Columnist Dr David Turner argues that if we want the NHS to survive, then we should consider charging those who can to pay for some of their healthcare
Earlier this year, former health secretary Sajid Javid said that charging for GP appointments and A&E visits is ‘crucial’ for the survival of the health service.
This is by no means a new suggestion, and it is usually met with a barrage of resistance. The mere suggestion that anyone should have to hand over even the most trivial sum of money for an NHS service seems to bring out the socialist in even the most hard-line right winger.
The NHS is seen by many as the great equaliser in society. You already know the argument: that anyone, rich or poor, can become ill at any point in their lives and may need the services of a tax-payer-funded healthcare service. And that’s all well and good, only the argument is far from being that simple.
Name pretty much any disease or medical condition you like and you will find it is more prevalent among the poorest in society. The reasons for this are complex, but certainly substandard housing, polluted air, poor educational opportunities, lack of access to affordable healthy food and inadequate recreation facilities are some of the reasons the least well off are more likely to get ill to start with.
I suspect that few people in the UK would support a policy of state control over house and food prices to make the possibility of better accommodation and an improved diet more available to those on the lowest incomes. Yet, arguably, it would be money better spent: stopping people becoming ill, before they need the services of a state-funded health service.
Whether you agree with Mr Javid or not, it is an inescapable fact that the health service has to change. We are not living in 1948, and despite recent problems with inflation, most people are immeasurably better off than they were in the post-war years. Even middle-level earners, who would not consider themselves rich, take two or three holidays a year and update their car regularly. If we want to keep the NHS going for the genuinely poor, then maybe we should ask the richer in society to take one holiday fewer and postpone the new car purchase for a few years and use the money to pay for some of their healthcare.
We also must consider that the private sector is not going away. It continues to snap at the heels of the NHS, chewing off the easy-win chunks of healthcare. Instead of seeing the private sector as the enemy like many die-hard NHS stalwarts, how about we work with it to help unburden the NHS? If the richer in society can afford to pay for some of their care privately, then why shouldn’t they?
Many will argue this is not fair. And no, it isn’t. Life isn’t fair. It also isn’t fair that some of these people live in vast houses and send their children to be hot-housed in private schools. But unless we suggest their houses should be repossessed and repurposed for communal living, and their private schools closed down, we are not really being consistent with the ‘equality’ model of the NHS.
Now, don’t get me wrong, I would love to live in a more equal society. But I think this is unlikely to happen any time soon. Having worked on the NHS frontline for more than two decades, I have seen first hand the abuse and waste that is caused by some of the end-users of the service. Perhaps a small charge to those who can afford it may make people value the service they have a little more.
Some argue that charging for NHS services will delay the presentation of serious conditions. But where is the evidence for this? As Mr Javid points out in an article in the Times, lots of wealthy countries, including Norway and Sweden, charge patients to see the GP, and I don’t think their health outcomes are worse than ours. In fact, they are generally a lot better.
It is time to take off our blinkers, and think broad and wide. No idea can be off the table if we want the NHS to survive, in some form at least, for another 75 years.
Dr David Turner is a GP in Hertfordshire. Read more of his blogs here
I have worked in nhs 48 years. I don’t think asking people who are middle class to pay for nhs is fair. Doctors are paying 40% tax. 20% vat like every one. Taxes are what funds nhs. Nhs expenses are enormous. No amount of money will be sufficient. No point in making higher earner’s life a misery. Reduce taxes , give tax break for private health, reduce wastage ( huge potential). Very rich already pay a lot to HMRC and use private health service.
If you work hard to earn decent wages then you are entitled to holidays and a decent car.
No! No charges. Demand appears excessive because provision is inadequate. Because we are underfunded. Add charging patients to the list of crap foisted on us to alleviate the fundamental problem of underfunding. Triage, IT solutions, Remote consulting, all necessitated by demand exceeding provision, for which read funding. Bullshit.
I don’t have a problem with the concept of paying for services received or the notion that the NHS does have to change. What I am not clear about is the aim of introducing charges? What would this income generate? The NHS needs a cross party committee to agree a long term (30yr+) strategy to which Joe public can align with, not punitive charges (to which only 1 in 5 would pay; vis prescriptions) with no defined benefit.
I agree
Personally I think the separation of private and NHS should cease. If you have health insurance and break your leg or see a GP etc then that insurance should cover a proportion of these costs. Having completely separate systems in which private healthcare cherry picks what it wants merely makes it more likely that we’ll end up with an American style health system. I think the sooner we have a long term plan on funding which ensure protections of the poorest but also recognizes that lots of people get health insurance through work which could add extra money into the pot for everyone the better. Healthcare is only going to get more and more expensive and there is a limit to what taxation can pay for unfortunately NHS spending has relatively been protected from cuts (unlike social care or education) and its still not enough money – (there will never be enough money for healthcare in the western world) therefore we have to look at a different funding model and it seems obvious to me to join the insurance based system up with the taxation system.
