Memorandum submitted by Which? (CP 17)
RE: CO-PAYMENTS AND CHARGES IN THE NHS
SUMMARY
NHS patient charges can act as a barrier to
people getting the care or treatment they need, when they need
it. They can also cause people to defer treatment which can result
in higher long-term costs to the NHS.
The burden of charges often falls heaviest on
those who have the poorest health despite significant numbers
of people being exempt from paying charges. Low income exemptions
are confusing and many people do not know whether they are exempt
from charges or not.
The proposed new system of NHS dental charges
will bring greater simplicity and transparency, but it will not
overcome all the problems associated with the current charge system.
Proposed charges for bands 2 and 3 are still too high. We also
suggest that the oral health assessment should be free of charge.
The growth in charges for hotel facilities and
non-clinical services, including parking, is worrying. While the
costs of providing such services should not be met from NHS funds,
they should not be used as a source of income generation.
Travel costs, including parking charges, will
be increasingly important with changes in the way healthcare is
provided in the NHS. We suggest various reforms to ensure these
do not act as a barrier to people seeking or receiving treatment.
A fundamental review of exemptions should be
undertaken to ensure greater consistency and fairness, and to
eradicate the historical anomalies between different types of
NHS charges and the groups of patients that are exempt from charges.
This should be based primarily on clinical considerations, and
ensure that no-one is precluded from treatment because of low-income.
Abolition of all patient charges will require
either significant additional investment or take money from other
areas of NHS care. In the cash-limited NHS, it is questionable
whether this is the best use of money. A thorough cost-benefit
analysis is needed to assess whether the costs of removing NHS
dental and prescription charges will be off-set by healthcare
gains for individual patients and across the NHS as well as savings
of administration costs. This should include assessments from
the patient's perspective as well as strict economic or clinical
considerations.
Other approaches may help overcome some of the
problems caused by charges. For example, adopting a maximum charge
payable in any one 12-month period at a level no greater than
the current pre-payment certificate. In order to aid budgeting,
it should be possible for people to make these payments on a monthly
as well as quarterly or annual basis.
INTRODUCTION
1. Which?, formerly known as Consumers'
Association, is an independent, not-for-profit consumer organisation
with around 700,000 members. Based in the UK, it is the largest
consumer organisation in Europe. Entirely independent of government
and industry, we are funded through the sale of our Which? range
of consumer magazines and books, and Drug and Therapeutics
Bulletin—our publication for healthcare professionals.
2. We campaign on a wide range of issues
of importance to consumers, one of which is health. Our health
campaign aims to ensure all consumers have access to safe, high-quality
and patient-focused healthcare whenever and wherever they need
it, together with the necessary information and support to be
able to make informed decisions about their healthcare. This aim
is supported through consumer and health policy research.
3. In compiling this memorandum, we have
drawn particularly on our work on dentistry. Which? was a member
of the Department of Health working group on NHS dentistry patient
charges.
Are charges for treatments, including prescriptions,
dentistry and optical services, and charges for hospital services
equitable and appropriate?
4. It is undeniable that charges for NHS
treatments act as a deterrent or prevent some people getting treatment
when they needed it. This is despite significant groups of people
who are exempt from paying charges. Evidence from the Commonwealth
Fund comparative study of five countries (including the UK)[87]
indicates that 4% of people failed to fill a prescription or skipped
a dose because of cost, rising to 6% for those with below average
incomes. While these figures are much lower than for other countries
in the study (probably as a result of exemptions), they still
represent a worrying number of people who are unable to take required
medication because of its cost. For dentistry, the figures are
even more concerning. Twenty-one per cent of people had not seen
a dentist even though they needed dental care because of cost,
rising to 24% for people with below-average income.
5. This research confirms findings from
NACAB (now known as Citizen's Advice) in its 2001 study of NHS
charges, which found prescription, dental and optical charges
all acted as barriers to people getting treatment.[88]
6. Delaying treatment or failing to seek
early or preventive treatments can often result in the need for
more extensive and more expensive interventions at a later date.
For example, a person with asthma who chooses only to obtain the
prescription for medicines that bring immediate relief for their
condition, is much more likely to experience crises that require
emergency intervention, and in some cases hospitalisation. Thus,
for the want of £6.50, the individual patient experiences
much poorer long-term management of their condition and the NHS
bears significantly higher costs.
