The introduction of co-payments as a means of affording a just health service in times of austerity is suggested by David Jewell.1 In reality they have existed for some time in many European countries, including Italy where there is a national health service very similar to that of the UK.
The National Institute for Health and Clinical Excellence is approving at least some of these new approaches. In Italy there is one filter, the LEA (Essential Level of Assistance), which considers every year what should be deemed essential and thus totally free. The only way to keep within budget is to restrict what is provided, and clearly inform patients that some services will no longer be available as totally free for all.
In Italy everything is free for patients who are declared as ‘poor’. There are very few subsidies for the ‘not-so-poor’ with chronic conditions. For all others, charges on visits, procedures, and prescriptions are still subsidised, but to a maximum of €50. Additionally, a larger number of commentators see benefit in having at least some co-payments applied. There is even a triage system for hospital emergency rooms whereby some patients incur a charge. Co-payments can be made for higher quality meals for example.
For primary care attendances, some are advocating a nominal payment for every GP consultation to prevent the recent growing, and overwhelming, access to crowded practices for non-problems or for frequent attenders availing themselves of a free service. A ‘ticket booklet’ is therefore under consideration in some countries such as Germany.
The vigorous growth of private health insurance is currently curtailed due to major national, even international, financial crises.
The introduction of a co-payment system would simply maximise inequity, burdening especially those who already pay as a proportion of their income, the most for their health care, often for the management of chronic conditions. Raising co-payments in proportion with people’s income (in three or more levels) could be a sensible choice, but there is the risk that many ‘rich’ and also ‘not-so-rich’ people will not use the NHS, choosing instead some ‘low cost’ (that is almost the same of co-payment or little more) private poli-specialistic services, as the ones now growing in Italy.
- © British Journal of General Practice 2012