in other countries for these types of systems that avoid high incoming-call charges? If so, could you help the Committee and tell us where these examples are? Mr Williams: At a high level we are aware that there are alternative bases for recovering the costs of the investment necessarily to roll out bedside communications units. I do not know whether my colleague has any further information on that. Mr Stewart: The biggest single difference is between those countries where hospitals decide to undertake the capital cost directly - and therefore are not simply recovering the capital cost of these systems purely on a particular group of users, in the way that applies in the UK. We know from evidence which we gathered in our investigation of a number of countries where that is the case ---- Q538 Mr Amess: Where are these countries? Mr Stewart: Holland and the US, for example, both have systems that are funded, as I understand it, on that basis. Q539 Mr Amess: Are they good examples to apply to England? Mr Stewart: In a sense, it is a financial trade-off. Do you make an investment directly using public funds and secure a benefit that can then be managed along with all of the other assets in the hospital? Q540 Mr Amess: I just wondered. Holland is a tiny little country and we are tiny with a huge population. America has a state system. I am trying to think how you would apply those two examples. Mr Williams: I think it is just a matter of Government policy. You can take a view that the cost of these services, which are to provide facilities for patients, should be recovered through a commercial payment by patients or not. To be honest, it is not a matter for Ofcom to take a judgment on that. Mr Stewart: To answer the question behind your question: I am not sure what the situation is in Australia. Q541 Dr Taylor: I would like to go on a little bit longer because I too was intrigued by the complex web. I think really we are discovering that the Government ordered a Rolls Royce with absolutely every extra, when there was no way all those extras could be used. If you are having the electronic patient record available, when it is not available (because the NHS computer system is so far behind schedule), they have made Trusts buy a system that cannot possibly be used. Is that not right? As we put it to Patientline last week, their message at the beginning of the phone call should have said, "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" and Patientline agreed. Are we not within our right to condemn the Department of Health for ordering something as complex as we have which could not be used? Mr Williams: I think it is not for Ofcom to make a judgment about the state of the system. We could say that it is clear to us that it is a highly specified system and that it is costly to install and that the consequence of the costs and the fact that all those costs have to be recovered through charges is that consumers will pay higher prices. Q542 Dr Taylor: Right. I would like just to get a bit of detail. We believe that Chelsea and Westminster are using some of the capability. Can you give us detail? Are they using all the capability? Mr Stewart: We are aware of a few cases where there are services being used by hospitals rather than end-users. We did not look in huge detail at this question, but our understanding is that that relates to issues like gathering orders for patients' food and other distribution of information of that kind. I am happy to come back to the Committee with details, but the other point to make, I guess, is that that is a question you might put to them. Q543 Dr Taylor: You would not know about any other hospitals that are using the service a bit more fully. Mr Stewart: It is certainly not widespread. There are a number of instances where it is going on, but it is certainly a handful of hospitals. Mr Williams: Again, I think it is really for the providers and the Department to answer that. Q544 Dr Taylor: Would you know if the capability would be there to order pathological investigations, x-rays on the system? Mr Williams: I think you would need to ask the other providers in the Department. Q545 Dr Taylor: Right. Could you see the telecom system in hospitals developing further? In what way would you think it is possible for it to go further - or is this, for the moment, the ultimate if it were fully used? Mr Williams: I think it is something that the Patient Power Review Group will have to work through because there is now a considerable investment in bedside communications. They therefore have an established position and it will be for the providers and the Department to work out how they can best be used and what further functionality and developments there could be. Q546 Dr Taylor: This review group has been constituted already, has it? Mr Williams: That is my understanding. Mr Stewart: That is right. Q547 Dr Taylor: By the Department of Health. Mr Stewart: That is right, and I believe it is due to report in June this year. Dr Taylor: Thank you. Q548 Chairman: Mr Williams, you said it is really not for you to comment, and I accept that to some extent. Your report was quite hard-hitting. I am looking at the letter you sent to the Secretary of State, in which you said, "Currently there is no skip facility enabling repeat callers having to hear the same message each time they call. This further raises the cost of each call." That is pretty tough stuff. People reading that will think only one thing: that they are getting ripped off. In the message that Richard just read out, they do not have to listen to that or pay to listen to it for more than one occasion. Would you not say that is right? Mr Williams: We have remitted to the Department to consider whether or not a skip facility should be instituted in order to skip that message. Q549 Chairman: Technically there is no problem with that. Mr Stewart: That is right and we welcome the commitment on all sides to discuss that issue. We have pushed in our discussions with them that it be on the agenda, so we are very pleased that it is. Chairman: Okay. Q550 Charlotte Atkins: You have not really found any wrongdoing, as such. How worthwhile was your investigation? Mr Williams: We have our own statutory duties to look after the interests of citizens and consumers in the communications markets. It was clearly a matter of public concern that these call prices should be so high. It was clearly, therefore, appropriate for us to look into the matter and I think it was an investigation that was definitely worthwhile. We invested a certain amount of resource, not untypical of such investigations. In this particular instance we found that it was not a matter of the application for competition law but a matter of Government policy. It might have turned out otherwise. It is often the case that we open investigations into matters of concern and at the outset we do not know what the outcome is going to be. Q551 Charlotte Atkins: Any investigation that you do will obviously preclude you doing other investigations if you have limited resources. We have heard from the NHS Confederation that these units are very popular with patients. Mr Williams: Yes, indeed. I think we would endorse the view that they provide valued services to patients. All I would say is that I do not think we have not done something else in our investigations programme because we have done this. Within the discretion we have over what things we should investigate and should not, I think we are of the view that we have investigated all those things that we should have done and this was one of them. Mr Stewart: You are right, of course, to observe that we do have limited resources, but, as Sean said, you do not know when you begin an investigation quite where that might lead. You do know that there is an issue of consumer concern and that you have a responsibility to choose from amongst the issues of consumer concern that you see which issues you need to explore further. Having crossed that first hurdle - in other words, having realised that there was a reason to suspect an issue of competition law in this case - we then investigated that, but we did so in a way which I think reflects the fact that, as soon as we were able to reach a conclusion that this was not one to take further forward, the right thing for us to do was to package up those findings and hand those issues back to the Department and back to the providers to see if they could come up with some data solutions. So we have not carried forward the investigation past the point when it was apparent that that was the best way forward, and I think we are satisfied that that means that the investment of resources has been that which is necessary effectively to discharge our duties and hopefully make some contribution to a way forward but not an over-investment. I think the most telling outcome really is that, as a consequence of our investigation, there is now a Patient Power Review Group that will be looking at these issues. Q552 Charlotte Atkins: The main issue that comes out of your investigation is the huge cost of incoming calls to patients. Would you see that as one of the areas which the NHS should be looking at most acutely? Mr Stewart: Yes. Q553 Charlotte Atkins: This tax on friends and relatives having to pay for this extraordinarily expensive system. Mr Williams: It is certainly the case that the issue about the balance of charges between the different users is something that the review group should look at. Q554 Charlotte Atkins: Especially, presumably, as when people are calling in they do not get the shock of the overall cost until they get their telephone bill. Mr Stewart: Q555 Charlotte Atkins: Whereas the patient presumably pays upfront for the use of those calls. Mr Stewart: That is certainly a common theme running through the complaints that have been made to Ofcom. Q556 Charlotte Atkins: And you have made recommendations to the NHS that something should be done about the fact that, very often, despite the message - which presumably people do not listen to very carefully - they are not aware they are going to be charged so hugely for a call to a friend or relative in hospital. Mr Williams: In a sense, our letter to the Secretary of State is our suggestion that they should look at exactly those kinds of issues. Charlotte Atkins: Thank you. Q557 Chairman: Could I thank you both very much indeed for coming along and helping us with our inquiry. I have no doubt that we will be reporting on this in due course - hopefully it will not too long anyway. Mr Williams: Thank you very much, Chairman, for the invitation to come along and help you. We are very happy to help. Q558 Chairman: Hopefully your investigation is going to be helpful in the next few months. Mr Williams: We hope so too. Witnesses: Rt Hon Jane Kennedy, a Member of the House, Minster of State for Quality and Patient Safety, Ms Rosie Winterton, a Member of the House, Minister of State for Health Services, Dr Felicity Harvey, Head of Medicines, Pharmacy and Industry Group, and Mr Ben Dyson, Head of Dental and Ophthalmic Services, Department of Health, gave evidence. Q559 Chairman: I was going to say welcome back - I think three of you have been in front of us just a few weeks ago - but good morning anyway. I wonder if I could just ask you to introduce yourselves for the record, please. Mr Dyson: I am Ben Dyson. I am Head of Dental and Ophthalmic Services at the Department of Health. Ms Winterton: Rosie Winterton, Minister of State at the Department of Health. Jane Kennedy: Jane Kennedy, Minster of State, Department of Health. Dr Harvey: Felicity Harvey, Head of Medicines, Pharmacy and Industry Group within the Department of Health. Q560 Chairman: Thank you very much. Welcome to the fourth session of our investigation into NHS charges. You have probably heard this quote on many occasions before. Lord Lipsey, the Social Market Foundation described NHS charges as a "dog's dinner lacking any basis in fairness or logic". One of the areas, of course, is the issue that the prescription charges exemptions have not been properly reviewed since 1968. The officials told us when they came in that this was for historical reasons, as it were. Does historical inertia justify maintaining a system that is unfair and clearly is not working? Many witnesses have told us that in the last few weeks. Jane Kennedy: For the avoidance of any doubt on this, we are very firmly of the view that charges and prescription charges are a valuable and legitimate source of revenue for the National Health Service. We have sought to develop a system in which those people who can afford to pay are required to contribute, but those people who cannot afford to pay are exempt - and many other people in fact who could afford to pay are also exempt. We know the way in which prescription charges have arisen - and you will have heard a lot of evidence about that - and they are part and parcel of the way in which we manage the health service and they are a valuable source of resources. Probably the areas of exemption and the changes that we have been making to the low-income scheme and to the prepayment certificate scheme have been areas in which we have been able to help people on the margins. Chairman: You will look into that a little bit further. Q561 Dr Stoate: As a brief supplementary on that, Minister you said that you felt he principle was right that people who could afford to pay should be made to pay - and I do not entirely disagree with that principle - but if that is the case why do they not simply remove the mildly illogical exemptions for people, for example, with under-active thyroid compared with those with an over-active thyroid, or exemptions for people who need oral medication for their diabetes as compared with people who do not need oral medication for their diabetes? If you simply want to base it on ability to pay, why have any exemptions at all for those rather arcane conditions, which do not bear much relationship to modern medicine? Jane Kennedy: Because to abolish exemptions would have cost implications. If we were to have a different set of exemptions, there would be some conditions that we may determine were not suitable to be exempt. Q562 Dr Stoate: Why have exemptions at all? Why not simply reduce the cost, say, to a fiver and remove all the exemptions? At least it would be a level playing field for all medical conditions. I am not saying you should do that but what is wrong with that? Jane Kennedy: We reviewed prescription charges through the CSR 1998. We looked at the prescription charging system and, having looked at it, decided that we would not make changes to it. We were not the first government to have done that: since they were introduced, they have been looked at many times, and on each occasion it has been concluded that, whilst there are anomalies in the system - and we accept that - the system we have is probably best left as it is. There will always be groups of patients who feel that their condition should be exempt. I hear the point you are making, but every time we do that there is a cost implication. Q563 Dr Stoate: Minister, you said that it is your view that things should be left alone. You are probably fairly unique in thinking that, because all the witnesses we have heard from, either orally or in writing, feel the system should not be left alone. If you are saying that it should be, I have to say that you are in the minority with that view. Jane Kennedy: Yes. Probably. I have found the preparation for this inquiry, and the requirement, as you do prepare, to look at the system, very useful. We will look at the recommendations the Select Committee brings forward and we will consider those carefully, but I get representations from patients with a whole range of different conditions who believe they should be exempt from prescription charges, and if you took that route you would effectively abolish prescription charges. Dr Stoate: I appreciate that. Q564 Chairman: On that, Minister, we had a witness last week, a young adult now, who is a cystic fibrosis sufferer. Twenty-five years ago, when the list