The outsourcing of the NHS continues to go well, as previously described, and this ‘aggravated pimping’ of the NHS was not in any political manifesto. It did really happen, though. It was not simply a bad dream. That is indeed fairly symptomatic of most incremental shifts in policy which has seen the bulk transfer of a State-run “national health service” into a private sector-dominated “fragmented illness service”. The NHS is an explosive issue, to an extent that nobody really wishes to talk about it. Labour wish to campaign on various issues as or when it suits them, such as the spike of mortality in the elderly recently reported, or on ‘whole person care’. And yet it has been perfectly happy to float ideas, such as co-payments, without much warning, though you can probably find the original seeds of such policies in a thinktank or management consultancy document a few years back. The idea of GPs charging is another one of those ideas, in that you could imagine any political party implementing it at the drop of the hat. It might be too optimistic to say ‘it will never happen’, in that many thought the 493 pages of the “Health and Social Care Act” would never happen either. Welcome to the age of policy of stealth, after yet another ‘big bang’ of NHS reforms.

The idea of GPs charging their patients fundamentally runs counterintuitive to the ‘principle of universality’, repeated here by Simon Burns MP, a Conservative, on the Department of Health website:

“An NHS that still provides a universal service, free at the point of use, and is as far removed from a US-style insurance system as any other health service on the planet.”

It’s been successfully argued that rationing to some extent has existed within the NHS or years now; for instance, for cosmetic procedures such as varicose veins stripping, alternative therapies and IVF. This appears to make financial sense at a time when the burden of ill health continues to rise, and possibly the term ‘rationing’ is a perjorative extreme of what might make reasonable policy-sense, an equitable distribution of resources for the most number of people, a fundamentally utilitarian approach. Unlike many other countries, English General Practitioners (GPs) in the UK have always acted as gatekeepers to secondary care services. A torrent of policy steps in the last two decades has seen whether GPs are somewhat ‘overzealous’ gatekeepers, for example in the initial diagnosis of a diagnosis of dementia, and whether the floodgates to secondary care should be opened through alternative routes such as “NHS 111″ (or, previously, “NHS Direct”).

A poll of 440 GPs by Pulse magazine found that 51 per cent were in favour of making patients pay a small fee for routine appointments.  This latest introduction of the GPs charges policy plank came from ‘evidence’ that most family doctors think patients should be charged for appointments to deter them from turning up at surgeries ‘for no reason’, according to a poll. They apparently want the NHS to impose fees of between £5 and £25 per consultation, with some arguing that wealthier patients should pay £150 a time. Except, the evidence here is ‘flimsy’. It was done through a Survey Monkey platform, which means that, without doing a breakdown of the IP addresses, you cannot tell whether the respondents are ‘genuine’, or even from this jurisdiction. This is of course a criticism of any form of electronic market research. What is intriguing is that this poll has actually returned a verdict in favour of GPs charging, allegedly from GPs, whereas previous negative findings have not been published. This is of course exactly the statistical artefact which Ben Goldacre describes on a totally different level to how Big Pharma present the evidence to sway national policy. The Pulse survey also demonstrates a much discussed warning about electronic survey methods; that is, ‘fake respondents’ can theoretically bias the response, and this is precisely the fear in the implementation, whenever it happens, of the “Friends and Family Test”.

The numbers of patients seeking appointments is expected to double over the next 25 years. It is said that this is “driven by the ageing population with more people falling ill”, but this tragically is to submit yourself to the narrative that elderly citizens are a ‘burden’ on the rest of society, whatever social value or capital they might contribute. Of course, this basic narrative itself is resented by many. Experts say the only way the NHS will be able to afford to care for all these people is by charging for some treatments and services which are free. The majority said the charges should be between £5 and £25 per appointment but one anonymous doctor called for means testing with the wealthiest patients paying £150. We are now having this ‘frank and honest’ debate as ‘the cat is out of the bag’, or ‘the horse has bolted’. It is, of course, somewhat of a Pyrrhic victory that we can now discuss the best way of implementing privatisation of the NHS, when many of us didn’t want it in the first place, but there are a number of perceived “advantages” of introducing GP charges. Such an approach ultimately engages well with the ideological drive to reform ‘public services’, so that it is easier to “process map” a public service, and commodify it for economic purposes. GPs might argue that having a deterrent in the form of cost might be useful to stop the NHS being “abused”, in that if the front door is shut in a person’s face, he or she cannot “abuse” the rest of the service. Such restrictions on the “abuse” of GPs might lead to GPs being more respected if one believes that ‘earning power’ provides equivalence between different vocations and professions such as lawyers, plumbers or footballers. Furthermore, the money generated by such a policy move could potentially help to pay for more services, and ‘every little bit helps’, especially when at a time when the NHS is seeking ‘efficiency savings’ of the order of billions before 2020.