NHS Dental Charges
7. In the case of dentistry, the financial
burden of NHS treatment currently often falls hardest on those
with the greatest needs, especially those with low-incomes, but
who are above the low-income threshold for exemptions. This is
particularly concerning given the close correlation between poor
dental health and socio-economic status. And because people aged
over 60 years are not automatically exempt from dental charges,
many who fall into this group are older people living on limited,
fixed incomes.
8. The current dental charge regime is extremely
complex and grossly opaque, and acts as a real disincentive for
many people to seeking treatment. Additionally, the actual level
of charges that patients pay can be very high (80% of the cost
of treatment up to a maximum of £384 for a course of treatment).
Many people put off going to the dentist by the fears of what
any treatment might cost.
9. Which? research conducted earlier this
year shows that dental charges act as a major barrier to many
consumers receiving care and treatment. Seven per cent of people
who had not visited the dentist in the last year were put off
by the cost of treatment and 58% of people agreed with the statement
that dentistry costs too much even if it's provided by the NHS.[89]
Additionally, many of the stories from consumers left on our website
as part of our dentistry campaign, illustrated the real problems
many people face meeting the costs of NHS dentistry. Our research
and information from consumers paint a picture of people deferring
visiting a dentist until it is unavoidable, often resulting in
a failure to seek the regular preventive care that is essential
to improving oral health.
10. As a member of the DH working group
on NHS dental patient charges, Which? has contributed to the development
of the new system of patient charges that will be introduced in
England from April 2006. We believe this new system of patient
charges is a significant improvement to the current charge regime.
We have particularly welcomed the reduction in the maximum charge
now payable for a course of NHS treatment to just less than half
the current charge (from £384 to £189). Additionally,
the three-band system offers much-needed simplicity and greater
clarity so that patients will know in advance what they have to
pay for their care. It will also be much clearer when people are
receiving private treatment and when it is NHS.
11. Although the new system of NHS patient
dental charges is much improved, it is not ideal. In formulating
the proposals for the new system, the DH working group was required
to work within the strictures of ensuring the new charge regime
generated the same levels of income as is currently raised by
the existing regime (£0.5-0.6 billion pa). This requirement
has determined the levels at which the charges are set. It also
precluded making dental check-ups or the oral health assessment
free as is being done in Scotland and Wales.
12. Which? has argued that the band charges
for levels 2 and 3 are too high, and Band 3 should be set at about
£125-130. In our response to the DH consultation on the new
system of dental patient charges, we also argued that including
repair and replacement of dentures or orthodontic appliances in
Band 3 would cause significant hardship, with many people, including
older people on fixed incomes, paying significantly more under
the new system. While inevitably some people will pay less under
the new system and some more, we are pleased that the Government
has responded to our concerns in its final scheme for patient
dental charges.
Travel costs, and parking and other charges
13. In addition to NHS prescription, dental,
optical and other charges, the costs of travel, including parking
charges, are becoming an increasingly important additional financial
burden for patients that can seriously affect access to care.
Problems are particularly acute for patients who require long
courses of treatment such as physiotherapy, chemotherapy or radiotherapy,
or who have low incomes. These charges are of increasing importance
as more care is provided on an out-patient or day-care basis,
and services are rationalised or centralised on single sites.
Additionally, roll-out of patient choice across the NHS will mean
more people are likely to travel to receive treatment.
14. As with all charges, the burden of these
costs falls heaviest on those who are sickest or who have low-incomes.
In our recent report Which Choice? Health[90],
we highlighted the impact of travel costs on limiting the choices
of people, particularly those on low incomes or living in rural
areas, and the need for assistance with travel costs to ensure
they are not disadvantaged in their choice of treatment options
because of the cost of getting there.
15. Help with travel costs is available
for people on low-incomes but is only provided to attend a hospital
or other facility for NHS treatment under the care of a consultant.