was drawn up about long-term conditions, it would have been the case that people with cystic fibrosis would not have survived childhood and consequently there would never have been a question of them having to pay what are multiple prescription costs for their particular condition. It seems completely unfair that that particular case has not been reviewed. It seems that a system that cannot review that - because medical science is moving on - has something wrong with it. But you think it is best left alone. Jane Kennedy: If we were to review it and look at the medical exemptions - but if we were to do it from the point of view of staying cost neutral overall - as I say, you would have to take some conditions out and put others in, and we have taken the view from the outset, when we first reviewed it, that actually the contribution that prescription charges makes to the health service is a valuable one. We have other priorities that we would rather spend the resource on than giving relief in particular cases like this. Q565 Dr Stoate: But even were it cost neutral, you could still come up with a system that was considered to be fairer. The suggestion I have made, for example, of reducing the overall prescription charge for each item but removing some of the exemptions, would be cost neutral, but at least it would be a more level playing field if we are really trying to stick to the principle that those who can afford to pay should pay. At the moment, that is not the case. Jane Kennedy: It will be interesting to see what your formula is, Dr Stoate. We will have a look at that. Q566 Mr Burstow: Could I pick up on this issue of reviews. With the current scheme of exemptions, 1968, various written answers that I have seen on this refer back to the CSR as being one of the reviews that took place. When the Committee took evidence from officials a few weeks ago, we were rather given the impression that there had not been a major, if you like, root and branch examination of the scheme at all. Can you tell me a little bit more about how thorough the examination of the scheme was when the CSR review took place? Jane Kennedy: I cannot go into detail but it was a serious examination of the scheme. It was determined that, if we were to begin, for example, to review the list of medical exemptions, you would generate as many losers as winners. Ms Winterton: I can add to that. During the evidence it was said that ministers had looked at it, and I did used to have responsibility for this area. I think, frankly, that every minister who comes in then gets the postbags of letters from people saying why can this condition, that condition, the other condition not be added to it? Because medical science has changed, and, as you said, Chairman, people with cystic fibrosis are living longer, and there are other conditions, some cancer conditions, that are almost long-term conditions now as opposed to killers. It is something that I think ministers look at. As Jane Kennedy has said, one of the issues is that within that there will always be losers. People who have had an expectation, and perhaps for 20 or 30 years have received medication, if all the exemptions were removed would lose that. That is obviously something that I am sure the Committee would want to consider. Q567 Mr Burstow: Just to be clear, it is one thing to have a look at; it is another thing to issue instructions to officials to come up with workable options along the lines that Dr Stoate has put forward that will enable you to make a judgment as to whether or not there are better ways of achieving your objectives than the current 1968 exemption scheme. Have you done that, and had specific options looked at and costed? Ms Winterton: That was, I believe, the 1998 review. Jane Kennedy: As I have said, there are anomalies in the current system, but it was difficult to make a case for removing exemption from one group of patients (however we do it) and extending it to another group. Q568 Chairman: What about when somebody has a long-term condition which they are given a free prescription for, but then something else in their health crops up - which it could potentially in all of us - and they get a free prescription for that which is nothing to do with their long-term condition? It is hardly fair, is it? Jane Kennedy: As I have said, there are anomalies and it is not the perfect system. I mean, 87% of prescriptions are exempt from charges and that has increased since 1997. The cost of prescriptions has been increasing by 10p a year since 1997, and, therefore, in comparison to inflation, the increases have been much lower than inflation. The numbers of people who are helped by the low-income scheme and who now use the prepayment certificate approach are increasing - or, rather, the numbers being helped by the low-income scheme are not, but we believe they are being exempted by other means. We have been seeking to improve the current system without going through the wholesale root and branch review that members of the Committee clearly think it requires, because we believe that by doing that we will create as much upset and disquiet as we would satisfy. Chairman: That leads very well into our visit last week to a devolved assembly and what they are doing and the wonders of having devolved powers in the United Kingdom now. Richard. Q569 Dr Taylor: Thank you very much. We really heard exactly the same argument from the people in Cardiff leading to the diametrically opposite conclusion. Because they told us that any review would simply lead to a different set of anomalies and complications - which is really exactly what you have said - but from that they took the jump and said the only fair thing to do is to abolish the charges, which they are working on at the moment. Obviously it is going to cost them less, but, proportionately, we worked it out and it is about the same - so their proportion is about the same as the £450 million in England. It is very, very hard, I think, to argue it your way round. You are attacking it at the margin: prepayment certificates, the low-income scheme. Do you not really think the only fair thing is to abolish and then work desperately on how we can make the £450 million with a different route? Jane Kennedy: Frankly, no, because we have higher priorities for the health budget. That is the answer. Q570 Dr Taylor: Absolutely. Jane Kennedy: In the end, both the Welsh Assembly and we have come to similar conclusions, if you like, in terms of the evidence that we have been giving to you, but we have taken different decisions as a result of that. It is a question of how you prioritise and that is why the Welsh Assembly have made that decision. Q571 Dr Taylor: Another really dramatic suggestion they were looking at in Wales was getting a Welsh national formulary. We have the British National Formulary at the moment which is absolutely superb, but what we need and what they were looking at in Wales is a sort of breakdown of that into the drugs that the NHS would pay for - probably leaving out some of the ones that it would not, because there were perfectly effective alternatives. Could you see anything like that happening here, a review to produce a national formulary of the drugs that would be afforded by the NHS? Jane Kennedy: As Rosie says, the National Institute for Health and Clinical Excellence performs that role for new medicines and for treatments. You are saying that we should look at the way that the national formulary works and use that. It would be interesting. I want to think about it. Q572 Dr Taylor: NICE is superb, as fast as it can go on new medicines, but really I am looking at everything that is in the BNF. Should there be a limitation on some of those, for which there are alternatives that are perhaps cheaper? Jane Kennedy: I do not know if Felicity has a view on that. Dr Harvey: I think the BNF includes all licensed drugs. Q573 Dr Taylor: Absolutely. Dr Harvey: In terms of paying for licensed drugs, a doctor, as you well know, can prescribe any licensed drug and, indeed, any unlicensed drug. In fact, as soon as a new drug comes on the market and has been licensed, then they can be prescribed. There is no wait for reimbursement agreements, because that happens automatically through the PPRS. Q574 Dr Taylor: I am getting at an examination of this very basic right of a doctor to prescribe absolutely anything that is in the BNF regardless of price if there is a cheaper alternative. Dr Harvey: I think that has always been a matter of clinical freedom based on the clinician's decision as to what medication is required for a particular patient. Q575 Dr Taylor: Have we not got to the point, because the financial problems are so intense in so many places, where this form of health care rationing has to be considered? - however politically dangerous it is. Jane Kennedy: I want to give some thought to what you are saying. It would be quite a major step. Q576 Dr Taylor: I know. Jane Kennedy: It would be interesting to see if the Welsh Assembly finally does take that step. I would be reluctant to consider such a step at this stage, but I want to think about what the Committee has got to say. Dr Taylor: Thank you. Q577 Mr Burstow: Before I come on to my question, with reference to the 1998 review it would be very helpful if we could possibly have a note which sets out the options that were considered; the costings, if any, that were done; and the conclusions that were reached. We know the main conclusion - the conclusion was not to change it - but it would be very helpful., if possible to have a note on that. Is that okay? Jane Kennedy: Yes. Q578 Mr Burstow: Thank you. We have been exploring this and in the opening statement from Jane Kennedy we have had some sense of it, but what is the point of health charges? What criteria guide the Government's policy? We have heard raising revenue is seen as a good purpose. Is that one of the reasons? We have heard it is. Is it also, though, to limit demand for services? Ms Winterton: Could I come in here, Chairman? Going back to your previous quote from Lord Lipsey, I have to say that the system we had of dental charges, for example, was extremely complicated for dentists and for patients: 400 different items of service. In the reforms, we have tried to take that down to a much simpler system, but, of course, in undertaking that review, obviously the questions arose as to whether you should have any system of charging at all. Certainly, in the dental field, since 1951 there have always been charges for dental work. We wanted to see a system that was much simpler. As I say, if you say, "Should we have this system at all?" you do then have to look at the revenue implications of taking that away, which in the dental service would be about £600 million. Again, as Jane Kennedy has said, when you are reviewing this, those are the kinds of issues you go back to. During the course of the review of dental charges, we did say, "Well, this is something which has existed for a long time" - and I think successive governments, frankly, have looked at and decided it is, in a sense, inbuilt now in these areas. There might be all kinds of reasons why you would consider taking it away, but you would then have to look at the revenue coming from elsewhere, so, overall, I suppose one would go back to the original 1951 decision to introduce it. Once you have got there, then the considerations that govern changing the system obviously come into play, and some of those are the amount of revenue that is collected from that. Q579 Mr Burstow: To summarise, the reason we are doing it is because we have always done it that way. Ms Winterton: If you are looking at it and you are reviewing it, as we did with the dental charges - and of course it crosses your mind: Do you reverse what has been happening for 50 years? - you have to be realistic and say, "This is something that has gone on for 50 years. People to a certain extent do accept it." And if you look at comparisons with other countries, I think we spend more in public money on dentistry than any other of a comparable nature. You have to say, given all those circumstances, given the history, in particular, of dentistry and charging, do you want to take it away and find the money from elsewhere? Q580 Mr Burstow: Just to expand it beyond dentistry, is that the rationalisation of the position that would apply to all of the health care charges that we currently have within the NHS? Ms Winterton: There are those considerations, yes. I think there are those considerations that if this has been something that, as I have said, successive governments have looked at, I am sure ----- Jane Kennedy: But there are other charges which you face. If you go to hospital, to park your car you very often, these days, pay a car-parking fee. These are valuable sources of revenue - but they are not just a valuable source of revenue: they also help hospitals manage space, which is at a premium, around the hospital; they help them manage the flows of traffic - and I think it is perfectly legitimate way in which ----- Q581 Mr Burstow: We are coming on to car-park charges a bit later, so I am not going to trample on that ground, but I do want to ask one other question. It is this: If we did start with a blank piece of paper and the question was being asked: "We have to raise one billion pounds of revenue from the operations of the NHS, and currently we are trying to raise that through charging people with life-threatening conditions, by charging for access to their medicines and, in some cases, for their dentistry, would it be appropriate to consider switching, for example, a much greater emphasis on to the hotel cost sides of the NHS (the cost of being accommodated, the costs of, as we are seeing increasingly, the introduction of the telephone service)?" the provision of those sorts of services is nothing to do with the direct treatment and health of the individual but is the hotel and accommodation costs, is that not a more legitimate area to look into to raise revenue, rather than directly on the provision of health care? Jane Kennedy: Certainly if you were comparing it to prescription charges, I do not necessarily agree with that. If you have to go into hospital and you have to go into hospital for treatment, I do not think you should be charged for the care that you receive and the hospital services that you receive. I think if there are enhancements, that is perhaps a different matter - and we will come on to talk about the telephone services and the TV services that are provided - but I think it is important to remember on the prescription charging scheme, for example, if we are dealing with that, that the payment for that is income based. And, whilst there are anomalies in the scheme, those people who cannot afford to pay or who are on the margins of affordability are exempt from payment and they are not prevented from getting access to their medicines. It is only those people who are in a position to be able to pay who we ask to contribute to the cost - and they do not pay the full cost: the prescription charge is a contribution to the cost of the medicine. Ms Winterton: I think it is a balance between ensuring that the people who might be deterred because of the cost are protected. Certainly the evidence in the dental field (what people say and surveys that have been carried out) it is not charging which prevents people going to a dentist. I think it is about getting that balance right, between saying that if there is a contribution that is going to be made, let us make sure that we protect the people who might be deterred from going by things such as the low-income scheme or in certain instances in introducing these prepayment certificates. Q582 Mr Burstow: I think Howard is going to ask some more about that in a minute. I just want to end with this issue of dentistry one more time, and particularly the question of the provision of dentures, which is something that I raised with the minister at the session we had with you back in January. It is this concern we have had put to us both by Citizens Advice and Age Concern, that, for as