Some of you may have picked up on the fallout from the BMA annual GP conference this year. The controversial topic of patient charges reared its head, whilst GPs voted against the proposal it has still generated debate. Senior GPs have described general practice as becoming ‘conveyor belt medicine’. This brings back memories of discussions within our own profession in 2005 when we prepared to hang up our running shoes and come off the treadmill. I recall that patient charges also featured in our own deliberations at that time, but not in relation to whether we should charge but in relation to what we should charge for? It was specifically losing the ability to charge for failed NHS appointments that caused controversy.
The idea of charging fees has been described by well known GPs as being unethical, dangerous and disingenuous. Some GPs who reluctantly favoured charging suggested that by doing so patients may be more likely to value services. Some commentators may have been quite extreme about their views on charging fees; however the underlying message is that charges may result in disquiet. It seems unlikely that fee charging could really be described as being unsafe. There are relatively few services that exist which are unsafe because people have to pay for them. In most parts of the world, including the UK, private providers of most services, including private GPs, charge for their appointments and it’s not often they are described as being unethical.
In dentistry the issue of fee charging is muddied because the charges are for the benefit of the state; NHS dental providers are in effect tax collectors. The problem is that most patients do not realise this and they find it even more difficult is to separate the quantity of treatment provided from the fee they are paying. It’s easy for both providers and patients to consider value based on the amount paid and not necessarily based on any other dimension of cost effectiveness.
I expect all practices have had their fair share of complaints about NHS charges. I was recently approached by a colleague about an extensive complaint. The patient would not accept that subsequent courses of treatment attract a separate charge. The patient’s argument was that a treatment plan is continuous and runs from the original examination. The patient was unhappy about having to pay an NHS charge for a subsequent course of treatment some four months later. Clearly this type of complaint about charges does interfere between the patient-practice relationship and makes it difficult to meet a patient’s needs.
Charging patients fees for NHS services is becoming increasingly complex, the rules on eligibility for state benefits are ever changing and the cost of collecting and processing payments on behalf of the NHS is also an expense to practices that is not reimbursed by commissioners. There is the added challenge of having to manage expectations of those patients who are exempt from prescription charges but not from dental charges. In times of financial hardship it’s not surprising that bad debtors also increase, which is another cost pressure to practices. In some respects the sentiment of GPs may be right, charging for NHS services is cumbersome and if the Government through the NHS needs to charge then perhaps it should also take over the bureaucracy of being the counting house. Perhaps a contactless payment solution for NHS services could be one answer, it could work a little bit like the Oyster Card on London’s transport system. That way the Government can have direct control over managing its exemption rules for individual users. This might seem like an extreme solution but could be one way of dealing with all NHS services that need to charge a user fee.
The feedback from some of the practices participating in the NHS pilot scheme seems to indicate that patient charges are of real concern. In my view, charging for NHS services is always going to be challenging and therefore any contract reform should properly consider this issue and helping patients understand that the charging system is designed by NHS commissioners on behalf of the Government.