UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 815-i

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

 

 

NHS CHARGES

 

 

Thursday 19 January 2006

DR FELICITY HARVEY, DR BARRY COCKROFT, MR BEN DYSON,
MR ROB SMITH and MR MIKE BROWNLEE

MR ANDREW HALDENBY

Evidence heard in Public Questions 1 - 137

 

 

USE OF THE TRANSCRIPT

1.	This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
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Oral Evidence

Taken before the Health Committee

on Thursday 19 January 2006

Members present

Mr Kevin Barron, in the Chair

Mr David Amess

Charlotte Atkins

Mr Ronnie Campbell

Anne Milton

Dr Doug Naysmith

Dr Howard Stoate

Dr Richard Taylor

________________

Witnesses: Dr Felicity Harvey, Head of Medicines, Mr Mike Brownlee, Deputy Head of Medicines, Pharmacy and Industry Group, Dr Barry Cockcroft, Acting Chief Dental Officer, Mr Ben Dyson, Head of Dental and Ophthalmic Services, and Mr Rob Smith, Director of Estates and Facilities Management, Department of Health, gave evidence.

Q1 Chairman: Welcome to the first evidence session that we are taking on our inquiry into NHS charges. I wonder if I could ask you to introduce yourselves.

Dr Harvey: I am Dr Felicity Harvey and I am head of Medicines, Pharmacy and Industry Group within the Department of Health. My group looks after prescription charge policy and the NHS Low Income Scheme.

Mr Brownlee: My name is Mike Brownlee and I am Dr Harvey's deputy.

Mr Smith: My name is Rob Smith. I am Director of Estates and Facilities Management, which covers car park issues and patient telephones and patient televisions.

Dr Cockcroft: I am Barry Cockcroft. I am Acting Chief Dental Officer for England, responsible for professional advice within the Department of Health on dental issues.

Mr Dyson: I am Ben Dyson, I am Head of the Dental and Ophthalmic Services Division within the Department of Health.

Q2 Chairman: Thank you very much. I wonder if I could start with the first question, directed to any or all of you. You will have probably heard this comment before: Lord Lipsey of the Social Market Foundation described the current system of health charges as "a dog's dinner, lacking any basis in fairness or logic". What are the underlying principles of the system that we currently operate?

Dr Harvey: The charges we currently have for prescriptions, dental treatment and ophthalmic services date back to 1951 to 1952. That is the time that charges were first introduced. Certainly, if you look for prescription, charges, they remained until 1965, were abolished, and then reintroduced due to concerns, we understand, about the rising drugs bill. The policy on the individual areas has very much related to the clinical services which they support. Certainly in terms of prescription charges, the policy in terms of the broad levels of exemptions has been relatively unchanged really since 1968. I do not know whether my colleagues on the optical and dental services would like to comment from their particular perspective.

Dr Cockcroft: From a dental point of view, the system of charges for patients is based very much on the way the clinicians are remunerated for the services they provide. It has been a constant source of complaint for some time, both the complicated way we remunerate dentists and the complicated way in which patients therefore are charged. That has been a really difficult issue for the last few years. We have just been through a programme of reform of patients charges, with significant patient involvement. A significant message from the patients was that we needed a much, simpler clearer system, and that fits very neatly into the reform of the way we remunerate dentists which we are going through at the moment. We are addressing that issue at the moment in the dental charges.

Mr Dyson: If you look at charges for dental services and the system of the NHS sight tests, successive administrations have taken the view that it is reasonable to ask those who can afford to do so to make a contribution to the cost of those services. I think it is also important perhaps to distinguish between some of the factors that may have led the governments of the past to introduce such systems. If you look back, for instance, to 1951, there were special circumstances that surrounded dentistry, with, I think it is fair to say, an unexpected level of demand for dentures, so different factors may have influenced the introduction of those charges in the first place. The decision that has faced administration since then has been more about whether to continue with these systems or whether to abolish or alter them in some way, and of course different considerations then come into play. Governments have had to take into account the contribution which the system of charges makes towards meeting the overall costs to the health service; they have had to take into account the fact that there is little evidence to suggest that those charges produce poorer health outcomes; and they have had to take into account the fact that these systems are now well established and, broadly, I think it is fair to say, accepted, in the sense that, where we receive concerns from patients about, for instance, dental charges, as Dr Cockcroft says, these tend to be more about the structure of the system than about the principle of charging per se.

Dr Harvey: I think underlying all of this has been the principle, for those areas in which the Government decided the charges should be levied, that those that are able to contribute should do so and those who are unable to should be protected through either benefits or, indeed, the NHS Low Income Scheme.

Q3 Chairman: My colleagues will be taking one or two of these matters up on a more individual and focused based later on. Whilst you cover the areas that you have outlined to us, you will not be immune to the debate that is taking place in different parts of the United Kingdom about the potential to abolish prescription charges. I wonder if you have any views on what the costs of abolishing charges would be in terms of prescriptions, optical and dental services.

Dr Harvey: In terms of prescription charges, at the moment they bring in an income of about £427 million per year. Over the last year, that has fluctuated slightly: £422 million, £426 million, but it is roughly in that sort of area.

Mr Dyson: In terms of dental charges, it is always slightly difficult to predict in advance exactly what level of dental charges are going to be collected, but the aim of the new dental charging system, amongst the benefits it brings for patients, is to make sure that we do not raise a greater proportion of charges than now. That would mean that abolishing that system would mean that the NHS would forego income of up to around £600 million. For sight tests, we estimate that if you were to extend free sight tests to all those who currently pay privately for sight tests, the costs would be about an additional £92 million, based on the current rate of £18.39 per test.

Q4 Chairman: Are both of those figures, the £92 million and £600 million, per annum?

Mr Dyson: Yes.

Q5 Chairman: Was your figure per annum, Dr Harvey.

Dr Harvey: It is a per annum figure.

Q6 Chairman: That would be the costs of abolition, effectively, as far as England is concerned.

Mr Brownlee: I wonder if I might add, in terms of prescription charges - and I do not have a figure for you - that we believe there might also be an influence on the drugs bill, in the sense that, for some of those people who are currently paying charges and perhaps go to their community pharmacy and buy something over the counter, there might be an incentive to go to their GP and get something. But it is almost impossible for us to forecast potential changes in behaviour, and one has to say that, if you compare the growth of the drugs bill since 2001 between England and Wales, since the Welsh Assembly decided to start reducing their prescription charge there has not been any noticeable change in trend.

Q7 Chairman: Is there any evidence that charges should be increased, on the basis that if they were increased people would seek to take responsibilities for their own health as opposed to relying on the National Health Service?

Dr Harvey: From the prescription charge perspective, certainly the prescription charge has been looked at in recent years annually by ministers - I think, in the same way that many of the benefits are - and there has not been any decision to raise them more than in recent years. Since about 1997, the increase has been ten pence per year, which actually, if you look over the period, that particular period, is in fact a real terms decrease of 4.5%. I think the Government is very well aware that there is an issue of affordability. Certainly, from the work that was done by the Citizens Advice and the MORI work back in 2001, we are aware that there are some low-income groups where a huge rise in prescription charges would be very difficult. In fact, a lot of the work we are doing through the Prescription Pricing Authority is for the prescription charge that we currently have trying to get better and better at targeting those low income groups, so that they are aware not only of the benefits that are available to them through the Department of Work and Pensions but also the NHS Low Income Scheme.

Q8 Chairman: Do you think this is flexible enough at this stage, or do you think there is a level of inflexibility about it leading from that?

Dr Harvey: Certainly, in terms of the Low Income Scheme and the information we have been aware of through the Citizens Advice work and other work that is being done by academics such as Peter Noyce, we have tried over that period to make some minor amendments to the Low Income Scheme so that it is slightly more flexible in terms of meeting the needs of those people who have low incomes.

Dr Cockcroft: With regard to dentistry, patients' charges have always been calculated as a percentage of the fee the dentist receives, so there has always been a direct link between the percentage increase in dental fees paid to the dentist and the patient's charge. That has been there since the dental charges were introduced. From April next year, that link is taken away, but we have been involved with patients' groups in working out the new system of patients' charges, and we have not detected the intention to make any increase in dental charges disproportionate in the new system.

Q9 Dr Stoate: Just for the record, could I start by reminding the Committee of my declaration in the Members' interest book that I am still a practising GP. We have heard from Dr Harvey the reasons why we have charges and how it happened, but I have not yet heard the underlying principles behind it. Are we really saying this is about raising money, reducing demand on services or reducing the drugs bill?

Dr Harvey: The fundamental principle that we had back in 1951-52 is historical. I could not tell you exactly why the charges were decided to be made on those particular things. We do think that back in 1968, when prescription charges were reintroduced, there may have been concerns about the NHS drugs bill at that time.

Q10 Dr Stoate: But that does not answer the question as to why particular conditions were singled out. If the government was simply trying to reduce the cost of prescriptions, why was there not simply a blanket charge for prescriptions? A prescription costs this much - end of story. I still have not understood the principles behind it.

Dr Harvey: Historically, in terms of why particular medical conditions were chosen, it is something that happened in consultation with the medical profession back in 1968. Those conditions have been unchanged since that time, even though we have had representations from a number of different chronic disease conditions groups. But the principle has really been around that of: those who can afford to contribute to pay, should do so, and that we protect those who have difficulty in affording. That has really been the basis of the changes that have taken place in recent years.

Q11 Chairman: This sounds suspiciously like: We have always done it and therefore we are carrying on doing it. You still have not explained to me. The prescription charge principle having been put in place nearly 40 years ago, no-one seems to have challenged the reason why it was brought in and why we have not changed it.

Dr Harvey: From what we understand, the issue of the particular medical conditions that we have at the moment, which date back to 1968, has been looked at on a few occasions but on each of those occasions ministers have made the decision not to add or change the list of medical conditions that are exempt from prescription charges.

Q12 Dr Stoate: Does that mean that no serious consideration has been given in that case to a more flexible system or an alternative system completely. For example have we looked in detail at some of the European alternatives? Have we really considered in detail what other countries do, in Scandinavia, for example, or have we simply said, "We do this, therefore we have to carry on doing it"?

Dr Harvey: On the occasions when ministers have looked at prescription charges, they have not made any decisions to change from the broad principles that we currently have. I think there is also an issue in terms of the medical conditions that we currently have. Clearly there are now very many chronic medical conditions that we are able to treat and treat very effectively. I suppose the issue is that, if you have a large number of medical conditions, where might one draw the line? The approach has certainly recently been in terms of affordability and trying to ensure that those who would have difficulty in paying are protected. The other thing that it would be worth adding is that certainly with the pre-payment certificates that have been brought in by the Prescription Pricing Authority (PPA) and which are administered through them, we now have a maximum charge for prescription charges annually of £93.20, or, for a four month period, of £33.90. If you look at the number of prescription items for the exempted groups, they are quite a lot higher than the average. The higher prescription item per person per year is about 14. If you look at those people who pay for their prescriptions and have the pre-payment certificates, it is about 46 items per year, and, if you look at those who are medically exempt, I think it is about 23 prescription items per year. But I think we should also remember that, in terms of prescription items, currently 87% of prescription items are exempt prescription charges. So it is only 13% of prescription items where a charge is paid and in fact 5% of prescription charge items are paid through pre-payment certificates.

