John Humphrys asks: Should we pay for visiting a GP?
From its foundation in 1948, the NHS has been committed to what is almost a sacred principle: that the health service should be free to everyone at the point of use. But now it is being proposed that we should all have to pay a fee when we visit our GP. The idea comes not from some free-market think-tank, keen to pare back the state and slash taxation, but from a senior nurse. Such is the financial crisis looming in the health service that this radical idea is being debated by the Royal College of Nursing at its congress in Liverpool. Should it be adopted?
The point of offering health services ‘free at the point of use’ and footing the bill from taxation and national insurance contributions is obvious enough. The whole idea of the NHS is that it should provide health care for everyone at the moment they need it and not just for those who have got the cash when the need arises.
It’s a principle still largely followed, though there have been breaches in the past that have caused huge trouble. When Clement Attlee’s government, which set up the NHS, decided to impose prescription charges in 1951, three senior ministers resigned in protest. And for long afterwards, every time the government of the day increased the charges to keep them up with inflation, there was a political furore, even though most prescriptions were exempt from the charge.
Now, the demands on the NHS budget are becoming so great that unless something is done, the health service is heading for a huge financial crisis. Since the current government came to power in 2010, the NHS budget has been protected while the axe has swung vigorously in most other government departments. But the protection has been only limited: the overall budget has been frozen for four years in real terms, meaning its cash budget has risen only in line with inflation. The problem is that rising demand has meant that money has had to do more and more.
Several factors have added to the pressure.
- The population is growing. We are living much longer and it’s the elderly who make the most use of the NHS.
- The number of nurses has increased.
- The cost of drugs has risen sharply and so have staff pension costs.
Shifts of spending between parts of the service cause acute strains in those areas that have to forgo money. For example, in the next financial year, £2bn is being taken from the hospital budget to finance a Better Care Fund, which will help the NHS and local councils to integrate health and social care and so, it is hoped, ultimately relieve the burden on the acute services.
The result of all this is that next year NHS England will probably face a £2bn funding gap in its £100bn budget. One in three hospitals is believed already to be in the red. On current forecasts, NHS England faces a £30bn black hole by the end of the decade.
It is in this dire financial context that Andy McGovern, a hospital nurse from east London, has proposed the motion at the RCN congress that the nursing union should support the introduction of a fixed fee for visits to a GP. A figure floated is £10 a visit. This, it’s estimated, would raise about £1.2bn a year.
Mr McGovern thinks there would be additional benefits from the measure, notably deterring people from wasting GP’s time by making appointments when they don’t really need them, or simply not bothering to turn up.
There is strong opposition from patients groups. Katherine Murphy, chief executive of the Patients Association, said: “Charging for GP appointments could have a devastating impact on many vulnerable and disadvantaged people. There are many people who cannot afford to pay for GP appointments. In addition, with many GP practices strictly enforcing ‘one problem per appointment’, many patients will decide that their best option is to present at A & E, adding extra pressure to an already overstretched system.” It has also been argued that since a charging system would have to include exemptions (as prescription charges do), it would be bureaucratically expensive to collect the new charge.
Mr McGovern is not alone, however, in wanting us to pay. The Kings Fund, the leading health think tank, recently suggested a charge of between £10 and £25 be imposed not only on those visiting a GP, but also on those attending A & E. Lord Warner, a health minister in the last Labour government, floated the idea of imposing on everyone a £10-per-month NHS ‘membership fee’.
None of these ideas has been picked up by the government and it seemed unlikely that the RCN would vote for Mr McGovern’s motion. Indeed his own motivation in proposing it seems to have been rather broader. He said: “We need to have a robust and honest debate about what we’re going to do in the future, because the money isn’t there. We want something that gets people talking about how we pay for NHS services going forward.”
This raises the question of how, if such charges are not going to be imposed, the NHS can avoid the financial hole it is racing towards. An obvious answer is for the government simply to put up taxes to pay for it, and there are those who advocate just that. But they do not seem to include the leaders of the main political parties who clearly believe it would be electoral suicide openly to campaign for higher taxes.
That leaves the option of cutting NHS services. Jeremy Hunt, the health secretary, has suggested two ways this might be done. First, the NHS should stop providing free cosmetic surgery except in the most obvious and extreme circumstances. And, secondly, it should take a more rigorous approach to charging foreign users of NHS services.
A more radical suggestion would involve a fundamental change in how the NHS is conceived. Instead of being a general service, providing all healthcare needs and funded through taxation, it should become more like an insurance scheme, financed through national insurance charges but, as in the case of other sorts of insurance policy, with very clearly defined terms about what is and (more importantly) what is not covered by the insurance policy. All healthcare outside the policy would then have to be paid for privately. The objection to this is that it would mean an end to the NHS’s claim to be able to provide universal cover.
Whether politicians will be ready to have a debate about all this so close to an election remains to be seen. Probably they will all avoid it like the plague. But it’s an issue we cannot dodge forever. Meanwhile, a nurse has suggested we should pay for visiting our doctor. Do you think he’s right? Would you be happy to pay a tenner a visit? And, if not, how else do you think we should stop the NHS falling over a financial cliff?
