Next: the end of our free health service?

A winter crisis looms in hospitals across the country as a groundswell of opinion grows behind the idea of charging patients for their treatment. Yesterday, doctors' leaders began to `think the unthinkable'.

Jeremy Laurance, Health Editor, asks if we are looking at the end of free care by the NHS.

Britain's doctors will next week peer over the precipice and contemplate the prospect of a National Health Service for which patients have to pay.

Pay for visits to the doctor, "hotel charges" for patients to cover the cost of bed and board in hospitals, and changes to prescription charges. We may also end up paying for other service such as X-rays, hospital tests and immunisations.

Sandy Macara, British Medical Association chairman, said yesterday that as the NHS moved on to a "war-footing" to cope with the expected surge in emergencies this winter, NHS trusts were already stopping routine surgery. "We don't like doing it [considering the introduction of charges] but we have to think the unthinkable in what is clearly a crisis situation," he said.

The council of the BMA has approved a report, to be published next week, which examines in detail the impact of charging patients, including the level at which fees might be set, what they would cost to collect and what they could be expected to raise. The controversial document, which would undermine a founding principle of the NHS if implemented, comes as health experts say charging may be the least unacceptable way of bridging the funding gap between what the NHS needs and what the Government, through tax revenues, can afford to pay.

The findings of the report are likely to be seized on by Treasury ministers who are conducting a comprehensive review of Government spending which is examining charging among other measures for raising extra funds. Last June, Frank Dobson, the Secretary of State for Health, refused to rule out the possibility of new NHS charges although he later insisted that any proposal from the review would have to meet Labour's manifesto commitment that access to the NHS would be based on need and not ability to pay.

Experts point out that charging has already been introduced for dental care, eye tests and long term care for the elderly - all of which are now largely paid for by patients - with little public protest. Although raising funds through taxation is the cheapest and simplest option it is widely seen as politically impossible.

The idea of imposing new NHS charges was floated in a report, Healthcare 2000, chaired by former NHS chief executive Sir Duncan Nichol, published in 1995. Although widely criticised at the time, senior members of the Audit Commission, the NHS watchdog, now privately believe that charging may be the only way for the NHS to make ends meet.

Evidence from a survey of 24 OECD countries shows that the UK imposes among the lowest charges for basic medical care in the western world. Only Canada, Spain and Greece share the UK's reluctance to make patients pay.

Jennifer Dixon, a health policy analyst at the Kings Fund, the independent think-tank, said the survey showed that even egalitarian nations with publicly funded health systems such as the Scandinavian countries charged more than the UK.

In Norway, it cost the equivalent of $11 US dollars to see a GP, $16 to see a specialist and $11 for an X-ray at the time of the survey in 1993. Patients paid 25 per cent of the cost of drugs up to a maximum of $43. Similar charges were levied in Sweden and Finland.

Dr Dixon said: "We are quite unusual here. But why penalise the sick when taxes are cheap to collect? It would be inefficient and unfair."

Professor Chris Ham, director of the Health Services Management Centre at Birmingham University, said imposing patient charges would be highly sensitive and very unpopular but it had to be part of the debate about the future funding of health care. "The challenge for the Government would be how to reconcile charging with its stated intent to reduce health inequalities and increase access for the poor and chronically sick," he said.

Yesterday, the BMA said its official policy remained against charging. However, at the annual conference of GPs last June one in three voted in favour of charges.

"We are a democratic organisation and it will be for our members to tell us what they think," said Mr Macara. "I cannot believe we would change our position but we might be forced to do so."