many as 45% of older people who have no natural teeth, the issue of having access to dentures is very important to them in terms of their health and welfare. At the moment, with the new scheme, there is an increase in the amount that an individual will have to pay for replacing dentures that are needing replacement simply because of wear and tear which is higher than in the situation where someone has lost their dentures, where they are only going to have to pay 30% of the new highest rate. If they got to the point where they are no longer any good through wear and tear, they are seeing an increase from about £100 to £189, so that is directly increasing the cost, potentially increasing the incentive either to carry on using very inadequate and unsatisfactory worn out dentures or not to have anything at all. Ms Winterton: I think there are a number of issues here. I am not sure of the actual figures of people who have no teeth at all. Q583 Mr Burstow: The figure we have had supplied as evidence is up to 45% of older adults. Ms Winterton: I would look at whether that is people who actually have no teeth. I understood that the figures for people who have no teeth is relatively small and that it is more likely that dentures are for partial dentures, in which case you look at the figure in the higher band, band 3, of £189. Within that band would be included not only preventative health advice but looking at the other teeth, checking up any fillings, any other work that needed to be done, so the whole course of treatment including replacement dentures, would be included in that. That is a cut, from £384, which was the maximum you could pay previously, down to £189. The reason we made that top band much cheaper than it had been before - and Age Concern were particularly pleased that we made that change - was because older people do tend to require more treatment and they do tend to be at the higher end of the payment spectrum - as is the case, as well, with people on lower incomes. We had to strike that balance. Within the system that we have established, there will be some winners and losers, but, overall - and I think that is why the scheme has been welcomed by groups representing older people - we have been able to lower that higher price. Also, referring to your point about the 30%, there is actually no difference in the current system. I know we have had this exchange before, but, effectively, if somebody loses their dentures, there is a decision made that it is probably through no fault of their own - one would hope that people do not go around throwing their dentures in a fit of pique or something - and they only have to pay 30% of the replacement costs. We can have arguments about whether that is the right thing or the wrong thing, but it is an attempt, I think, to be fair in the assumption that people are not being careless with them or just being irresponsible. It is a judgment. But we have kept the system as it is at the moment, because some people would think it was rather mean to have taken it away. Q584 Dr Stoate: I would like to explore some alternative ways to raise revenue from the NHS. Jane, you mentioned that you were not in favour at all of hotel charges for hospital patients - and I have to say I entirely agree with that. As I understand it you are not having any plans to introduce hotel charges. But, as a GP, if I have an elderly person recovering from a chest infection and I have decided that person can no longer manage in the community and really needs some sort of residential care, if I send that person into hospital they do not pay anything at all; if I send that person into a respite home or social services care home they may well have to pay for that care. What is the logic in saying to that elderly person, "If I get you into the geriatric unit down the road it will be free; if I get you into the old folks' home down the road you may have to pay for some of those charges - not the nursing element but the hotel charges." Where is the logic of charging hotel charges for nursing home patients and no hotel charges for hospital patients for the same condition? Jane Kennedy: Again, it comes back to the same argument we have been having, which is that when you have a system and you consider a reform of that nature, you consider the pros and cons of the proposal, and you have to determine where in your list of priorities for reform and change such a proposal fits. The costs of such a proposal would be very significant. Our view has been that we have other priorities that we will use the revenue that we have, which is finite ---- Q585 Dr Stoate: I have no problem with your views on priorities of finance, and I entirely accept that the NHS needs to raise money from somewhere to develop and to improve services. I take issue with whether this is the right way. Are there not alternative ways that could be found to raise precisely the same amount of money? Can we not come up with alternative ways? Have other countries not come up with alternative ways that look fairer than ours? If that is the case, why are we not pursuing those alternatives? Jane Kennedy: I would be interested to see the examples that the Committee might have of alternative ways of raising revenue. In the circumstances that we are in at the moment, our view has been that we should not make that change. I am aware that it has been something that has been hotly debated: it was debated very much at the last general election and it has been something that we have considered, but consistently, having considered it, we have taken the view that it is not a high enough priority for us to believe we need to do something about. Q586 Dr Stoate: I have this nagging feeling about unfairness and I hate unfairness. I will give you another very simple example. I have two patients in my surgery: one has an under-active thyroid, one has an over-active thyroid, they both have throat infections. I say to patient (a) with the under-active thyroid, "Here's your fee prescription" and I say to patient (b) with an over-active thyroid, "You've got to go and pay £6.50 for that prescription," despite the fact that neither condition has anything to do with their thyroid disease and the patients are in all other respect identical. It sounds like a DirectLine advert, but the fact is that that literally does happen. That is just unfair and there has to be a way of reducing unfairness at that level. Jane Kennedy: As I have said, the anomalies in this system are clear. The benefits have changed over time and for those who are entitled to relief from prescription charging the definitions have changed over time. Wherever we have made those changes, the intention has been to preserve an existing entitlement; it has never been to take one away. Where there is a possibility of extending or increasing entitlement to free prescriptions, we do have to balance the needs of those patients who might benefit from that, against those who would lose as a result, and there would always be some who would - not necessarily if we were to deal with prescription charges in the way that you should, not just around prescription charges, but somewhere else in the health service there would be a cost that would have to be made. Q587 Dr Stoate: I accept that, but, to tie you down a bit, I gather you did not answer the beginning of my question - I have been reminded by the advisers - on alternative countries. Have you looked at alternative countries? If so, which ones, and, if not, why not? I would like to know about the work the Department has done on alternative structures, because there are plenty of good examples from across the world that you could have looked at. Are there any you have looked at, and, if so, what have you found? If you have not looked at them, why not? Jane Kennedy: We have looked at others. We have obviously been following developments in the two devolved administrations. We have looked at Ireland and the experience in Ireland. Looking through my notes, if you will allow me, we have looked at the system in Germany, and in Italy, where the systems are regionally based and regionally determined. We have looked at the system in France, in Spain - right across Europe - in Sweden, Denmark, Finland and the Netherlands. We have tended to look across Europe for comparators. Q588 Chairman: What have you learned from those comparators? Jane Kennedy: There are quite a variety of ways in which they system operates. If you look at Italy, as I have said it is a regionally based system and the amount that is charged is charged per pack of medicines and not per prescription item. Some regions do not have any charge at all but all regions do pay a degree ... I will get you the detail. Dr Harvey: They pay the difference between the reference price and the actual price, because they have reference pricing. Jane Kennedy: It is similar in France. In Spain they have, quite interestingly, different systems depending on whether you are a civil servant or not - which I found intriguing. I see some interest from the advisers at that. Those who are chronically sick in Spain do pay a maximum charge. The equivalent in the UK would be about £1.80, but, again, that is around the definition of illness. We can provide you with this sort of detail if it would help. Q589 Dr Stoate: It would be helpful. There is written evidence that the BMA suggested a nominal charge, say, of £1 for everybody except children. Do you have a response to the BMA's suggestion? Jane Kennedy: Again, you would be withdrawing an entitlement from a large number of people to achieve that. I would want to look at the findings of this Committee and to look at the recommendations that the Committee makes, but our view is that a review of that nature would produce as many people who would be discontent with the outcome as those who would be pleased with it. So we would have some concerns. Q590 Chairman: I accept that entirely, that you would have a situation where, if you were to restrict somebody with a long-term condition just to have free prescriptions for that condition, they would have to pay - and that would be a simple change - for other conditions that came along, but that is taking unfairness out of the system as most people would see it. There cannot be anything wrong with that, can there? Jane Kennedy: Again, it depends how you define long-term condition. You would be extending exemptions in some areas which would have cost implications, and if we were extending it in some areas and trying to do it in a way which was cost neutral you have other areas which would face an increase or a loss of entitlement or the costs would be borne somewhere else within the health service. We keep coming back to that point. We have not been able to find a solution which protects current entitlement and does not bring about a significant cost to the health service. Ms Winterton: Chairman, I can also send some information about dentistry in other countries. Q591 Chairman: We would greatly appreciate that if you could do that. Could I ask both of you, while on this issue: a crude interpretation would be, "We are going to keep it like this because it has been like this for 50 years, other than this three year blip, on prescription charges" but that is not a rule of thumb, that you look at the NHS and say, "We're going to leave it like that because it has been like that for 50 years," is it? It is far from it, is it not? You are looking at other areas that you would probably like to change before NHS charges. Jane Kennedy: That is the key, and in the end that has been how we have determined our approach to it. Ms Winterton: There is also an issue in dental care as well. People very often, at the moment, mix NHS care with cosmetic care. There have been a lot of changes that, in a sense, even further complicate that particular system. We have tried to make it clearer to people what they can get on the NHS, with the charge that goes with that, and what they are then charged for privately on top of that. But it has been a growing, if you like, mixed economy in terms of dental care. Jane Kennedy: One more point, where we are having that general discussion, just to reiterate: the numbers of prescriptions that are now exempt from payment is 87%. Of the 13% for which charges are raised, about 5% are now paid under the prepayment certificate, so there is a maximum that is paid in any one year on that. We have improved the low-income scheme and the PPA, the authority who administer the scheme, are looking at introducing monthly payments which would ease the burden on those who do have to pay. Q592 Charlotte Atkins: For the 13% who do pay, what is the Government's policy? Is it to raise charges in line with inflation or to keep the income from the charges at generally the same proportion of the NHS budget? Jane Kennedy: Our policy has been to have a nominal increase, almost, in prescription charges since we were elected in 1997. Year on year it has only gone up by 10p per year. The view that we have taken is that to abolish them would be too big a step, but we acknowledge the burden that it can be for those at the margins, just above the low-income scheme level and so on. We have accepted, overall, the contribution that prescription charges costs are making is reducing. Q593 Charlotte Atkins: Basically, the answer to that question is neither - neither to keep it in line with inflation, nor as a proportion of the NHS budget. I understood that in reviewing the system of NHS dentistry charges the new system was required to raise the same proportion of funds as the old one. Is that correct? Jane Kennedy: Yes. Ms Winterton: Yes. Q594 Charlotte Atkins: Therefore, did you decide how this new banded charging system would affect patient behaviour, because we have heard in a previous inquiry, when we were talking to you, Rosie, that people are predicting that patient behaviour will change and that they will store up treatments, get into a higher band, get greater value for money. When you were looking at that did you make those predictions? Ms Winterton: What we looked at in terms of the new charging system and the relationship between patient behaviour is that, because of the reform system and because of the changes in the NICE guidelines, which mean that instead of going back every six months, if the dentist decides that somebody does not need to come back within six months but could wait maybe one or two years, then the patient behaviour, the patient pattern, if you like, changes. I do challenge this idea that people are going to store up their fillings to get into different bands, frankly. Q595 Charlotte Atkins: Everyone loves a bargain! Ms Winterton: I find it very difficult to think that people would say, "If I hang on six months to get another filling, I can get that one in the same band." Do you know what I mean? It is an argument that people make. I find it quite a curious assumption, because I do think that if people were in that bad a position there would be assistance given through the various schemes. The Committee may have a different view, but I just find it a bit bizarre that people would behave like that. I also think that when a person goes for their initial examination under the new system, within one cost, they can have a check-up, they can have a scale and polish, they can have preventative advice and they can have, if necessary, x-rays as well all within that first band. If the dentist were to say (and Ben may correct me if I am wrong here), "Look, there is an immediate filling but there is one that will need a little bit of attention within two or three months", then that would count as a course of treatment. If the dentist says, "This is what is clinically necessary", then it can extend over that time. I would challenge some of the assumptions that are being made about patient behaviour, but I would say that there are differences in the way the system will operate, and the charging system was meant to take into account some of those changes, but overall the system was designed, frankly, just to be simpler for patients to understand, because too many times - and I think I have