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A faulty production line

It’s time to talk about charging patients

Dr Karim Adab

I recently took a trip out to Western Australia to visit family, and while there took the opportunity to meet my GP friend Dave Jones for a beer - on the beach, of course. He has absolutely no intention of returning, and I don’t blame him for a second. At home, mournfully shaking the sand from my shoes, I couldn’t help but feel that he and the other Antipodean NHS refugees might be onto something. Perhaps there’s something we can learn here?

The Australian system consists of complex alchemy between public and private funding; so complex, in fact, that I beg you forgive me for the odd factual inaccuracy.

Essentially, state-held Medicare insurance pays a percentage toward primary care and outpatient appointments, depending on individual means. The state foots the bill for emergency and inpatient care. To balance the books those who can afford private health insurance are expected to pay for it. If you choose not to, you accept an equivalent tax levy. Packages are often sweetened with dental care and incentives such as gym memberships. If you look after yourself, your premiums are lower.

Yes, sometimes cost is a barrier to access. However, Australians still foster the same doctor-dependency that we bear with chagrin: it seems that even having to stump up for an appointment doesn’t prohibit people from seeing their GP.

 Australian GPs are generally a less put-upon species

Both systems are of exceptionally high standard, and Australians lead the way in many parameters of public health. They have one of the lowest smoking prevalences in the developed world (one might quite reasonably suggest that this is a consequence of people making different decisions with their disposable income when they have to pay for healthcare). Their life expectancy outstrips almost all of their Western equivalents.

The OECD recently criticised their hospital admission rates for chronic conditions, but they’re still doing better than we are.

But, most importantly, things just work. Dave offered a useful anecdote: earlier that week he’d seen a woman with a suspicious neck mass. He called up one of his radiology colleagues, who obligingly saw her that afternoon for ultrasound and guided biopsy. The biopsy was analysed within 24 hours and flagged for malignant cells. He slung the report and a letter over to the relevant local oncologist for an appointment the following morning.

That’s 48 hours from suspicion to secondary care, including diagnosis. Spare me NICE’s guidelines, over-reliant on mythical GP access to imaging. Save me from their migraine-inducing cancer referral wall chart, a spaghetti junction of roads to nowhere.

If someone demands a scan, they can pay for one out of their own pocket. This in turn disincentives further unnecessary investigation. Dave was certain that by increasing access to routine investigations patients are more satisfied they have been properly investigated and are less likely to re-present and demand onward referral.

GPs are treated well

Outside of the consultation room, Australian GPs are generally a less put-upon species. They exist unburdened by criticism from amorphous Quango head honchos. There’s a welcome dearth of talking heads-in-jars that operate under the fanciful conceit of patient advocacy.

Pay is good, and what’s more, you can earn well and still preserve your sanity. Administration is taken care of by someone else. If you get bored in the city, you can fly-in/fly-out to the Bush to marvel at the exotic pathology.

People like to see their doctors successful: a friend of mine who’s an emergency department registrar in Sydney recently remarked that a Porsche in car park was perceived as an accolade of excellent practice as opposed to a dartboard for the disaffected.

What’s more, all public sector workers are entitled to a proportion of their pay allocated up front, tax-free for living expenses and entertainment. Incentivising public sector workers! Seems a bit radical to me.

Of course there are problems. The indigenous people suffer grave health and social inequality. Alcohol and crystal meth abuse are virulent throughout the European majority. Waistlines are ever expanding. Public waiting times for simple procedures are often worse than ours, mental health provision is similarly poor. You can still encounter a sometimes surprisingly unreconstructed worldview.

The NHS is proudly held to this nation’s breast as an emblem of our society, and we must do our utmost to defend its principles. Sadly, its current trajectory is inexorably set for a two tier system by default, if not design. The elephant in the room teeters precariously.

We need to ask ourselves: is it really in the best interests of our patients to have to wait eight weeks for physio, or five months for a routine outpatient appointment? Would it not just be the grown up thing to have the discussion, listen to the pros and cons, and make an informed decision about the future of our healthcare system?

