Health matters, A&E, GP Costs and Income Support

I see that Gerard Baudains is coming into the JDA fold, or at any rate has his own page on their website.

The latest wheeze is by Deputy Gorst of St Clement - the Social Security minister - who proposed raiding our pension fund to cover inefficiencies and poor management in another department. I thought only Robert Maxwell did things like that. (1)

Now this relates to the

DRAFT HEALTH INSURANCE FUND (MISCELLANEOUS PROVISIONS) (JERSEY) LAW 201-

and at first sight, it seems to be about taking money from social security to pay for health by raiding the social security pension fund.

But matters are not as simple as that. As I understand it, from reading the proposition, and looking at what has been suggested in detail, the pension fund is being kept well away from any transfer of funds.

There are two components to social security - the pension scheme and the health / medical side, which were accounted for separately, with a fixed percentage of the social security money going into the health / medical side. On the health side, the proposition notes that:

The Health Insurance Fund (the "Fund") was established when the Health Insurance (Jersey) Law 1967 (the "Law") came into force on 4th December 1967. The Fund receives a set percentage allocation of all social security contributions collected under the Social Security Law, which is currently 2% (made up of a 0.8% contribution from employees and a 1.2% contribution from employers) of the 12.5% total contributions collected. The Law specifies that the Fund is to use the contributions received to meet primary health care costs, which are currently limited to medical and pharmaceutical benefits. The level of medical benefit is set by the States by Regulation and was increased this May to assist in establishing General Practitioner governance arrangements. Currently the Fund subsidises patients to the tune of £19 for each G.P. visit and also covers the cost of prescriptions dispensed by Community Pharmacists. (2)

The proposition (and debate) makes it quite clear that the Health Fund and the Pension Fund are quite different entities, with quite separate sets of accounts.

The proposition would leave the pension side untouched, but as the health / medical side had actually been running at a surplus for a number of years, and as it was providing healthcare related funding, the decision had been made to use some of that surplus - and not in any way the pension scheme - to take over the health and social services, as it all came under the health care umbrella.

To some extent, the health care part of the fund has changed it scope over the years from when it was set up in 1967:

Since 1967, the scope of primary care has expanded greatly and many different healthcare professions are now involved in first-line medical and healthcare treatment and care. Typically, primary care is provided in a community setting, such as a G.P. surgery or a health centre. In Jersey, some primary care services are delivered from the General Hospital. (2)

So it is not irrational, or in any way a Robert Maxwell style pension raid, to move some of the Health Care Fund monies - and those alone - over to the Hospital budget.

But what should be looked at in more detail is perhaps the use of A&E rather than doctor's surgeries, or out of hours call-outs (which are incredibly expensive to young families). There are currently proposals coming in to limit that, or to force people to pay for the services if they are the kind of services that could be obtained from a GP. What is not being considered is why people use the casualty department service in that way - it is assumed they are spongers, trying to save money by working the system.

In the UK, the same kind of problem occurs, surprisingly, and one study from Barnsley notes that:

Participants provided the following comments to explain why some people used A&E for minor illnesses.
. Because its quicker (don't have to wait for an appointment with GP)
. Because of lack of knowledge of other facilities and services
. Some people are suicidal and attention seeking
. "You think you'll get better care - they've got all the equipment"
. Its easy
. All they have been educated to do is to use A&E. This is reinforced
through television programmes such as Casualty. The public know about
A&E. It was suggested that there are no dramas about out of hours
services. (3)

The "Doctor Foster" medical site said one key was making sure people knew they could get proper services from their GP, and it would not cost them anything to do so:

Certain messages were key for encouraging people to consider the out-of-hours service: patients could first get assessed on the phone, could easily make an emergency appointment and would always receive the treatment they needed. (4)

There's the rub. In Jersey, while going to the GP is subsidised, the patient also has to pay a share of the cost, and when it is a callout, perhaps to a young child who is unwell, the charges can rise rapidly over a very short time. And recently, when the potential of a swine flu epidemic was thought to be coming, patients were told - wisely enough - not to attend surgeries, and the cost of call outs in these special circumstances would not be for the patient to pay (to ensure compliance). Clearly this is a problem, which does not occur in the UK, where re-education into the use of alternative free facilities is the main problem.