said this before - constituents have come to me and said, "That NHS is terrible. I have just paid a thousand pounds to have my teeth done." I say, "No, you have not, because all you can pay on the NHS, as is it stands at the moment, is £384. You should go back to your dentist and say, 'Wait a minute. What have I paid for on the NHS and what have I paid for privately?'" This system means that there are only three possible payments that people can make, and the dentist, under our regulations, has to make absolutely clear what is NHS and what is private. I think that that is a good change for patients and also, frankly, the system is less complicated for dentists. Q596 Charlotte Atkins: That is great if you can find an NHS dentist to apply those charges. What the Committee would be concerned about is to make sure that the charges were not operating against a preventative dentistry system, to actually encourage people (which is difficult anyway) to go to a dentist for preventative work. That is the important thing, to make sure that charges do not get in the way of that. Did you consider that when you were drawing up the new system? Ms Winterton: Absolutely. You will notice, I am sure, that within the first band there is an allowance for preventative work. If you move into the second band, the first band comes with you. You are not paying one charge of £15.50 and then another charge of £42.50. It is all encompassed, and so preventative work is allowed for. In terms of the contract itself in saying that the number of treatments can be reduced by 5%, the level of activity, that again is to take into account preventative work. I think there is a wider issue, though, about the whole reforms when it comes to preventative/public health work that, as we allow local commissioning within some of the schemes that are already working, it does allow dentists to be able to do more work, for example in schools, giving oral health advice. I have visited Newham recently which, extraordinarily, has an incredibly low rate of registration but NHS dentists who are longing for people to come through the door, and what the primary care trust has decided to do is to use some of them to go out into schools to say, "Please come and register with a dentist. This is why you should do it", and at the same time is able to give some oral health advice. Under the new system there is much more flexibility about allowing that kind of work to take place. Q597 Mr Burstow: I would like to come on to the way in which different policies interact with each other, particularly the very clear policy direction that came from the White Paper about a greater emphasis on community-based treatment. This is going mean that more patients who currently receive free medicines in hospitals will in future have to pay for them. Is that reasonable? Jane Kennedy: We will want to look at that. Clearly it is going to be something we are going to be looking at as we take forward the work and the development of the White Paper. There will be implications for other areas of cost as well, including travel costs, as we allow people to choose where they are being treated, so all of this field is under review. Q598 Mr Burstow: So that we are clear, is there a time line to which that review is working, and when might decisions be made as a result of such a review? Jane Kennedy: The development of the services that we said we would want to encourage in the White Paper will be taken forward over the coming months and years, and the impact of those services upon patients, and particularly, as you say, if they are being prescribed more frequently by GPs performing different roles than they are at the moment or even by pharmacists, then we will want to ensure that they are not disadvantaged. Q599 Mr Burstow: The danger, of course, is that there is never a clear point where a decision is absolutely necessary, because each part of the NHS will reconfigure and rearrange its services at different paces, and so there will never be a point where the whole of the NHS has got to where you want it to be, certainly not in the next few years, and yet this must have, on a locality by locality basis, impacts on the way in which the current prescription policy and exemptions will operate, meaning that some people who hitherto were getting their treatment in hospital may suddenly find themselves confronted with the fact that what was originally free simply because they were in a building, because they are now in their home taking the medication, they are having to pay for it. Jane Kennedy: These are issues that we are keeping closely under review as we take forward the work in developing the services. We will want to ensure that, as we are seeking to improve the services that people receive by delivering it more locally, that they are not disadvantaged in the way that you have said. Q600 Mr Burstow: There is one other specific to consider perhaps in that regard. We have had some evidence indirectly from the British Association of Day Surgery, and they tell us that day case patients are being required to take pay for painkillers which they take once they return home, and this is as a result of a policy that was promulgated from the Department. Is this policy of charging for painkillers for people who have had day surgery consistent with a policy of trying to encourage an increased emphasis on people opting for a day surgery rather than becoming inpatients? Ms Winterton: I think we have got to be realistic about what is a deterrent. I had day surgery on my foot and had to buy painkillers, but I think that was preferable to spending four days in a hospital. If you are looking at saying: is that going to stop people going for surgery? Are they going to take an overall view of what they prefer? The usual complaint is that people say that they are having to go unnecessarily into a hospital setting or are staying there too long. I think that, on balance, it is about saying there are some very, very clear advantages to having the day surgery option and probably, if you balanced out all the costs of that to the individual themselves, they might still say they would prefer to take a day surgery approach than have to go into hospital for a week or so with all the attendant costs that there may be to them in that. I think it is a balance. Q601 Mr Burstow: Presumably you would be concerned if that behaviour was stimulated by this new charge for painkillers, if people were making part of their decision about whether they opted for day surgery. Would you actually know? Would you be in a position to have information that would inform on such a situation? Ms Winterton: Patient surveys very often show how people react, and I think the evidence from patient surgeries is that people like to have the minimal time in hospital. I have not seen any evidence. I do not know whether that has been specifically asked in patient surveys, but I have not seen any evidence of people saying, "I much prefer to go into hospital because I can get a free painkiller." Jane Kennedy: Do not forget, it is not a new charge. It is a charge that has come about because of the different way in which the medicine is being prescribed. There are only 13% of prescriptions that face a charge, and of those 13% there are ways in which you can ameliorate the cost of that. Q602 Mr Burstow: My point is that, as a result of policy decisions and choices you have made, a new set of anomalies start to emerge from something that has not been changed since 1968. Surely that does behove a further examination of the 1968 exemptions in the light of other policy changes. Jane Kennedy: And it is something we want to look at carefully as we take the work on the White Paper forward. Q603 Chairman: Can I ask about the issue of low income families in particular. We heard when we were in Cardiff last week that one of the reasons why they were moving in the way that they are is that they believe that prescription charges may act as a form of poverty trap, that people would be deterred from going back into work because of the cost of the prescription when they are in work as opposed to the exemption that they get because they are on means-tested state benefit. Have you any evidence of that? Jane Kennedy: There have been a number of studies. There was a study conducted in Manchester some two or three years ago which was a relatively small study of the impact of charges on those people who had to pay and what they took as a result of that from their prescription, but we have been reluctant to extrapolate from that because it has been a relatively small study. Professor Peter Noyce conducted that, but it was only 14 pharmacies. What he found was that, yes, people who were being asked to pay a charge were discussing with the pharmacist which items on the prescription were necessary and were there alternatives, over the counter medicines, that might have provided a cheaper alternative, but he found that a very low proportion within that small study were at risk of not taking a medicine that was actually important to them for medical reasons, but that is the only study we have on that front. Q604 Chairman: We had some evidence from the pharmacists last week in relation to that. I am more concerned about this issue of the threshold where you have to pay or do not have to pay. If you go into low-paid work from being unemployed altogether on a different benefit, you then would have to pay your prescriptions. There is no taper in this. You are either exempted from paying prescription charges because of your age or income or condition, in some cases, or you have to pay the full cost of the prescription. What they were saying to us in Cardiff is that they believe, and I do not think they have done any great study into this, that it was potentially a disincentive for somebody to go back into work, because, even in low-paid work, they would have to pay the full cost of their prescriptions and not be exempted from paying in that work situation. What worries me about that, Minister, is the potential for social exclusion not to be broken down in society. Of all the areas that this Government wants to work at to bring people back into society, to get them back into work, this particular area might be a disincentive for some people to do that. I do not know if any studies have been done in England about that. Jane Kennedy: I would share your concern. We have not commissioned a study specifically on that, but we do work very closely with the Department for Work and Pensions and we are, as you will know, joint partners with them in the schemes in which we are seeking to help people who are on incapacity benefit return work, and this sort of issue has very much informed the policies as we have been developing them in that scheme. It is one of the reasons why the Low Income Scheme was extended to 12 months rather than six months, so that, even if you have gone back into work and the particular condition for which you got the exemption in the first place is ameliorated and goes away, you can still get relief on prescription charges for the rest of the year. It is that kind of work that we have been doing to try and deal with that problem, should it arise. Q605 Chairman: Do you have any regular meetings yourself with ministers from the Department for Work and Pensions? Jane Kennedy: I have not. That is not to say other colleagues across the Department have not. Q606 Dr Taylor: I am coming on to the age-based exemptions, because they do not really seem to make sense when there are lots of people who are retired and well off who do not need those exemptions. Have you any comments on that? Ms Winterton: There obviously have been manifesto commitments, discussions with organisations representing older people and reintroducing free eye-tests for the over 60s was a very popular measure, widely welcomed and very good in terms of ensuring that a particular group of people who probably did need regular eye-tests were able to get them. That is a debate, in a sense, about how we decide to treat older people, frankly. Q607 Dr Taylor: In any possible review would there be a question of looking at the multi-millionaires in their 60s and 70s and reckoning that they should pay? Ms Winterton: I do not see, particularly on the eye-tests for over 60s, a change in that policy in the near future. Q608 Dr Taylor: And prescription charges? Jane Kennedy: We have no plans to do with prescription charges either. You will remember, the largest number of prescriptions is written for people in that older age group. Something like 57% of all prescriptions go to people in that age group. You are more likely as you age to require medical support, medical treatment and medicines, and we have taken the view that we should not take away entitlements, and that is the position that we hold. Ms Winterton: I suspect that Parliament, having voted in some of these changes, would be rather loath to remove them. Q609 Dr Taylor: But you have said that one of the principles is that those who can afford should pay. Are you not now contradicting that? Jane Kennedy: No, because we have exempted those who are in retirement and are not working. Q610 Dr Taylor: But you have also exempted a lot who could afford to pay? Jane Kennedy: That is true. Q611 Dr Taylor: Which goes against your principle? Jane Kennedy: If you like, we have refined the principle. Q612 Chairman: Do we not have a problem with extending principles that are in manifestos! Jane Kennedy: We do not mind refining, but extending is more difficult. Q613 Dr Taylor: I want you to refine another one. War disablement pensioners do not have to pay prescription charges but only in respect of the medication for their disablement. Could not the system be refined so that these lucky patients with an under-active thyroid only get free prescriptions for their thyroid, diabetics only get free prescriptions for the things directly related to their diabetes. If you can do it for war disablement pensioners, could you not do it more across the board? Jane Kennedy: I am reluctant to begin that sort of review, which would inevitably lead to representations from every patient group who believed that they were a case that should be considered for exemption. We have really discussed that earlier. It is not a policy discussion that is enticing us. It is not high on our priority list. Q614 Dr Taylor: No, we are back to the very strong argument for the abolition and not the review. One other final question. Is it true that a directive came from the Department of Health about out-patient charges that anybody who had been in hospital for less than 24 hours should pay a prescription charge for the drugs that they take away with them? As I am sure you know, one of the rather odd definitions is that if you manage to get a patient out of hospital at 23 hours, rather than 24, they count as a day case and therefore they would have to pay prescription charges, whereas, if they managed to stay 24 and a half hours, they would count as an inpatient and so they would be exempt? Jane Kennedy: I have to apologise. I am not cited on that. I would want to look into that and see. Q615 Chairman: I think since 1948 the definition of an "inpatient" is one who was occupying a bed at midnight. Jane Kennedy: As far as I know, there have been no recent changes to the rules, but I would want to look at what you say. Q616 Dr Taylor: We were told there was a directive sent round from the Department of Health about charging for people who were in for less than 24 hours. Jane Kennedy: It is not something of which I am aware. Q617 Chairman: I hear what you say about the issue of conditions exemptions, and, indeed, it was put to us that is not somebody suffering from depression a long-term condition as well and where do you stop? We heard that in Cardiff last week. Would it not be easier to say that, given in 1951 there probably were not as many millionaires living into their retirement, in fact there were not as many millionaires full stop as well as people living into their retirement, and given an exemption on age nowadays when we have got a massive amount of