The problem is, clearly, that this is a discussion requiring a degree of honesty, of testicular fortitude; qualities completely absent within the ranks of the modern political class. If we lead the discussion we can frame it, we can own it. This is surely preferable to shying away from it and doing the Government’s dirty work for them.

We owe our patients the truth: the truth that a well-resourced primary care service in any developed healthcare system ultimately saves millions – in pounds, consults and lives – but that currently we limp by with anything but. We would do well to remember that our ultimate responsibility is not to the future of the Health Service, only to those who use it. As my friend in Australia says: Perhaps faced with the options, the public might be prepared to accept change, but to do so would involve removing that incredibly powerful and increasingly unachievable aim: healthcare free at the point of use – or abuse.’

Dr Karim Adab is a GP in Manchester

With help from Dr David Jones, a GP in Perth

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Readers' comments (18)

  • Im suprised the author returned after his recent voyage...

    my message to the readership is simple and to the point...


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  • Well put. Time for change.

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  • What a welcome bit of reflection after the vacuous invective of the likes of Drs Beer and Chand.The NHS is not "the envy of the World", but can and indeed must incorporate new ways of working. Let us hear more of the positive suggestions; put up or shut up!

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  • Vinci Ho

    Balanced view in my opinion.
    It is boiling down to the honesty and integrity of these political leaders. The superficial ideology is a virtual utilitarianism : the more appointment and access , the 'happier and healthier' people are . But they are not willing to fund these extra activities . The underlying agenda is of course ,to take down the flag of NHS. Their abhorrent dishonesty will always prevent an open debate or even referendum of some sort for a judgement of the way to fund NHS. Sucking 7 days routine care into the equation is purely selling this virtual ulitility maximisation but evading the responsibility of funding that.
    While I agree a small fee is perhaps indicated for weekday appointments , I certainly stand by my argument that routine weekend appointments should be charged fully(provided that we have the GP workforce!)

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  • Agreed

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  • A simple start would be for everyone to pay towards their prescriptions, say £2 per item. That would stop the requests for paracetmol and put a price on something that as regularly stocked up. or stop any OTC drugs from being prescribed at all. Then go for £5 per GP appointment, £15 opd, £40 scans and £100 operations?

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  • I don't understand why no politician has admitted this. I suspect the public would respect a bit of honesty but the behaviour of politicians never fails to surprise/disappoint.

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  • Of course prescription charges are the ultimate form of "Taxation without representation". Dr decides, patient pays. Many will be familiar with the experience of patients who tell the pharmacist that they cannot afford the charges and ask which are the most important items on the prescription.

    As always it will be those at the margin (just above the threshold for any extra benefit) who will suffer from charges. The effect on dental and optical services (now virtually absent in NHS as NHS charges are so close to costs of private treatment of dental care).
    The answer is more honest demand management and deciding what the NHS is for (not just to get more votes!)

    Long ago I proposed that treatment for any condition that threatened life or livelihood (with inclusion of retired and children as if they were working) would be treated free and to high standard and quickly. Decision to be made by GP as doc of first contact. Patient may appeal but if appeal is judged frivolous they would have to pay costs of appeal. If appeal succeeded then costs incurred by patient would be reimbursed. No sanction to be applied against GP. I believe this would make NHS affordable and ensure that "Patients got the treatment they NEEDED" (NB Needs not wants) at affordable cost. Any other treatment patients "wanted" would be paid for by the patient.

    Needs a mix of political courage and effective management of the system neither of which appear to be very evident at the moment.

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  • What about OOH services.

    When I worked for Health-call and subsequently was Medical Director for Primecare we provided a good quality and safe OOH service form which patients could get advice (form a doctor) or treatment at any time. It was affordable and effective in the main. Management was streamlines and a minimal overhead.

    Since GPs were relieved of the "responsibility" for OOH (they continued to provide it for quite some time as there was no one else to do it) OOH has gone to hell in a basket. Duplicated services have multiplied, costs uncontrolled,service appalling and unsafe. Why? Because it was handed over to those who had no idea how to provide it.


    No lessons learned of course - just more of the same.

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  • Sorry about the typos.

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