If the Health Insurance Fund is running at a surplus, would it not be better to channel some of that into reducing the costs of going to the GP, especially perhaps when emergency out of hours calls are required? And rather than castigating Deputy Gorst on imaginary issues, would it not be better to ask questions about these very real issues?

Over-cautious parents are choosing to take their children to A&E with minor ailments such as coughs and colds instead of their GP. Under-pressure NHS staff are seeing youngsters with common illnesses which would usually be dealt with by their family doctor.(5)

Do we need some kind of out of hours community health care centre for minor ailments that is cheaper than call outs when they are not needed? The UK has quite a lot of those, and they reduce pressure on GPs. Might it not be a good idea to look at if something like that could be provided if A&E is closing its doors, so that alternatives are available? Even if there is still a charge - the same as that of going to the GP in daytime hours - that would still be a fraction of the cost of a call out.

The fact is that when a surgery closes (after 6 pm), any problems have to be dealt with by call-outs, and these cost a family (especially those trying to balance a budget) money that they can't afford, and I suspect this is one of the reasons why A&E gets people with more minor ailments.

In the 2008 Election, the JEP asked the prospective Senatorial candidates:

Question: Should the States pay more towards the cost of visits to the doctor? (6).

These were their replies. Perhaps we should ask them what has been done to improve matters since October 2008?

Mike Higgins: The cost of going to the doctor is crippling to some members of our society, so much so that they do not go and get the treatment they need and deserve. I believe in everyone receiving the health care they need, not based on what they can afford.

Montfort Tadier: Doctors' fees are prohibitively high for many people. There is currently an issue with those who are on limited means seeking treatment at A&E for this very reason, even though their sicknesses are not necessarily emergencies.

Philip Ozouf: The whole system of primary care needs reform. The Health Insurance Scheme is currently running with an annual surplus of £10 million with more than £60 million in the bank. Some of this fund should be used to subsidise visits to the doctor and also extend non-means-tested preventative care and screening, especially for senior citizens.

Sarah Ferguson: Why are the costs of going to the doctor so high? Perhaps the JCRA should investigate. Certainly those who were on HIE should be helped - but this is one of the areas where I think the forms required to apply for the various components of income support have been somewhat confusing, helped by the fact that it is a new system and the staff are not yet totally familiar with it.

Trevor Pitman: Affordable health care is surely one of the cornerstones of any true and modern democracy.

Alan Breckon: Paying doctors' costs for home or surgery visits is a concern to many people, especially those just above income support thresholds with children, or the elderly. Targeted support would be better than assistance for all. Prescription charges should not have been abolished. Assistance could have been focused on assisting others with medical, optical and dental treatment.

Alan Maclean: Those who can't afford to visit the doctor should have the necessary support to ensure that they can. Otherwise the hospital's A&E department faces an increased burden of non-emergencies, which is a false economy. In some cases, people will put off visits to their doctor, leading to more serious illness and ultimately greater cost to the health care system.

Ian le Marquand: Currently, drug prescriptions are free and £15 towards the cost of GP visits comes from Social Security. Income support is also meant to cover the cost of a reasonable number of visits to the doctor. This is an area in which the States should aim to gradually increase the £15, as the financial position allows. There is also an issue as to how well the new income support system is working. There appear to be cases in which people are having difficulty in obtaining the same level of medical support which they need and used to have.

Jeremy Macon: We should reintroduce HIE. This was an excellent system and currently low-income support only pays for four visits to the doctor. This is ridiculous for those on a low income who have to go to the doctor regularly for check-ups or tests. We were better off under the old system, where those who could not afford care did not have to worry about going to the doctor or calling him out if they had to.

Daniel Wimberley: The principle is clear: no-one should be barred from going to the doctor because they cannot afford it.

Links:
(1) jdajersey.co.uk/Gerard%20Baudains.htm
(2) www.statesassembly.gov.je/documents/propositions/28376-41910-1392010.pdf
(3) www.tcp-events.co.uk/wsmc/downloads/breakouts/Tuesday/1200/PCT/K%20Chaplin.pdf
(4) www.drfosterintelligence.co.uk/services/aande.asp
(5) www.theargus.co.uk/news/4424578.Brighton_parents_take_children_to_A_E_with_coughs_and_colds/
(6) www.thisisjersey.com/election/senators/issues/doctors-fees/#ixzz16f10TMbO