Introducing GP charges won't solve the primary care dilemma
Henry Featherstone 5:06pm
A common response to the impending age of austerity in the NHS is to suggest that charges are introduced for visits to the GP. The line of reasoning adopted by MEPs and think-tanks alike is that a means-tested £20 charge will "encourage healthy, wealthier people to use the NHS only when absolutely necessary."
Leaving aside the fact that such a system would cost more to administer than it would generate in revenue, a more interesting question is whether the converse holds true? That is, whether unhealthy and poor people aren't using GP services when they should be. The consequence of this is more profound because poor and unhealthy people tend to cost the NHS much more than few unnecessary appointments booked by the worried well.
Looking at a composite measure of the number of GPs per population, weighted for age and need, compared to how deprived that population is, we see that there is a shortage of doctors in the most deprived areas in England. Half-empty GP surgeries in wealthy areas might be a measure of success for some policies, but they won’t help address inequalities in GP access.
GPs are well-educated, relatively wealthy and mobile citizens and tend to want to live and work in affluent areas. So a policy which merely introduces a means test for GP access in affluent areas will do nothing to address the bigger issue, which is attracting more GPs into deprived areas where the burden of disease, and cost, is greatest. This task was once the preserve of the now defunct local Medical Practice Committees.
On the whole, GPs are good value for money. Roughly speaking, GPs see 80 percent of all patient consultations for about 7 percent of the NHS budget (excluding prescriptions). So a relatively cheap and simple solution to improving the overall health of the population, and particularly that in deprived areas, lies in providing more, and improved, primary care services.
Huge funding increases in recent years means that the NHS now employs more doctors, nurses and bureaucrats than ever before. Cutting bureaucracy should be a priority, of course, but delivering effective healthcare to a population also requires that we encourage enough GPs to set up where they are needed most.
Lord Darzi has attempted to remedy the inequalities of access to healthcare with the introduction of polyclinics. The idea is a sensible one, but the implementation flawed and top-down. Some patients in deprived areas are being given new polyclinics, but as with existing GP surgeries, the location is where the Primary Care Trust (PCT) dictates. In many case, if you don’t have a car a polyclinic placed by the PCT is just as inaccessible as a half-empty GP surgery in an affluent area.
For all these reasons, Policy Exchange is currently undertaking a research project on extending patient choice into primary care. Watch this space.
Henry Featherstone is Head of the Health and Social Care Unit at Policy Exhcange.
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Fergus Pickering
September 9th, 2009 5:42pm Report this commentA most interesting and illuminating piece telling me all sorts of things I didn't know. Thank you for that.
TrevorsDen
September 9th, 2009 5:55pm Report this commentBe careful where you step in this minefield.
RobertD
September 9th, 2009 6:04pm Report this commentTo avoid the charge just show up at A&E. Admin and care costs rocket. No savings in sight. Stupids.
Two issues on the uneven location of GP's. Firstly most GP's are still private contractors to the health service and not direct employees. There is no way the centre can compell people to move to less attractive areas. Secondly an increasingly high proprotion of GP's, now approaching 50%, are women. Some (possibly a majority) put location for their family to live and personal safety well ahead of financial reward so will not move to rough deprived areas whatever the money on offer. Until there is a comprehensive approach to to some of these areas incorporating GP services with housing, education, social services and tougher law enforcement they will continue to go downhill. Its not the money. Cash has been hosed at these issues for the last ten years. Its the lack of local authorities with the power and motivation to put all the pieces together.
Anne Wotana Kaye
September 9th, 2009 6:29pm Report this commentYears ago, a very wise and kind doctor said something I have never forgotten. I mentioned that half the people waiting to see him were either hypocondriacs or neurotic, if not clinically insane. Who, I asked, would want to hang around a miserable waiting room if they weren't either really ill or bonkers? My dear doctor smiled, and gently replied, "In either case, they are in dire need of any help I can offer."
Robert Eve
September 9th, 2009 6:34pm Report this commentSurely if you make charges for GP visits means tested you defeat the point of the charges.
