Earlier this month the British Medical Journal published a head-to-head on the issue of whether people in the UK should pay to see a GP. On the face of it, levying a small fee or “co-payment” makes sense. Demand for GP consultations is likely to double over the next 20 years, health costs are spiralling, fees are backed by high-profile figures including a former health secretary, and fees might deter the small number of repeat attenders who account for a disproportionate burden of consultations, prescriptions and referrals.
But hold your horses. There are five compelling reasons why this seemingly innocuous measure is a bad idea.
1. It doesn’t make economic sense
Fees are often introduced to act as “price signals”. Attaching a price to GP consultations is supposed to prompt consumers to consider whether the “product” is really worth the cost, hopefully leading to fewer inappropriate consultations.
Price signalling works beautifully with plastic bags . The 5p charge doesn’t really cost that much but “nudges” shoppers into using the service only when they really need it. The issue is that health isn’t like a plastic bag. Whereas consumers are able to judge the value of a carrier bag and whether they really need it or not, it is very difficult for a layperson to evaluate the value of a medical consultation.
This “information asymmetry”, where the provider knows more about the product than the consumer (think used car sales) makes price signalling inappropriate. Is £10 worth it to get this lump looked at? Only a doctor can tell you. If people can’t judge the quality of what they are paying for, those who can’t afford the fee stop seeing their doctor, regardless of whether they need to or not.
2. It won’t save money
While fees are often proposed in order to help raise money, they can result in higher costs for the health system. Administering fees cost Germany £260m a year and resulted in 120 hours of extra work for every health centre. Where patients delay seeking medical care because of fees, GPs can’t provide early preventive advice and the underlying condition can worsen, resulting in higher treatment costs further down the line. Prevention is hugely more cost effective than treatment, and catching cancers and serious illness early results in happier, healthier patients, along with lower costs for the NHS.
Fees can lead to inappropriate use of other NHS services, such as struggling emergency departments. At £44 a consultation, GPs provide surprisingly good value for money. A ten minute GP consultation is three times cheaper than assessing the same problem in A&E.
3. They don’t reduce demand
Proponents have argued that fees might reduce missed appointments, as seen with table booking in the restaurant industry. This effectively creates new slots for doctors to see more patients, but there’s no evidence to suggest that fees work in this way for consultations and the vast majority of GPs don’t want to introduce fees.
It would be disingenuous to suggest that fees have absolutely no effect on demand. Small fees do seem to deter some people. Unfortunately, those most likely to forgo medical attention are vulnerable as well as low-income groups.
4. It will hurt the poor
My biggest objection to fees is that they would exacerbate Britain’s widening health inequalities. Overall, low-paid people tend to experience much worse health than the affluent. A flat-rate fee will be a larger proportion of disposable income for someone on a low-income so fees would be regressive.
It is both illogical and unjust to introduce fees that present a proportionally larger disincentive to the group of people with the worst health. Low-income groups will be hurt financially and physically as a result. Countries can introduce caps, reimbursements and exceptions to mitigate disparities, but this all adds complexity and increases administration costs. Research has also shown that relying on market forces to balance supply and demand for medical care reduces the number of health professionals working in deprived areas.
Health news in pictures
Health news in pictures
1/19 Vaping backed as healthier nicotine alternative to cigarettes after latest study
Vaping has been given an emphatic thumbs up by health experts after the first long-term study of its effects in ex-smokers. After six months, people who switched from real to e-cigarettes had far fewer toxins and cancer-causing substances in their bodies than continual smokers, scientists found
2/19 Common method of cooking rice can leave traces of arsenic in food, scientists warn
Millions of people are putting themselves at risk by cooking their rice incorrectly, scientists have warned. Recent experiments show a common method of cooking rice — simply boiling it in a pan until the water has steamed out — can expose those who eat it to traces of the poison arsenic, which contaminates rice while it is growing as a result of industrial toxins and pesticides
3/19 Contraceptive gel that creates ‘reversible vasectomy’ shown to be effective in monkeys
An injectable contraceptive gel that acts as a ‘reversible vasectomy’ is a step closer to being offered to men following successful trials on monkeys. Vasalgel is injected into the vas deferens, the small duct between the testicles and the urethra. It has so far been found to prevent 100 per cent of conceptions
4/19 Shift work and heavy lifting may reduce women’s fertility, study finds
Women who work at night or do irregular shifts may experience a decline in fertility, a new study has found. Shift and night workers had fewer eggs capable of developing into healthy embryos than those who work regular daytime hours, according to researchers at Harvard University
5/19 Breakfast cereals targeted at children contain 'steadily high' sugar levels since 1992 despite producer claims
A major pressure group has issued a fresh warning about perilously high amounts of sugar in breakfast cereals, specifically those designed for children, and has said that levels have barely been cut at all in the last two and a half decades
6/19 Fight against pancreatic cancer takes ‘monumental leap forward’
Scientists have made a “monumental leap forward” in the treatment of pancreatic cancer after discovering using two drugs together dramatically improved patients’ chances of living more than five years after diagnosis.
7/19 Japanese government tells people to stop overworking
The Japanese government has announced measures to limit the amount of overtime employees can do – in an attempt to stop people literally working themselves to death. A fifth of Japan’s workforce are at risk of death by overwork, known as karoshi, as they work more than 80 hours of overtime each month, according to a government survey.
8/19 Over-cooked potatoes and burnt toast ‘could cause cancer’
The Food Standards Agency (FSA) has issued a public warning over the risks of acrylamide - a chemical compound that forms in some foods when they are cooked at high temperatures (above 120C).