millionaires who are able to get free prescriptions I think from the age of 60 now, is that not something that could be reviewed and stood on its own? I know it sounds like we are into class-bashing, and it is not meant in that respect. NHS charges are another form of tax, in a sense, and these people could well afford to pay £6.50, could they not? Jane Kennedy: The thing is that you would not introduce a system where you started saying people who had an income or asset base of a million pounds or more had to start paying more or had to start paying for their prescriptions. The vast majority of older people who are on acknowledged good pensions have planned for their retirement and taken into account that they will not have to pay prescription charges perhaps to a certain age, and to remove that would be just as controversial as some of the issues that you are asking us to consider in a different context. Q618 Chairman: What about doing it for people who pay the top rate in income tax when they retire? Ms Winterton: Sometimes it can be quite difficult, when you look at those systems. The cost of administering something like that can actually remove from the amount of revenue that you raise. Q619 Chairman: Have you looked at the costs of administration? Jane Kennedy: No, I must admit, we have not. Ms Winterton: I remember looking at the general admin costs and, at the time when I looked at them - this is all from my own interest, by the way, not some kind of fundamental review - it was fairly clear that the system was relatively simple at the time and the balance of administration was quite low, but I did think from that that, once you started introducing various different levels, it might become more complicated. Q620 Chairman: I accept that from your point of view, but looked at through the Inland Revenue's eyes it could be quite different, because you are easily picked out if you are on the top rate of income tax. Jane Kennedy: People who pay the top rate of income tax would argue that they already contribute by paying more tax. All of this is a fine balance. I was going to say, if Rosie had not said it, that when you start to have to work at how you administer such a scheme, the benefits that you get from it diminish. It sounds a simple thing to do, but actually doing it and doing it fairly is far more difficult to achieve. Q621 Chairman: You have not discussed this with the Treasury then? Jane Kennedy: No. Q622 Mr Burstow: The Department for Work and Pensions and the Government as a whole are considering issues around pensions and pension wages in terms of basic state pension entitlement. Is that something which the Department will be keeping in mind in terms of the age at which free prescription, free eye, free dental and other checks become available? In other words, will the age be kept aligned? Ms Winterton: I am sure that those will be part of the discussions that take place if any changes do occur. You mentioned the DWP. I wanted to say that one of the things that was highlighted in the recent Pack report was that people are not claiming some of the benefits, and this particularly related to cancer patients. I did check up on that, and we do try to ensure that "pounds departments" within hospitals and GPs surgeries, and so on, are given leaflets in order to make sure that people can take up the benefits that they are entitled to. Q623 Mr Campbell: Coming back to the charges again. Should eye-tests and dental checks not be free for everyone on the basis that if you do it early things like oral cancer could be caught early, costing the NHS less in the long run? Ms Winterton: In terms of the eye-tests - as you know, there are various groups who are entitled to free eye-tests - there is not any evidence that paying for an eye-test is deterring people. What we do try to do is to make sure that we have schemes in place, and we have looked at this, particularly, for example, schemes with pharmacists, to actually encourage people to go for eye-tests if they are in at-risk groups. Q624 Mr Campbell: It is a trait that we have got that if they have got to pay they are more reluctant. If I have got to pay for it I will not go. Ms Winterton: Your instinct might say that. I think the reality is, certainly if people feel they are having problems with their eyes or their eyesight is fading, they will go and have an eye-test. There is no evidence that people, frankly, just do not go because they could not afford it, because again there are the exemptions in there for people who would be on particularly low incomes, and, of course, again, for the over 60s, we have reintroduced free eye-tests, but we do try to encourage groups at risk to be able to go forward for that. Of course in some areas we have introduced regular eye-checks for people with particular long-term conditions. Q625 Mr Campbell: You have not done any costings to say that it is cost-effective by making it free earlier? Ms Winterton: I think everybody knows that, obviously, if it is caught early---. As I say, the key to this is not saying to people, "You can have a free eye-test" necessarily. The key is getting a message to people that they might be in an at-risk group. If we put adverts everywhere and said there are free eye-tests, people who needed it would not necessarily know. That is the key that you have to crack when you are dealing with the type of conditions that you are talking about. It is actually identifying people, getting the message through to them that they need to have an eye-test because they are in an at-risk group, which is in a sense the answer to saving the on-going costs further down the line. It is the people who do not come forward that is the problem, but I do not think it is connected to the fact that they feel they might have to pay for an eye-test, it is more likely because they do not realise they are in an at-risk group. Q626 Mr Campbell: Can I follow on with a question in regard to Mind, people with stress and people with mental problems. We had a witness last week from Mind who came in and when we asked her some questions it was amazing what she had to say. What she did have to say was basically that when a doctor gives a prescription to a patient who has a problem they went on a list, but the list was closed because it was as long as your arm. It was closed up to six months, she said, and so most patients, when they could afford it, had to go and get their own consultation and pay for it, and those that could not pay for it just did not, and, of course, further down the line it was going to cost more money because their condition never got better. Ms Winterton: I do not know whether she would be talking about---. Is she talking about a waiting list to see a psychiatrist? Mr Campbell: Yes. Q627 Dr Stoate: Psychotherapy, I think? Ms Winterton: There are certainly shortages of alternative counselling, and that is why in the manifesto we made a commitment to extend those kinds of services. We have trained more psychotherapists, and we are looking at the moment as to how we can extend that even further. We said in the recent White Paper that we would be looking at two demonstration sites to look at how you can provide some of those wider psychological therapists, because, you are absolutely right, there is a problem. Q628 Mr Campbell: It is a modern day disease? Ms Winterton: Yes. Q629 Mr Campbell: It could happen to anybody in this day and age? Ms Winterton: Yes, and it is something, it is absolutely true, which needs to be expanded. Q630 Mr Campbell: It is pretty shocking when you have a list and it is closed after six months and the doctor cannot get anybody on the list. Ms Winterton: Certainly there are long waiting times for psychotherapy at the moment, but that is why we are taking the action that we are doing. One of things that we have to do in expanding the counselling services is to make sure that we have got an adequate way of monitoring, or regulating those who are carrying out the services, and that is why we are talking at the moment with organisations like the British Association of Psychotherapists and Counsellors, I think it is called, to say how can we get some agreement about the different types of counselling that could be, in a sense, accredited so that if PCTs are commissioning it they know what they are commissioning, because you will find this varies from area to area. Some PCTs, for example, will provide bereavement services, others will not. Sometimes that is because some of them are not quite sure about some of the issues around accreditation. Q631 Dr Stoate: I would like to focus a bit more on the effects on health of charges. We have had quite a bit of evidence from pharmacists, from GPs and academics that groups of people simply choose which drugs to get from their pharmacist because they cannot afford them all and some patients do not take their drugs at all. Does the Department have any evidence of the effect this might have on people's health? Ms Winterton: With regard to pharmacists, that is exactly why we introduced the use your medicines properly schemes, which I think have been extremely effective. What there is evidence about is that, if people do not understand the possible side-effects of their medication, they can almost stop taking them without going back to, for example, a pharmacist and saying, "Is this right?", and sometimes the pharmacist will say, "Take it at a different time of day and that might reduce it." Q632 Dr Stoate: I am more concerned about the effect of charges on people. We have had pharmacists, and we have interviewed them, saying that they had first-hand experience of patients saying, "I cannot afford three drugs", or, "I cannot afford two drugs. Can you tell me which one I do not need?" and the pharmacists are finding themselves in an extremely difficult position. Do we have any evidence, any research on the scale of the problem and the effects it might have? Jane Kennedy: Other than the study that I referred to earlier, no, we do not. We have, of course, the Citizen's Advice Bureau work that was done a little while ago, in which they estimated about 100,000 people were not getting their medicine. We are looking at some of the representations that they have made and we are working with them to study that. There has also been a MORI poll, I think, but we do not know the scale of the poll. Q633 Dr Stoate: Is it not important that we do some research? We had Hamish Meldrum, for example, from the BMA last week, who is a GP, who felt that it was a significant problem, but he had no way of measuring the scale of it. Is it not something that the Department should be measuring? Ms Winterton: Some of the evidence, or some of anecdotal evidence, put it that way, is that people are not always told about the fact that there are Low Income Schemes, that there are exemption certificates, and so on. Q634 Dr Stoate: With respect, pharmacies will always tell a patient when they are entitled to a free prescription or not. The list is very clear in the pharmacy. They have got details, they have got literature and it the pharmacist's job is to make sure that patients get free prescriptions if they are entitled to them. I am talking about people who are not entitled to free prescriptions who will then say to the pharmacist, "I cannot afford three drugs. I can only afford two, or one. Which one can I afford to drop?" Surely that must have an implication on health, and why is not the Department doing some research on the scale of that potential problem? Jane Kennedy: As I say, we have that small study which indicated that for that small group of pharmacists the scale of the problem was not as great as you might have feared. We have no plans at the moment to commission any further evidence, but we want to consider that in the light of what the Committee might say. Q635 Dr Stoate: Mr Dyson, you are responsible for optical services. Being a GP, and it is well-known, for example, and any optician will tell you, that certain condition such as glaucoma, hypertension, diabetes can be picked up from an eye examination, and they are often conditions which have no symptoms whatever for many years and not until sometimes it is far too late to prevent long-term damage. Do we have any evidence that optical charges are putting people off attending for routine optical tests who may have those conditions but may have absolutely no inkling that they have got them unless they have an eye-test, and is there anything to show that might be a problem? Mr Dyson: It is perhaps first worth mentioning that diabetics and those diagnosed as having or being at risk of glaucoma are entitled to free sight-tests. Q636 Dr Stoate: I am talking about people who have not been diagnosed with diabetes or glaucoma. Once they have been diagnosed they are in the system. I am talking about otherwise fit, healthy adults who may have very high blood pressure, who may have diabetes, who may have glaucoma and be absolutely unaware of that because, as you know, those conditions do not manifest themselves unless they show signs. I am talking about people who potentially could be diagnosed. I am sent patients, on a fairly regular basis, by opticians because they have had an eye-test and the optician says, "You may have high blood pressure. You may have diabetes. Go and see your doctor." I am talking about people who have no idea they have got these conditions, and I am concerned about the effect that the charge may have on preventing such people coming forward for an eye-test? Mr Dyson: We are not aware of any evidence to show that the fact of having to pay for a sight-test has deterred people from coming forward. As we have put forward in evidence before, certainly the experience when free sight-tests were reintroduced for over 60s the overall volume of sight-tests as between the private and the NHS did not change significantly as a result, which implies certainly that the fact that some older people were having to pay for sight-tests privately had not deterred them. Q637 Dr Stoate: But with so many different providers in the field, can you possibly know how many people out there have or have not had a sight-test? Mr Dyson: We know the overall volume of NHS sight-tests and the overall volume of private tests, and that did not change significantly as a result of introducing free sight-tests for over 60s. Q638 Dr Stoate: But you have absolutely no research evidence whatever to back-up any assertions as to whether the charge does or does not put people off taking care? Mr Dyson: Our view is that the very fact that there was not a significant increase across the board was quite compelling evidence that, on the whole, people had not been put off by having to have a private sight-test before the change was introduced. Ms Winterton: I go back to the point that the key to this is actually reaching people who may be in at-risk groups and persuading them, as you obviously have, "You ought to think about going and having an eye-test if X, Y, Z." As I say, I think that for most people who perhaps are in that age range where their sight begins to fade a little, there is no evidence that they are not going because of a sight-test. I do not think it would be patient behaviour, frankly, because if you feel that there is something wrong you do tend to go. Q639 Dr Stoate: I am not talking about people with any symptoms whatever. I am talking about people who are otherwise, as far as they are concerned, completely fit and well who may well know they should have a dental check-up every year or two, and that is fine, but they have no reason to think that they need an optical test. I was simply concerned about some of those people who might think, "Why would I want to shell out £25 for an eye-test if I have not got any symptoms?" They are the ones I am concerned about, who may store up considerable damage to themselves before somebody says, "You have probably had diabetes for years", and that can easily happen before any symptoms develop. You may have had high blood pressure for years and you may not be aware of it until you have a stroke, but it may be that it could have been picked