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Why charging for care is not the answer



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