9/19 Cervical cancer screening attendance hits 19 year low
Cervical screening tests are a vital method of preventing cancer through the detection and treatment of abnormalities in the cervix, but new research shows that the number of women using this service has dropped to a 19 year low.
10/19 High blood pressure may protect over 80s from dementia
The ConversationIt is well known that high blood pressure is a risk factor for dementia, so the results of a new study from the University of California, Irvine, are quite surprising. The researchers found that people who developed high blood pressure between the ages of 80-89 are less likely to develop Alzheimer’s disease (the most common form of dementia) over the next three years than people of the same age with normal blood pressure.
11/19 Most child antidepressants are ineffective and can lead to suicidal thoughts
The majority of antidepressants are ineffective and may be unsafe, for children and teenager with major depression, experts have warned. In what is the most comprehensive comparison of 14 commonly prescribed antidepressant drugs to date, researchers found that only one brand was more effective at relieving symptoms of depression than a placebo. Another popular drug, venlafaxine, was shown increase the risk users engaging in suicidal thoughts and attempts at suicide
12/19 'Universal cancer vaccine’ breakthrough claimed by experts
Scientists have taken a “very positive step” towards creating a universal vaccine against cancer that makes the body’s immune system attack tumours as if they were a virus, experts have said. Writing in Nature, an international team of researchers described how they had taken pieces of cancer’s genetic RNA code, put them into tiny nanoparticles of fat and then injected the mixture into the bloodstreams of three patients in the advanced stages of the disease. The patients' immune systems responded by producing "killer" T-cells designed to attack cancer. The vaccine was also found to be effective in fighting “aggressively growing” tumours in mice, according to researchers, who were led by Professor Ugur Sahin from Johannes Gutenberg University in Germany
13/19 Green tea could be used to treat brain issues caused by Down’s Syndrome
A compound found in green tea could improve the cognitive abilities of those with Down’s syndrome, a team of scientists has discovered. Researchers found epigallocatechin gallate – which is especially present in green tea but can also be found in white and black teas – combined with cognitive stimulation, improved visual memory and led to more adaptive behaviour. Dr Rafael de la Torre, who led the year-long clinical trial along with Dr Mara Dierrssen, said: “The results suggest that individuals who received treatment with the green tea compound, together with the cognitive stimulation protocol, had better scores in their cognitive capacities”
14/19 Taking antidepressants in pregnancy ‘could double the risk of autism in toddlers’
Taking antidepressants during pregnancy could almost double the risk of a child being diagnosed with autism in the first years of life, a major study of nearly 150,000 pregnancies has suggested. Researchers have found a link between women in the later stages of pregnancy who were prescribed one of the most common types of antidepressant drugs, and autism diagnosed in children under seven years of age
15/19 Warning over Calpol
Parents have been warned that giving children paracetamol-based medicines such as Calpol and Disprol too often could lead to serious health issues later in life. Leading paediatrician and professor of general paediatrics at University College London, Alastair Sutcliffe, said parents were overusing paracetamol to treat mild fevers. As a result, the risk of developing asthma, as well as kidney, heart and liver damage is heightened
16/19 Connections between brain cells destroyed in early stages of Alzheimer’s disease
Scientists have pinpointed how connections in the brain are destroyed in the early stages of Alzheimer’s disease, in a study which it is hoped will help in the development of treatments for the debilitating condition. At the early stages of the development of Alzheimer’s disease the synapses – which connect the neurons in the brain – are destroyed, according to researchers at the University of New South Wales, Australia. The synapses are vital for brain function, particularly learning and forming memories
17/19 A prosthetic hand that lets people actually feel through
The technology lets paralysed people feel actual sensations when touching objects — including light taps on the mechanical finger — and could be a huge breakthrough for prosthetics, according to its makers. The tool was used to let a 28-year-old man who has been paralysed for more than a decade. While prosthetics have previously been able to be controlled directly from the brain, it is the first time that signals have been successfully sent the other way
18/19 Aspirin could help boost therapies that fight cancer
The latest therapies that fight cancer could work better when combined with aspirin, research has suggested. Scientists from the Francis Crick Institute in London say the anti-inflammatory pain killer suppresses a cancer molecule that allows tumours to evade the body’s immune defences. Laboratory tests have shown that skin, breast and bowel cancer cells often generate large amounts of this molecule, called prostaglandin E2 (PGE2). But Aspirin is one of a family of drugs that sends messages to the brain to block production of PGE2 and this means cancer cells can be attacked by the body’s natural defences
19/19 Potatoes reduce risk of stomach cancer
Scientists have found people who eat large amounts of white vegetables were a third less likely to contract stomach cancer. The study, undertaken by Chinese scientists at Zhejiang University, found eating cauliflower, potatoes and onions reduces the chance of contracting stomach cancer but that beer, spirits, salt and preserved foods increased a person’s risk of the cancer
5. Co-payments are a great leap backward
Internationally, other countries want what the UK has. The NHS consistently outperforms other health systems in countries spending much higher proportions of GDP on health. Provision of care to all on the basis of clinical need rather than ability to pay is a justifiable source of national pride, if not a crowning achievement of British public policy.
Signatories of the 2015 Sustainable Development Goals recently pledged to meet a wider range of ambitious development targets including the attainment of universal health coverage. This lofty aspiration – providing quality essential services for all while protecting patients from financial costs – is a living breathing reality in the UK. Introducing fees may appear to intuitively help with mounting financial and demographic pressures. However, they won’t work, and something much more important is at stake.