up by an optician earlier. Ms Winterton: Yes. As you say, the key is to get to people who are in at-risk groups and say, "Even though you may not be feeling something, it might be worth you going to do that". It is something that, whilst an eye-test may not be part of the new life-checks in itself, at least it would help to identify people that you would be saying, "Even if you are not having problems with your eyes, because of your family history, this is something that you should seriously consider doing." Q640 Mr Campbell: I heard Jane mention the monthly prepayment certificate before. You just mentioned that. I just caught the end of what you said. Jane Kennedy: It is not monthly at the moment. We are looking at that. Q641 Mr Campbell: Could you expand on that? Jane Kennedy: The Prescription Pricing Authority, who are the responsible body for administering the whole scheme and for making sure that reimbursement of prescriptions takes place, are looking at how they could develop such a scheme, and they will be reporting to me shortly on that. Mr Campbell: That is good. Q642 Mr Burstow: In addition to that, are there other options being looked at? Are they essentially looking at potentially a charging cap, so that, once you have paid a certain amount in a given period of time, you do not pay any more? Is that another option that is being considered? Jane Kennedy: It is capped anyway, and at the moment they are looking at both. Dr Harvey: It is a four-monthly certificate, but they are looking at monthly payments towards that, and they are also looking at the other thing that was raised by Citizens Advice, which was a reduced price PPC for those holding an HC3. Q643 Chairman: What about the issue of somebody who may not at the beginning of the year, or at any one time, know that they are going into a situation of long-term conditions that is going to mean a lot of medication but, probably three or six months down the road, suddenly realise that the amount of expenditure is quite high? I think one country we had evidence from put an annual cap on what somebody would pay on prescriptions and, if they met that cap, they would not pay any more for the following three months. Have you looked at anything like that? Dr Harvey: We are certainly aware of the situations, particularly in the Scandinavian countries, where that applies. There is the issue of the administration cost around all of that, but I think that is also why we are looking more at the monthly payments for PPCs and issues around the HC3 low-income scheme. Q644 Chairman: Okay. Another area we would like to look at is the cost of travel but in different circumstances than going to your local hospital. I have a constituency case I have been dealing with now for a number of years. One of my constituent's daughters was living in Sheffield, which is next door to me, and has ended up suffering from mental illness. She had to go into long-term care, and she is still in long-term care now. She was sent initially to Milton Keynes. Her mother could not get down to Milton Keynes to see her. She is an elderly lady and I do not think she has got a lot of income. I eventually got the system to move her a bit nearer. She is now in North Nottinghamshire, but she certainly could not get on a bus to go and see her. Why do we allow this situation? If it might have been a member of a family who went to prison, they could actually get travel costs to go and visit that person in prison. I had a letter from her a few weeks ago saying could we get her even nearer to North Nottinghamshire. If we could move her back to Sheffield she could go and see her on the bus a lot more. Why is it that we pay for people to go and visit prisoners and yet we cannot do that for people in long-term care in situations like that? Ms Winterton: Can I, first of all, make a general point about the mental healthcare provision. It is something that I am looking at, the general commissioning of mental healthcare, particularly in the relationship between the public sector and the private sector and how we can strengthen commissioning so that it is, in fact, closer to home in general. Q645 Chairman: It is very likely that these people will go into a place because of the status of that place, in terms of whether it is a secure unit or not, and, under those circumstances, we are not going to have one in every borough. I accept that entirely. I just think that it is very unfair that under those circumstances the family could visit, which could be very much for therapeutic reasons, and assist and certainly help a mother to see her daughter, and yet she does not get any assistance in being able to do that. Is that something that you could look at when you are looking at the issue of long-term care? Jane Kennedy: It is something that we could look at. I think we have focused the help in terms of transport on the patient so that the hospital transport scheme is focused on helping patients who have travel costs. This is a fair point, and I can appreciate the difficulties that some families of patients in those circumstances face. We would be happy to consider what the Committee has to say on this. Chairman: If somebody in the family had done wrong to society and been under lock and key, they could get assistance to go see them. Q646 Mr Burstow: Can I pick up this point. There was a report done a couple of years ago by the Social Exclusion Unit, Looking at Making Connections. It was published in 2003. It estimated that about 1.4 million people are put off taking up healthcare because of issues of access to transport and affordability of transport and so on. Preparing for this inquiry, what we have found it very difficult to do is to discern quite how the Department went about responding to the recommendations of that Social Exclusion Unit report. Can you tell us what you did with the recommendations to try and improve information for patients about how they could access transport and, indeed, this issue of how relatives can also have access to transport? Ms Winterton: There are two things. There are instances where people can apply for a social care grant for travel to see relatives in those situations. I think there is also an issue that is being looked at in terms of the wider expansion of the Choose and Book programme, and within that there is a look being taken at transport for visitors as well and I think, particularly in terms of mental health, that is something that we can look at within that. Q647 Mr Burstow: Specifically the Social Exclusion Unit report from three years ago. How was that taken forward? Jane Kennedy: First of all, the White Paper that we have just published sets out ways in which we respond to the recommendations of that report. They had one specific recommendation, which was that we should abolish the hospital transport scheme, which we have resisted because we actually think there is a value in helping those patients who would otherwise face costs specifically. However, there is a broad responsibility for ensuring that, as we are developing services and moving forward with our programme of taking services closer to people in the communities, local transport plans will also be required to play a role in making sure that transport arrangements in any given area take into account the accessibility of health service and health service provision. It is not just a health department responsibility to make sure that health facilities are accessible. Q648 Mr Burstow: On that last point - the model of care of having healthcare closer to home - one of the problems that can arise, and certainly in my own area where that model of care has now been put forward and has been taken forward, you may have very localised care facilities but they will not be able to provide the full range of diagnostics. Although you may have a local care hospital or a local facility on your door step, you still have to go right the other side of my local authority area, or further afield, still to get to the one that provides the service that you need. In some cases that may wind up with far more complex journeys than the original journey to the local key hospital. How is that going to be picked up? Is that simply going to be left very much to local transport plans and an interaction between the NHS locally and transport providers? Jane Kennedy: No, because if a patient requires, for medical reasons, to travel a distance for a diagnostic such as that and they fall within a category of patient for which the patient transport service will be able to provide transport, then they will be transported, so that will be provided. As I say, the other element of it is that for those patients who are not so critically ill that they require transport or have a condition which does not qualify for that support, there is the other scheme, which we have defended, which is the hospital transport scheme. Q649 Mr Burstow: So why are 1.4 million people a year turning down healthcare because of transport issues according to the Social Exclusion Unit? Jane Kennedy: As I say, our response to the Social Exclusion Unit report is contained within the White Paper, and if we take services more locally and provide services more locally, for example Clatterbridge Hospital in my area, a big cancer unit, well respected, has been developing for many years a system in which consultants go out and run clinics in localities around Merseyside and Cheshire and North Merseyside, so they will take their services to patients in Southport and deliver chemotherapy services in Southport. The patient does not have to go all the way through Liverpool to the Wirral to receive the treatment at the hospital. This is not rocket science, it is a simple process. It is a very sensible process of taking services out to where people want them, which is as close to home as they can have them. Q650 Mr Burstow: That is a good example of where that will work, but the point that I am making is again from practical work of modelling a better healthcare closer to home model of care. In my area they have recognised that there will be some services that will be provided in satellite facilities, but only one of them. They will not be moving around. There will still be people who have to travel further to get to those facilities. It is how those people are addressed when we know already 1.4 million people a year turn down access to healthcare because of transport difficulties. I am not clear how that is being fixed through what is being put forward. Jane Kennedy: We are taking services closer to people. That is how we are fixing it. Q651 Chairman: Could I ask you if you are happy that patients have adequate access to information regarding eligibility for assistance with health charges and if the Department do any checks on this. Last week we had in Citizen's Advice who said that health providers are not required to display information about the NHS Low Income Scheme. I know when you go into a GP's surgery there are leaflets and all sorts of things in there, but they do not have to provide this information on the NHS Low Income Scheme. They described it as quite amazing that they did not. Do you have any views on that? Jane Kennedy: The Prescription Pricing Authority is working with the Citizen's Advice Bureau. They have taken that finding very seriously and they are working with them to provide more information and working with the NUS to make sure there is information available to students on healthcare and health advice, so it is something that they are responding to. Ms Winterton: I am not sure if you make something a requirement, if somebody says that they were not then given it, whether you get into some legal difficulties. I am not sure whether that might be an issue if you put a requirement and then somebody says, "Yes, but I was not actually told it" - the definition of how you have displayed some information and whether it was drawn to their attention but there is certainly very heavy guidance, I think, on good practice as to how people's attention should be drawn to it. Jane Kennedy: For example, pharmacists are not contractually obliged to do it but good practice dictates that it would be something they should do. Q652 Chairman: I suppose that is one of the issues with new GP contracts and everything else as to whether or not you could make it a provision. What you are saying is if somebody says it falls short you then get into a mess of proving or disproving that information was available at the time when somebody went into a surgery. Is that what you are saying? Ms Winterton: It occurs to me that might be an issue around it and trying to do it through good practice may be the preferable route. Jane Kennedy: The HC11 form that does give guidance on the support that is available and on the Pre-payment Certificate is available from pharmacists and GPs and contractors. It is also available in JobCentre Plus and two major supermarkets, I understand. Chairman: You are not prepared to name them. Richard has got a question about that. Q653 Dr Taylor: That is the next question about the HC11. I am ashamed to say I have not looked at one myself but we are told it has got 77 pages and it is the major part of Age Concern's volunteers' work, to try to help people fill in this form. How could this be simplified? I think it was the CAB who said, "One thing you could do is say if you are entitled to a means-tested benefit then you get your free prescriptions". That would be so easy and it would save so many people so much time as opposed to this 77 page form. Is it 77 pages? Jane Kennedy: Yes. 79. But it does cover all the costs and all the help that you can get that is available, so it is of necessity detailed. However, there is a quick guide which my glamorous assistant will show you! Q654 Dr Taylor: Does the quick guide separate each of the sorts of things that you can claim for? Jane Kennedy: It gives details of what benefits would passport you through to receiving free prescriptions. Q655 Dr Taylor: Is there a short form on that that they have to fill in to claim it or do they still have to go back to the 79 page book? Ms Winterton: The form is HC1. Jane Kennedy: This is the advice booklet which explains what is available. Q656 Dr Taylor: How difficult is the form because Age Concern pointed out the extensive amount of time their members spend helping older adults complete the form? How many pages is the form? Jane Kennedy: I do not have an answer on that but we can find out. However, the patient partnerships have done a survey of opinion on the form. I think 94 % of those who responded to the survey said they found the form easy to fill in. We need to check because you have obviously got different information from us. Q657 Dr Taylor: It is just from Age Concern. Jane Kennedy: The HC1 form is 16 pages. Q658 Dr Taylor: The form is 16 pages? Jane Kennedy: Yes, 16, one-six.