As more treatment is provided outside hospital, many of these
clinics or facilities are not covered by the current scheme, which
can again limit access to treatment for some of the sickest and
most vulnerable people. This has been a particular problem for
people needing dental treatment who have to travel many miles
to receive care because of the difficulties in securing NHS dental
treatment locally. We suggest that the current scheme to provide
financial help with travel to hospital should be extended to cover
types of treatment that are provided in non-hospital settings
and are not under the care of a consultant.
16. The creep of local authority controlled
parking zones and introduction of the congestion charge for Central
London, sometimes means the operation of parking charges is outside
the control of the NHS facility where care is provided. However,
these all add additional elements to the cost of being sick and
getting treatment, and it should be possible to recoup under the
scheme for help with travel to hospital.
17. Where such charges are levied by an
NHS facility, they should not be used as a means of income generation.
However, the cost of maintaining parking facilities should not
take money from a trust's money for service provision.
18. Some hospitals already give exemption
to parking charges for people requiring long-term, essential treatment,
in addition to those who have a blue badge, disabled parking permit.
We suggest that where hospitals charge for parking they should
give priority to people receiving treatment at the hospital and
introduce permits to allow those who need to travel by private
transport, because of their health or clinical needs, to park
for free while they receive treatment or attend appointments.
19. The creeping introduction of charges
for other amenities such as TV and telephone use is a worrying
trend. Again we suggest that such schemes should not be used as
a means of income generation for trusts, however neither should
their provision detract from clinical services. We note that OFCOM
is undertaking an investigation of telephone charges levied by
Patientline, and await the outcome of this.
Exemptions from charges
20. Although for most types of NHS patient
charges there are various exemption categories intended to ensure
that particularly vulnerable groups are not prevented from seeking
or receiving treatment by its cost, current exemptions are rife
with anomalies and inconsistencies. As such, they can be inequitable
and very confusing for patients. For example:
— People aged over 60 are not automatically
exempt from dental charges but are from prescription charges.
— People aged over 60 and some high
risk groups receive free eye tests but not dental check-ups.
— People with diabetes are exempt from
all prescription charges, irrespective of whether they are associated
with managing their condition or not. However, those who suffer
from cystic fibrosis are not; similarly people with asthma or
who need life-long essential medication following an organ transplant
are not.
— Additionally, exemptions on the basis
of low-income are extremely complex and often very difficult for
consumers to understand whether or not they are exempt from charges.
21. The list of those groups that are exempt
from charges has evolved historically but has not kept pace with
recent medical developments or population changes. For example,
until fairly recently few people with cystic fibrosis survived
into adulthood, but now many are paying for prescription medicines
that are vital for life. Similarly, the blanket exemption for
people with diabetes was made at a time when incidence of the
disease was much lower than it currently is, and is forecast to
be in the future. And with the planned increase in the pension
age for women to 65, and the talk of increasing this still further
for both men and women in the future, there is little rationale
for continuance of the current exemption for prescription charges
for people over 60 years.
22. Which? suggests the over-riding basis
for exemption for any charges should be clinical need. Additionally,
no-one should be prevented from receiving treatment because of
low income. We recommend that there should be a systematic and
radical review of the exemption categories to eradicate anomalies
and inequalities and to ensure that charges do not prevent people
with low incomes or significant healthcare needs seeking or accessing
both preventative care and essential treatment.
23. Lessons from the review of dental charges
suggests that this will not be an easy task and removing exemption
status from groups that already have it is likely to be unpopular.
However, the growing numbers of people who likely to be eligible
for free prescriptions suggests that this is likely to become
an increasing burden on the NHS that takes resources from other
much-needed services. More and creative ways of looking at this
issue are needed, particularly if groups of patients who are not
currently exempt from charges, but need life-sustaining medication
are to be given exemption status. For example, should exemption
from charges be limited only to those prescription items that
are needed to manage the condition that grants exemption status?
24. We suggest that there should also be
greater consistency between exemption categories for prescription,
dental and optical charges to facilitate better consumer understanding.
Particular attention should be given to the exemption categories
for dental charges to afford greater consistency with prescription
and optical charges. This should include examining whether there
are certain groups of people who are clinically-disposed to greater
risks of poor dental health.
How should charges be set?
25. Which? suggests that where NHS patient
charges exist they should be based on the following principles:
— Transparency and simplicity.
— Consistency and fairness.
