Cookie policy notice

By continuing to use this site you agree to our cookies policy below:
Since 26 May 2011, the law now states that cookies on websites can ony be used with your specific consent. Cookies allow us to ensure that you enjoy the best browsing experience.

This site is intended for health professionals only

At the heart of general practice since 1960

Why charging for care is not the answer

  • Print
  • Comments (9)
  • Save

Dr Philip Lee recently wrote an article arguing that some individuals should contribute financially to their NHS care, because of their lifestyle choices. I enjoyed his piece, and admire him for sticking his head over the parapet in this way.

It is vital that we have free debate regarding ways to make the NHS viable. But I don’t believe the system he advocates would work, and I find it morally uncomfortable.

On the small off-chance that it isn’t abundantly clear by the end of this piece, let me say at the beginning that I have no special qualifications in medical ethics or economics, these are just my thoughts as a GP.

Firstly, let me quickly confess a personal interest: wariness of any bill that proposes ‘to require GPs to issue annually, to each person eligible for care provided by the NHS, an itemised account of the cost of his or her healthcare’. I‘ll say no more, except to refer you to Copperfield’s excellent rant on the fact that most GPs have physically run out of time.

Secondly, this strikes me as another example of profound confusion over the nature of our role.  Are we advocates for our patients, on their side when things go wrong, or are we agents of the Government? Is our first duty to the person in front of us or to the coffers of Whitehall? The answer may be that in straitened times we have no choice, if the system is to survive. But gathering data for the purpose of implementing charges on individuals is a sea-change, even from QOF. We should not breeze over it so easily.

Thirdly, I doubt our patients are really so foolish that they would give us accurate information, if it would inflate their healthcare bills. The bill would prompt a sudden increase in self-reported jogging, and the pubs would be full of people who had just lied to their GP. But if this system wouldn’t work on self-reporting, how would it work? The prospect of cross-checking people’s claims about their lifestyles against their real activities will lead us rapidly into deep, dark, and dystopian waters.

Dr Lee doesn’t specifically mention which lifestyle choices would prompt an additional charge. But I imagine that the familiar four horsemen of medical apocalypse will amble by on wheezing steeds: Smoking, Alcohol, Poor Diet, and Sedentary Lifestyle. These are the easiest targets – highly visible, chronic choices that unarguably have an impact on health, and which already have honourable mention in the more ‘nanny state’ parts of QOF. But even introducing charges for these would not be a simple thing.

These risk factors are overwhelmingly more common in deprived areas. Imposing additional charges for them would crank up the power of the inverse-care rule. It would also be practically unenforceable; if your patients are anything like mine, the ones who make the most self-destructive lifestyle choices usually don’t have the healthiest bank accounts either. Would we squeeze what money we could out of them, before withdrawing their medicines when funds ran out? Would we never provide them with any care they couldn’t pay for, and risk the media’s fury? Or would individual clinicians quietly sabotage the system by caving in and treating them anyway, regardless of ability to pay, because that’s what we all joined the NHS to do?

It isn’t clear where the lines would be drawn. There is something Puritanical that delights in punishing smoking and drinking – and they already pay heavy ‘sin taxes’. But what about nice middle-class activities like rugby, or horse-riding, which predictably increase the risk of injury? If I get run over crossing the street, and the NHS has to patch me up, should I be billed if CCTV footage can prove I showed scant regard for the Green Cross Code? Should golfers and tennis players be charged more for their epicondylitis than anyone else? And this is before we have started considering concurrent mental health problems. Will A&E units charge for dealing with overdoses? What will we say to patients who tell us their poor lifestyle choices were driven by depression?

I believe that lawyers, not patients or the NHS, will benefit from the imposition of charges on a selected subsection of the population. Not just because people will inevitably challenge any assessment that makes them pay more than their neighbour (and probably with added costs for the distress of the whole affair). The study of genetics is advancing every day. If in 2013 we charge somebody for treatment of her diabetes, because her lifestyle probably contributed to its development, we are sowing trouble for the future. Imagine that in 2023 a court sees her personalized genome report, proving that she was doomed to become diabetic however she behaved: could the NHS avoid ten years of reimbursements, with interest, and additional payments for compensation? Conversely, would we offerlower tariffs for those who could show protective genes?

