Income Support: free GP access

STATES OF JERSEY

INCOME SUPPORT: FREE GP ACCESS

Lodged au Greffe on 28th May 2014 by Deputy G.P. Southern of St. Helier

STATES GREFFE

2014   Price code: B  P.101

PROPOSITION

THE STATES are asked to decide whether they are of opinion

to  introduce  free  access  to  GP  consultations  for  those  Income  Support recipients who currently qualify for a Household Medical Account to assist with their medical costs.

DEPUTY G.P. SOUTHERN OF ST. HELIER

REPORT

The  Income  Support  (IS)  system  was  designed  to  meet  the  income  needs  of households in a wide range of circumstances, and as such it represents the minimum needed to survive. It was set up to replace many of the benefits previously paid through a variety of States departments and the parish welfare system. It provides financial help to local residents in need towards the costs of housing, living, medical needs and child care.

I have long held reservations concerning the capacity of Income Support to deliver sufficient help towards the costs of medical needs and in particular over the effective use of Household Medical Accounts (HMA).

The numbers in receipt of assistance with medical costs, for example, have been seriously reduced over time. In November 2007, prior to the introduction of Income Support,  there  were  a  total  of  2,966  households  (around  4,000  individuals)  who qualified for Health Insurance Exemption (HIE) and thereby were entitled to free access to GP consultations. As of March 2008, there were only 158 individuals who were  previously in receipt of HIE who were  not receiving Income  Support or a Protected Payment. All the remaining households had a HMA set up to assist them with GP costs. By the end of 2011, however, the number of households with a HMA had been reduced to 1,429, and by 2012 this had fallen further to 1,099.

Faced with a choice over whether or not to continue supporting free access to GP services in designing the IS system prior to its introduction in 2008, it was argued that the list of households which qualified for HIE was an insufficiently accurate indicator of those with the greatest need. Free access to GP services was therefore abandoned, and replaced by additional support through the HMA. The need for support with medical costs was reviewed over the first 3 years of delivery, and removed as shown above from around 50% of recipients. The result is that we now have an accurate understanding of which families are in greatest need of assistance with their medical costs.

However in addition to the refining of the numbers, there has also been a change in the funding for HMAs as is shown below. The end result is that what started as additional sums have been replaced by the redirection of IS components to medical needs from other areas of need. This makes those with high need worse off than they should be.

GP Costs

In answer to a question posed in April 2008, the then Minister for Social Security, Senator Paul Routier clearly laid out how these HMAs were structured and funded, when he stated:

"For clarification, the HMA is a payment mechanism available to Income Support recipients, including those receiving Protected Payments, and not a benefit. The amount of benefit given depends upon the clinical need of the individual family members, which may include home visits.

The actual funding of GP visits is through monies included in the living allowances  and  the  impairment  component,  specifically  the  clinical  cost element. Therefore, all households on Income Support have received funding towards the cost of GP visits but most will not have an HMA as this facility

has, in the initial stages of implementation, been targeted as priority to former HIE recipients.

The clinical cost element (CCE) provides additional funding for individuals who have ongoing, increased medical need. The rate of the CCE was based on the average cost of a doctor's visit and resulting prescription charges. As prescription  charges  have  been  removed,  individuals  have  more  money available to pay for GPs and other medical costs. Further funding may be available through a special payment, for those who require higher levels of medical care in the form of home visits, which, if they have one, can be paid directly into the family's HMA.

Individuals previously receiving support with Family Nursing & Home Care costs through the Parish Welfare system continue to receive the same level of support  through  Income  Support.  New  FNHC  clients  can  apply  for  the personal care element of the impairment component to assist with the cost of personal care services provided by for Family Nursing and Home Care Services. The personal care element is set at 3 separate levels providing more flexibility than previous disability benefits."

On another occasion he laid out further details:

"The department recognises a G.P.'s duty to treat patients when there is a genuine  medical  need.  The  G.P.  will  always  provide  a  medical  service regardless of the previous number of visits that the patient has had.

Support  for  G.P.  visits  is  provided  in  a  number  of  ways,  under  income support. The basic living component covers up to 4 surgery visits in a year, which is the average for a healthy person. Then, on top of that, the clinical cost component provides additional support, up to a total of 12 visits a year, for individuals with chronic illness.

Then there is also the additional personal care component and the mobility component,  which  provides  additional  assistance  for  individuals  who  are housebound.

The household medical account allows individuals to save an appropriate amount from their weekly benefit to cover the costs of the visits that they require. If someone is in genuine need of home visits, the weekly amount saved can be increased to cover this cost. Special payments can also be made to assist people who have unusually high needs or to cover the costs of a serious bout of illness. There is no specific limit on the number of visits for which a claim can be made.

.As  I  said  in  my  comments,  the  payments  will  be  made.  There  is  a mechanism  in  place  that,  if  the  person's  medical  account  does  not  have sufficient in it, there is a mechanism for special payments to be made. It is the G.P. who will decide whether those visits are necessary and if the G.P. decides those visits are necessary then the account will be paid."

In a  more  recent response  given  in February 2013, the  current minister revealed changes in funding mechanisms in covering the costs of GP consultations within Income Support:

"The basic IS component which covers day- to- day living costs assumes that the individual may need up to four GP visits per year. The clinical cost component is specifically designed to provide additional assistance with the cost of GP visits for individuals with medical conditions that require regular monitoring from a GP.