If I was a GP I certainly would much prefer to live in an affluent area.
chris W
September 9th, 2009 7:07pm Report this commentSo, Harriet Harman is not wrong in wanting to introduce a social background dimension into allocation of taxpayer funded resources then? Positive discrimination in siting of clinics, schools and access to social help will always yield greater leverage if applied to disadvantaged "rough" areas. It is the will to change, and the follow through to make it effective that is lacking from all governments. Let private enterprise in, and cut out public sector admin overheads, that will provide the incentive which will make the step change. then support until results come through.
Andy
September 9th, 2009 7:14pm Report this commentVia our taxes we already pay for visits to the GP.
If additional charges were to be introduced would GPs miraculously start seeing people at their alloted appointment times or would they continue to keep busy people waiting 40 minutes beyond the alloted time as they currently, invariably, do?
Colin
September 9th, 2009 8:15pm Report this comment"The line of reasoning adopted by MEPs and think-tanks alike is that a means-tested £20 charge will "encourage healthy, wealthier people to use the NHS only when absolutely necessary." "
I think you'll find that given the patchy and in some cases dire state of the NHS, most healthy and wealthier people already use the NHS, only when absolutely necessary, if at all.
Finding a way to stop GP's surgeries being used by some people as a kind of tearoom, with professional sympathy, would be a better way forward.
2trueblue
September 9th, 2009 10:12pm Report this commentAbout 11.5% of your paycheck, plus a 12.5% contribution by your employer is paid in NI contributions.
Why should those who are working and paying this tax, or those who have done so all their working lives be asked to pay again?
The whole idea was that we pay whilst employed so that when we need the service, it is free at the point of delivery?
I would happily have my contributions back, plus interest and take care of it a myself.
MEPs are being dishonest as they are dealing mostly with the EU where different approaches are in operation.
My son and his French wife moved to France and as she was 6mths pregnant at the time of their move they were asked for e2,000 deposit up front at the hospital. On top of that they had a bill for the deivery. The original e2,000 took 18mths to come through.
Later when our young grandson had an accident he had to pay the bills on the spot. We did not have any help with interpreters during the visits to causalty and subsequent appointmants. His wife was at another hospital as an inpatient.
Clearly we run a very different service that is free to all who pitch up, and now we want to charge those who are currently funding the system through their taxes.
MPS and those in 'think tanks' have shown us that they inhabit a totaly different world. Let us send them into space where they beong.
I have now given the picture of a system that is being challenged by total idiots.
There must be some real human beings around who are living in our world and can come up with real solutions to serve us? Think tanks, quangos, MPs, they all seem to inhabit a very rarified world, and are there by our gift. How can we ensure that we get good service? We are entitled to it, all of us.
Simon
September 9th, 2009 10:24pm Report this commentAndy - what GPs do is to try and allot people the time that their condition demands.
If problems were all neatly packaged in 10 minute parcels - or if people only had one problem at each visit, or if GPs weren't encouraged to tick an insane amount of boxes, or if GPs could avoid the IT nightmare that is the Choose and Book referral system, or if there weren't the occasional emergency, or if all patients turned up on time for their appointments - THEN we could guarantee that you would be seen at your allotted appointment slot.
Until that Utopia comes, you'll have to wait your turn (or change your GP, if you're not too busy).
Donald Acheson
September 9th, 2009 10:53pm Report this commentAnything that encourages a patient to engage their brain before making an appointment( or just turning up and demanding to be seen as it is an "emergency") is to be welcome.Unfortunately anything that is not directly paid for is not valued in modern Britain ( indirect payment via tax doesnt count Andy)
British general practice is being overwhelmed by insatiable demand encouraged by politicians.Anything that encourages the public to engage their brain before consulting an already overworked doctor is to be welcomed
Fergus Pickering
September 9th, 2009 11:26pm Report this commentAndy, has it ever occurred to you why doctors keep you waiting? Because they are seeing other patients, you doughnut. You want them to turf the buggers out so that they can see busy old you just when you want? My GP is excellent, thorough and caring. And I have to wait to see her because that is what she is doing. I suppose you want the GP to take time over YOU. Of course you do.