Q13 Dr Stoate: When you talk about affordability, which I would like to come on to now, figures we have seen from Which?, for example, show that 6% of those on low incomes fail to take courses of prescribed medications because of cost and 24% fail to consult a dentist for the same reason. Certainly, as a GP I can recount many occasions when people have said to me, "I simply cannot afford three prescriptions, which one can I do without?" My pharmacist colleagues say exactly the same thing: people will take their prescription to the pharmacist and have quite a difficult discussion sometimes with the pharmacist about which of the medications they can strike off, which cannot possibly be good for patient care. You talk about equitable charges and you talk about affordability and yet there is very good evidence from a number of sources that some people simply are not getting the drugs their doctor says they ought to have because of cost.

Dr Harvey: We are very conscious, particularly, of the Citizens Advice work that was done in 2001 and, indeed, Peter Noyce's work around the same period, and, it is as a result of that, that in 2004 we made the change to the NHS Low Income Scheme which increased the level of the Low Income Scheme to include half the cost of a prescription. Particularly for those people on incapacity benefit, who are not passported automatically to free healthcare costs and they would have to apply through the NHS Low Income Scheme, we are aware that from that change about 44,000 additional people within income benefits, who were only able to have partial help before that, became able to have full help. We are very much aware of these issues, which is why there have been the changes to the NHS Low Income Scheme - which include giving people over 65 five-year exemption certificates rather than the 12 months which we have for other people.

Q14 Dr Stoate: People who are 60 do not pay prescription charges at all.

Dr Harvey: But they do pay for dental, optical and also health care travel costs.

Q15 Dr Stoate: Nevertheless, whichever system you bring in, there are going to be people above the threshold level. Whatever you do to the threshold level, there will always be people just above it. Have you considered a tapering scheme to help such people?

Dr Harvey: Again, as a result of the work that has been done, the PPA, who took over the administration of the pre-payment certificate in October 2002, have been looking at the recommendations that came from Citizens Advice, which were things such as: Have we considered a one monthly pre-payment certificate? and also: "Have we considered doing something through the Low Income Scheme in terms of a sliding scale. These are issues which the PPA has been looking at. We think they are due to be coming to ministers in the not-to-distant future.

Q16 Dr Taylor: Dr Harvey, I think you have lost me and I would like to go back over some of this mass of figures you have given us. First, you have said that the principle is that: those able to contribute should and those unable to should be protected. I fear that is going to raise an absolute furore, because there are many who could contribute a great deal more who are exempt and there are many ... Think of somebody with hypertension, who has to have at least a combination of three drugs, all separate, who is on a low income but not sufficiently low for them to be free. Three charges, three times £6.50 a month, is a vast amount. People are exempt, on average, 23 items per year. Is that what you said?

Dr Harvey: People who have medical exemption I think have about 23 prescription items per person per year on average.

Q17 Dr Taylor: Then, for those who were not exempt, you said it was something like 46.

Dr Harvey: Those who have a pre-payment certificate, which is 8% of prescription items, they have on average 46 prescription items per year.

Q18 Dr Taylor: Obviously they are people who are not exempt, who know they are going to have to pay an awful lot, pre-paying, so that they pay a bit less

Dr Harvey: They pre-pay, which means that the maximum they would pay, with a 12 months certificate, would be £93.20 per annum.

Q19 Dr Taylor: I find the 23 items per year for those exempt relatively small.

Dr Harvey: I am sorry, I apologise. In fact it is 33 items per year for those who are medically exempt. My apologies.

Q20 Dr Taylor: Even that is still quite low. No, it is just more than two items per month. Then you finish up with a figure that something like only 13% of items are charged.

Dr Harvey: They are. In total 13% of prescription items are charged for. In total 8% are paid for by people paying at the point of dispensing and 5% in total have a prescription pre-payment certificate.

Q21 Dr Taylor: That 13% raises £427 million per year.

Dr Harvey: That is correct. The issue is that those people who are medically exempt are medically exempt for the condition they have; but they are medically exempt, as a result of which, they are exempt any prescription charge on any item. That, again, is historical.

Q22 Dr Taylor: Which seems pretty unfair.

Dr Harvey: Although perhaps I could add that the difficulty, where you have people who have a medical exemption, in deciding which of the medications might be either directly related to their condition or, indeed, partially related to their condition would need quite a lot of clinical input to make those decisions.

Q23 Dr Taylor: Meaning that somebody with diabetes you would argue that their treatment for hypertension was so important for the diabetes that it was related. I see what you mean.

Dr Harvey: I think that is probably one of the reasons why, for those who are exempt, all of the prescriptions are medically exempt rather than just those specifically tied to the condition. I am not exactly sure why, but I would surmise that may have been ----

Q24 Dr Taylor: Dr Stoate rather touched on this, but is there evidence that the prescription charges reduce the take-up of medicines by those who really cannot afford to pay?

Dr Cockcroft: Certainly, from the Citizens Advice research that was done back in 2001, they were flagging that there was a concern that up to 290,000 non exempt patients might suffer as a result of the charges. Since that time, we have made further changes to the NHS Low Income Scheme. The other thing - and I know this has been flagged - is that there may well be people who could get help through the NHS Low Income Scheme but are not aware of it, and that is why the Prescription Pricing Authority, since they took over responsibility for this - and, indeed, they on behalf of the Department of Health take forward all the publicity - lead with a publication of this particular document. We have provided for the Committee copies of the sort of information that is published. That is why they are working very hard with patient groups, Citizen Advice, and, indeed, the NUS, who are another group, around trying to ensure that we better target the information about help with health costs to those who need it. It might be worth adding also that that information is also on the patient's part of the prescription form - and, again, we have supplied a copy in the information to the Committee.

Q25 Dr Taylor: Do you have any feel of the drugs that cost less than £6.50 for the number of people who buy those that are available without a prescription? Was that one of the figures you gave us?

Dr Harvey: No. The information I have available is that there is an average net ingredient cost for each of these groupings. If you look at the net ingredient cost for all of those people who pay for prescriptions, whether it be by pre-payment certificate or actually at point of collection, the average net ingredient cost is £14.32, and obviously the prescription charge is about 45% of that. But clearly the prescription items that are prescribed vary in their cost. Some are much more expensive.

Q26 Dr Taylor: Is there any regular information given to a patient, "The prescription charge is £6.50. This would only cost you £5 if you bought it without a prescription." Is there any record of the sorts of people who get that information and take it up?

Dr Harvey: I do not particularly know of it, although anecdotally one is aware that sometimes general practitioners might say to patients, "These are the things you need. You might want to get that from your pharmacist." But I do not have any information on that, I am afraid, no.

Mr Brownlee: Chairman, anything that is sold to a patient as an over-the-counter medicine is the private business of community pharmacists and we do not have any remit or record of what takes place.

Dr Harvey: But items that are on an FP10, as you know, are the items that are prescribed under the NHS.

Q27 Dr Taylor: Would chemists have the right, if something was on an FP10 and they knew it only cost £4, to cross it off and suggest the patient bought it at £4?

Mr Brownlee: I do not think they have the right. I think I am right in saying that, if something is prescribed by a doctor, then that is what they have to dispense. What happens in real life, sometimes, might be different.

Q28 Dr Taylor: Again anecdotally we hear stories of people who have been frightened to go to the doctor because of the risk of the amount they had to pay and they could not find it. Is there any evidence to back that up?

Dr Harvey: The information we have on that dates back to the research that was done by Citizens Advice. That is actually why the Prescription Pricing Authority are working quite hard with Citizens Advice, the National Union of Students and other patient groups around both the targeting of information about both pre-payment certificates as well as the NHS Low Income Scheme. So they are working quite hard with those groups.

Mr Brownlee: Chairman, we know also that there are other reasons why patients either do not go to the doctor or, having been to the doctor and got a prescription, decide not to obtain it, and then, even when they have got it, decide not to take it. We know there is something like probably £200 million worth a year of medicines in people's medicine cabinets that are not taken, so there is a whole raft of reasons there.

Q29 Chairman: Evidence about pre-payment - the £93.20, you said.

Dr Harvey: £93.20 per 12 months.

Q30 Chairman: That is money up front, is it?

Dr Harvey: It is indeed.

Q31 Chairman: Is there any evidence that that is a problem in terms of people accessing that system, having to find £93.20.

Dr Harvey: We certainly know that in terms of the take up of pre-payment certificates (PPCs) the take-up is increasing year on year. We are aware though, again from the previous research, that there may be issues of affordability for those who are over the threshold for the Low Income Scheme and that is why the Prescription Pricing Authority is doing work around the possibility of monthly prescription pre-payment certificates, and also the other thing which was raised, a sliding scale with a low income. They are looking at that at the moment and will clearly come to ministers. Is it worth adding, Chairman, that in terms of the average number of prescription items per script, the average number is two. If one were able to move to a monthly prescription pre-paid certificate, in fact that is likely to be less than two prescription items. Also, once you have 15 prescription items per year, then in fact that is the pre-payment certificate paid and that is the level at which it is capped.

Q32 Dr Naysmith: I would like to explore with Dr Harvey some things that have already been touched on. It is this question of the logic behind exemptions - not just particular diseases being exempt, some are and some are not, but, if you are in hospital, you get your drugs free, but as soon as you come out of hospital you are back on to paying prescription charges again if you are in a certain category. There are one or two other anomalies of this whole system. For instance, if you are in an exempt category for a particular disease, then you get all your prescriptions free, not just the one that applies to the exemption. It is riddled with anomalies and lack of logic, as we have already touched on this morning, but why does the Department not review this list and get rid of these anomalies now? I have written to them on a number of occasions, often to do with cystic fibrosis, as I know a little bit about it, and I get two replies back, either that this is being held under constant review - but you or the Department or the particular minister does not say that anything has ever happened since 1968 to all these reviews - or they say, "We have recently reviewed it and we are not going to review it again for a while." These answers from the Department indicate that it is not a priority at least. Why do you not review this list and get rid of these anomalies?

Dr Harvey: In response to your comment about whether or not things are being reviewed, it is certainly true to say that when we have issues that are raised in correspondence from yourselves, we do look at the issues, particularly in terms of the affordability and the feasibility, and it is on the basis of those that actually many changes, particularly to the Low Income Scheme, the length of time we have certificates for, et cetera, have indeed been changed. In terms of major reviews of the prescription cost system, this is not something that ministers have asked us to do at the moment. We are not undertaking a major review of prescription costs, although, as I say, we do keep under constant review particular issues around affordability and making the system work better.

Q33 Dr Naysmith: But not the disease categories and that kind of thing.

Dr Harvey: These are issues that ministers have asked to have looked at on a few occasions over the years, but on each occasion that they have been looked at the ministers decisions have been not to change them but more around the affordability issues.

Q34 Dr Naysmith: Sticking with this question of the anomalies - and I think you hinted at it earlier on - there have been such differences and medical improvements in a number of these conditions, and there is a series of cancers that are very good examples and also cystic fibrosis as well, that people survive much longer.

Dr Harvey: Yes.