GPs’ charges also touches upon an emerging concept generally in policy, known as the “contributory principle”.Ed Miliband used one of his speeches speech to bring the contributory principle back into the heart of Labour thinking on welfare reform. It is less clear, however, that the contributory principle can really serve to underpin a modernisation of the welfare state for the 21st century. It only now covers around 10% of working age benefits. Critically, it is not possible simply to withdraw public services or benefits for people who are in need. Children must be housed and educated, whatever their parents have done. Article 3 of the Human Rights Act also places a floor under the welfare state, preventing people from suffering humiliating and degrading treatment through destitution. Nonetheless, reciprocity is vital to public support for the welfare state and the strength of community solidarity, hence the debate about “contribution” in wider broader terms: not just to embrace caring and community activities, but to mean reciprocity across a range of services and entitlements, whether funded by general taxation, National Insurance or hybrid state-private insurance policies.  This could potentially include GPs charging, and through talking about responsibility from top-to-bottom of society Miliband has also refused to allow this debate to be focused on the poorest alone. While right-wing think-tanks and others want social justice to be reduced to what happens to an “underclass”, Labour’s leader is keeping the whole of society in view, or indeed the “One Nation” philosophy. Knowing which patients use the NHS most, or which “customers” use the NHS most to think of it in free market terms, it is argued, leads to greater clarity in resource allocation and incremental budgeting for primary healthcare services. Charging patients at the point of use, if coupled with an appropriate IT infrastructure for implementing an integrated co-ordinated service, could allow a ‘way in’ for a mechanism to allow how “money follows the patient”. It has long been held, erroneously or not. that the money in the NHS should in theory, the areas of greatest ‘activity’ (a phenomenon known as ‘activity based costing’ by management accountants).

However, it’s easily possible to mount a defence of the “status quo”. You would have thought that was the natural inclination of the “Conservative” Party? Above all, when it might seem that an overwhelming purpose of English health policy is to reduce inequality, with growing appreciation of the social determinants of disease, it will definitely be perceived as an anethema to introduce GP charges. Whatever the finding of this online survey, it can hardly be considered a policy drive of practising Doctors to introduce recklessly or knowingly ‘barriers to access’ for the financially disadvantaged or underprivileged in society. Firstly, it may not be necessary to impose shifts in English health policy, especially at a time when George Osborne is insisting that “the economy is healing” (despite the fact that Osborne claims it has been healing for the last few months, while the rate of unemployment increase has remained stable). A main concern is also that introducing GPs charging further emboldens a public perception, which the media are fond of, that GPs are in fact ‘money grabbing bastards’, and that it is not particularly fair for politicians or think tanks to breed resentment in this way. Furthermore, the policy could disproportionately discriminate against certain population demographics. For example, currently the people who make the most appointments are the elderly. Some conditions might necessarily involve a person to see his or her GP, like depression, pregnancy or disability, and it seems intuitively unfair to ‘punish’ people for needing to see their GP. Whilst there are powerful “generational attitudes” at play here, in the sense that younger people are much more likely to ‘bother’ their GP than elderly citizens for a whole host of reasons, it could be that the elderly are “the hardest hit”, as they have the greatest number of medical and social care morbidities.

The policy could also disproportionately affect individuals with a single diagnosis which embraces a number of effects across different systems of the body (e.g. ophthalmological, rheumtological, respiratory, dermatological, hepatobiliary, neurological). Examples of certain conditions have multi-system effects which have this effect, e.g. rheumatoid disease, systemic lupus erythematosus, Crohn’s disease, ulcerative colitis. Despite the planning of ‘integrated services’ for such conditions, a system of GP charges might simply not be able to cope. Also, patients may be put off from seeing their GP where in fact unknown to them their general medicine may demand it. For example, an individual on warfarin, an anticoagulant, following a prosthetic heart valve may not appreciate that their dosing of warfarin has changed following prescription of the antibiotic amoxicillin hospital for pneumonia. Numerous examples of the interaction of drug interactions exist, and even drug-non-drug interactions, such as grapefruit and the oral contraceptive pill, which could be completely unknown to any individual patient. The less frequently an individual sees his or her GP is bound to have an effect on the quality, both in content and style, of the doctor-patient relationship. A less frequent attendee of the NHS may find that a rarer diagnosis, e.g. of idiopathic thromboytopaenia purpura, is missed, and this could lead to substantial ‘cost implications’ distally. Charging people to see the GP might also have serious unintended consequences in policy with a shift away from a well person consulting a GP on preventive medicine to a patient having to a doctor for treatment for a medical illness or disease; this might be significant in particular medical specialties especially, for example chlamydia screening to prevent pelvic inflammatory disease, an important cause of infertility. Besides, the bother (and cost) of collecting the information for billing purposes may not be worth the hassle (and this is indeed one of the notorious criticisms of ‘activity based costing’ in management accounting described earlier.) Finally, shutting off the route of persons and patients to General Practice in any way could have damaging knock-on effects for the rest of the service. It might lead to longer queues in A&E or Early Admissions Units, which is of course a particular policy concern given a potential A&E beds crisis this winter.

This depends on whether English health policy follows or leads. Barely any policy is based on scientific evidence, especially when that evidence is so poor, with no quantitative analysis of the power or confidence of replies. However, on the balance of probabilities, it is a debate that is better ‘out than in’. The irony of research evidence purporting to reflect GPs’ views is that GPs have been comprehensively ignored in the introduction of clinical-based commissioning groups (GPs) which have no compulsion to have GPs at all as they are simply state-run insurance schemes. Any party can introduce GP charges, but in the grand scheme of things, is probably a trivial issue compared to the ‘aggravated pimping’ of the section 75 mechanism for the outsourcing and subsequent privatisation of the NHS. That is, until it happens.