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.

Photo: Getty
Show Hide image

Can Philip Hammond save the Conservatives from public anger at their DUP deal?

The Chancellor has the wriggle room to get close to the DUP's spending increase – but emotion matters more than facts in politics.

The magic money tree exists, and it is growing in Northern Ireland. That’s the attack line that Labour will throw at Theresa May in the wake of her £1bn deal with the DUP to keep her party in office.

It’s worth noting that while £1bn is a big deal in terms of Northern Ireland’s budget – just a touch under £10bn in 2016/17 – as far as the total expenditure of the British government goes, it’s peanuts.

The British government spent £778bn last year – we’re talking about spending an amount of money in Northern Ireland over the course of two years that the NHS loses in pen theft over the course of one in England. To match the increase in relative terms, you’d be looking at a £35bn increase in spending.

But, of course, political arguments are about gut instinct rather than actual numbers. The perception that the streets of Antrim are being paved by gold while the public realm in England, Scotland and Wales falls into disrepair is a real danger to the Conservatives.

But the good news for them is that last year Philip Hammond tweaked his targets to give himself greater headroom in case of a Brexit shock. Now the Tories have experienced a shock of a different kind – a Corbyn shock. That shock was partly due to the Labour leader’s good campaign and May’s bad campaign, but it was also powered by anger at cuts to schools and anger among NHS workers at Jeremy Hunt’s stewardship of the NHS. Conservative MPs have already made it clear to May that the party must not go to the country again while defending cuts to school spending.

Hammond can get to slightly under that £35bn and still stick to his targets. That will mean that the DUP still get to rave about their higher-than-average increase, while avoiding another election in which cuts to schools are front-and-centre. But whether that deprives Labour of their “cuts for you, but not for them” attack line is another question entirely. 

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to domestic and global politics.

0800 7318496