Q35 Dr Naysmith: It is a very different situation, looking at these diseases now to looking at them 20 years ago. Why is the logic not extended? You are not going to say it is the ministers' fault, are you?

Dr Harvey: Absolutely not. The issue is that clearly there are very many very serious chronic conditions and these have not been reviewed for a while. The issue would always be: where would you draw the line? Therefore the approach has very much been around affordability and capping the cost of prescriptions for those who pay. Again, only 13% of prescription items are paid for; 87% are exempt prescription charges through age, benefit passporting, NHS Low Income Scheme, or, indeed, maternity certificates.

Q36 Dr Naysmith: You would accept that for some disease areas it is a kind of thing that people cannot understand, why their particular disease is not exempt where others are.

Dr Harvey: We do understand that there are many, many patient groups which have major concerns about why, indeed, their condition is not exempt.

Q37 Anne Milton: I know this may be slightly tricky for you. You did say at the beginning that you were responsible for prescription policy. I cannot see the policy that makes the diseases exempt that are exempt, and some, as my colleague mentioned, like cystic fibrosis, not exempt. What is the policy that lies behind that?

Dr Harvey: As I said, the exemptions date back to when they were brought in in 1968. On the occasions that ministers have looked at them, the list has not been extended but we have been looking at the affordability issues.

Q38 Anne Milton: Nobody is going to change that list of diseases, as far as you know.

Dr Harvey: To date there have been no changes in that list of conditions that are medically exempt.

Q39 Anne Milton: Are you aware that there is going to be in the future?

Dr Harvey: We have not at the moment been asked to do a review of medical conditions.

Anne Milton: Thank you.

Q40 Dr Naysmith: One of my questions was going to be: When are you going to look at the list again? The other thing you have not answered is whether there is any logic. If someone is on the list and gets the prescription free for that particular condition, if they develop another condition do they get the prescription free as well? - even though they may not be poor.

Dr Harvey: I think the issue is one of complexity; that is, to be able to categorise which prescription items, for example, for somebody who is medically exempt, were nothing to do with the underlying condition which gives them medical exemption. That could at times be quite complex and would need a great deal of clinical input to do that.

Dr Naysmith: You could almost certainly find a GP who would back up whichever argument you were making. I should not have said that, Howard!

Q41 Dr Stoate: You talked about affordability as being the criterion, if you really are concerned with affordability the only logical thing is to abolish all prescription charges because then probability goes away.

Dr Harvey: Prescription charges do bring in £427 million a year.

Q42 Dr Stoate: If affordability is your criterion then that is the way of getting round it.

Dr Harvey: I think it comes back to the principle of those who are able to contribute.

Dr Stoate: I do not mean to butt in on this, but I have one final point, a very quick intervention. If I treat someone with an overactive thyroid, I give them Carbimazole and they pay for it. The moment I give them too much Carbimazole and their thyroid becomes under-active - which very frequently happens - they do not pay ever again. Where is the logic in that?

Q43 Dr Naysmith: And can it ever make sense for wealthy old-age pensioners like me to get their prescriptions free when some people who are very close to the levels of cut-off do not get that.

Dr Harvey: In terms of the age that we currently have for exemption being 60, the age in fact for men was 65, the age for women was reduced to 60 in 1974, and in fact it was due to a case within the European Court on equality issues that in 1995 the charges were exempted for men aged 60 as well.

Q44 Dr Naysmith: But that is explaining why they got rid of the equality differences, not why people who can well afford to pay for the prescriptions get them free and some people who cannot really afford to pay for them have to pay for them.

Dr Harvey: And I think again the exemption for those - which was age 65 and has now become age 60, as I explained - really goes back to 1968, when the prescription charges were reintroduced.

Q45 Dr Naysmith: Continuing on this line in mental health conditions, changes recently -and there are more likely to be more in the future - provide for compulsory treatment in the community under non-residential treatment orders. The liberty of patients who are involved in this is clearly dependent on their compliance with a medication regime, and yet they have to pay for prescriptions. If they are admitted to an institution they do not pay, but while they are in the community they do pay. Here is another anomaly. What are we going to do about that?

Mr Brownlee: The issue has been that over the years these anomalies or things similar to them - and obviously they have changed over the years - have been looked at by successive illustrations. The outcome of this, in the main, apart from the areas we have already identified to you, has been to retain broadly the same system.

Q46 Dr Naysmith: So it is a series of ministers' faults.

Mr Brownlee: I am not trying to attribute blame. I do not want to give you the impression that this has never been considered by anybody ever in the Department of Health.

Q47 Dr Naysmith: I am sure it has, but I am looking to see if there is any real rationale behind it. With people suffering from ill health mental conditions, this is happening because treatment is changing, not because anything else is changing.

Mr Brownlee: Every time you are thinking of changing or abolishing, as was mentioned just now, it is a matter of the loss of £420 million or £430 million, or whatever the figure has been at the time, and the priorities that administrations have put to that income versus the loss of that income to the NHS on other services. If you do something that maintains whatever the level of income is but there are changes, there are going to be other losers to pay for those people who are benefiting.

Q48 Dr Naysmith: Have the figures been done to look at what the costs would be for extending the list to include the patients suffering from mental illness that I have mentioned and then cancer patients and then those with cystic fibrosis? Have the costs been worked out for individual conditions and the loss of revenue that would be involved?

Mr Brownlee: The answer to your question is no, and I will explain why. Because of the exemption from all conditions, to say what the cost would be is ... You can do quite a big study through the GPRD database, but we have not done that. Equally, we do not know how many patients suffering from those conditions or any other conditions are already exempt through other bases. It is almost a very difficult calculation to do.

Dr Harvey: Could I respond to your earlier point on mental health patients? The issue around treatment for mental health patients has been looked at around the mental health Bill and is under consideration at the moment.

Q49 Dr Naysmith: As a member of the joint Commons and Lords committee that looked into the mental health Bill, some of the costs are going to be tremendous. But maybe that is for another day. Finally, sometimes the argument is used - and I do not think you have used it yet today - that exempting people from prescription charges leads to the frivolous use of medicines and therefore unnecessary charges. Is there any evidence for that?

Mr Brownlee: I am not aware of it. On the basis that you have 87% already exempt, clearly we have other measures in the Department in terms of advising prescribers, in terms of what should be prescribed, and that is the way of getting at that; not trying to do it through prescription charges. If we were trying to do it through prescription charges, having exempt 87% to start with, then it would not be effective.

Q50 Dr Naysmith: If there were any evidence for it, then one could get an answer to this question of whether it exists by comparing the two groups, those who are exempt and those who are not, and seeing whether there was an increase in frivolous use of medicines in the groups that were getting them free or exempted.

Mr Brownlee: I think the way this has been looked at is through advice on prescribing across the piece, for everybody, not just looking at whether they are exempt or not exempt. Those are the measures the Department has done over a number of years, generic prescribing rather than brand medicines and that sort of thing.

Dr Harvey: Perhaps I might add that there is certainly quite a lot of advice to prescribers, both that produced by the National Prescribing Centre but also the Drugs and Therapeutics Committees and also, indeed, prescribing advisers within primary care. So there is quite a lot of advice around prescribing and, indeed, the data from prescribing is data that is received by PCTs so that they are indeed aware of the sorts of prescribing habits that are going on. But I think that is very much a clinical issue, since prescribing is very much the domain of the clinical practitioner, primarily doctors, but now also extended to some other clinical groups as well.

Q51 Chairman: Could I ask a supplementary, Mr Brownlee, about this situation of people with certain mental illness conditions. By implication, non-residential treatment programmes save quite substantial amounts of money because people are not living in residency. Has that been taken into account when looking round at the issue about whether or not these patients should have free prescriptions, or is that still being looked at now?

Mr Brownlee: It still comes under the category of what we said just now: "This area is being looked at."

Q52 Chairman: Has it been costed as to the savings you would make on a non residential treatment programme?

Mr Brownlee: Not to my knowledge, but in a sense that is not my area.

Dr Harvey: We are not aware of it.

Q53 Charlotte Atkins: Moving now to the issue of dental charges, could you identify any broad changes in dental health since charges were introduced for dental examinations back in 1989?

Dr Cockcroft: For dental examinations specifically?

Q54 Charlotte Atkins: Yes.

Dr Cockcroft: The dental health of the nation has been improving at a steady rate for a considerable period of time now, both in children, adults and older people. I do not think there has been any change in that pattern since 1989. The only area where there has been a flattening out of that improvement is in the very youngest children, where the improvement in health is more related to diet and education than it is to the provision of treatment. Of course, the introduction of charges for examinations in 1989 would not have affected those anyway because they were obviously exempt from charges, but I am not aware of a slowdown in the improvement in the oral health of adults who are liable for charges since they were introduced in 1989.

Q55 Charlotte Atkins: You would put the improvement in dental health to better diet and education or to issues like fluoridation.

Dr Cockcroft: I think it is a combination of factors. Quite clearly, fluoridation, both of water in some areas where that has happened, and its now almost universal availability in toothpaste has been probably the most significant factor in the improvement of oral health across the board. Obviously patient expectation and increasing awareness of oral health and education have also played a part as well.

Q56 Charlotte Atkins: In April this year, there is a new dental contract coming into effect. Do you think that will have a significant impact on the dental health of particularly those groups which find dental charges hard to afford?

Dr Cockcroft: I think the contract will have a significant impact on the way services are delivered. The service was effectively designed in 1948, when dental disease was rampant, and the focus of that system was about the so-called drill and fill and it was appropriate at that time because there was a need for that service. The dental health of the population is so improved now that that particular treatment modality is inappropriate and we want to go to a more preventive phase and build on patients' expectations. We are clear that we want to make the new system of charges consistent with that and not introduce any perverse incentives into the system that take dentists away from adopting a more preventive approach, and we are keen to maintain that in the new system. We are not changing any of the exemption categories. Obviously there are different areas there about tackling inequalities and addressing the education issues, and we have just published an oral health plan for England which focuses PCTs' minds on growing preventive services in their local community and making it part of their local development plans.

Q57 Charlotte Atkins: The new charging system obviously will simplify the whole situation. There are something like 400 charges at the moment, which are obviously very difficult for patients to understand. One of the complaints I often get is that a particular procedure that they want is not available on the NHS, but obviously would be available if they paid privately for it. What impact will the new charging system have on that? Will there be a re-look at what procedures are allowable under private arrangements as opposed to NHS arrangements?

Dr Cockcroft: One of the difficulties is the complexity of the current system. There is relatively little that is not available on the NHS that is clinically necessary. I cannot think of anything in any particular situation which is clinically necessary which truly the NHS does not fund, whether you have to pay the charges having done the ----

Q58 Charlotte Atkins: When you are dealing with something like teeth, clearly there can be an overlap between what is necessary and what is cosmetically desirable.