The challenge to all this is, of course, to come up with something better. There is an urgent need to make NHS finances more robust. I would love to hear Dr Lee’s reply to the above, and if we can get a productive debate going, I will be thrilled. But in its current format, the system he proposes seems to me unworkable, likely to drive a further wedge between doctors and patients, and potentially fraught with unintended consequences.

Dr Nick Ramscar is a GP in Bracknell, Berkshire

Readers' comments (9)

  • I have to agree with the author on this one. We can't go expecting the poor to pay for treatment on the grounds of their lifestyle choice! Often being poor is not a matter of choice, however, rather more something that can be inflicted upon oneself due to poor health e.g the cardiac patient. Lived a normal happy life with a good income, good lifestyle including healthy diet and plenty of exercise as gym membership could be afforded.....then BANG! Your patient has a heart attack......is retired from work due to ill health, their home is repossessed along with the healthy lifestyle. This poor patient goes bankrupt whilst waiting for the DWP to make up their minds about benefit and the circumstances regarding this individuals' case.
    Then the patient is (hypothetically) denied care on the grounds of their lifestyle choice. It's a bit harsh don't you think? We would do far better to make cost savings on our utility bills. Install light and movement sensors so that lighting only comes on when something moves and triggers the sensor. Reduce heating bills by maintaining the heating at a lower temperature, switching it off altogether during the summer!

    Unsuitable or offensive? Report this comment

  • Apart from the moral objections (with which I concur), it seems to me that Dr Philip Lee has a very poor understanding of causality, Even in the case of cigarette smoking, there are some cases of lung cancer in non-smokers and therefore probably some cases in smokers that weren't caused by their smoking.

    But smoking is by far the best-evidenced case. Who knows whether an overweight person's diabetes was caused by their lifestyle? Lee's views on charging are not only morally repugnant but also show a deep ignorance about the limitations of correlations observed in observational epidemiology.

    Unsuitable or offensive? Report this comment

  • I think charging for lifestyle misses the biggest point. The group 'wasting' the most money are those anxious about their health. Those who ask to see a GP to check their chest when they have a cold. Those who take their child's bruise to a+e to make sure it is not broken. Many of these would not bother if there was a small charge to seek reassurance. Very few would do so if they paid the actual cost of the attendance.

    Is anyone brave enough to tackle this issue?

    Unsuitable or offensive? Report this comment

  • They don't trek all the way up to A andE,, where they know there is likely to be hours of tedious waiting..for 'reassurance' but totally reasonably to get the problem checked out ,usually it must be said - by staff who totally understand the need to do so..

    Unsuitable or offensive? Report this comment

  • I agree with Bryan. It's the worried well and these are usually the middle class educated A small charge might be the answer but who has the balls for that ?

    Unsuitable or offensive? Report this comment

  • So there we have it. The "morally repugnant " card has been played, so we can kiss goodbye to any rational discussion as to how to fund healthcare in this country. I guess our colleagues around the world clearly have no sense of morals.

    Unsuitable or offensive? Report this comment

  • Mark Struthers

    You have to laugh: David Colquhoon with his silly shows of moral repugnance. Take the three year trial of the Royal Free Three (Wakefield, Walker-Smith & Murch) was a moral outrage, beyond any possible reasonable doubt. However, this time-expired academic found the GMC’s outrageous conduct to be something morally acceptable. Disgraceful!

    Unsuitable or offensive? Report this comment

  • This comment has been moderated

  • Mark Struthers

    The trial of the Royal Free Three was a moral outrage, beyond any reasonable doubt. This is what I meant to say. The behaviour of the GMC was "morally repugnant", whatever Professor Colquhoon might possibly think.

    Unsuitable or offensive? Report this comment

  • Perhaps the answer lies not in imposing charges on one group or another but in seeking opportunities to value add and differentiate services for a fee. At the time Apple introduced the iPhone we had all been trained to expect our carrier would keep giving us a 'free' handset when we renewed our contract. There were a plethora of those who doubted Apple would be able to charge for something people had hitherto expected for nothing. History demonstrates the reality.
    As an example, I am sure there are many time-poor middle class customers who would be prepared to pay for healthcare convenience (telehealth monitoring of chronic conditions; priority out-of-hours appointments and so on).
    Perhaps the focus should be on what added value can be introduced to the system to generate additional revenue.

    Unsuitable or offensive? Report this comment

Have your say

  • Print
  • Comments (9)
  • Save