UKH

All my life I have been in favour of an NHS which is free at the point of delivery. But one recent experience has made me think again;

I visited my GP and local hospital for a non-CoVID problem. I was literally the only patient in both waiting rooms and got seen in minutes. A friend in the NHS commented that, confronted with the risk of death from the virus, many people have decided their other medical issues can wait. 
 

Is it time to start charging for some NHS Services, such as visiting the GP? 


 

No.  

No

I have thought about this and do wonder if the prescription charge should revenue-neutrally be moved to being a charge for seeing a GP (with the same eligibility criteria) because as things stand it's unfair that if you need a drug prescribing you pay whereas if you need physio (say) you don't.

Other than that I'd be more inclined to reduce the need for GP visits by way of more phone/online consultations and the likes.

No. While a few people may be "time wasters" charging would be hard to administer and would discourage many people from going, particularly poorer large families. This would have a bad effect on the nation's health and lead to treatment being delayed which would then become more costly and less effective.

The empty GP surgery was preumeably the decision of the practice as anyone, time waster or not, has to make an appointment.

The whole crisis may accelerate use of telephone appointments (inc video links) in selected cases saving money and time.

No, because people don’t then go to get things checked-out which lead to greater problems further down the line. 

^^ This.  I cancelled an appointment to have two, almost certainly  nothing, itchy moles removed for testing.  I bet there are many that are something. 

Errrr.   No

This was tried in Germany (€10 for the first visit per quarter) to reduce trivial visits, it didn't work at all and was abandoned in 2013.

No. And your argument frankly makes no sense. People aren't deciding their "other medical issues" are trivial - they're in some cases deciding that they can wait because (a, altruistically) the entire NHS is massively over stretched right now, and (b, self-interestedly) visiting medical premises carries some risk right now.

We pay for it one way or the other (indirectly through taxation at the moment, and not necessarily in a good way becuase some flat rate taxes e.g. 20% VAT hit lower incomes harder).  Whatever point someone comes up with, somewhere else there will be a counterpoint.  IMHO, something to make people think twice before reaching for the phone for an ambulance (free taxi) to get to the hospital becuase paying for a taxi isn't attractive compared to a free ambulance might be useful or suggesting they pop down to the pharmacist for e.g. an injured finger instead of automatically going to A&E.  Universal free access isn't always necessarily a Good Thing.  I don't know the answer, and I wouldn't want to be the person who has to make some of those decisions, but the NHS doesn't have unlimited resources and does have unlimited demand, and therein lies the issue.  Pricing may be one way of addressing that mismatch, not necessarily the best, and there may be others.

I have wondered if there is going to be a secondary mortality rate due to all the conditions that will go undiagnosed during this crisis because people hold back from going to the doctor.

It's standard in Norway. Seems to work just fine. You pay around 25 quid for any doctor visit, and I think some hospital stuff too. It's up to an annual ceiling of 200 quid, after which everything is free.

I'm sure that someone could research different solutions in different countries and see what works and what doesn't. But having lived in UK, Netherlands, Norway and Switzerland and seen things that work and things that don't, I believe that every country is so up their own arse that they very rarely look beyond their own borders for inspiration. 

it'll be off set by the reduced mortality due to improved air quality.

Up 40000 deaths p.a. in the UK have a contributing link to air quality

Or benefits because people aren't overtreated.

It will just move the problem elsewhere, already people call ambulances and go to A&E for problems that they should see their GP for. If you start charging more people will start misusing these services. Putting extra strain on an already overloaded system.

There are certainly aspects of human behaviour that make me think perhaps payment would discourage that behaviour. But that would be more like a fixed penalty fine and I can't see it happening.

Immediately spring to mind are people who make appointments with their GP and don't turn up, nor cancel and mopping up binge drunk people off the pavement and taking them to AandE.

Actually, I have an alternative proposal. You pay if you properly miss your appointment without warning and justification. Missed appointments cost the NHS.

Just need to make sure that doesn't mean "oh, you're 10 minutes later than the time you've been allocated to start your two hour wait to be seen, here's a fine".

Not advocating charging, but then you just charge for A&E attendance too, as they do in Ireland and the Channel Islands. 

And is currently the system in Sweden where it works well

How has this been measured? in terms of attendence or in terms of overall impact?

As others have mentioned a major problem with this approach is that it either prevents people using the service until their health has deteriorated to a point where it is far more costly to help them or pushes them to alternate approaches. An example would be going to A&E instead.

I do think there is a case for fining non attendees (although it would need carefully designing) but charging per session whilst it might get rid of the timewasters it will put off poorer people who need help.

Pricing is the most obvious way of limiting demand...I get that people don’t like it, but I haven’t (yet) heard any alternatives.

The alternative is to ensure all the alternative options are in place and accessible.  

I went  into the A and E waiting area at night just a week or 2 before this virus.  It was almost empty.  

This was probably because I (and others who would otherwise have been in there) were being seen by an out of hours GP and nurse next door. 

For some £10 in no way limits a frivolous demand and for others £10 is prohibitive so how would pricing be related to income & savings? Or is pricing set to limit demand from the poor only?