Dr Cockcroft: Yes, I think that is absolutely right. One of the things we have said very carefully is that we will pay for what is clinically necessary and the dentist has the freedom to use his clinical judgment in the new system about what is clinically necessary. Also we are going to have a programme of patient information starting relatively soon, to explain to them what is available, when it is appropriate for the NHS not to pay somebody because there is not a clinical need for that, but also the clarity of the charges. The difficulty with the charges at the moment is two-fold. Because you do not know in advance what the charge is going to be because of the way it is calculated, that creates a sort of nervousness in patients, and the new banding system takes that away. There is also in some areas a clear difficulty in people differentiating between when they are paying for private treatment and when they are paying for National Health Service treatment. One of the clear advantages of the new system is that it is one of the regulations that the dentist has to put in his surgery, in the waiting room where it is clearly visible, what these new banded charges are. It would be very obvious to a patient then, if they are being charged something which is not one of those bands, if this treatment includes an item which is not a National Health Service treatment.

Q59 Charlotte Atkins: I we take a particular case, say an older person with a fixed income who needs a partial repair to a denture, would that person under the new system not be paying more than she is at the moment?

Dr Cockcroft: The fundamental difference between the new system and the old system is that in the old system you were paying individually for every single little item of service and in the new system you are paying for an overall course of treatment. So it is very easy to pick out individual items at the moment that are less than the banded charge and make the comparison. Overall, we considered that when we were looking at the system, and patients groups were very keen on the clarity thing being the most important thing. But if you look at an overall course of treatment, it does not only include the particular item to which you may be drawing attention; it would also include an examination, diagnostic x-rays, and, in the case of a partial denture, any other treatment that the patient needs on the rest of the mouth.

Q60 Charlotte Atkins: But if that was the only item, then she would be paying more.

Dr Cockcroft: There will be instances when that happens, when you go for a fee per item to a banded system. But we have done an analysis of the case and obviously the maximum charge comes down very significantly, from nearly £400 to under £200, and we know that a large number of people in the system, if they are doing that, will pay less rather than more.

Q61 Charlotte Atkins: Of course, the big issue as far as dentistry is concerned is the availability of NHS dentists to carry out NHS dentistry. That is obviously the big issue. One issue that has been raised with me very significantly is the situation where parents are possibly bribed to take up a Denplan arrangement so that their children can receive NHS dentistry. Will you tell me what the new contract will do for that and what impact that will have on NHS dentists who are providing NHS dentistry for both parents and children?

Dr Cockcroft: First of all, to make acceptance of a child conditional on signing up for private treatment would be a breach of the regulations from April.

Q62 Charlotte Atkins: But it happens widely now, does it not?

Dr Cockcroft: It does. We are well aware of that.

Q63 Charlotte Atkins: How many children are affected?

Dr Cockcroft: I do not think we would have figures about that.

Q64 Charlotte Atkins: It worries me that we are having a significant change here in the contract and you are telling me that you do not know how many children potentially might be affected by the new contract coming in and the possibility that the dentist will not be treating those children on the NHS from next April.

Dr Cockcroft: Certainly that was a clear issue for dentists who were operating an acceptance policy, not that it is conditional but they do treat children. If a practice treats adults privately and children on the NHS, that is a decision for them to take. It is a breach of regulations to make one conditional on the other. I think that is different. We are saying, if you want to agree a contract with a dentist or a PCT wishes to agree a contract with a dentist which allows that practice at the moment to contract and provide services to children, it can do that, but it does not allow them to make acceptance of those children conditional on the adults accepting the private policy.

Q65 Charlotte Atkins: You are saying they can treat the parents or adults under Denplan and they can also, at the same time, treat any children under the NHS.

Dr Cockcroft: Yes. Absolutely clearly.

Q66 Charlotte Atkins: But it would be incorrect and against the regulations for one to be conditional on the other.

Dr Cockcroft: Yes.

Q67 Charlotte Atkins: The idea that dentists cannot treat children on the NHS while still carrying out private practice is incorrect.

Dr Cockcroft: Yes.

Charlotte Atkins: Thank you.

Mr Amess: Witnesses, you must watch yourselves on the parliamentary channel. Dr Harvey apart, up until now you really look as if you are auditioning for a part on The Glums. Do give the impression you are enjoying things a bit!

Charlotte Atkins: They are not.

Mr Amess: Clearly they are not.

Charlotte Atkins: We want you to show the teeth.

Q68 Mr Amess: Smile! Before I get to optical services, Dr Cockcroft, why are you only the Acting Chief Dental Officer?

Dr Cockcroft: The previous Chief Dental Officer, Raman Bedi, went back to his Chair at King's in October. I was previously Deputy Duty Dental officer and I had been leading on the modernisation of primary care. I was asked to carry on the work that I was already doing in terms of leading on the modernisation of NHS dentistry, so it did not seem a very sensible time, certainly to me and I hope the rest of the Department, to bring in somebody new to do that. I am acting because I have not been substantively appointed as the Chief Dental Officer and been through the process to do that.

Q69 Mr Amess: But you are in the frame to get the job.

Dr Cockcroft: Mr Amess is determined to make me smile, I can see. I think the job has not been advertised. I was substantively appointed as Deputy Chief Dental Officer.

Q70 Mr Amess: Right. Now we turn to Mr Dyson - and you are not related to the vacuum cleaners either.

Mr Dyson: No.

Q71 Mr Amess: Going back in my parliamentary annals, when I was Edwina Currie's private parliamentary secretary and she was taking the committee stage of the Bill, I can remember as if it were yesterday when we introduced charges, and Jerry Hayes, who was then an MP, leaked a very embarrassing letter to the Committee. Of course nowadays it has all changed completely. Perhaps you would tell us something about total expenditure on sight tests, because it has obviously changed an awful lot over the last decade.

Mr Dyson: The current level of expenditure on NHS-funded sight tests is about £184 million. The most significant step increase over recent years was obviously in 1999-2000, after the Government had reintroduced free sight tests for those aged over 60, and that that point expenditure grew from what had been just over £100 million in the previous year to just under £150 million. Since 1999 expenditure on sight tests has grown steadily each year. In 2004-05 there was a 6% increase over the previous year; the year before that there had been a 7% increase, and so on and so forth.

Q72 Mr Amess: You may not have it in your brief there, because I do not know if our wonderful clerk gives you a tip off, but in real terms what would roughly be the increase in expenditure from ten years ago?

Mr Dyson: First of all, I should emphasise that the increase over the last ten years will have been heavily influenced by that one year when we re-introduced free sight tests for over 60s. With that caveat, I think the increase - and I would have to check these figures - in cash terms is about 55-60%. I would need to check the real terms increase.

Q73 Mr Amess: Perhaps you would write to us about that. The current eye sight test is well below the cost of providing the service and until recently, it was expected to cover the cost. Why has this principle, which we were told was very important, been abandoned?

Mr Dyson: It is perhaps worth making a few comments there. First of all, just for the sake of clarity, it is important to be clear that the fee that the NHS pays to those who undertake the sight test has nothing to do with the cost to the patient. In terms of the fee paid to the optometrist or the ophthalmic medical practitioner, it is true that until about the early 1990s the approach was to have a so-called cost-plus approach to setting fees, where the Department would look with representatives at the professionals and companies who provided sight tests and the costs involved. There were two difficulties with that. First of all, it s quite difficult to pinpoint the true cost of providing a sight test, because you have to take a number of factors that are common to running an overall business and then make judgments about how you apportion those between the different elements of the business. The second concern was that the cost-plus approach was perhaps over mechanistic. It overlooked, and in some cases maybe even discouraged, efficiency improvements, so that the view the Department took was that rather than a cost-plus approach we should negotiate with representatives of the profession, taking into account recruitment, retention and motivation. On those criteria, the current system works very well. We have what I think almost everyone would accept is a function of a service that provides a great degree of choice for patients, encourages a wide variety of providers, and, indeed, our minister Rosie Winterton has recently offered fresh assurances to representatives of the profession that that system will continue. Perhaps I could add that it is difficult to make comparisons but the Federation of Ophthalmic and Dispensing Opticians, which represents a number of providers, recently did a survey amongst their members (so not entirely representative but it is an interesting comparison nonetheless) about the average charge that they levied for private sight tests, and that average sight test fee was an average slightly below the NHS sight test. So, taking 2004-05 as an example, the NHS fee was just under £18 and the private sight test fee was an average £17.68, so very, very similar.

Q74 Mr Amess: I shall not take it any further. That is a splendidly crafted argument but it does seem to me that the principle has been abandoned. I am a little bit confused as to your justification of that, but c'est la vie. Deregulation of optical services, which has had a huge, huge impact - not even touching on laser treatment and all that - has it affected the entry of new providers or waiting times?

Mr Dyson: I think it is important to be clear what one means by regulation or deregulation. It remains the fact that any practitioner who provides optical services have to register with the General Optical Council, so they are regulated in that sense. They have to demonstrate that they are properly qualified, that they undertake continuing education and training, that they remain fit to practice. So this is a regulated system in that sense, and of course practitioners also have to be listed with the primary care trusts where they provide services and the PCTs can undertake additional checks. They will take clinical references, they will inspect premises and equipment and so on and so forth. I assume the question is more about ----

Q75 Mr Amess: I wondered, first of all, is the Department happy with deregulation? You can practically go into a petrol station now and pick up a pair of spectacles. Is the Department happy with the way deregulation has turned out in practice?

Mr Dyson: I think it is slightly misleading, with respect, to refer to a completely deregulated system. Whether you are an optometrist or ophthalmic medical practitioner who is undertaking a sight test or you are a dispensing optician who is dispensing spectacles or contact lenses or whatever, you have to be registered with the General Ophthalmic council and you have to show that you are fit to practice, and both the conduct of the sight test and the dispensing of appliances is governed by national standards. In terms of the fact that there are no controls, in the sense that the NHS does not say, "We are going to dictate who provides NHS ophthalmic services in this area," we are not going to have a limit on the number of people; we are not going to place restrictions on patients as to which provider they can go to, provided that the people carrying out the clinical work are registered and appropriately qualified. The Department takes the view that that system works very well, in that it promotes patient choice, and this is an area where we receive very few complaints about the quality of the service they receive.

Q76 Mr Amess: Fine. Fourteen years on, it has been a success, the Department is happy with it and it has made a real contribution to waiting times.

Mr Dyson: As I have said, the minister recently had cause to offer some reassurances to representatives of the profession who were concerned that the current ophthalmic provisions in the Health Bill might lead to a degree of tighter regulation. The minister was at pains to point out that this was a misunderstanding of the clauses in the Health Bill. We are satisfied that the current system works well in terms of quality and choice for patients.

Mr Amess: Thank you.

Q77 Anne Milton: Mr Smith, it is your moment to cheer up, to smile at the camera! The one subject that causes a huge amount of grief in people is car parking charges. Maybe you could tell us what the principles are underlying the provision of car parking in NHS hospitals.

