Are GPs right to support charging?

Elliot Bidgood, 30 July 2013

A finding from Pulse magazine’s online poll of GPs has drawn national newspaper attention and provoked intense debate in the past few days. The poll found 51% of GPs supported charging a fee for GP visits, with 36% against. This represented a substantial increase from just last September, when only 34% supported the idea.

Pulse’s editor Steve Nowottny has said that the poll is not scientific per se, as some critics warned, although he also noted that many Pulse polls have predicted the mood of the profession with relative accuracy. Nowottny further cautioned that the result may be more of a general reflection of concerns about “unprecedented” GP workloads and that “GPs fervently believe in the principle of an NHS which is free at the point of delivery, and if they now support charges do so only with the greatest reluctance”. Nevertheless, the poll has again raised debate about charges.

It has been shown in Germany and elsewhere that user charges (co-payments) do indeed tend to reduce immediate demand, either through people delaying, seeking assistance elsewhere or dropping off altogether. Studies also tend to confirm that this includes some of the demanding “worried well” staying away, as the GPs advocating fees hope. This is partly why France and some countries with tax-financed publicly-run health services comparable to ours (New Zealand, Iceland, Norway, Sweden, Ireland) utilise GP charges, subject to caps or exemptions.

However, there are also clear risks. Some researchers have warned that charges are a “blunt instrument”, since the lay public cannot always assess their symptoms, meaning fees can discourage the genuinely sick from accessing care too. This may affect public health – a New England Journal of Medicine study linked charges to increased complications among patients with high blood pressure, for example – but can also create additional demands on the health system in terms of the hidden costs of people turning up later in a more severe state. The Commonwealth Fund found that “sicker adults” in countries where co-payment is a larger element such as Norway, France, Germany, New Zealand and Australia were more likely to report “cost-related access problems” or “serious problems paying bills” than those in the UK. In Ireland, which has similar problems, the government plans to scrap GP charges as part of an ambitious shift towards a competition-based universal social insurance system modelled on the Dutch system, a move worth emulating here.

In other words, pro-fees GPs are correct that appointment charges might reduce immediate demands on primary care. But they might also impede equity and public health and shift costs towards A&E and inpatient services. The NHS faces unprecedented funding challenges and frank debates about radical new options and foreign experiences are absolutely essential if the standard of care expected by the public is to be upheld in the coming years, but GP charges may not be a panacea.

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