[1] Q659 Dr Taylor: Could you possibly leave us a form because I think it would be terribly useful if we saw it. Ms Winterton: Would you like this quick guide? Dr Taylor: Absolutely. Yes, please. Q660 Chairman: He is all right, he does not need them anyway. Can I ask you about best practice within the NHS for getting information about the Low Income Scheme. Could we take it as read that would be the case for the private providers that the NHS do now contract with, that we are likely to see these things in the areas where people go for private provision as well? Jane Kennedy: Yes. Certainly we will look to make sure it is understood that such advice should be available. Q661 Chairman: We may be going on a visit to one or two of these so we look forward to seeing them displayed in these areas. Dr Harvey: In terms of the transport scheme, as part of the consultation that will be taking place over a three month period one of the issues they are going to be looking at is how to raise awareness of the HC2 and HC3 for the Low Income Scheme help with travel costs for both staff and patients. Q662 Chairman: We are moving on to another area now. You probably know that last week we had Patientline in here and questioned them, and earlier today we had Ofcom questioning them as well about their report and their letter that was sent to the Secretary of State in relation to the policy on telecommunications in hospitals. Could you comment on the failings of the Department in regards to its policy on telecommunications services and what clearly most people would say is an inability to protect patients' relatives particularly and friends from unreasonably high charges? Ofcom were very diplomatic this morning but it is quite clear from the contents of the letter they sent to the Secretary of State on incoming telephone charges that they are extortionate - my words, not theirs - in terms of what people have to pay to phone a relative. How wrong do you think coming to a contract with these people was? Jane Kennedy: First of all, I would say Ofcom had undertaken an investigation into the provision of these services. They have now dropped that investigation because the Department and the contractors have expressed a willingness to work with Ofcom to address some of these criticisms that have been raised. There were about 70 complaints raised, which is a significant number, but when you think of the total number of people who have been using the services actually it is a relatively small number of people who are complaining. The majority of the complaints were about the costs. Among those people who have been using the service there is quite a high customer satisfaction rate with the services that they are receiving. In comparison with what was there before the services are seen as a very big improvement. Q663 Chairman: I accept that, but Ofcom stated in their letter to the Secretary of State that they had: "not therefore reached a final conclusion in respect of the lawfulness under competition law of the contractual arrangement entered into by the NHS Trusts and the providers". That does suggest this particular contract is suspicious, even to suggest it may or may not have been lawful in their view. It was not against competition law, they have clearly said that, but they have not passed it back to you with any glowing references about the scheme. They made it quite clear you need to do a critical analysis of what people have signed up for here. Jane Kennedy: On the day that Ofcom communicated with us to say that they were not taking their inquiry forward we made quite clearly a statement to say we accepted we need to review the arrangements and that is what we are doing and we will be in a position to announce the membership of the review group very shortly. It would be wrong of me to go into too much detail about what the perceived shortcomings might be in the current scheme. I need to let that group of people do their work. Q664 Chairman: You do not think that in any way the Department was duped into buying what some people would say is an expensive toy? Jane Kennedy: I take comfort from the fact that a lot of the users of the service have said that they think they are getting a good service. Q665 Chairman: I have to say my niece, who has just had a child, is in Rotherham Hospital and I was there Sunday evening and she said the system they have got there is wonderful, but I am not sure the relatives who have been phoning in will think that when they get the phone bills. Jane Kennedy: If I can just add one further point. The reason why I think these services are important is my elderly father-in-law went into hospital and spent a long time in hospital in his declining months. His one pleasure in life was watching Liverpool Football Club. His daughter took a television set in so he could watch the FA Cup Final when Liverpool were playing in a recent FA Cup Final, as they often do, and she was told she could not plug the TV in until it was checked by an electrician. She left the TV with the hospital ward for them to do that, it was never plugged in and the old gentleman did not get to see the last FA Cup that he would have been able to see with Liverpool playing. To have a service that is there that they can purchase that is there to provide that kind of service to patients is infinitely better than that kind of experience. If we have not got it right here we are working with the contractors to see what we can do to improve it. Q666 Mr Campbell: Sometimes it is a bit of a rip-off though. Jane Kennedy: I hear that criticism. Chairman: I have to say I was hospitalised in 1992 and I hired a television at the bottom of my bed and it kept me sane in a sense. I did not like visitors because they were interrupting my viewing pattern! Q667 Charlotte Atkins: I think we are being a little bit complacent here. Yes, of course the system is great for patients but it is a nasty shock for people who are ringing in when they get a huge bill. Maybe the complaints are not very high because they get it in their quarterly telephone bill three months later. That is the issue, is it not? Jane Kennedy: You have to appreciate that when we said we would develop this scheme it was to be at no cost to the NHS, therefore the contractors are investing significant sums in the roll-out and development of this facility for patients. Part of the quid pro quo of that is that they have to recover their costs. These are all issues that we will want to look at. We have taken the Ofcom comments very seriously and we want to review the arrangements. Q668 Charlotte Atkins: Maybe you could have a look at the people who are calling in and are being subjected to these very high costs. It may well be that you are talking about poorer friends and relatives of people in hospital who cannot afford to visit them in hospital or are unable to for whatever reason. Is it not the case also that, yes, they have got to recoup their costs but the point is they are recouping their costs for a very expensive bit of kit which is not being fully used by the NHS? Jane Kennedy: One of the criticisms which I heard was that when people ring in, the first 25 seconds or so is a message that says you are going to be charged at premium rate and this is how much it is going to cost you. If you are ringing in regularly that is not only irritating but also quite an expense. We are going to look at all of this and I just want to give the Committee---- Q669 Charlotte Atkins: It costs more to ring in than it does to ring Australia. When you are given the cost in a message when you are anxious to talk to a friend or relative it does not always sink in what the total price will be. Of course, you are right, it is an irritation to have that message especially if you are a repeat caller who constantly has to pay to hear this irritating message. Jane Kennedy: I am one of those people who is very irritated by telephone menus anyway, so I have a lot of sympathy for callers in those circumstances. I really cannot say much more at this point other than we are working with Ofcom and the companies and I will be announcing the membership of the review group soon. Q670 Charlotte Atkins: Will you also be looking at whether the NHS is going to have any prospect of using this expensive kit or will it just be not a toy but an expensive white elephant? Jane Kennedy: It has got about 40% usage, so perhaps part of the review may well look at how we can promote use of it. There are alternatives. There are payphones still in most hospital wards and very often TV rooms too. There are alternatives to this service if patients or relatives choose not to use it. The basis on which we allowed it to go forward was that it should not cost the Health Service any money. Working through that sort of detailed contract, there have to be ways of paying for it. Q671 Charlotte Atkins: Real competition would be the use of a mobile phone. Are you going to be looking at the issues around the use of mobile phones? I appreciate that there are clinical reasons why mobile phones should not be used but that would be the alternative choice for most relatives and patients. Jane Kennedy: I had not intended that this review would look at the extended use of mobile phones in hospitals. I am told yes, we will be looking at mobile phones. Charlotte Atkins: Excellent. An immediate change of policy, marvellous. Q672 Dr Stoate: It is called manifesto-plus. Jane Kennedy: But not as part of this review. Q673 Chairman: I think that was one of the things in the Ofcom letter to the Secretary of State, the issue of mobile phone usage in hospitals. Could I move on to another area which is the issue of hospitals and car parking. Should hospitals use parking to raise money? Jane Kennedy: I see absolutely nothing wrong with it. Q674 Chairman: Do you think that Trusts are providing enough free parking for regular attendees, such as cancer patients? We have gone from ten years ago when you would probably go into the acute sector for a week or a fortnight to now where you go in every day for an hour a day. Do you think Trusts ought to be issued with guidelines saying that regular patients like that should be exempt from charges? Jane Kennedy: It is very much for local Trusts to determine how they are going to manage their car parking facilities. The vast majority do have exemptions from charges. Hospital staff are pretty good usually at advising patients when they might get exemptions from car parking. It is very much a matter for local determination. Q675 Chairman: Do you keep a check on them at all? Jane Kennedy: I think we are content that the policies are being applied properly. Most hospitals will say it is enabling them to manage, as I said earlier on this morning, the space around them more efficiently, it discourages other people who are not using the hospital from using the car parking space, which in an inner city area is quite a problem for hospitals, and there are exemptions in place. Obviously nothing is ever perfect but I think they are getting it broadly right. Q676 Chairman: No concerns about having it on a pro rata basis? Some of these car parking charges are very high, as high as airports and everything else. I know you are not there for 24 hours but they are quite high charges for a short stay on occasions. You do not really have a view, that is a matter for the Trust, is it? Jane Kennedy: I would pay easily - I am not sure what it is in Liverpool now - a pound an hour to park in the city centre to go shopping. I think these are comparative charges and, therefore, fair in that context. Q677 Chairman: Dame Gill Morgan from the NHS Confederation last week was sitting where you are sitting and she said that car parking will increasingly be used as a competitive lever by hospitals to attract patients. Would you be happy to see hospitals build large car parks to win patients over? Jane Kennedy: I do not see it as a draw for patients, I see it as a service for patients, and I am sure that staff would welcome it as well. Q678 Chairman: Looked at through eyes like that, in view of what you said earlier about this issue of a sustainable transport system and taking things out into the community, it could have an adverse effect if we were to see this type of competition as far as transport was concerned, forget the health side of it. Do you think that there is a danger of that? Ms Winterton: I know in my constituency the constant complaint is there is not enough parking and the residents nearby say "people visiting the hospital park outside our house" and visitors and others say it is difficult. I think it is quite important that hospitals do respond to that. If people are saying this is making life difficult not only for them but for people who might want to come and see them, making life difficult for local residents, I think what she may be getting at is if hospitals feel that is something that patients are asking for they will respond to it. I think that is quite good, it can make people feel quite valued if they think the hospital is responding to the points they have been making about the facilities available. Q679 Charlotte Atkins: One of the areas which I am concerned about is chiropody. It increasingly seems to be moving into the private sector so elderly people, who rely very much on chiropody and it can have a real impact on their mobility, are being charged for that valuable service by default. Ms Winterton: I think there has been a longstanding argument about chiropody services. What I have been impressed with is the way that nowadays, particularly for people with diabetes, for example, who do need very good chiropody services, and beyond that podiatric services, increasingly in the way some of the centres are operating they do provide that. There are always issues between whether people in terms of having their nails cut have that on the NHS or whether you ensure that because of the terrible long-term effects of something like diabetes and you do not have proper corresponding chiropody services, you look at exactly what might happen if it is not treated. It is important to think we do target our resources where there is going to be the most effect, in a sense, and where it is going to make a real clinical difference. Q680 Charlotte Atkins: I can understand that, but if you are elderly and are unable to cut your own toenails, the impact of that can be as devastating as if you have a condition which requires you to have professional help. If you literally cannot cut your toenails then it will affect your ability to walk and mobility. I have had constituents who have said they are unwilling to go to a chiropodist to have their toenails cut because they do not think this is something they should be doing on the NHS sometimes, and some who can afford to will go private but there are others who will not be able to afford to do that on a regular basis. Ms Winterton: I think there may be some examples where PCTs may commission those kinds of services for particular groups and perhaps it might be helpful if we look into where there are good examples of that for the Committee. Charlotte Atkins: I think so otherwise we are talking about a whole group of elderly people being housebound when there is no need for that to happen. Q681 Chairman: Could I ask you about the likely effect of changes in the NHS to the structures of charging. This "greater diversity of providers" mentioned in the White Paper, does that not suggest there is likely to be an extension of charges? Ms Winterton: I do not think that should automatically follow from that. The White Paper is about looking at how we can provide more NHS services in the community, making it more convenient to people, making it closer to home, but it is not allowing within that an ability to say if you have day care surgery that comes under a different provider - I accept the point about the following medication - that provider would be allowed to charge for the service. It is about NHS services being offered in a different setting. Q682 Chairman: I have not got the White Paper with me but what about areas of alternative medicine? I go along to a private sector person for acupuncture. I know you can get it in some pain clinics in hospitals but I decided to do that myself. It is mainstream in some parts of the NHS and I could foresee a situation where a GP could turn round and say, "Maybe acupuncture is a way of doing it. My commissioning says I can give you one hour and we will see how that goes", whereas somebody might then go along and say, "For a small charge I will extend what the GP has commissioned". Do you see things like that could happen? Jane Kennedy: GPs are limited in what they can charge for NHS patients who are on their list. It is a very limited range of services that they can charge for and we have not got any plans to change that. If somebody like yourself was looking for acupuncture provided through a referral from a GP you would not be able to be charged for it unless it was on that very narrow list. In effect, the patient would have to come off the NHS list for the doctor to then say, "If you want to go privately" ---- Ms Winterton: I think NICE is looking at some of the alternative therapies that are available. Q683 Chairman: The White Paper suggests that will be part and parcel of looking after people's wellbeing. Ms Winterton: If NICE looks at therapies that it thinks