Mr Smith: The principles are different from those which have been discussed so far and lie in a number of roots. One is that trusts are able to generate income from a variety of sources - and I think that was put in the note to you from the Department. The other roots are the rise of car ownership and the desire of people to drive to wherever they want to go to and the burgeoning demand on hospitals, the fact that we deal with a whole spectrum of situations from acute hospitals in very tight urban situations that have virtually no car parking, to hospitals in more rural settings that have plenty of land and plenty of availability, and overlaying that - and very importantly, because it is a directive to many trusts that operate the hospitals - is the fact that Crown immunity was lifted and local planning authorities are able, when hospital developments take place, to impose planning constraints on the hospitals that lead them to implement sustainable travel plans, to try to organise a shift of travel from cars to other means of transport, including for patients. That whole variety of circumstances has led to a situation where it has not been deemed sensible to try to impose central regulation, which could not deal with all the circumstances. Indeed, some hospitals that have undertaken major developments have had to make annual contributions to provide bus services to and from the hospitals. I have worked and been a director of estates in hospitals where, before we introduced car parking controls and charges to pay for those, we were seen as an unofficial parking site for people who worked in office blocks locally. Rather than draw on NHS funding, which was directed for patients, certainly the trust that I worked in chose to levy a charge both on visitors and staff to cover the costs that were incurred in setting that system up and running it - because it required not just materials and controllers to be bought, but staff to be employed to run that. It was a very conscious decision not to place that as a charge against the NHS.

Q78 Anne Milton: The issue you raise about hospital car parks being seen as the town centre car park have been a real problem in the past. I think one of the problems now is that they are seen and viewed by many patients and visitors as a cash can, in that the hospital will maximise any income they can from it, irrespective of the hardship that it causes patients or visitors. Are there any plans to offer extensions to specific groups of patients or are you going to leave it simply down to local decision making?

Mr Smith: At the moment it is left to local decision making. Again, in the organisations in which I have worked, consideration has been given not to particular people suffering from particular disease groups, but more to the concern: Do people have to attend for a course of treatment on a regular basis? and exemptions have been available for part of the payment. But it is a matter very much for local discussion. I am not aware that the Department has contemplated changing that view.

Dr Harvey: Could I add that within the NHS Low Income Scheme you do get help with travel costs and indeed car parking, so those people under the NHS Low Income Scheme who are exempt would get a refund from the local trust for their car parking, I think I am correct in saying.

Mr Smith: Absolutely true.

Dr Harvey: And indeed, for the travel costs for travel to the hospital.

Q79 Anne Milton: The burden, if you are attending for a frequent course of treatment, is quite substantial at some hospitals, and actually those people are probably the people least able to make alternative arrangements on public transport because they are not well, obviously, by definition. What about assistance for travel to non-hospital settings which, of course, is going to become more and more relevant with the Government's drive trying not to treat people in acute hospitals?

Dr Harvey: Certainly travel to primary care organisations where a patient is under the care of a hospital consultant, an NHS consultant, is indeed covered within the NHS low income scheme; so if you are being treated under the care of a consultant, wherever that might be, then, indeed, you are covered.

Q80 Anne Milton: So even if it is not, I mean for physiotherapy, speech therapy, something like that.

Dr Harvey: The stipulation is that you are under the care of an NHS consultant.

Q81 Anne Milton: If you are having physiotherapy, are you? Yes, you are.

Dr Harvey: It would depend, I presume, whether that is a referral through your consultant.

Q82 Anne Milton: Yes, it would be. What about visitors? I think it is particularly relevant for elderly people, particularly the frail elderly, whose contact with visitors could be said to be part of their treatment - they do much better, they get less disorientated if they are out of hospital for care. Are there any exemptions or is there help for car parking for those visitors?

Dr Harvey: I think if I might add just from the NHS low income scheme perspective, it does cover patients but also, where those patients require escorting because of the condition that they have, on medical grounds, then those escorts would also be exempt.

Q83 Anne Milton: But not the visitors. As I say, it is particularly relevant, I think, to elderly people?

Mr Smith: I do not believe that the hospital travel cost scheme does cover visitors unless they are escorting people, so that would not help. In terms of visitors in the majority of acute hospitals - we have no collected central information on this, this is just information that I have observed in places that I have worked in or have visited - a reduction in cost is usual. If you have a relative in a critical care unit and there is a recognition that you will be visiting and staying for long periods of time, the local organisation usually provides relief in those circumstances, but the median of charges in hospitals is one pound an hour, the median cost across hospitals in the UK, for the first three hours, so it is only after that time that charges generally start to escalate significantly, but those charges are levied on all visitors.

Q84 Anne Milton: Do you have any information about how people get to hospital: because, I think, on the small bits of research I have seen, irrespective of where this problem is, irrespective of how good public transport is, people will always travel by car? They will get a neighbour, they will get somebody to take them to hospital by car.

Dr Harvey: I am not aware of any research personally, but certainly, of course, some people will have travel to hospital covered under the patient transport services - the non-emergency ambulances - and those would be on medical grounds, and that would be that it has been recommended by a doctor that, either due to a physical condition or particularly a medical condition that they have, they would need transport plus or minus an escort, depending on the conditions, and so those people would be covered under the patient transport services. I am not aware of any other issues. I wonder whether it is worth raising that some of these issues have been raised during the consultation, Your Health Your Care Your Say, around the patient transport services and, indeed, hospital travel cost schemes and we know that they are being looked at at the moment.

Q85 Dr Taylor: The crucial question to me is where do the profits go from car parking: because they are mostly run by private contractors? Do they get the profits or does the NHS get the profits?

Dr Harvey: I think it is difficult to say. The car parking situations are normally run by private contractors. I certainly have no evidence for that, but, equally, I find it difficult to disprove it.

Q86 Dr Taylor: You mean many hospitals run their own car parking?

Mr Smith: Absolutely.

Q87 Dr Taylor: Surely you must have some figures for that, because every hospital I know does not run their own car parking system.

Mr Smith: I do not have figures for that, but I am talking from the visits that I have made to hospital. I was going to go on to say that in many cases, although the facilities may be operated by a private company, they are paid a fee for that and, if there is any excess income over and above that fee, it will go to the hospital trust - those are the circumstances that I am used to - other than where the trust, because of space constraints or lack of availability of finance, may have worked with a private car park operator who will have financed and built a car park adjacent to the hospital, and an example of that would be at Queen's Medical Centre in Nottingham - one exists there - and in that circumstance it is the operator of the car park who keeps the revenue from people using that car park.

Q88 Dr Taylor: Would it be possible to have a breakdown of figures across the country, or would that be a huge work?

Mr Smith: We do not collect that information at the moment. We ask trusts to tell us whether they charge or not and the level of the charge. We do not ask them to supply the information about is that car park run, operated or where does the finance go. The information is not collected.

Q89 Dr Taylor: Maybe it is on the telephone side, because in the information you have given us the cost of incoming telephone calls ranges from 15p to 49p a minute for somebody who is phoning up the patient at their bedside phone. Where do those profits go to?

Mr Smith: It is a different circumstance. The installations have been paid for by private sector companies, who retain the income from the telephone charges, the charges for the television, for the provision of those additional services. They retain a basket of income from those services to pay for the capital investment and the running costs of operating that service. That money does not go to the NHS.

Q90 Dr Taylor: Is there any reason why the range of costs is so wide - 15p to 49p a minute?

Mr Smith: Ofcom have been running an investigation into that which concluded with the closure notice yesterday, and they have asked the Department of Health to work with the providers of those services and with Ofcom to look into that, but they have acknowledged that it is a very complex area and complex issue. The Department of Health has already agreed to undertake that work working with the private sector providers, working with Ofcom, to look at what can be done about those high charges.

Q91 Dr Taylor: If you phone a patient, is that automatically a warning of what it is going to cost you?

Mr Smith: It is my clear understanding that when you phone into the hospital you are always given a warning message.

Q92 Dr Stoate: This is a fascinating inquiry, because the more we look into this the madder the system becomes. I would like to pick up on something that Dr Harvey has just said about the NHS low income scheme about travel to hospital. It appears, therefore, if I refer a patient for physiotherapy the patient cannot claim the money back for travel to the hospital to get the physiotherapy. If, on the other hand, I waste vast amounts of public money by referring the patient to the rheumatologist, who then refers the patient for physiotherapy, they can claim their travel to the hospital. Therefore, I have got to say to my patient, "I can save you a few quid", although I am wasting a few hundred quid by referring someone to rheumatology that does not need to see them. The whole point about general practice is that we avoid referring to hospital where possible, but we do access secondary care services on direct referral because that is very efficient and very quick, but you are now telling me the patient cannot claim the cost. It is daft.

Dr Harvey: These are issue that are being raised during consultation with the National Health Service and LHAs and they are being looked at at the moment.

Q93 Dr Stoate: The whole system gets madder and madder by the minute. I am genuinely amazed. I did not know about this. I am learning a lot this morning.

Dr Harvey: I think the issue is that the way in which services have delivered is changing over time, and I think quite a lot of these issues, as I say, have been raised during the consultation period.

Q94 Dr Stoate: If under my new practice-based commissioning arrangements I invite the consultant to drop in on a Thursday afternoon, presumably at my expense, and the consultant just signs a load of forms for people to have physio, they can claim the money back for it, whereas if I do not take the trouble to invite the rheumatologist over to do that, the patient cannot get the money back?

Dr Harvey: We can certainly send you further information on this, but I know this is an issue that is at the moment being looked at.

Dr Stoate: Thank you, Chairman. I am gobsmacked!

Chairman: Anne, have you got a supplementary on this?

Anne Milton: No, I just have to back-up what Dr Stoate has said. The impression I am left with is that a lot has been attacked, a lot is under consideration but, fundamentally, it is all too difficult for anybody to ever change anything. You do not have to comment. It sounds like a very difficult issue.

Chairman: Maybe that is an issue we can have when we draw up this report. We are going to the area about information for patients now.

Q95 Mr Campbell: There have been many submissions made that patients were not aware of what they can claim and what they can get in relation to prescription charges. Even Citizens Advice submitted that a lot of people are now facing court action because they have been falsely claiming prescription charges. The question is: are you failing to ensure that patients are made aware that they can claim? I know you were brandishing a book before, and sometimes I get worried when I see these because some of these are very complicated and you need a degree to read them. It is like when you get a toy at Christmas, when you get the instructions you need to be a rocket scientist to put it together. Sometimes these information packs that are produced are very heavy for an ordinary person to read. Are you failing, because if Citizens Advice write, and a lot of people are suffering, there is something wrong with the system?

Dr Harvey: I think since the Prescription Pricing Authority took over responsibility for the PPCs, and in fact now they cover all the certificates of exemption for those that need passporting, like, for example, tax credits, but they have been working quite hard with citizens advice, with National Union of Students and with other patient groups because of a concern that some people are not aware that they may well be eligible for help with health costs. This is the primary publication that they have, which is HC11. There are very many quick guides.

Q96 Mr Campbell: Is it simple to read?

Dr Harvey: It is very simple to read, but, in fact, we do also have a number of quick guides.

Q97 Mr Campbell: It is 77 pages?

Dr Harvey: This one is, but there is another one that is literally a fold-out.

Mr Brownlee: It is a small fold-out.

