Why the debate over NHS charges won't go away

The looming funding crisis means that a third of GPs now support patient charges, with the number only likely to increase.

During last week's debate over the introduction of new NHS charges for migrants, few noted one salient point: that the introduction of payments for some patients (and the creation of an accompanying infrastructure) makes the eventual introduction of payments for all patients more likely. Just a few days on, that issue has risen again after a poll of 800 GPs found that 32% support charging patients for A&E visits in order to reduce unnecessary attendances. The public would be required to pay £5-£10 each time they use the service and would have the money refunded if their condition was shown to need attention. One doctor says: "Charging even a nominal fee of about £10 for each ­­attendance will probably cut the attendances by half", while another comments: "If patients had to pay a £5 charge to attend A&E – that could be refunded for appropriate attendances – they would be more inclined to take their coughs to the pharmacist where they belong."

Both the government and Labour have given the idea short shrift today. The Department of Health said that "charging patients goes against the founding ­principles of the NHS" and shadow public health minister Luciana Berger said: "Forcing patients to pay at the door of A&E is not the way to end David Cameron's crisis. Under this government, it's become harder to get a GP appointment after Ministers took away the support for evening and weekend opening in 2010. They must help patients see their family doctor and stop the closure of NHS Walk-in Centres to reduce the pressure on A&E. A staggering number of GPs can see that Jeremy Hunt's plan to keep older patients away from A&E will have little effect. He and David Cameron must bring forward realistic plans to tackle the crisis they've caused."

The proposal is also opposed by the Royal College of GPs, the British Medical Association and the Patients Association. The RCGP’s Dr Helen ­Stokes-Lampard said: "It would put us on the ­slippery slope to the Americanisation of ­care, where only those who can afford it get it." But for several reasons, the debate over NHS charges is unlikely to end here.

At present, despite the common view that it has been shielded from austerity (expressed by Liam Fox yesterday), the NHS is experiencing the toughest spending settlement in its history. Since 1950, health spending has grown at an average annual rate of 4%, but over the current Spending Review it will rise by an average of just 0.5%. As a result, in the words of a recent Social Market Foundation paper, there has been "an effective cut of £16bn from the health budget in terms of what patients expect the NHS to deliver". Should the NHS receive flat real settlements for the three years from 2015-16 (as seems probable), this cut will increase to £34bn or 23%.

If they wish to avoid a significant fall in the quality of the health service, this government and future ones are left with three choices: to raise taxes (my preference), to cut spending elsewhere, or to impose patient charges. With all parties, and the Tories in particular, keen to avoid any major tax rises, and other services already enduring unsustainable cuts, the option of charges is likely to attract the support of an increasing proportion of doctors and Conservative MPs.

If this seems heretical, it's worth remembering that our "free" health service hasn't been truly free since Labour chancellor Hugh Gaitskell introduced prescription charges for glasses and dentures in his 1951 Budget (although they have since been abolished in Scotland, Wales and Northern Ireland). Morally speaking, there is no difference between these fees and co-payments.

There is also growing public recognition that a high-quality NHS will need to be paid for. A recent Ipsos MORI poll for The King's Fund found that there is support for introducing charges for treatments that are not perceived as "clinically necessary" (such as cosmetic surgery and elective caesarean sections), for people thought to "misuse services" (e.g. missing appointments or arriving drunk at A&E), for patients requiring treatment as a result of "lifestyle choices" (e.g. smoking and obesity) and for 'top-ups' to non-clinical aspects of care (e.g. private rooms and other 'hotel' services). 

For now, the Tories insist that they will not go down this road. After Malcolm Grant, the chair of the NHS Commissioning Board warned last year that the next government would have to consider introducing "new charging systems" unless "the economy has picked up sufficiently", Jeremy Hunt told MPs: "Professor Malcolm Grant did not say that. What he actually said was that if the NHS considered charging, he would oppose it. I agree with him; I would oppose it, too." But just as pensioner benefits, once considered untouchable, are now being targeted by all parties for cuts, it should not be assumed that a "free NHS" will survive the age of austerity. 

