Introduction of a different set
148. A further option is to abolish some or all existing
charges but replace them with a new set of charges. Ideally such
charges would encourage desirable behaviour and not deter people
from seeking treatment as the present system does. Professor Smith,
of York University, sent us a memorandum arguing for a major reform.
His proposals were:
- The establishment of a set
of core NHS treatments to be provided for free;
- A number of additional treatments which are not
considered clinically necessary which patients would pay for in
whole or in part;
- Levying small 'user' charges on a range of services
which the NHS provides which would reduce excessive demand for
health services; the aim would be to choose charges which did
not deter patients from seeking treatment when it was appropriate.
149. Professor Smith argued that some degree of healthcare
rationing was inevitable. He proposed the provision of a "core
package" of essential care free of charge to everyone. 'Extra'
services would then be defined and charges levied for these procedures
The central policy problem is to decide which
health care technologies should be subsidized from public funds.
User charges policy then flows naturally from the choice of the
subsidized treatments. Once the 'public' package of care is chosen,
patients would still be free to purchase the remaining unsubsidized
The private sector, as well as the NHS, could provide
services that are additional to core clinical treatment for a
fee. This already happens for treatment no longer available on
the NHS, such as the cosmetic procedures performed by the Foundation
Skin Clinic in Harrogate. Simplyhealth stated:
there are no markets or services of any
kind in any area of our lives where we can all have the very best
of everything all the time, how and where we want it. This is
not the case with food or shelter or education. It is unreasonable
therefore to expect it of healthcare, it is not possible.
150. Ministers may be considering something similar.
At a meeting of the Liaison Committee last year, the Prime Minister
suggested that co-payments in certain non-core areas of public
services should be looked at.
Jane Kennedy told us that although she was opposed to healthcare
What we have been discussing this morning is
where on the edge of that definition it might be possible for
NHS organisations and others, and indeed the state, to raise resources
by charging. That is the debate that we are having today and we
will continue to have, I am sure.
151. A range of charges are employed in other European
countries to promote the better use of services. In Sweden, patients
are charged for each outpatient visit (to a nurse, GP or specialist,
and for each visit to A&E), and pay a 'hotel' charge for inpatient
stays. Patients are encouraged to visit the appropriate healthcare
professional by different levels of charges; thus, it costs less
to see a nurse than a consultant and therefore patients are less
likely to use the services of a specialist in the first instance.
Patients pay around £6 to see a nurse, £9-10 to see
a GP and £17-20 to see a specialist. It costs about £10
to go to A&E. Swedish patients also pay for dentistry and
152. There are few exemptions to charges. Instead,
expense is mitigated by the use of an annual cap on payment for
outpatient care, and pharmaceuticals. The annual cost ceiling
is £66 for outpatient care. Inpatient care is capped at £6
per day, but there in no annual limit. For medicines, each patient
(or all the children in a family together) does not pay more than
£134 per year. Co-payments have been in place in Sweden since
the 1970s and generate approximately 3% of total healthcare resources.
153. There are similar charges in the rest of Europe.
In Germany, from 2004, there has been a 10 charge for the
first appointment with a doctor in each three month period, up
to an income-related maximum. In France, from January 2005, patients
have been charged 1 for each consultation, intervention
and test. French adults not suffering a long term illness are
charged a fee for consulting a specialist without the endorsement
of a 'gatekeeper' physician. Introducing a charge of £1 to
see a GP here would raise £200 million, in gross terms, if
appointment rates remained stable.
154. Establishing a core package of free NHS services
and adopting a "European" system of charges of the type
used in Sweden (including access charges and hotel charges) would
have advantages. It is better to be clear about what is funded
for free and what is not. Otherwise, according to Professor Smith,
it is probable that we will have to:
reduce the scope and quality of the NHS
by stealth, and reduce the widespread support for tax funding
of the NHS, an outcome that cannot be to the general public good.
155. "European" style charges could persuade
patients to use the NHS more appropriately. Every year, 15 million
GP and practice nurse appointments are missed and patients do
not attend one in 10 hospital appointments.
Missed GP appointments cost the NHS over £162 million annually
and missed hospital appointments cost £680 million.
A survey of 683 GP surgeries by the group Developing Patient Partnerships
(DPP) found that two-thirds of respondents would support charging
patients who did not attend or cancel their appointment.
156. If charges of this type were introduced it would
be possible to abolish existing charges on medicines and dentistry
and make sight tests free. Thus charges which discouraged bad
behaviour (failing to turn up for appointments) would replace
the current charges on medicines, dentistry and sight tests which
adversely affect healthcare.
157. On the other hand, the introduction of "European"
style charges would also have disadvantages:
- major changes would be made
to raise what is in the context of the total NHS budget a relatively
- they could be complicated and costly to administer;
- they could put people on low incomes off seeking
158. If the aim of the new charges is to replace
all existing charges, they will need to raise £1billion net
which is only a little more than 1% of the NHS budget. Is it worth
a radical overhaul with all the disruption involved for such a
sum? Modest access charges would be unlikely to bring in large
sums: Swedish charges raise 3% of the budget but that includes
charges for pharmaceuticals.
159. A new system of charges would require hospitals
and GPs' practices to collect access and hotel charges. We were
told that collection is straightforward and causes few difficulties
in Sweden, but is unlikely to be as easy in England. In Sweden,
the system is well-established; here it would be new and it is
likely that neither hospitals nor GPs would welcome having to
collect the charges. We were told that in Sweden patients were
sent a bill for their time in hospital and pay it. A similar response
could not necessarily be expected in England.
160. Even in Sweden charges create some problems
for those on low incomes. Charges to see clinicians discourage
some people from seeking health advice or treatment. A recent
large-scale study showed that of Swedish people with "financial
difficulties", over one-third refrained from seeing a doctor
compared to around 10% of the group as a whole.
A survey by the Swedish National Board of Health & Welfare
in 1999 found that around 3% of the Swedish population avoided
using healthcare due to charges. The figure would probably be
higher in England since the same survey concluded that 4% of Swedes
did not fill prescriptions or buy medicines, and 15% did not seek
dental care whereas
the comparable English figures are 6% and 24%.