Dr Harvey: We have provided the Committee with a pack of the information that is available to patients and the public that the Prescription Pricing Authority publish, but I think to start with one needs to say that there are advice lines both for the Department of Health for the PPA through which all of this information can be received, there is information on every prescription form, on the information side for patients, which also deals with how you can get information about help with health costs and, indeed, payment certificates. There is also this information provided through the Waiting Room Services information service, which many primary care organisations subscribe to, but also information available to all primary care practitioners, including pharmacies. However, having said that, we are still concerned and the PPA are still concerned with making sure that the way in which they are targeting the information does actually get to those groups - particularly one group that has been raised with them and with us is those on incapacity benefit who are not passported - so that they are aware of the fact that there is help with health costs. The other thing is that all of the Jobcentre Plus bodies also have these leaflets available for people and there is information on the DWP websites, and lots of other government departments and other bodies that have been working with the PPA also have information on their websites; so we are working quite hard. I think if you look back to October 2002 before the PPA took over all of this, possibly information was not as readily available as it should be, but we are now working and the PPA are working very hard to try and ensure that more people are more aware that they may well be able to have exemption, and, indeed, we know that DWP have done a lot of work around the benefits, many of which are passported to free prescriptions and healthcare costs so that people are aware that they can claim those.

Q98 Mr Campbell: How do you monitor the primary care groups regarding information?

Dr Harvey: I am sorry.

Q99 Mr Campbell: How do you monitor the primary care groups that have to give this information out? I was sat on the select committee for the ombudsman for many years, and in the hospitals there was never a leaflet about how you can complain to the ombudsman. There was a leaflet about how you complain to the hospital, but never the ombudsman. He was always left out of the loop. I have a funny feeling that sometimes the primary care leaves lot of information out of the loop.

Dr Harvey: Certainly, through the PPA, they actually do send information to all GPs' surgeries whether or not they are a member of the waiting room scheme, but the PPA do have regular discussions with their board and, indeed, with us looking at the effectiveness of what they are doing terms of getting the information about health costs to patients, but they are always striving to make sure that they do it better. We know, for example, with the incapacity benefit, when we increased the NHS list level by half the prescription charge, we did have an additional 44,000 people who went from partial help to full help group. I do not know if Brown-Lee has any additional information.

Mr Brownlee: All I would say is that we are aware that the position certainly was not as it should have been two or three years ago, which is why we took the action we did. We are also aware that one can always do more in this sort of area, frankly, in terms of effort and money spent, and we are in discussion fairly frequently with the PPA on this, although leaving it to them to do it. We are not just saying, "Go away and get on with it." It is a balance of looking at the overall position.

Q100 Mr Campbell: We have got a situation where evidence suggests that the availability of pre-payments, PPCs, are not being taken up. In fact the Breast Cancer Care Report said that less than 40% responded to taking up the PPCs. There has got to be something wrong there when cancer patients, who obviously need the medical treatment, are not taking this up. Again, it comes down, I think, to the information.

Mr Brownlee: Can I respond by saying that the use of PPCs - I have not got figures for particular conditions, but the use of PPCs has clearly increased over the last five years since the PPA has taken responsibility. They have taken measures in terms of writing to people, when the PPC runs out, to remind them, campaigns through various organisations to make sure the existence of PPCs are known, and the use of PPCs is, if you like, going against the trend in terms of the reduced percentage of items that are in fact paid for. The use of them over the last five years has gone up by something like 50% in terms of items, and, whereas the growth of items has gone up by about 30% over the last five years - and I have taken five years purely because that is the time when you are trying to do something about it - the use of PPCs has gone up per item in terms of items spent by about 40%. I am not trying to say there is not more that should be done, but it is going in the right direction.

Dr Harvey: I think certainly the PPA would say that this is why they are continuing to work with patient groups, and if there are ways they can do thing better that is what they will be striving to do.

Q101 Mr Campbell: I think we certainly need to see more take up. Can I go to the Social Exclusion Unit Report 2003 Making the Connections. It recommended that the department develop options to provide information and advice assessing healthcare facilities, including transport issues. Is the department giving any credence to this sort of thing?

Dr Harvey: We understand that this is an issue that is also under consideration at the moment and is one of the issues that has been raised around the consultation.

Q102 Mr Campbell: There are lot of things under consideration here. It was 2003 when that report came out. It is 2006 now. How long are we going to wait for these things to happen?

Dr Harvey: I think this is an issue that has been raised again within the consultation and therefore it is one of the issues that is being considered around the White Paper at the moment.

Mr Campbell: I am afraid we are going to have to consider it in our report as well. Thank you, Chairman.

Q103 Chairman: Could I ask you a general question. The cost of healthcare, I think most people would say, is going to be driven up by technological innovation and by the introduction of new drugs as well. What work has the department done to estimate the likely costs of such developments and assess whether they are affordable without a significant increase or an extension of charges that we have talked about this morning in terms of the prescription charges, et cetera?

Mr Brownlee: Clearly, we do work in terms of forecasting costs, so it does not happen - I mean this is a wider group in terms of our finance colleagues, I think. I do not think that we have been asked to do any specific work in terms of if this happens therefore charges should be at a higher level. What we have said about charges being looked at annually - I do not want to repeat what we said half an hour or so ago - but I do not think we look at the level of the charge in relation to the cost. If the average cost of the medicine was going to go up by X%, therefore charges should go up by a similar percentage.

Q104 Chairman: My own PCT is accepting that in the next financial year, not in this one, it could cost them a million pounds more than they currently pay. Has the department looked at that in any sense of charges?

Dr Harvey: I think in terms of the costs of new innovations as they are coming forward, clearly the department provides the work programme for the National Institute of Health and Clinical Excellence and through that we do look - a horizon scan - at both those new pharmaceutical agents that are in development at the moment and, indeed, those new devices that are likely to come to the NHS in the future, and, indeed, we do look within the funding envelope generally for the NHS at the sorts of impacts of those new technologies: because, as you are very well aware, in terms of quality of patient care, we are trying to ensure that patients have high quality patient care and, in fact, where innovative medicines should be used for their conditions that they are indeed used, and that is why we have those drugs going through the National Institute of Clinical and Health Excellence so that we can have clinical and cost effectiveness advice for the NHS on those drugs. What we have not done is specifically looked across at prescription charges in relation to that, but we do, indeed, look and forecast the sort of impacts that those new innovations would have on the NHS.

Q105 Chairman: Quite clearly, if there is mention of one particular drug or one technological innovation, if there was a family of drugs coming into the NHS that was going to substantially move, let us say, just the drugs bill up inside the NHS because of this new family of cancer drugs and things like that, would you have to look at the issue that currently you get somewhere in the region of, I think you said, £426 million from prescription charges? Would that inevitably mean an increase in there?

Dr Harvey: I think we have very much have looked at it in terms of the overall NHS expenditure, what that means in terms of the drug bill growth, and I think I am right in saying that the drug bill growth is round about 8% per annum, although at the moment it is relatively flat, but we have just got the new agreement on PPRS, the Pharmaceutical Price Regulation Scheme, where, in fact, we have a 7% price reduction, and that is a five-year scheme, so we do, indeed, look at it in terms of growth of the drugs bill and, indeed, the growth of both branded and generic medicines and, indeed, the take up of generic medicines when branded medicines no longer have exclusivity.

Q106 Chairman: There is no direct correlation between the drugs bill and the cost of my prescription then?

Dr Harvey: We have not specifically looked at the prescription charge in relation to that.

Q107 Dr Naysmith: A chance to ask a couple of tidying up questions really for Mr Dyson and Dr Cockcroft relating to things that they mentioned during their evidence. One is that under optical services you said that there has been some apprehension in the profession about how the new system was likely to work in the Health Bill, and you had met some particularly small practitioners - particularly it is small practitioners in my area that I am interested in - and you were able to reassure them that they misunderstood the qualities in the Bill, and presumably they went away quite happy after you had reassured them. Is there any chance of getting something in writing about what you used to reassure them submitted to the Committee?

Mr Dyson: Of course, yes. The Minister has written to a number of stakeholders to make clear that the purpose in introducing the Bill was to do two things, it was to strengthen controls over redemption of optical vouchers and, more relevantly in the context of sight tests, it was to remove some restrictions on the range of providers who can provide a sight test. The Minister has reassured stakeholders that this is not about altering the current system whereby sight tests are paid for.

Q108 Dr Naysmith: It would be nice to see that sort of evidence.

Mr Dyson: I am very happy to provide that.

Q109 Dr Naysmith: Dr Cockcroft, again talking about dental services this time, there seems to be a bit of apprehension around orthodontics, which I am sure you are aware of, and now that it is moving towards the primary care trust who will be responsible for commissioning services, as I understand it, which was not the case before, how do you intend to oversee this and make sure that services do not just disappear? In particular, there is supposed to be some sort of appeal procedure, which has not appeared yet but orthodontic practitioners would like to see soon. I notice this is a very fast moving situation, but I want to raise it today because I know there is quite a lot of concern.

Dr Cockcroft: It is not only orthodontics, even the generalist, this is the first time the PCT has had the responsibility for the whole service. A lot of orthodontic services were provided through general dental practitioners or specialists working in primary care before the system came in. It has been a huge area of uncertainty for orthodontists, and part of my job since I have become Acting Chief Dental Officer is to go out and meet lots of people, and I am doing that. It has been a specific issue for orthodontists for a couple of reasons. One is because they have to work under PDS agreements if they are only doing orthodontics.

Q110 Dr Naysmith: It is the long-term nature of the contract as well.

Dr Cockcroft: Yes, whereas the generalist contract is open-ended. If they are only providing specialist services, it has to be under a PDS agreement, which is necessarily time limited. The legislation does not contain any specific time limit, but in the guidance we have provided to PCTs we have said quite clearly that the starting point for an orthodontic contract will be a five-year contract, and we have been working very closely with the British Orthodontic Society, who seem very reassured by that.

Q111 Dr Naysmith: As I understand it, there are some problems to do with appeal procedures about providing future income.

Dr Cockcroft: I was not aware of that. We have it very clearly in the primary legislation - and they are all entitled to a contract if they have a contract now - that, if they are unhappy with the terms of that contract, they have a right of appeal to the Litigation Authority, and that is binding on the PCT, although it is not necessarily binding on the clinician. We would hope it would not get to that situation in most cases, but obviously there is a protection for specific people there; but part of the process recently has been a much clearer process of giving information, a real programme of concentrated information provision to practitioners, and I think there is less degree of uncertainty and misinformation - like Mrs Atkins was talking earlier on about the child list thing - than there was relatively recently.

Q112 Chairman: First of all, a short apology. We have run on a few minutes longer than we originally said we would do on this. Thank you all very much indeed for coming along and giving us this information. I am sure it is going to be enormously useful for us in terms of the rest of the inquiry and other witnesses as well, including your ministers, I suspect. Thank you very much indeed for your evidence.

Witness: Mr Andrew Haldenby, Director, Reform, gave evidence.

Q113 Chairman: Could I welcome you along, and thank you very much indeed. You are sat alone. I am afraid the witness that we were getting from the Socialist Health Association, we were told earlier, is on a train with a fire on it coming from Manchester. It seems to me that, unless it is a steam train, he has got rather a difficult problem. In those circumstances, I am afraid, you are on your own. I hope this is not too much of a disjointed session, because we wanted to strike a dialogue up with yourselves as well as ourselves. Perhaps I could open up by saying: what are your views on the extension or reduction of health charges and what would be the effect of greater charges on equity of access to healthcare?