are effective it can, in a sense, recommend those. It might be up to individual PCTs as to whether they want to fund them completely in the first instance. Q684 Chairman: What would you say if you had a private provider who was in deficit and they said they would like to develop some chargeable services at the margins of their activities? Presumably you would not be able to stop them. In the case of a Foundation Trust, if they were to offer services like this would you say that was simply a matter for the independent regulator? Jane Kennedy: Foundation Trusts are strictly limited in how much private work, if you want to call it that, they can do. They are specifically prevented in law from expanding the private provision that they provide within that Trust faster than their expansion of service delivery through NHS provision. There is a private patient cap. Chairman: You will know where this is going because we took evidence on this last week from a National Health Service Foundation Trust. I am going to bring Charlotte in now. Q685 Charlotte Atkins: I would be interested to know what your view is of the Jentle midwifery scheme at Queen Charlotte's. We had evidence from Dame Gill Morgan who said it made her feel slightly uneasy and she described it as an "uncomfortable situation". What is your view? Jane Kennedy: I would share that view. I have asked for a report arising from the evidence you have received about this and I am looking for officials to investigate what has been developed at Queen Charlotte's. The other response to make is one-to-one midwifery support is part of the National Service Framework, it is a commitment we made in our manifesto. The brake on us delivering that is the lack of midwives and we are working hard, as in other areas, to increase the numbers of people in that area. I think it has increased by 2,200. Progress is being made on that score but it is slow. In the meantime I want to really understand what is happening in this particular case because I am also uncomfortable with what I have heard about this example. Q686 Charlotte Atkins: In your view, a one-to-one midwifery service should be available to people on the NHS? Jane Kennedy: Yes. Q687 Charlotte Atkins: It should not be seen as a way of getting half price private treatment? Jane Kennedy: It is what we believe should be the service that women should get from the Health Service, yes. The only reason they are not getting it is because we do not have enough midwives to be able to provide it and that is why we are increasing the numbers and trying to raise the profile of midwifery as a career and promoting it as a career. Q688 Charlotte Atkins: Schemes such as the Jentle midwifery scheme could reduce the number of midwives still further. Jane Kennedy: It has caused a degree of concern to me, yes. Q689 Chairman: Could I ask you a question I asked a witness last week. Do you think there is anything different in principle from that additional charge that there is in Chelsea Hospital to the charge for a prescription? Ms Winterton: In a sense where you have to draw the line is if we were in a situation whereby something that should be provided because it is clinically necessary is being charged for quite independently, that would be very difficult. The issue of a prescription charge is that it is something which is in law for whatever for reason but it has been accepted as a generalised way of operation, it is a national scheme that applies everywhere. The general principles outwith that are that it is sometimes possible for people to provide extra facilities but it is a very fine line when it comes to what is clinical treatment. That would be my instinct. Jane Kennedy: I think as far as this particular case is concerned, if you are a young woman pregnancy and childbirth is probably the single greatest risk to your health that you are going to face in that period of your life and, therefore, if we have established what we believe should be the national standard of service that you should get when you are facing that level of risk I think we should be providing that and that should be a provision the Health Service should provide. In this case what is of particular concern is that what is being offered is the national standard as opposed to an additional service. Chairman: I think we were told that the only difference - they are both deemed to be NHS patients - is you would have a named midwife who would be with you in all prenatal situations and with you at the birth as opposed to having a midwife with you at the birth. Charlotte Atkins: They have extras as well, that was obviously clear. Q690 Chairman: That was my next question. In principle is that what your initial thoughts are about the uneasiness on this? Jane Kennedy: I want to look in detail at what has happened here before coming to any judgment on it. Q691 Chairman: The other thing that was said to us, and I would just like your views on this, and it is quite cold, I accept this, was that this scheme has raised quite a large amount of money for that particular hospital which they have reinvested back into employing people in there and improving their service, as it were, presumably for everybody as opposed to just these people who are paying this extra money. What do you feel about that? Jane Kennedy: We are going to face this kind of initiative happening. We want to be sure that when such initiatives are being taken forward by NHS Trusts, they are doing it in a way which does not set precedents for other examples that we would not wish to see happen. We do need to be well informed about what exactly is being developed. Q692 Charlotte Atkins: Can you just outline what the Government responsibilities are in terms of these sorts of services being offered by independent hospital Trusts? What responsibilities do you have? They operate independently, so what is the role of the Government in this respect? Ms Winterton: In this particular instance I presume it is a Foundation Trust. Jane Kennedy: No, this one is not. Q693 Charlotte Atkins: In general, if it was an independent Trust, what would your responsibilities be? Ms Winterton: If it was a Foundation Trust then obviously Monitor are given guidelines, as Jane Kennedy set out, as to the extent to which they can offer private or add-on facilities. If there was felt to be something going outside of that then it is possible for ministers, in this case it would be Norman Warner, to draw that to the attention of Monitor, particularly if it had been raised by Members of Parliament, the public and so on. Q694 Chairman: The other one that we got information on was a dermatology clinic in Harrogate. I cannot remember exactly, I have not got the letter with me, but they were removing moles and what was described to us as "cosmetic things" and they were charging for that whilst other things were being done on the National Health Service. Do you have any views on that? Ms Winterton: Again, that is something Norman Warner has asked for further information about because it is not quite clear in terms of what I have seen whether in a sense that was cosmetic surgery being offered or it is something which should be part of the clinical pathway, if you like. Q695 Chairman: One of the things in the letter was about botox. There are botox clinics up and down the land now. If they are offering that service in an NHS establishment but charging for it, what would your feelings be about that? Obviously it is cosmetic. You would not be against that, would you? Jane Kennedy: I am less concerned about that than I am the maternity example. I do not have the thorough detail but what I understand of the second example is they are offering services that otherwise would not be available on the NHS because it is treatments that are not being done for clinical reasons and in those circumstances it does not seem to me too unreasonable for a Trust to do that. Q696 Chairman: It is a bit like a large part of dentistry which is cosmetic as opposed to a medical or clinical need. Ms Winterton: It may well be. As I say, I do not know the complete details of it. I know that Norman Warner has asked for more information about it. Chairman: We will be interested to hear your views on that. Q697 Mr Campbell: Now that we have got a lot of private providers coming into the Health Service, do you see the charges increasing over this period of time? Ms Winterton: As we have said, the key to the way that we invited private providers in is to always say that these are services which are provided free to NHS patients. That is the way the contracts are drawn up. There is no question of saying in any sense the patient has to contribute to the cost of their operation. Q698 Mr Campbell: If I want to go to a hospital with a gourmet meal with a glass of wine, a pint of beer in my case, would I have to pay for that? Ms Winterton: I suspect you might, yes. Free beer on the NHS is not necessarily the point. Q699 Mr Campbell: These private people are getting in there and doing the business and I expect over time we will get these gourmet meals in hospital but will there be a cap put on it? Ms Winterton: There are issues here that if a private hospital was offering a service, it would not be able to charge back for the beer because it would be on the tariff as would take place in any other. It might say to you that it was making beer available and you might want a pint, if it was allowed in the circumstances. That might be something that would make you say, "I would quite like to go there because I get a free pint". Howard is looking horrified by this. Q700 Dr Stoate: Just the opposite. When I was a junior doctor we used to prescribe sherry and brandy for medicinal purposes. Long may it continue. Ms Winterton: Put that in a review. Q701 Mr Amess: I think these Ministers have done a brilliant job of blocking everything that we have slung at them. Ms Winterton: You always say that. Q702 Mr Amess: They have even managed to survive the vicious attacks of Dr Richard Taylor this afternoon! I shall always remember that expression "refine the principles". On that very point, as far as the National Health Service is concerned, does the Government think that the NHS will have to be redefined so that there will be a core package of services provided by the NHS above which you could have varying degrees of payments according to the income of the patient? This would be the bottom line of what you could get on the NHS and the rest of it, depending on what money the patient had, you could be charged for all sorts of other services. Jane Kennedy: I do not think I accept that scenario. We have brought forward and established National Service Frameworks in a wide range of fields and they set a national standard by which we expect the NHS to deliver services. What we have done is say it does not always have to be provided through an NHS organisation, it is possible to allow other organisations to provide these services albeit paid for by the NHS. In a sense we already have a definition of what services should be available through the NHS. What we have been discussing this morning is where on the edge of that definition it might be possible for NHS organisations and others, and indeed the state, to raise resources by charging. That is the debate that we are having today and we will continue to have, I am sure. Ms Winterton: I think it goes back to the Chairman's point about the television that he rented during his time in hospital because in a sense that was something that gave a great deal of comfort and relieved the boredom perhaps or whatever. Q703 Chairman: I was in traction at the time. Ms Winterton: It is about saying if people want some of those extras, if you like, that not everybody wants all the time, they can have those. The very basic principle is that clinically necessary treatment is free and will remain so under this Government. Jane Kennedy: On the point Mr Campbell raised about the gourmet meal and drink, the whole trend of hospital treatment these days is towards a shorter and shorter stay in hospital. You could expect to be genuinely asked the question if you are being offered a gourmet meal in hospital, what are you doing in hospital when you could be at home? The Health Service is going through a huge amount of change, not just the reforms that we are bringing to it but the way in which treatments are being delivered is being transformed by the way in which new medicines and treatments are being developed and the new innovations that are coming down the road. We have to have a service, a public service, that responds to that as well as providing a service that protects and provides the quality of service that we all expect and demand. Q704 Mr Amess: Finally, looking into your crystal ball, surely it must be the case that in five years' time there will be more charging because the way things are going with the endless demand there is no way we can keep collecting it all from taxation. Surely it will be the case that in five years there will have to be a lot of charges. Ms Winterton: Do you mean demands for different treatments? Q705 Mr Amess: Yes. Ms Winterton: In a sense that is the system that we have where drugs and treatments are looked at as to whether they are effective, whether they are safe, whether it is something that should be widespread across the whole of the NHS. There is a system which does look at those issues as to exactly what we can expect the National Health Service to provide but, as I say, that is rather different from what one might talk about as added extras that are not to do with a clinical treatment. Q706 Mr Amess: Surely there is a worry that with an ageing population, okay not in five years but ten, 15, 20 years, with less of a proportion working I do not quite see where the money is going to come from just through taxation because of the huge demands. Jane Kennedy: The prescription charge, if we take that as an example, was 45p in 1979. It rose to about £5.80 in 1998 and it has gone up by 10p a year since then. That is a slowing down in the overall charge rate. When you couple that with the reduction in the number of people who are having to pay, or rather the growing number of people being exempt, then the experience of people in the prescription charge field is that charges are declining in the sense that we are charging fewer people. In the end it is clearly a matter of political judgment as to how far you allow the boundary of charging to encroach. Our position is quite clear: patients should receive the treatment that they need at the point they need it and it should be free and not dependent upon their ability to pay, with the exception of prescription charges. Chairman: And dental charges and optician's charges. Q707 Mr Amess: I am sure that I speak on behalf of everyone, all those who were here last week to hear the evidence from the lady who was suffering from cystic fibrosis, when I say if anything comes out of this inquiry we really, really, really hope that when you look at our report ---- I understand the reasons for not changing anything but the evidence that we were given last week really moved us. Ms Winterton: Did you have a private Member's bill on that? Mr Amess: Might have! Q708 Dr Taylor: A very quick question. Having looked at HC1 I am absolutely horrified. It is the most impossible form anybody could ever have to fill in even if they were 50 with an IQ of 150. Could you consider the Citizen's Advice Bureau's suggestion to "simply state anyone on a means-tested benefit should be eligible for exemption from charges" and look into that and see what that would mean in financial terms. This is horrifying. Jane Kennedy: I am happy to look at what the Citizen's Advice Bureau recommended on that score. Chairman: Ministers, could I thank you for coming. I know we have had quite a long session again today but thank you very much indeed. I hope we will be able to make some recommendations that go beyond the review that we have had for the last 25 years. [1] Note by witness: The Prescription Pricing Authority (PPA) offer an HC1 form completion service which is available by phone |