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.