Mr Haldenby: Thank you, Chairman. I would like to frame my remarks in the context of the overall funding position of the service, and in that respect I wonder if these remarks follow on slightly from some of your recent sessions on expenditure. If I may, because I would like to offer a more positive view about the role of charges, the tone of the session this morning was very much that charges are a necessary evil, if you like, but there is a more positive view, which is that in a world of very great funding restraints, which I think the service is about to enter, additional monies, obviously organised in an equitable way, will perhaps enable the service to develop new areas of treatment and new innovations which it might not be able to do otherwise given the funding constraints. I might even go a little further to say that there are perhaps existing areas of service, existing areas of treatment, which, however much there may seem to be a guarantee for those services, and here I can talk a bit more, but two examples I could raise would be audiology and stroke rehabilitation, actually the service does not really provide on any kind of level, so perhaps the introduction of charges in those areas might be a way of developing a service which the NHS does not currently provide. I would perhaps just flesh that out slightly. I do not know if you are aware of the report that Professor Bosanquet and other wrote for us recently which looked at the costs pressures, particularly in the years after 2008 when, as we know, the very rapid spending increases of the last eight years are going to come to an end, and we measured the funding increase between 2006 and 2010, given the fall in funding of about £11.5 billion, and we looked at the cost commitments for that time based heavily on the increases in costs in recent years - PFI schemes, extra staffing, prescribing, did the GMS contracts, new pharmacy contracts, new IT schemes particularly, a number of things which certainly I will be able to tell you I have seen in the report and also new activity to meet the 18-week target and so on - and the total cost of those additional commitments amount to over £18 billion, so by 2010 there is a clear deficit approaching £7 billion. In the responses to that report that we have had there has been a certain amount of discussion about the overall numbers, but the picture has been accepted, and this will be a period of extreme financial pressure for the service. As I say, that said, if we are looking to develop new areas of service and perhaps to look at areas of service which are currently not being provided effectively, it is not realistic to say we should expect more resources from the tax-payer, because that is really the opposite of the situation in which the NHS finds itself. To take on the second point of your question, Chairman, about equity, I think it is essential that services must be equitably provided, and that is an essential part of the NHS and should remain so, and so I would say that it should remain the case that any system of charges should have a series of exemptions for those who are unable to pay. As Dr Harvey said, the principle should be that those who can afford to pay should do so and those who cannot should not, and that seems to me to be an appropriate principle for charges.

Q114 Chairman: I think you were sat in on the last session and so you will have heard, not our assumption but assumptions of written evidence that have been sent to us that effectively suggest that the greater the degree of private finance and private payments within our system the higher the levels of inequality. What does Reform say about that?

Mr Haldenby: Let us be specific about it. The example of optical care, for example, or, indeed, prescription charges, there are clear exemptions for people who are on low incomes. The evidence this morning demonstrated that it is a very complex system of exemptions and perhaps a slightly illogical one and perhaps one which could be amended in various different ways, but, nevertheless, it does exist and so it does protect those vulnerable groups. Perhaps I can focus on one of the specific areas of care that I mentioned for audiology. Here I am referring to a report by the British Society of Hearing Aid Audiologists from September last year. Perhaps if I could suggest that we have in mind the positive development of optical services that we have seen in a recent years since deregulation - big increase in capacity, instant treatment and so on and then audiology - this report points out that the average waiting time for an NHS patient to have a hearing-aid fitted from beginning to end of treatment is rising steeply. It rose by seven weeks over the last year and it now stands at 47 weeks, so this is an area of the service which is barely provided, and yet in some parts of the country they highlight, for example City Hospital in Birmingham, which has, as I say, the distinction of having the longest waiting time in the UK, patients there can expect to wait three years for their hearing aid to be fitted, so this is an extraordinary difference in performance. If one was to suggest, as I might, that this area of treatment might be an area where charges might be introduced, what can we expect to see on the basis of the optical model? You would expect to see that people on low incomes would move from a position - this is particularly elderly people - of having to wait up to a year and rising for their hearing-aids to a position where, once the new capacity had come in they would be seen extremely quickly. That would seem to be a great again in equity and also making sense, making a reality of the comprehensiveness of the NHS system. If I can just quote, to emphasise the point, Malcolm Bruce, speaking at the British Society conference last autumn, said he failed to understand why, when he had a problem with eyesight, he could walk into his High Street optician and get a pair of spectacles but to be fixed up with a hearing aid he has to see his GP, be referred to a hospital and has to wait for years. It would seem to me that perhaps there will be an example of a service where the introduction of charges with appropriate exemptions would dramatically benefit patients, including those on low incomes.

Q115 Dr Stoate: I have been doing a lot of work on hearing aids recently. There is already deregulation. Anybody can ring up Siemens, go and get themselves a hearing test and pay £2,000 for a Siemens top of the range system, no problem at all. We have already got that. The fact of the matter is that hearing aids are fantastically expensive in the private sector. They cost literally thousands, and certainly many hundreds. The NHS can provide the same hearing-aid behind the ear for £300 or less - in fact if you bulk purchase you can get them for £150. I do not see what sort of level of charges you are proposing to introduce that could possibly make any meaningful difference to that, because you will probably have to introduce very significant NHS charges to provide the increased capacity in the high street availability that you are proposing to level them up with opticians. I do not see how you could possibly get there?

Mr Haldenby: All I would say is that, in the context of the current funding difficulty, what we are suggesting on the basis of the status quo is that only people who can afford to pay £2,000 will be able to have a modern hearing-aid with any reasonable length of time for treatment. Another approach may be, and I agree one would have to look at the numbers of it, of course, to take the money that the NHS spends at the moment on care, which I can quite confidently say is not being spent very effectively, and use it to subsidise patients on low incomes. That would be my response.

Q116 Dr Naysmith: I was going to ask this a little bit later on, but since Howard has started off on it, at what point would you draw the line around services for which core payments would be required? I think in your evidence you talked about, "There are many services at different levels of intensity which are subject to individual choice. Although core services will be tax-funded, there will be many supplementary services at different levels, but there will be an element of co-payment." How do you define core services? I know you have perhaps done it already, but if this is what we focus in on how do you decide which are the core services?

Mr Haldenby: It has been discussed a little bit already in the example of dental care. There was a distinction made between "clinically necessarily" and, as it were, "desirable". This is a matter for long discussion, but it would seem to me that for services which are clearly medically definable and clinically necessary, they will always remain, as it were, part of the core NHS tax-funded and so, there is no doubt about it, we are talking about the great majority of healthcare, but for services on the margin of that, and obviously dental care and optical care would be examples of that, another example might be infertility treatment, where there is already - I think it varies by the area - but a well developed system of co-payment.

Q117 Dr Naysmith: That is when "clinically necessary" comes in. Who decides what is clinically necessary in infertility treatment?

Mr Haldenby: I think at the moment those decisions are being taken, for example, on the question of infertility, on a local level, on a PCT level. Perhaps, if they continue to be taken in that way, we would continue to see something of a patchwork provision and perhaps a variety of different charges emerging, as we have already seen. The example of infertility perhaps is something for NICE to consider going forward of what should be core and supplementary.

Q118 Dr Naysmith: You would have to set up something like NICE to do it.

Mr Haldenby: I suppose the point I am trying to make is that in practice some of these decisions are being taken, so maybe you need to systemise that.

Q119 Anne Milton: To come in on the topic of clinical necessity, if you could define that there would probably be a great deal of money in selling it, because it is almost impossible to do, and a lot of the things that I think we as members of this House are facing at the moment is being caught between PCTs who have got huge financial problems and clinicians who say, "This is necessary", and PCTs say, "It is not." The difficulty is when you have got two clinicians who disagree over the clinical necessity, because what we are talking about a lot of the time, and what Dr Stoate was talking about, is suffering. If you do not get a decent hearing-aid, if you do not have two grand to pay on a decent hearing-aid, you end up with the NHS £300 one. You can hear a bit, but you suffer slightly because your hearing, in many instances, is not as good. What we are measuring is not clinical necessity or clinical unnecessity, it is about suffering, and that is a slope, and it is at what point you cut that line.

Mr Haldenby: I agree with you. As I say, I think these are discussions that are being played out around the country. I have not got a hard and fast answer, I am sure you agree. All I am saying is that it was clear from discussions that basically there are, we would all understand, a range of treatments between what is obviously core necessity and what could be described as supplementary, and some things are on the margin of that, and those would be the areas for discussion. To talk from a slightly different perspective, as it were, there are some services at the moment which, I suppose, we would say would be clinically necessary, which, as I pointed out, are not being provided, and another area which I said I would cover would be stroke rehabilitation. The National Audit Office produced a report in November of last year which pointed out that rehabilitation for stroke patients is exceptionally important if they are going to enjoy an improved quality of life after that stroke. However, it is an example, again, of extremely poor and patchy provision. They pointed to data only from South London, but they thought it was representative that only a quarter of patients receive physical and occupational therapy, only a seventh of patients receive speech and language therapy in the year after their discharge. Whether this is clinically necessary or supplementary, it is not happening, no matter how much we may want it to.

Q120 Dr Naysmith: The interesting thing about that report is that it also pointed out that basic core services for stroke were very fragmentary and pretty awful in some parts of the country. Maybe if you could get the core services better then there would be more people requiring long-term rehabilitation.

Mr Haldenby: Perhaps that is the case. My grandmother has just had a stroke and has just failed to have any physiotherapy up in Aberdeen, and so I am conscious of this. All I would suggest is that if there was an opportunity to pay something towards the cost of private physiotherapy for those patients who need it, with exemptions for those who cannot afford it, it would enable the service to offer better treatment, I would suggest.

Q121 Chairman: Coming back to infertility treatment, IVF in particular. I have had a personal interest in this as a politician over the past number of years now. It seems to me that even the Government announced two years ago about the IVF treatment that would be brought forward in England particularly, England and Wales, upon the National Health Service, because prior to that people who had actually paid wholly for IVF treatment themselves were then discriminated against inside the NHS because they had paid for it and, therefore, they could not have one of the few interventions on the National Health Service. Would not looking at that service about part-payment get us into all sorts of terrible problems? How would you envisage the cost of an IVF treatment having £2,000 being part-paid for?

Mr Haldenby: I quote infertility as an example, I think, of where this is already happening. In Lambeth PCT, for example, where I live, the PCT will pay for, I think it is, one full course of treatment and it will also pay for two courses of drugs for people who want to pay privately. Not many couples who have IVF will just want to do it once, unless it happens the first time, it is two or three or four times, so we are already in a position where the Government, the NHS will cover what in truth is part of the treatment but not the whole course of treatment, and this is already moving towards a part payment model where people who want to go private pay for the treatment and not the drugs. Clearly that does raise questions of equity, because some people are able to afford to pay for those extra courses of treatment, but again I come back to the core point, and here perhaps I would disagree with my absent opponent, as it were. Perhaps he might say all efforts should be made to take out the charges, all efforts should be made to have the NHS fund all those courses of treatment. All I would say is that I do not think that is a credible way forward given the funding position.

Q122 Chairman: We accept that. For IVF NICE recommended there should be three interventions. There is only one, and that does not happen on some occasions because of the criteria that is laid out by the commissioning body, the Primary Care Trust, anyway. When you say that people pay for it anyway, they pay for it out of the frustration of not being able to get it on the National Health Service. Few people would go and borrow £2,000 from the bank to pay for an IVF intervention if they were not totally frustrated by the lack of ability to have it on the NHS, even when it is recommended now for the last couple of years. There are issues there that are far wider than you can improve that particular service by a bit of co-payment, are there not? There are issues that have to be addressed, major funding issues, under the circumstances of what is recommended as opposed to what is currently afforded by the NHS.

