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Wednesday, July 19, 2006

Health Select Committee finds the system of health charging is a mess

The House of Commons Health Select Committee in it's report on health charges finds that the system of health charges in England is a mess. Charges for prescriptions and dentistry have been in place for over 50 years and sight tests for almost 20 years. They have not been introduced following detailed analysis of their likely consequences; rather they have come about piecemeal, often in response to the need to raise money. There are no comprehensible underlying principles. The charges remain largely for ‘historical’ reasons.

In recent years, hospital patients and their visitors have also had to pay increasing sums for non-clinical services, such as car parking and bedside telecommunications. International research has shown that health charges have a negative effect on health, and that patients with long-term illnesses suffer particularly when charges are in place. There is also some survey-based and anecdotal evidence which suggests that patients are less likely to visit their dentist or have prescriptions dispensed in full because of the costs.

There are exemptions, which aim to mitigate the negative effects of charges on health. Patients are exempt from paying for prescriptions, dental services and sight tests on the basis of age, income and where they are treated.

In addition, patients with specific conditions are exempt from the prescription charge (eg. if they have insulin-controlled diabetes) or sight test fee (eg. if they have glaucoma); pregnant women and those who have recently given birth also receive free dentistry and medicines. Financial assistance towards the cost of charges, and vouchers for spectacles, are available to specified groups.

The system of exemptions is full of anomalies. Age and income exempt some people, but this does not apply across the board. Pensioners are exempt from prescription and sight test charges, regardless of their income, but must pay for dentistry unless they receive help through the NHS Low Income Scheme (LIS). Those in receipt of certain benefits are automatically exempt, others must apply for financial assistance or exemption through the LIS.

The system of medical exemptions to the prescription charge is particularly confusing. People with diabetes who require insulin receive free medicines for all conditions while people with diabetes controlled by diet must pay for all their medication. The list of exemptions was compiled in 1968 and has not changed. Given the vast improvements in medical science since that time, this is unacceptable. People with cystic fibrosis who would have died of their illness during childhood in the 1960s now reach adulthood. Diseases such as HIV/AIDS did not exist in 1968. The original list could not have taken these conditions into account.

The current system of charges must change. However, even after over 50 years of operation, there is a woeful absence of evidence about the effects of charges in this country. It is known that harmful effects occur but they are largely unquantified. The English evidence is limited and one of our key recommendations is that more research on the effects of charges be carried out here.

We need to know the extent to which charges deter patients from seeking medical, dental or ophthalmologic help when they need it and how this affects their health status. Similarly, we do not know what the consequences would be of making large-scale changes to the charging system. It is therefore difficult at this stage to decide what should be done. Accordingly, we recommend that evidence is gathered on:
• public attitudes to health charges;
• the extent to which charges affect the use of health services and, in the long term, health;
• the extent to which charges reduce ‘frivolous’ demand.
There are a number of short-term changes that should be implemented immediately to improve the situation.

Take up of the Prescription Pre-payment Certificate (PPC) is low. We recommend that a monthly PPC be introduced to help those on low incomes who cannot, or prefer not to, buy a yearly PPC. The cost of the yearly PPC should be pegged at 12 times the cost of a single prescription. The cost of a monthly PPC should be pegged at the cost of one prescription. There should also be a reduced price PPC for those receiving help through the Low Income Scheme.

The dental contract, which includes a new, banded system of charges, was introduced in April 2006; it is therefore too early to know how patient care will be affected. Criticisms of the contract include the lack of consideration given to preventative care and the risk that fewer NHS patients will be treated. We therefore recommend a review to report the effects of the new contract on patient access and care, including prevention, and on NHS dentist numbers, recruitment, salaries and workload.

It is unclear whether the sight test fee deters patients from visiting their optician. Sight test numbers, and consequent referrals to hospital for specialist treatment, certainly fell after the free sight test was abolished. However, the Department reported that numbers of over 60s seeking sight tests did not rise significantly after the charge was removed once more for this group. Many opticians practices do not sell spectacles within the value of vouchers provided by the NHS to those eligible for help.

We recommend that all practices carry stock within the value of these vouchers. It is also clear that many of those at risk of eye disease are not being targeted effectively. We recommend that greater efforts be made to improve attendance among these groups, and that sight tests for all children be reintroduced.

The setting of treatments has changed significantly in recent years. Patients who would previously have stayed in hospital now often receive treatment on an outpatient basis. This has led to problems with the cost of attending hospital. While car parking charges must remain a matter for hospital trusts, we recommend that they provide reduced rates for patients and their visitors who attend hospital regularly and free parking for those who must attend on a daily basis.

Those unable to visit friends and family in hospital now usually have the possibility of telephoning loved ones’ bedside telephones. Unfortunately, they have often paid a high price to do so. We recommend that this problem be addressed immediately.

The minor recommendations detailed above will lead to small improvements for patients, but will not address the fundamental problems in the current system of health charges. We heard several other options for major improvements to the system of charges. Inevitably they each have positive and negative consequences and the evidence is not sufficient to reach a conclusion as to which of these options would be best. Little work has been done in this country on the costs or benefits of the different possible systems.

This work needs to be done urgently so that an alternative charging system, with consistent underlying principles, can be developed. The Government should undertake a major review to assess the costs and benefits of the following:
• abolishing all the existing health charges;
• abolishing only the prescription charge;
• abolishing only charges for initial consultation and diagnosis, such as dental check-ups and eye tests;
• establishing a system of reference pricing for medicines;
• completely revising the medical exemptions to the prescription charge;
• introducing a flat-rate prescription charge with no exemptions; and
• basing exemption to charges solely on income so that those who can afford to pay for their prescriptions, dental care and sight tests do so.

The review should also consider a system of charges appropriate for future challenges. In the future, the NHS may not be able to pay for every possible medical treatment in a country with an ageing population, demographic pressures, rising public expectations and increased possibilities of medical treatment and long-term therapies.

Some treatments or procedures may have to be charged for. The Government should consider this possibility sooner rather than later to ensure that a set of consistent criteria apply to those areas for which a fee is charged, to avoid the development of charges in an ad hoc way, as has been the case until now.

With the introduction of such a system, it may be possible to abolish health charges which currently have a negative effect on health outcomes. The key principles that should be considered in this review are:
• services that are clinically necessary should be free;
• fees should not deter patients visiting their doctor or accessing healthcare; and
• any system chosen should be adaptable (to changing medical practice, treatments etc)
and consistent.

The review should include:
• the possibility of establishing a package of core services which would be free (these might include prescriptions and dental care); and
• a set of treatments for which the NHS could charge.

Treatments/interventions that are not cost-effective, such as branded drugs where an effective generic exists, could be subject to a charge. The use of charges to promote more responsible use of services could also be considered, including:
• the introduction of a small charge for non-emergency patients presenting to A&E.
This would encourage people to register with a GP, and make better use of out-of hours services; and
• a fee for patients who do not attend or fail to cancel GP or hospital appointments.


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