NHS Blog Doctor: Doctors for reform : core medical services

Today I came across the most horrifying expression I have heard since the inception of NHS BLOG DOCTOR. “Core services” sounds benign, but put it in the context of the modern NHS and marry it up to the shibboleth of “free at the point of entry” and see what you get.

Not much.

Doctors for Reform have just produced a characteristically thoughtful document:

click on image

This document addresses the NHS sin that dare not speak its name. The sin of charging for health care.

Whatever the politicians may tell you, the NHS is no longer “free at the point of entry.” It may be as far as the letter of the law is concerned, but it is not in spirit. For a long time but particularly over the last ten years the door to decent healthcare has been closed to many patients.

Examples are legion. To name but a few: varicose vein surgery , anything that can be labelled as cosmetic, IVF, and dental treatment have long been near impossible to find on the NHS. Front line treatment for various cancers depends on your postcode. The NHS lung cancer patient gets his hand patted by the “lung cancer nurse specialist". The private patient gets Tarceva.

Dr Crippen has had patients die on the waiting list for radiotherapy and for cardiac surgery. That does not happen if you have private health insurance.

Something needs to be done. What do we wish to achieve?

Every UK citizen should be entitled to, and be able to obtain, a reasonable standard of medical care within a reasonable period of time, independent of wealth and status. (Dr Crippen's NHS mission statement)

Note that I do not say that the NHS should be committed to health care “free at the point of entry”. The politicians say that. They dare not say anything else. It is a lie. Healthcare has never been truly free at the point of entry. Some health care has been free but (and more and more) much is not.

The “great and the good” have always gone privately and received a better standard of care. Now more and more people are, as the above document shows, “topping up” their health care. And if you are waiting for coronary artery surgery, this is the only sensible action, if you can afford it. Make no mistake, if you cannot afford to, you have a higher risk of dying.

Healthcare has to be rationed. The only question is how best to do it. You can ration it by stealth; by closing the NHS doors to patients with certain conditions; or by pretending there is no rationing by having waiting lists upon which some patients will die. We can mitigate the need for rationing by eliminating abuse of the service. Sometimes it is cynical abuse, more often it is abuse by people who do not understand that health care is expensive.

There needs to be a front end charge for health care. Yes, a “charge” at the point of entry. That charge needs to be a percentage of the costs of care that each patient needs. And yes, that means that some will pay more than others; that those with poor health will pay more. The system must be properly safety netted by means testing so that none will be denied health care because of cost but all must pay something.

A front end charge at A/E departments and health centres of, say, £20 would overnight solve most of the problems of abuse. We can go on from there. A charge of £30 for missed appointments; a charge for lost prescriptions; a charge for ambulances with a penalty charge for those who thoughtlessly use ambulances rather than taxis.

The figures I give are off the top of my head. The precise charges would need thought. But the principle is essential. People must be taught that health care is expensive and the only way to do that is to make them reach for their wallets.

Everytime I float this idea, there are howls of anger. But, make no mistake, many patients are already taking the initiative and paying for a health-care “upgrade”. Doctors for Reform say:

We have also described key trends, widely accepted among healthcare commentators, that suggest that such payments will become more rather than less prevalent over time. Yet at present the issue of “top-up” payment and indeed funding reform remains a taboo in frontline politics.

It has to be recognised that the use of top-up payments is increasing but on an ad hoc and dispersed basis. We need to face up to this rather than ignore it. We need a more realistic debate than politicians of all parties are willing to allow on how to define core services and the role of top-up payments.

In simple terms, the rich are buying additional quality health care whilst the poor make do with a “core service”

The concept of Patricia Hewitt defining NHS “core services” is horrifying. But that is where we are headed. The poor folk can be educated in the comprehensive schools by teaching assistants, and have their health needs catered for by nurse-practitioners and health-care assistants. The rich will continue to pay for public schools and for medical advice from doctors.

We need to give all people the right to contribute an amount they can afford towards their health care. If we do not, soon only the rich will be able to access decent health care provided by doctors whilst the poor struggle on with a second rate service from "health care assistants".