Mr Haldenby: Of course, I accept that, and of course, as I think you yourself would recognise, no matter what the recommendation has been, and I am sure there are equivalent recommendations in the area of audiology and stroke rehabilitation as well, they have not been delivered and people may be acting out of frustration or they may have little alternative. There may be a way to move towards a different way of funding IVF treatment which again uses tax-payers funding a different way. Instead of funding a rather thin service, to focus more funding on people on low incomes. That would be an alternative way of doing it.

Q123 Chairman: I do not want to get party political at all, but the last election was fought when one of the major parties had a point that the National Health Service would pay for half of the cost of the private sector. Does Reform go down that road? Do you think that is a feasible way of approaching healthcare needs?

Mr Haldenby: We thought that the patients passport was a bad policy because, apart from anything else, for one thing it is an opt out which would only benefit some members of society, which I think was the political point that was made, but also, without increases in supply, all that would happen would be that they would increase the demand for treatment and that would either increase waiting lists or drive up the costs; so it was a badly framed policy. Perhaps there is another trend of policy which enables us to discuss these matters perhaps a little bit more positively and openly, and that is, I would say, the change from a monopoly, uniform NHS towards an NHS full of much greater diversity. This is an argument rather than a fact, I suppose, but it seems to me that it made more sense to have an entirely tax-funded system in a smaller, more uniform, rationed service of the kind that we were used to what is now one or two decades ago in 2008 when it will be a much more diverse system with new kinds of providers, some of them private, profit making, and it is accepted policy for all the parties now for there to be that variety of provision. In that world it would seem to me only to be expected that many of those providers will be charging or offering the opportunity to charge for their services and it may become a more common part of the health experience. I think the Tory policy was wrong, but the general trend of policy, I think, does perhaps lead us particularly to this discussion.

Q124 Chairman: We have this debate now about patient choice and, looking at it not exactly from the outside, it seems to extend just beyond the National Health Service in terms of the use of the independent sector. Do you foresee that co-payment would be one of the issues about patient choice and that you could choose an area with a co-payment that might be more efficient or might be better for your needs, as it were, than one of the other areas?

Mr Haldenby: Kingston Hospital, which I was looking at over the last couple of days, has a private unit where it provides private physiotherapy. Physiotherapy would seem to me to be one of those services that could be provided at different levels of intensity and comfort, and so on, and so might have an element of co-payment.

Q125 Chairman: An element of co-payment with protection for opting out?

Mr Haldenby: Absolutely. This is slightly more speculative. I think the policy statement is simply that the position is that from 2008 anyone who can provide up to the tariff - I do not need to tell you - will be able to be chosen, but in a world of new providers, and I particularly need to emphasise the fact that they are new and they are coming along and offering new treatment, that would seem to rather inevitably pose the question of whether patients may want to pay a bit extra to access some of those services.

Q126 Dr Naysmith: Do you accept that the proposals will mean more investment in the private sector?

Mr Haldenby: In the private sector, yes.

Q127 Dr Naysmith: Developing more private sector----

Mr Haldenby: Yes, as we have seen in the opposite core sector.

Q128 Dr Naysmith: You would the expect that to happen?

Mr Haldenby: In a way, I think it is almost the point of it really.

Q129 Dr Naysmith: Would it not be more likely that that will occur in more affluent communities where people are more likely to be able to afford additional payments, and that is the exact opposite really of what we need in the National Health Service, which is investment in other areas where facilities are not very good?

Mr Haldenby: All I would say is that this will remain at the margins of NHS activity. As I tried to say at the beginning, this offers a very positive possible addition to NHS care, but the great majority of NHS care is going to be funded from taxation and, so I think decisions over the problems of equity, which others have identified, will remain really a question for that tax-funded part of the NHS, but then, I think, it comes back to the question of exemptions. We have already heard that there are very wide exemptions, and so if those exemptions are concentrated in deprived areas, those are resources that are moving into those areas, so I do not think it is quite as black and white as is suggested.

Q130 Dr Naysmith: Possibly it will end up with all sorts of anomalies, such as the ones we were talking about earlier today for prescription charges. For instances, talking about physiotherapy, if you start providing lots of private sector physiotherapy - I happen to think that much more widely available physiotherapy available on the National Health Service would save the National Health Service a huge amount of money, because there have been a number of studies which have shown that if you take people off orthopaedics waiting lists and give them a bit of free physiotherapy, then they come off the surgical waiting list without the surgery, but if you are going to spread out lots more physiotherapy units where people go and pay I suppose you will argue they will never get on the orthopaedic waiting list in the first place, but does seem like an argument for the National Health Service to do a bit more investment in physiotherapy.

Mr Haldenby: All I am trying to do is perhaps to try and be practical and to recognise that, certainly to take the two examples that I have mentioned, however much one would wish the additional investment to be there to improve those services, the recent years of kind of maximum spending increases, and I do not think we can expect any more ever, not ever, but for the foreseeable future on the scale, have not solved these problems and, as I said at the beginning, I am not sure, however much we might want to, we can realistically expect too much more funding, and so that might be a reason to look at a different route.

Q131 Dr Stoate: You have given examples of audiology and physiotherapy being possibles for co-payment, but in order to make a meaningful difference to the level of service provided by these two things, we would have to have far more audiologists, far more physiotherapists. I am not against that, but the level of co-payment needed to generate that extra capacity would be enormous. We would not be talking about six pounds something for a prescription, we would be talking about hundreds if not thousands of pounds more in order to stimulate enough of a growth in these difficult areas. I cannot see anybody but the richest even vaguely being able to pay for it, and even the Conservative Party's passport scheme with 50% being paid by the NHS, we are still talking about the majority of people being priced completely out of private physio or private audiology. I cannot see how co-payment would ever even begin to dent the scale of the problem.

Mr Haldenby: I think one would need to look at the extent of the funding that has already been committed to those services.

Q132 Dr Stoate: The answer is, not much, and that is the reason why we have got such shortages. To make a meaningful change to physiotherapy and a meaningful change to audiology would mean very large spending and significant investment indeed, which would have to come from somewhere, and I simply cannot see how co-payments for the rather better off in society could even begin to scratch the surface of those areas.

Mr Haldenby: Perhaps then we are not talking about co-payment for the most expensive services, we are talking about co-payment for a certain level of service which is affordable but which cannot be provided on a certain level. I am not in any way suggesting that in an ideological sort of way - everybody must be expected to pay for the most expensive services - not at all. All I am trying to do is to suggest that in this period of extreme high pressure, however much we may regret the reality of services and the unlikeliness of extra funding, that is the reality. I am sure there will remain services at the top end of the cost which almost nobody will be able to afford, but perhaps there may be something we can do at the affordable end.

Q133 Dr Stoate: The point is that things like audiology and physiotherapy are not expensive high end services. They are actually very basic and cheap services. The fact of the matter is that people in this country, I do not think, have not got a real grasp of just how much even basic NHS services cost. I do not think many people in this country realise what a day in hospital costs - we are not talking about a few quid - and even though physiotherapy and audiology are basic relatively low cost services, they are not high tech in any way, nevertheless, the true cost of those services is very high. I do not want to go on. I want to look at something slightly more philosophical from the argument that you have been putting forward, and that is that currently co-payments have been used either to prevent frivolous use of services or, for pure economics, to try and put a lid on expenditure or simply to generate some income through the NHS. I want to move beyond that and I want to ask you should charges be used as a deliberate instrument of health policy, and if so how?

Mr Haldenby: I think I would agree with the muddle to compromise that we heard about this morning. We are where we are, and although other people will put forward the theory of charges, I suppose what I am trying to put forward as we sit here today is why we are having his discussion - because of the financial position - and what might be the benefits, and I do not think we are wrong to discuss this. If I might quote one or two, but not take very long, the Social Market Foundation did a report on charges 18 months ago, and they said, no introduction, "Ultimately the case for reform of the existing charging system might seem weak in an era when the NHS is enjoying unprecedented levels of increased funding. However, we can expect the arguments for reforming that we present here to take on greater savings when this increased funding levels off, as at some point it inevitably will." It is not a philosophical, it is just it is a very practical point. Then Patricia Hewitt, the Secretary of State for Health, in 1996 was the Deputy Chairman of a health commission which concluded, "We are committed to general taxation being maintained as a political source of funding health services. However, we believe it is not possible to expect the continuing gap between resources and demand to be closed through increased tax-funding alone." This is a debate which we have had before and which, it seems to me, recurs at times of real pressure. So rather than a philosophical nature, I think it is a more timely reason for it

Q134 Dr Taylor: I want to go on really exploring this, but, starting from what we heard in the first session that it is only 13% of items that are actually charged, even though that raises 427 million, with all the anomalies that we have heard about, to me the only answer to that is to abolish those charges altogether. That leaves us with an even bigger gap. If you had a blank piece of paper, you have told us we could raise a little bit with direct payments for audiology and stroke rehab, what else could we charge people for within the NHS, people who have got the money? What else could we charge them for?

Mr Haldenby: I am going to stick to the examples. When I was preparing my evidence, rather than present an absolutely exhaustive list, because I think this will always be part of negotiation and can always be determined really by levels of funding almost year by year, I thought I would present those examples, particularly in areas of service, which, however much they appear to be guarantees to provide at the moment, are not properly provided and that also refers to the previous remarks about the difference between core and supplementary services.

Q135 Dr Taylor: Would you not be prepared to theorise a little bit? There are so many other things that perhaps could be charged for: hotel charges always come up, insurance for sports injuries, the SMF in their thing thought that prescription charges should be linked to the therapeutic value of the medicine?

Mr Haldenby: Since you mention Social Market Foundation, one of the ideas they proposed was charges for out of hours, what they call "convenient GPs appointments" as an example of an area of service which is not currently being provided effectively but which some professionals may wish to pay to visit the a GP on a Sunday afternoon, which is more convenient for them. I do not think I am prepared to theorise on some of the detail, but I might just confine myself to my previous remarks.

Q136 Dr Taylor: I would like to come out of this inquiry with some ideas for other ways because the deficits are so enormous?

Mr Haldenby: Chairman, perhaps I could say we will give it more thought and submit written work.

Q137 Chairman: We would more than appreciate that. Already the debate has started, although we should be asking questions and taking answers, but I think that the areas that you have brought up are quite right. I have to say that I buy private acupuncture for my problems at work dealt with many years ago the National Health Service not to my satisfaction. I do not have a problem with that, but I have the requisite income as well and the time and availability to be able to go and have treatment as and when I feel fit. These areas are not closed off, I do not think, at all, and may be coming out of this report when we have ideas. Can I thank you for giving us this evidence session, particularly because, certainly as far as you are concerned, with no other witnesses there is absolutely no respite whatsoever, whereas at least we can sit back and gather our thoughts before we ask the next question. Thank you very much indeed - I found that very enjoyable - and we would appreciate any further written submissions you could give us. Thank you very much.

Mr Haldenby: Thank you.