Should NHS Doctors charge for patient appointments?

Faced with an ageing population and increased demand from diabetic and asthmatic patients, many GPs fear the current NHS system is unsustainable. As a growing number of practices struggle to survive on overstretched resources, the issue regarding how future funding will be obtained has been pushed to the forefront of NHS concerns. Subject to a vote cast by family doctors this month, the answer could be simple – directly from the patients themselves.

Plans for patients to be charged between £10 to £25 per NHS GP appointment will soon be debated at the Local Medical Committees Conference in York. If the motion is passed, GPs will lobby the Department of Health to introduce the charges. As is the case in the NHS dentistry market, some patients will be exempt from the fees, such as children, the elderly, disabled and unemployed.

A survey conducted by online general practice magazine, Pulse found that over 50% of GPs would welcome appointment fees as a way to make their workload more manageable. While some leading figures in the NHS support the move, with the view that ‘desperate times call for desperate measures’, others are vehemently opposed, arguing the proposed changes go against the very foundation and principles the NHS is built on.

Chairman of the GP Committee at the British Medical Association, Chaand Nagpaul has said ‘The BMA policy still is that we do not support charging patients because it is against the NHS’s care being provided at the point of delivery. Anyone who is ill should not have to consider cost as a barrier to seeing their GP.’

Arguments for charging for patient appointments:

• Cut missed appointments – An estimated £152m is lost as a result of missed NHS appointments each year. Yet without sufficient penalties in place, the DNA rate shows no signs of dipping. Not only will the charges present a big incentive for patients to turn up, the money generated may go towards email and SMS confirmations and reminders, shown to dramatically reduce non-attendance.

• People could take their health more seriously – The end of free primary care could mean the beginning of a healthier Britain, as more people realise the financial benefit of eating well, smoking less and staying in top condition.

• Encourage people to avoid booking unnecessary appointments – As many as one in five NHS GP appointments are filled by patients complaining of back pain, headaches and coughs. Minor ailments such as these can be dealt with easily by pharmacists, yet take up a disproportionate amount of practice resources.

• Dentists already charge for NHS appointments - A dental check up on the NHS is £18.50, yet dental health in the country continues to improve. A survey by the Office of Fair Trading has found that from the period 1998 – 2009, the percentage of adults with cavities fell from 46% to 28%.

• Other European Countries charge successfully for appointments– Supporters argue that French GP practices charge 23 euros per appointment, called ‘responsibility payments’ yet there is no evidence public health is sacrificed as a result.

• Charges will lead to higher standards of care – Payments will go directly to the practice, meaning extra resources for a patient-centred approach. Technology such as online booking and extra care and attention given to each patient may help improve the quality of service and patient outcomes.

• Charges could slow down health tourism – Figures released by the Department of Health last year reveal that health tourists cost the NHS between £60m – £80m every year. While GP appointment fees will not eradicate health tourism, the appointment fees should significantly lighten the burden.

• Prevent patients being fobbed off – Many NHS patients exit the practice having been incorrectly diagnosed. Left in pain and fearing they will be labelled hypochondriacs if they return too often, the charges may help, through reduced demand, direct extra resources to patients who are truly in need.

Arguments against charging for patient appointments:

• Strain on Accident and Emergency – After a string of campaigns and initiatives to reduce the number of unnecessary admissions to A&E, the last thing the NHS need is more reason for people to turn to emergency services rather than their local GP for help.

• The most vulnerable people in society will not receive care – Some people are already stretched to pay for their prescription at £8.05 without the additional £25 for an appointment. Patients Association member Dr Mike Smith has said that ‘A move to charge for routine appointments will have a devastating impact on many vulnerable patients. This will put pressure on already stretched A&E services as people would be reluctant to pay to visit their GP.”

• Reduced Early Detection of Serious Conditions – People who may previously have visited their GP early on in regards to an unusual symptom could leave the problem to fester before spending £25 on an appointment. For some, the consequences of the charges could be life threatening.

• Charges go against everything the NHS stands for – Since the NHS was established in 1948, GPs have not charged for appointments. In a statement by Dr Helen Stokes-Lampard, Honorary Treasurer of the Royal College of General Practititioners, she says ‘Introducing a charge for appointments would fundamentally change one of the founding principles of general practice – that healthcare is free at the point of need.’

• Reduced trust between patients and GPs – Some healthcare professions have gained a reputation for profiteering from the unwell. Opponents to the new proposals suggest this could be the case if practices start charging per appointment. Dr Kailash Chand, the Deputy Chairman of the BMA has said in an article for GP Online ‘One consequence of charging patients would be to do irreparable damage to the doctor/patient relationship and to assist profit-driven private companies to oust GPs from their traditional gatekeeper role, facilitating the creeping privatisation of primary care.’

What are the alternatives?

The upcoming vote highlights the critical need for a debate about how the NHS will move forward and tackle growing patient demand. Several alternatives have been put forward, some more promising than others.

• Encourage more pharmacy visits – Community pharmacists are trained to offer advice on a wide range of problems. If a patient believes they have a minor ailment that is not symptomatic of a more serious problem, such as a cold or flu, pharmacies offer a more appropriate alternative to a GP. A campaign to send patients to pharmacies directly, with more information provided about what sort of problems they can help with, could reduce the pressure on practices.

• Telehealth and Telecare – Despite the financial benefits and extra security offered to elderly and disabled patients, Telehealth has failed to take off in the UK. As the majority of NHS appointments are booked by patients who visit regularly, a more energetic effort to establish Skype calls and remote care as the norm for diabetics and others will dramatically ease GP workload.

• Refundable deposits for appointments – One of the key reasons cited for the recent proposal is the sheer number of missed appointments faced by practices every day. Rather than charging per appointment, some health professionals have suggested the practices could simply collect a deposit that is refunded immediately after the patient checks in at the practice.

• Charge per month for NHS membership – Former labour health minister, Lord Warner recently called for the NHS to impose a £10 a month ‘membership charge’ to all patients. While this may end up being more expensive for some patients, it would solve many of the problems associated with charging per appointment.

• Hospital Closures – Without an additional source of funding, the future of the NHS could be very bleak indeed. Wessex Local Medical Committee’s Chief Executive Dr Nigel Watson believes that primary care should be free at the point of access but states that there simply isn’t enough funding to ensure NHS care can meet the standards expected of it. Watson has said that if the funding cannot be obtained from taxation ‘it’s going to have to come either from closing hospitals down – which is incredibly difficult – or resources need to come from elsewhere.’