Sunday, July 19, 2009

This call is being charged at £2 per minute

Today I woke up and looked through my BBC News twitterfeed to see the headline:

"Patients should be charged £20 to see a GP in a bid to limit demands placed on the health service, a centre-rig.."

Twitter and the 140 character limit. A slightly panicked click-through to the actual story reassures us that there isn't (currently) an intended government policy to charge people £20 for a ten-minute GP's appointment, it's just an idea that a "think tank" called the Social Market Foundation has come up with.

It's pre-9am on a Sunday, I'm still on my first cup of tea, and even so I can think of several things that are wrong with their proposals. Lord knows what this think-tank think they've been doing, but I don't think it was thinking.

First problem: "The group said it would not breach the values of the NHS as charges already applied to dentistry and prescriptions."

Yes, and I can introduce you to people who don't go to the dentist, don't have the necessary dental work done, don't fill their prescriptions, or try things like taking "daily" medications every-other-day, in the name of economy. Generally they end up bouncing on the safety net of emergency care, at an even greater cost to the NHS, once the problem that should have been dealt with in its early stages has been allowed to progress to a much more extreme (and harder/more expensive to deal with) level.

To my mind, charging for essential medical care like this is a breach of the values of the NHS. And just because there's one breach, doesn't mean it's permissible to add a few more.

Second problem: "[David Furness, the author of the report] said "It would get people thinking twice about whether the visit was essential."

Isn't it rather rare to just have one GP's appointment? Most people I know seem to have at least two. There's the first one, where they get told "Have some paracetamol/a bit of a rest/drink more water/make sure you keep it clean/etc, and come back next week if it hasn't cleared up/if it gets worse/if you develop a rash/etc." This is the one where before calling, you say to yourself "is this really bad enough that I need to see a doctor?" and probably the one Mr Furness is thinking about.

But then there's the second one a week later which goes "ah, you're still oozing/wheezing/vomiting, looks like you might be ill after all, let's get you some tests/medications." In an ideal world you'll get prescribed a short course of treatment which resolves the issue and trundle off into the sunset, £40 lighter but perfectly healthy.

Nice idea. However, if you don't get better, there's the third, fourth and fifth appointments, which go "we've got the results of your tests back, and now we need to give you medication/refer you for hospital treatment/send you for more tests/monitor you for a fortnight." Before making these appointments, Mr Furness wants you to think twice about whether it's really essential to carry on trying to establish what's wrong and how to treat it. See previous point about bouncing on the safety net of emergency care and allowing simple, treatable conditions to progress into complex ones.

Third problem: The 250-odd page report crashes my browser after ten minutes, but I did get a chance to double-check on exemptions. Mr Furness feels that instead of "arbitrary" exemptions such as pregnancy or retirement, exemptions from the fees should be based purely on "wealth". He defines "wealthy people" as everyone apart from "children and those receiving tax credits". I could not find any mention of provision for people on other forms of welfare or those on low incomes who are not entitled to or do not claim tax credits. I'm not sure how "children" is any less arbitrary than "pensioners" as a wealth-based category.

The time of my life when I had the most GP's appointments was at the beginning of my illness, when we were trying to figure out what was wrong with me. This makes sense and is not unusual.
This was also, obviously, the time when:
  • My job contract had ended and as I was signed off sick, I was not eligible for an extension or able to apply for other jobs. I therefore had no earned income. This makes sense and is not unusual.

  • As I was not working, I could not claim or receive tax credits. This makes sense and is not unusual.

  • I had not yet been approved to receive any benefits or practical assistance. I therefore had no income at all. This is also not unusual.

I was therefore not exempt, but also not in a position to hand over £20 per GP's appointment, at the time when I needed it most. My situation was not unusual at all. Also, I was ill. It's not the time to be dumping additional financial hardship onto people. This scheme may be designed to discourage the "worried well" from using up resources, but the people it will impact most are the people who are actually sick and in need of healthcare.

But Mr Furness's final, beautiful demonstration of idiocy had to be: "[he] said the think-tank was opposed to fees being levied on any form of emergency care."

The emergency care service has been creaking at the seams for years for various reasons, including the decreased "Out Of Hours" GP cover. Presented with a choice between phoning a free ambulance to come and visit you at home, or going out to attend a £20 GP appointment, what are most people going to do? I suspect that any savings Mr Furness's ideas might make GP-side would be dwarfed by the increased costs of emergency care.

Mind you, then he could get paid to write a report about how it would be a good idea to charge for that, as well.


The Goldfish said...

The thing that really bugs me about this proposal is the £20. I know a few people I regard as pretty well-off but I don't know anyone for whom £20 is not a significant amount of money. So even a wealthy person, who wasn't certain whether they should or should not talk to the GP about that mysterious lump or wait for it to go away, might well be put off by a £20 fee. If £20 is your weekly food budget (as it is for some), GP healthcare just isn't an option.

Whilst I think it would be totally wrong to charge for GP appointments anyway, if they'd said three or four pounds I might think we were at least on the same planet.

Even so, any financial disincentive to seeking medical help is going to endanger some people, usually poor people or those people who are reluctant to seek help anyway. If we want to reduce the number of people going to GPs (or perhaps in particular, booking appointments and never turning up), we need to do that through educating people and changing culture.

Anonymous said...

Yes; but this report *is* authored by the so-called SMF which is such a leading thinktank that no-one's ever heard of it, one that puts markets first and the 'individual' second. As you have adeptly pointed out, their claim that they "... use sound argument and clear evidence to make [their] case" is entirely unfounded.

butterflywings said...

Couldn't agree more, Bagardotsgirl.
People who are just hypochondriacs, but have the money to spare, will probably hand over the £20. Some might think twice, but not most. These people are just self-absorbed.
It would just discourage those who might genuinely have a problem.
And what's wrong with being genuinely concerned? Some things *could* be a major problem and could be nothing, but there is nothing wrong in getting these things seen. I once injured my foot. It could well have been broken. It wasn't, but not being a doctor, or having x-ray vision, I didn't actually know! I was made to feel like a time-waster. Aaargh.

Dorothy said...

This is very well written, says much of what went through my mind when I heard the same news story.

I'm currently hoping not to slip from the post viral fatigue category, rather than ME, but am going into 4th month off work and down to half-pay. £20 is a lot of money!

Can't put in words how glad I am of the NHS! By the way, I got here via Ravelry and 'cos of your lovely account of tea party etiquette.