It's a slight variation - you paythe first time and then the rest of the episode is free.

Outcomes have been looked at in several ways; mainly relevance scoring (the kind of thing that tells us 30% of people at UK A&E don't need to be there).

The whole point is to manage trivial demand; it costs money (rather than being profitable) but it's worth it to suppress "free buffet" mentality.

Of note in the UK is that footfall in GP surgeries has almost doubled in the past decade.  People aren't much sicker (although there are a few more of them) - they have simply changed behaviour, which in turn is down to a few big societal drivers:

- the NHS being central in every election discussion and a high profile political football generally; pushing the idea that folk should be more demanding

- easy access to information and misinformation, driving footfall

- increasing sense of everyone for themselves (highly manifest recently) and reduced social responsibility (ditto by some on this very website!)

- loss of self-care skills

Demand is already rationed because it has to be.  Co-pay (which already exists on scrips, and dental and eye-care) could be a sensible part of that; particularly in discouraging frivolous use of A&E and GPs.  And the wretched TV shows that put on joke music for idiots rather than them getting sent away with a flea in their ear...

Edit: and I should add that the NHS isn't actually short of money.  The levels of waste are phenomenal, but the changes are soooooo damn hard to make.  The system is fragmented and misaligned and set up almost perfectly to sustain the status quo.  Simon Stevens must tear his hair out.

No

'Edit: and I should add that the NHS isn't actually short of money.  The levels of waste are phenomenal, but the changes are soooooo damn hard to make.'

Yep, that's been my perception for a long time - and the situation hasn't always been helped by the Labour party banging on about funding as though that was the only problem.

As for demand - that's partly a cultural thing, partly educational. Maybe what is needed are campaigns to make inappropriate demands on the NHS socially unacceptable, like drinking and driving, smoking or not wearing seatbelts have become.

There's also a whole sociology to be studied about how the NHS is the one manifestation of the state that otherwise disenfranchised and/or poor people have some power over. Go to your local council or the DHSS and demand 'your rights', and see how far that gets you; go to your GP or A & E, or call an ambulance, and you will, on the whole, be treated as though you matter. It must be intoxicating, in a way that those of us with sharper elbows in other spheres can't imagine.  

The risk that people who can't afford it would stop going is too high. Perhaps something like the Australian system where it is a separate line item as 'medicare' in your tax and this was then ringfenced for the NHS. I seem to remember that ambulances weren't free and you had to have another insurance for this but it may have changed.

I do think that there is too much waste and management bureaucracy in the NHS though. Bound to happen in an organisation with 1.5 million employees.

You pay per visit in Sweden too, but if you are very poor you don't and there is an annual cap of about £150. 

For this to work you need a life long individual id number, an id card and a nationally joined up IT system. The UK has none of these. 

It's worth noting that we have fees for seeing a dentist, and that doesn't seem to be a big problem. 

No

Yes it sodding well is!
You want to (probably not) see the state of my teeth.
I'm holding out for free dentistry in my ever increasing old age.

NHS dentists used to charge for late or missed appointments (and yes some would charge while the patient was right outside struggling with change for a misbehaving parking meter). The NHS got rid of the ability to charge because they  didn’t believe that the amount of time wasted was enough to get in the way of a practice’s ability to get the required amount of dentistry done. And dentists have an advantage over hospitals that they are set up to routinely take money from patients, and the patients aren’t particularly likely to be vulnerable or have life or death stuff going on.

Health insurance companies would be rubbing their hands together.

We do pay for the NHS through taxation. Personally I'm lucky and go to the doctors once in a blue moon, but my partner needs regular visits and lots of prescriptions. Would it be fair to make her pay more than me because she's unlucky enough to have a health condition? No. 

Also, even among people that can afford it, the times you need the NHS are probably the exact same times you’re least able to afford it, perhaps because you can’t work.

In my case, I barely set foot in a doctors surgery for 20 years but I’ve lost count of the number of appointments (nurse, gp, hospital) we’ve had over the 3 years we’ve had kids. For most people the period where they have infants is going to be one of the most expensive in their lives.

A point to note; in countries like Norway and Sweden which charge a nominal fee per visit, all medical services and prescriptions are free for kids. 

I don’t think that direct payment is the answer, but perhaps we should as in Germany, have ring fenced compulsory medical insurance for all to supplement the NHS. As a result of this Germany has best Medicare in Europe.

 France has a similar system

Aside from the debate as to whether or not the NHS should be free at the point of delivery, it's quite likely that the only way to get any kind of timely healthcare in the post-covid world will be to pay.

Even prior to covid, local waiting times were 6 months for most specialties, 1 year for neurology and 2 years for hip replacements. There's a minimum 3 month increase on all of these waits already as it's all stopped. Many local GP surgeries had 2-3 week waits for routine appointments and there's going to be huge backlog here too as a lot of routine stuff has been suspended.

I wouldn't expect there to be any extra state money to sort these problems, as there'll be a recession and a huge deficit to deal with.