Dr No seems to be volunteering to be taxed to kingdom come, and also compelling everyone else to be subject to higher inflation. Vote-winner, that one.
Why would you consider introduction of charges? The argument has always been that this will reduce demand by stopping unnecessary usage of the system. In Northern Ireland we have a working example next door in the Republic of Ireland. In the Republic charges to see a GP range from 60-70 euros with additional charges for further tests and prescriptions
30% are exempt through the medical card 50% have some sort of insurance to cover part of the costs This leaves a so called squeezed middle who earn enough to be exempt from the card but not enough to feel able to pay.
The Republic has found that this leads to perverse disincentives to avoid care due to costs
As usual the issue here is not about unnecessary demand but under provision of the service with not enough boots on the ground We need to expand the workforce through radical root and branch change of the GP system
I strongly disagree.
I worked for a GP who told me about his experience charging pre NHS. Patients present late and do not want any follow up due to charges.
France tried this in the early 2000s and abandoned it as it reduced health care access.
Do you not remember we increased Vat from 17.5q to 20% to cover increase money to nhs.
We also increased NI charges to increase nhs money.
Where is this extra money now. Its not been allocated to the NHS?
Any extra money from charges, would just be subtracted from total government nhs money. Don’t be naieve.
It’s just a way to reduce demand.
Take off your rose tinted spectacles – health care in a patient paying fee for service is a nightmare for GPs providing the service, why would any of you want to introduce any extra hurdles to your daily routines. It would be a nightmare to run, other countries do it sure, but lots of ex UK GPs return from such systems because “free at the point of use” is so much more efficient.
A free at the point of use service whilst ideal has clearly led to the issues we currently have. People do not take any responsibility for their own health and you see excessive trivia. Asking the better well off to pay is also unfair as they are paying more than their fair share within a progressive taxation system. Maybe the solution should be some level of basic charges to access ED and GP serrvice which are access points for Care to deal with these issues. Regarding secondary care needs, a top up system to provide priority access for those that can afford it which goes to fund better services overall (rather than back to hmg coffers) might improve services for all. Need a mixed approach using subsidised private care for those who may be able to afford it to take the pressure off basic nhs services to improve access. The current situation we have is not good for anyone with a totally not functioning nhs system with the majority not able to fully go private.As far as nhs funding through taxation goes it could be better but a FATPOU service will not deliver better care and the resources will just go down a black hole.we have already done this many times and it has not worked. Things need to change.
I think what is interesting is to look at where fees are charged. The assumption seems to be GP and A&E but in reality these do not have the waiting lists. The problem is in secondary care. In France this is the privatised bit with state type insurance paying a fixed fee. The hospitals especially posher/better ones charge more than the state fee and these the patient pays. But what is created is genuine competitive market in the secondary sector. Patients see the cost and get to make their choice. The GP’s don’t chase around the patients do the shopping. This is seen in various guises across Europe with superior outcomes. Primary care is valued because they can help you avoid unnecessary secondary care expense. So no demanding referrals and no GP to chase stuff.
I’d quite like to be able to see a GP as a patient.
Would charges help with that?
The rhetoric about a FATPOA health service is pretty disingenuous at best – we DO pay for healthcare in taxes in all their wondrous variety and the government of the day apportions a percentage of their taking towards healthcare. It’s not unreasonable to suggest that the “free” bit does incentivise those who have no respect for the service to call their GP at the drop of a hat, which has been worsened by telemedicine and email contact – how many of us would agree that probably 20% per day of patient contacts are spurious BS that should never pass the door? The question really, and AFAIK there is no hard evidence, is whether a small levy would offset those spurious unnecessary contacts freeing up capacity. And if so, having exemption at any level of earnings misses the point – if we are charging, there should be a charge for ALL – even if it’s only a couple of quid for low income people.
There is good evidence from the psychology world that people have no respect for that which has no perceived monetary value and I fear that at least part of the loss of respect for the health service is that it’s a free service and therefore naturally loses its kudos as a result of being FATPOA
A dead argument that keeps on resurrecting.
Forget it.
Completely un-workable .
It would be unpopular. It would probably be inefficient introducing management costs.
Evidence that it would be inequitable acting as a barrier to whichever population group sits at the boundary between those on benefits and those required to contribute.
That group (the working poor) has been hammered already over decades.
Patients and doctors consume all resources within any system. We need to determine what is needed (vs what is wanted). Sensibly evaluate the costs of providing this care then fund to that level.
Copayment could be used to fund what is wanted rather than needed although I suspect the argument over want vs need is beyond the politicians who use unrealistic promises re the nhs in order to win votes.
We will get the NHS that we deserve as a nation. Priorities of the public remain self evident.