Dr John Crippen: A fair contribution at the point of entry

Dr John "Crippen", of NHS Blog Doctor, is a full time family doctor working somewhere north of London. He is grateful to Wat Tyler, of Burning Our Money, for detailed advice on health care finance.

Free at the point of entry? Free at the point of need?

The newspapers highlighted the tragic case of a young women, aged only 26, who died recently of bowel cancer. Assisted by family and friends she spent the last few weeks of her life begging and borrowing money to buy a private prescription for Avastin, a drug that her PCT (Primary Care Trust) would not fund.

Examples like this are legion. They make excellent journalistic copy. They are the tip of an iceberg that no politician to date has been able to acknowledge.

The facts are simple.  No country can afford to provide its citizens with all that modern medical technology has to offer.

Britain has been the health care miser of Europe, spending less than 7% of GDP on health. Tony Blair pledged to match the European average of 8%. We duly increased our expenditure from 7% to 8% of GDP but by the time we got there, the European average was over 9%. It is a moving target.

And who is to say that Europe has got it right? The USA spends a massive 15% of their GDP on health.

The total world health care spend is currently $3 trillion. For those who like their noughts, that is $3,000,000,000,000. It gets worse. Health care is the world’s largest industry, bigger even than defence, and it is growing at twice the rate of the world GDP. By the year 2100 it will account for…everything. The total world GDP will be spent on health care.

The choice is ours.

We can take control. We can abandon short-termism. We can stop tinkering around the edges. We can look at the radical changes that are needed to control this modern Leviathan.

If we do not take control, decent health care will eventually only be available for the rich. The seeds are already sown. It is happening in the USA. It is beginning to happen here.

Society (that is a pompous word for "you and me") needs to understand that our infinite health care capability has to be rationed. It is already being rationed in the UK by stealth; by the postcode lottery, by waiting lists and, most of all, by dumbing down the service provided for those without private health insurance.

Private patients and the “great and the good” see doctors. NHS patients see nurse-specialists, EMTs and a whole range of (latest buzz word approaching) “Health Care Professionals”. The expression, “Health Care Professional” has an air of New Labour plausibility. It means “we cannot afford to provide a doctor”.

There is breathtaking financial irresponsibility within the NHS. To take but one example. £20 billion and rising spent on an IT system. As Richard Bacon MP said:

"At a time when hard-pressed NHS trusts are having to make painful choices to reduce deficits, they are being forced to pay money they don't have and release staff they can't spare, for something they don't want and which doesn't work ..."

The NHS is a nationalised industry. No amount of government controls, checks, targets and bean counting are a substitute for the financial accountability of a free market economy.

Twelve years ago there was a glimmer of hope. GPs were allowed to become “fund-holders”. In simple terms, a system in which “the money followed the patient”. The hospitals competed to attract work from well-organised fundholding practices. The care our patients received improved. 

When New Labour came to power in 1997, for purely doctrinal reasons, they abolished fundholding. Not only did they abolish fundholding, which was relatively new, but they also abolished the freedom of choice of referral which family doctors had had since the inception of the health service. We were compelled to send all our patients to the local hospital. The hospitals no longer had to compete for our custom. The standard of service declined.

The Labour government has recognised the merits of fundholding and is re-introducing it. Under a different name of course. This time it is to be called Practice Based Commissioning (PBC). It is difficult not to smile. Sadly, it is unlikely to work. The government hatred of professional autonomy is so great that they are tying PBC up in a network of committee based bureaucratic controls which will stifle initiative.

There has to be a re-introduction of the principle of a free market economy within the NHS.  We had a taste of it in the nineties. Heady days! Let the doctors get on with their jobs. Let the money follow the patient. Hospitals and general practices that deliver will thrive. The ones that do not deliver will fail. Let them. The fact that we are working in health care is no reason to buttress the incompetent.

Finally, the most difficult area. Financial irresponsibility from the outside of the system, from the health care consumer. The patients. That which is free, or perceived to be free, is not valued.

A family doctor colleague from New Zealand wrote to me recently about his experience of working in the UK:

"I worked in the UK for a few weeks. I could not believe that you did not have to pay to see a GP, but that it took two days to get an appointment. I was staggered by the trivia, by the nonsense. The number of people, for example, who attended with bad colds. Here in New Zealand it costs the equivalent of £30 to see a GP.  It may a barrier to someone with a bad cold but, when you are really ill, you can get an immediate appointment. I prefer our system."

The mantra of health care in the UK is “free at the point of entry.” It is a beguiling catch phrase, a wonderful slogan. But it is no longer true and probably never was wholly true.

There is only free entry to the NHS when the door is open. For many it is closed. Dr Crippen has patients still waiting after a year for surgery for the same cardiac problems that afflicted the Prime Minister. PCTs refuse to finance expensive cancer drugs. Patients with ischaemic heart disease on the “non-urgent” (sic) waiting list die before they get surgery.

The list is long.

A nettle has to be grasped. We have to think the unthinkable. Speak the unspeakable.

When Tony Blair became leader of the Labour Party, one of his first political moves was to ditch Clause IV. In practice, Clause IV meant nothing. But doctrinally, its abolition was a courageous political move. It took New Labour into new political territory.

We need to accept that the finance is not available to allow free, instant access to healthcare for any condition, however trivial. “Free at the point of entry” is the Clause IV of the NHS.

It has to go.

Unrealistic expectations and excessive, wasteful health care demands can only be controlled by a front end charge and by a direct contribution from the patient towards the cost of ongoing medical care.

It will not be easy. It will need to be properly safety netted. But if a politician can find a way of making this acceptable to the public, there is a real possibility of genuine equality of health care.

“A fair contribution at the point of entry” should become the new, and realistic, health care slogan.