Health Secretary Jeremy Hunt delivers a speech during his visit with David Cameron to the Evelina London Children's Hospital on July 5, 2013. Photograph: Getty Images.

George Eaton is political editor of the New Statesman.

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After the leadership battle, immigration is Labour's new dividing line

Some MPs are making a progressive case for freedom of movement controls. 

After three brutal months of infighting, culminating in another sweeping victory for Jeremy Corbyn, the buzzword at the Labour party conference is unity. But while Corbyn’s opponents may have resigned themselves at least temporarily to their leader, a new fissure is opening up.

Considering it was sparked by Brexit, the Labour leadership contest included surprisingly little debate about freedom of movement. In the immediate aftermath of the EU referendum, Corbyn declared he was “not afraid to talk about immigration”.  Owen Smith, his rival, referred to the “progressive case against freedom of movement”. But ultimately, the contest embodied a clash between the will of the membership and the parliamentary Labour party. 

Now, though, the question can no longer be dodged. What position should Labour take on freedom of movement? And is it time for a fundamental shift on immigration?

Labour’s 2015 pledge to “control immigration” was widely derided by its own party activists – not least when it appeared on a gift shop mug. Apart from making a rather authoritarian present, one of the flaws in this promise was, at the time, that the only way of really controlling immigration would be to leave the EU. 

But an increasingly vocal group of MPs are arguing that everything has changed. Heavyweights from the Miliband era are now, from the back benches, trying to define limits to freedom of movement and immigration. Chief among them are Rachel Reeves and Chuka Umunna. 

Reeves makes her case from an economic perspective. She argues that freedom of movement from the EU has depressed wages (the cause and effect is disputed). At a Resolution Foundation event during Labour conference, she recalled visiting a factory in her constituency where workers complained the jobs went to foreigners. 

Umunna, on the other hand, argues unease with immigration has a cultural element as well. He has said that immigrants need to stop leading “parallel lives”. At the Resolution event, he declared of Brexit: “This isn’t all about economic equality – it is about identity politics.” Umunna's tough talk on integration may coincide with his bid to chair the Home Office select committee, but his observations about the underlying distrust of immigrants rings true. 

How Labour copes with freedom of movement depends on which view prevails. It is possible to imagine the party coming up with an answer to the freedom of movement question that involves Corbynite economic themes, such as protecting wages, labour rights and restrictions on agency recruitment. Lisa Nandy, another speaker at the Resolution event, rallied the audience with a story of workers on low wages standing “in solidarity side by side” with migrant workers. It would be a distinctly left-wing argument that critiques the Government’s tolerance of zero-hours contracts and other precarious employment practices. 

But if, as Umunna suggests, Brexit is also an articulation of a deeper anti-immigrant feeling, Labour is entering more dangerous territory. On a tactical level, it is hard to see how the party can beat the May Government when it comes to social conservatism. It undermines any attempt to broker a "soft Brexit", which many of Labour's members, who voted Remain, will want. 

And then there's the prospect of the party most closely associated with ethnic minorities condoning xenophobia. Labour activists point out that some of the Brexit backlash is plain old racism. Speaking at a Momentum rally during the leadership contest, Diane Abbott, the shadow health secretary and one of Corbyn’s closest allies, declared: "Anyone who tells you maybe you have to do something about these Eastern Europeans, it's not about skin colour, what we've seen since the Brexit vote gives lie to that. 

“If you give ground to anti-immigrant politics, it will sweep away all of us. And we cannot give ground to that stuff. You cannot as a Labour movement take a position that one part of the working class is a problem of another section of the working class."

More pragmatic MPs too, still remember the ill-fated immigration mug. They see the new “tough on immigration” line as an uneasy alliance between working-class MPs on the Labour right, and a group of middle-class metropolitans who have spotted a gap in the market and jumped on it. Should this second attempt, Labour MPs will have achieved nothing except alienating their activist base. 

Ultimately, the initiative lies with Corbyn. If he can set out a radical agenda for protecting workers’ rights, he may be able to bring the party with him. But if this fails to shift opinion polls, immigration could be the next issue to disunite the party.