At 2 o'clock today the British Medical Association will vote whether or not to lobby the Government to introduce a charge for GP appointments. The motion, put forward by the local committee in Wiltshire, suggests that "it is no longer viable for general practice to provide all patients with all NHS services free at the point of delivery". Wiltshire was not alone, with similar calls to consider alternative funding put forward by Avon, Gloucestershire, Kingston and Richmond, and Mid Mersey committees.
Though likely to divide the crowd, the very notion that a user charge is up for discussion by the BMA is a serious wake up call as to the times we live in. NHS England has forecast a £30billion black hole in the NHS budget by the end of the decade as an ageing population and rising patient expectations place increasing demand on all health systems. While there is scope for improved value for money within existing budgets, the NHS is not on track to close the gap through efficiency savings alone. Yet increasing the NHS budget, or even continuing to protect it, means further starving other vital public services of the limited resource available to Departments within the confines of Government spending plans.
In this difficult landscape charges offer a route to much needed revenue. Research by Reform last year found that a £10 charge for GP consultations could raise an additional £1.2billion each year. Although a controversial proposal, charging is nothing new. Prescription charges and means tested social care have existed side by side with free at the point of use services since the 1950s. Overseas, two thirds of OECD countries charge for GP appointments where co-payment is a tried and tested way to raise additional revenue at times of financial strain; just last week the Australian government announced a new £3.90 charge per GP consultation.
However the case for charging put forward is not simply the revenue it could raise. As the Gloucestershire committee suggests, a national charge could form part of "a strategy for demand management." GPs are stretched to the limit; demographic shifts and new responsibilities for commissioning have placed increasing demand on GPs. A fee could work to manage demand by giving patients the incentives to be more engaged in their own health and be more responsible consumers of NHS services.
Moreover, giving patients "skin in the game" would make patients expect and demand a higher quality, consumer friendly service like they enjoy in other areas of their lives. Varying and often poor access to GP services, for example, is a major source of frustration for patients. A survey out today found that patients are waiting more than two weeks for an appointment in a fifth of GP surgeries. Rising patient expectations will give new momentum to NHS efforts to give patients easy routes to more convenient clinical advice outside the GP surgery, whether that is online or through alternative services such as local pharmacies.
Charging does come with the concern that patients, particularly those on low incomes, will be deterred from seeking preventative care. However all systems have mechanisms to protect those on low incomes to ensure that essential services are always within the means of those who need them. Moreover the administrative costs involved will fall dramatically in the coming years with the advance of wireless payment collection and the increasing digitization of the NHS.
In many ways the greatest barrier remains attitudes to user charges. Difficult decisions need to be made, but they will have little lasting impact if they do not carry the public and professionals will them. In Germany, for example, a £10 fee was introduced for GP appointments raising £2 billion each year and yet it was reversed in 2013 in the face of widespread opposition from the public and clinicians.
In England the idea remains controversial, with politicians of all three parties ruling out these kinds of charges as incompatible with the founding principles of the NHS. Yet as the fiscal backdrop worsens the debate is slowly changing. A survey last year found that over 50 per cent of doctors would support a GP charge and earlier this year a poll of 100 MPs found that 48 per cent believed the NHS may not be able to remain free at the point of use indefinitely. Few will want to debate higher charges, but today's vote is a sign that the tough choices on funding are becoming increasingly difficult to ignore.
Cathy Corrie is a Researcher at the independent think tank Reform