There are also other medical components contained within IS for personal care and mobility needs that individuals can claim to assist with associated costs, depending on the nature and severity of their condition.  In certain circumstances part of the mobility element of the medical component may be used to assist with the cost of home visits by GPs, where the additional cost of the visit is due to the mobility difficulties of the individual."

The current provision for funding GP consultations is made clear on page 57 of the recently released IS Policy Guidelines (V3.0).

Household Medical Account (HMA)

If an Income Support Household is prevented from being able to budget for the cost of GP visits, a Household Medical Account (HMA) may be available to assist them. This could be due to complex medical need or specific illnesses that affect a person's ability  to  budget.  The  HMA  is  not  an  additional  benefit,  but  a  means  to  assist households in this position with budgeting for GP visits.

Each week, part of the Income Support benefit is set aside in the HMA. The basic personal component of Income Support contains provision for each person to visit their GP 4 times a year, and so an equivalent deduction is made on a weekly basis towards the HMA. For individuals receiving clinical cost components, the full value of that component is also included in the amount to be saved.

In cases where members of the household visit the GP more frequently, additional savings  may  be  made  from  impairment  awards.  These  additional  savings  will typically be up to 50% of the personal care level 1 award and up to 50% of the mobility component, depending on the needs of the household.

When a member of the Income Support Household with a HMA visits the doctor –

1. The doctor will be notified that the household has a HMA.
2. The Department provides a medical benefit (£20.28 as of June 2012) towards the cost of the visit. This payment is made under the Health Insurance Law, which is not part of the Income Support system.
3. The remainder of the cost is deducted from the HMA.

The HMA allows the Income Support Household to budget for GP visits steadily, throughout the year, regardless of when the visits actually take place. The HMA account  is  designed  to  be  able  to  go  into  debt  from  time  to  time.  In  normal

circumstances, the account will build up again and return to credit. If it remains in debt, additional savings will be made from impairment awards.

In summary, the cost of 4 visits per year to a GP is built into Income Support, currently £3.15 weekly, or £163.80 per year. If Income Support recipients have need of a greater number of visits, then they must apply for clinical component (level 1) which provides additional funds for a further 4 consultations (up to 8 in total). A further  level  of  clinical  care  exists  to  provide  up  to  12  (monthly)  consultations annually. These sums may be put into a household medical account, and set aside by the department to allow Income Support households to cover its GP bills.

If at any time an individual requires more than 12 consultations in a year, or needs home visits from the GP, then these costs can be claimed through special payments.

The full range of components available to those on IS in medical need is as follows:

Personal care

The personal care component is available for people who need assistance with their own personal care. This includes activities such as housework, shopping, cooking, washing and dressing. There are 3 levels of personal care component, and they can be awarded for physical, sensory and mental impairments.

Mobility

The  mobility  component  is  available  for  those  who  have  an  impairment  which seriously affects their mobility outside their home environment. There is a higher rate paid to people who work to assist with additional costs incurred travelling to and from work. This rate is paid as long as the net earned income from the work exceeds the value of the higher rate.

Clinical cost

The clinical cost component is designed to help people who need to visit their GP regularly  because  of  a  chronic  or  progressive  condition.  It  is  also  available  for individuals receiving palliative care.

Members should note that –

1. there is nothing built into the IS Law or Regulations to bring the Household Medical Account into existence. The HMA is simply an administrative aid to permit IS recipients to budget for GP consultations. It is a scheme designed by social security officers; and
2. the source of funding for the HMA has become more flexible as the years have gone by.

In 2008 "extra needs would be met from special payments". By 2013 "part of the mobility payment may be used to pay the cost of home visits by the GP." or, in other words, "additional savings will be made from impairment awards".

This gradual shift of funding from special payments to using other components to cover  medical  bills  runs  the  danger  of  affecting  the  quality  of  life  of  some  IS recipients. This section takes a number of cases where medical costs are being met from other components, in some cases, removing significant sums from and putting additional stresses on household budgets.

1. Single Parent, 2 children, no impairment or mobility, HMA: £15.26 per week (£800 annually).
2. Family with 3 children, child impairment, HMA: £47.60 per week (£2,500 annually).
3. Single female, no impairment, HMA: £35 per week (£1,800 annually). This award left her to find over £70 weekly towards her rent.
4. Elderly  single  female,  PC2  and  mobility,  HMA:  £28  per  week  (annual £1,400).
5. Elderly couple, Multiple disability, HMA: £47.95 per week.
6. Elderly couple, PC2, M1, CC2: HMA: £39.62 (£2,060 annually).

I believe  that one  of the factors involved  in persuading the  States to accept the abandonment of the parish welfare system and the removal of free access to GPs for some (those on HIE) was the guarantee given to members that those on income support with high medical needs would have their medical costs met, if necessary, through special payments. It was never envisaged that other components of income support awards should be swallowed up in medical costs and thus be unavailable for other needs.

After 6 years of the delivery of benefits through Income Support, I believe that the time  has  come  to  assess  how  the  system  might  be  improved.  In  particular,  the examples given above reveal deficiencies in the support delivered for those needing a high level of GP care. This proposition goes some way to addressing this need.

Financial and manpower implications

We are informed that 35% of IS claims (2,300) have at least one medical component but without further detail of the distribution, an estimate of financial costs cannot be

made. By way of example, if all of those on HMA were on Clinical Component 2 and were to get free GP visits, the financial cost of this would be some £360,000 annually. It is worth noting that since IS is tax funded, this would be a transfer of funding from the tax payer to the medical benefit element of the Health Insurance Fund.