— Affordability, particularly for those
on low incomes and with the greatest clinical needs, such that
charges do not act as a barrier to care.
— Supportive of preventive care.
— Ease of administration.
— Ease of understanding for patients.
Additionally the costs of administering any
low-income exemptions should not be so great as to negate the
value of any charge income levied.
26. We also suggest that any annual increases
in the level of charges should be limited to at most the current
rate of inflation, otherwise the burden for those on fixed incomes
becomes too onerous.
Should charges be abolished?
27. In an ideal world, there would be no
charges within the NHS. However, this is not a realistic option
given the limited pool of funding available for NHS care. Removing
dental, optical and prescription charges would have significant
financial implications for the NHS that would either require significant
additional funding or would take money away from other aspects
of service provision. For example, making all NHS dental care
free would require, under current levels of activity, investment
of a further £0.5-0.6 billion a year. Despite the healthcare
benefits that would no doubt accrue together with significant
savings in an administration costs, it is questionable whether
this would be the best use of limited NHS resources.
28. In relation to prescription charges,
Which? has been neutral on whether they should be abolished, arguing
for the need for a proper cost-benefit analysis of the likely
costs and benefits of such a scheme, both now and in the future,
which takes full account of the patient's perspective as well
as strict economic considerations. While over 80% are already
dispensed without a charge, the costs of making all prescriptions
free would be significant and likely to increase significantly
in the future. The amount spent on medicines in the NHS continues
to increase at a rate greater than inflation each year, and the
number of average number of prescription items dispensed increases
each year—13.7 in 2004 compared with 9.5 in 1994. Of particular
concern is the fact that many of these medicines are never actually
used.
29. There is a real danger that if NHS prescription
charges were abolished, the drug bill might escalate out of control
unless there are some limits on what types of medicine can be
prescribed free. In some European countries, the level of prescription
charges depends on the therapeutic level of the medicine (for
example in Belgium and France) with some drugs requiring as little
as a 15% co-payment while others require a full 100% payment for
any drug that is not on the national list. Alternatively, in Sweden
and Denmark, what patients pay towards the costs of medicines
is determined by their overall annual levels of co-payments, with
a set maximum limit in any 12 month period above which all medicines
are free.
30. If NHS prescription charges are to continue,
we suggest that fixing a maximum annual level of charges that
patients pay would be fairer for all. This way people who are
chronically ill (but are not on the exemption list) or who suffer
a period of ill-health would receive help with their prescriptions.
This annual limit could be set at the level no greater than the
annual season ticket (pre-payment certificate) of £93.20,
and people should be able to purchase this on a monthly basis
as well as quarterly and annually.
31. In relation to dentistry other issues
arise. We suggest there is little rationale why charges exist
for dental care but not for other types of healthcare. For the
consumer, there is very little difference between the pain and
health implications of an ear infection and those of a dental
infection, but for one there is no charge to see the health professional
and for the other there is. While we would not argue that there
should be no NHS dental charges, we do suggest that the current
charge for the oral health assessment (or check up) should be
abolished to encourage more people into preventive care. This
could be particularly important in picking up the early stages
of oral cancer.
32. For the future, it is likely that the
costs of providing universal healthcare under the NHS will continue
to rise. This is likely to lead to increased pressure to introduce
new or increase existing co-payments for NHS services. What will
be important in this context is to ensure that people with equal,
but different clinical, needs are treated fairly and consistently
what ever type of care or treatment they need. It is also vital
that the short-term gains of introducing or increasing co-payment
are not allowed to obscure the longer-term benefits, both for
individuals and the healthcare system as a whole, of ensuring
people receive early and preventive care to deal with their condition
or illness.
Frances Blunden
Which?
7 December 2005
87 Commonwealth International Health Policy Survey
2004 (covering Australia, Canada, New Zealand, United Kingdom
and United States) http://www.cmwf.org/surveys/surveys_show.htm?doc_id=245240. Back
88
National Association of Citizens Advice Bureau Unhealthy Charges
(2001). Back
89
Which? omnibus survey of interviews conducted in-home between
12-16 January 2005 with a nationally representative sample of
1,894 GB adults aged 16+. Back
90
Which Choice? Health (July, 2005). Back
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