Frankie
September 10th, 2009 9:04am Report this commentChris W - positive discrimination in GP surgeries already exists: the Primary Care Service Framework (May 2009)requires GPs to give preference to Gypsies and Travellers over all other patients, by seeing them first, even if they have no appointment, and by giving them a longer consultation time.
So much for 'equality of access' and the principle of treating people according to need.
Barbara Owen
September 10th, 2009 10:43am Report this commentWell done Policy Exchange - Health Section, for tackling such a difficult problem.
I look forward to reading the results of your research.
Tiberius
September 10th, 2009 1:30pm Report this commentMost of the above just doesn't have relevance to my experience with my GP.
In recent years, we've gone from appointments only in the afternoon and open surgery in the mornings, to fewer GP hours being worked for more pay(thanks to that idiot Patricia Hewitt), and an appointments only system which is operated by a triage nurse. I now have to phone up to log a call back from the triage nurse. If I'm on the phone when she calls back, she doesn't try to ring again. If I do get to speak to her, humiliatingly I am forced to describe my symptoms to her over the phone if I want to be considered for an appointment. I have no idea or reassurance that the secretarial staff are outside the loop over the conversation. Emporer Nero would have approved of a system which includes a "thumbs-down" option.
We are where we are. Cameron is right to tackle education first and leave the NHS for later. But immediate improvements can be achieved by abolishing the GP service like the one I endure, and opening 24 hour, non-appointment polyclinics. I have no problem seeing an unfamiliar doctor as long as they are qualified and not exhausted. Get rid of triage nurses (send them back to the hospital wards where they are of some use), and dismiss the jobsworths who "manage" GP practices.
As for travel to polyclinics by the "deprived", are we really to believe they cannot use the same means of transport they use to get to town, the supermarket, car-boot sale, or pub? It's patronizing to think they can't.
Polyclinics operated thus would cut out the need to ration GP visits by means of a fee. We have all already paid once, after all.
Peter from Maidstone
September 10th, 2009 2:11pm Report this commentIf the GP bill is 7% of the NHS budget then it works out roughly ar 6.3 billion a year, which is about £1000 per person per year. With my family of 6 that is £6000 a year. Is the GP service I receive worth £6000 a year? I am not sure or very convinced. A few appointments for blood tests, and a bit of a skin rash. Probably less than 2 hours time for my whole family most years. Even when the children were younger no more than 12 hours a year. Is it worth £500-£3000 an hour? I am not sure. I don't think so.
Verity
September 10th, 2009 2:47pm Report this commentInstead of obsessing about how many angels can dance on the head of a pin, why don't you just adopt the French or Singapore system wholesale? The money follows the patient. It works. All the heavy lifting's been done. All you have to do is follow the exact template.
Donald Acheson
September 10th, 2009 3:17pm Report this commentPeter you have miscalculated by a factor of 10.A GP practice receives approximately £60 per patient per year to provide basic services. Additional money eg for chronic disease management pulls it up to about £100 as a very rough average( it varies between practices). I would suggest you are getting a bargain.
Verity
September 10th, 2009 3:48pm Report this commentCopy France. In fact, let them come over and run it. It is aces. France and the US continually teeter between 1st and 2nd best healthcare in the world. Except in France, there is no charge at point of delivery.
Peter from Maidstone
September 11th, 2009 5:51pm Report this commentDonald Acheson, I have taken 7% of the NHS budget, which comes to £6 billion. It may well be that each GP gets less, but if the cost to my family to support the NHS is as I describe then that is how much it costs me. Is either the budget (£90 billion) or the % for GP provision in the article, wrong?
Donald Acheson
September 11th, 2009 10:52pm Report this commentPeter as the yanks say do the math.NHS budget approximately £90 billion, 7% of which equals £6.3 billion, UK population approx 63 million. 6.3 billion divided by 63 million equals 100 pounds per patient. One billion equals one thousand million, duh!.
The NHS may be grossly inefficient, British general practice is not.
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