Should patients pay to see the GP?

Drug prescriptions and dentistry

People in the UK already pay towards drug prescriptions and dentistry, which were free at the NHS’s inception,7 showing that the public accepts that an entirely free healthcare model is not sustainable today. Prescriptions, despite 90% of items being exempt from charges, generate in excess of £400m gross income a year.8

We should follow many other developed countries and also pay a fee when we see our GP. Given that the average patient visits their primary physician 5.5 times a year,9 a £10 fee, which most GPs would find acceptable,10 could raise billions of pounds. Vulnerable groups, including children and elderly people, would be exempt from charges as they are for existing prescription charges.

Charges may offer other benefits. These include a reduction in missed appointments, which are estimated to cost the NHS £162m a year.11 Charges have been shown to reduce missed reservations in other industries,12 13 and they might also encourage patients to take more personal responsibility, leading to fewer people attending with conditions that they could manage themselves or that would be better managed through other primary care services (pharmacists, dentists, nurses, etc). This would lead to greater service availability and shorter waiting times in general practice.

Although demographics differ, annual GP attendances per person in Australia (mean 5.6) are comparable with those in the UK,14 as are the number of emergency department attendances (mean 0.29/person/year in Australia v 0.33 in UK)15 16 17 18 and life expectancy.19 This suggests that copayments are unlikely to affect care seeking behaviour or overall health. Any increase in use of secondary care to avoid fees could be countered by effective triage and redirection to an increased provision of hospital based GPs.

No superior alternative

In a recent poll more than half of 440 GPs supported implementing charges for appointments.20 Copayments would not be a vote winning strategy for politicians, with healthcare unions and the public understandably against losing a free service.3 4 However, with billions of pounds of savings needed to keep the health service afloat, political popularity will be tough whatever the strategy.

To maintain the highest possible standards for all patients, amid ever increasing healthcare costs, we need radical measures to ensure the continued success of the NHS. If we could accept the morality of paying for consultations while ensuring strategies to protect vulnerable people, we could reap the benefits of a more prosperous and less strained healthcare system.

Copayments don’t work

Some countries have tried to limit patient demand or reduce spending on healthcare by introducing copayments. This has resulted in increased health disparities with no change in patient demand.25 26 27 28 Governments in these countries end up reimbursing, capping, and waiving the copayment to reduce health disparities.24

The overall costs of these remedial actions are not usually available. However, Germany introduced a fee for service copayment in 2004, which it scrapped in 2012. It cost the German government €360m (£260m; $400m) a year to run, and on average for every medical centre each year the scheme cost €4100 in administration and resulted in 120 hours of extra work.25 29

In other countries, for example, New Zealand and the Irish Republic, where patients have always made a copayment to GPs, it has interfered with initial access to care and deterred preventive care measures, resulting in greater health spending in secondary care.23 26 27 28

Charges also have a detrimental effect on the doctor-patient relationship. I have 15 years’ experience as a UK trained GP working in several different countries with different levels of copayment. Even in countries that never offered free consultations, many patients complained about fees or were unable to pay them for many reasons. Financial discussions could arise at any stage of the consultation and on a daily basis. This can immediately change the dynamic and outcome of the consultation.

Copayments can deter doctors from asking patients to return for review or deter patients from meeting your request. They can deter patients from seeing the GP as advised after medical or surgical discharge from hospital. They can encourage patients to collect multiple problems to discuss in a single consultation and pressure doctors to deal with them all at once. And they can encourage unnecessary prescribing or referral—“I’ve paid, do as I say.”

Some practices may be tempted to deal with complaints from patients by offering a refund of the copayment rather than improve their service. They act as a financial deterrent and encourage deferring attendance until very unwell, with more likelihood of a need for hospital admission.

Copayments make no discernible difference to rates of non-attendance and no difference to attendance rates of the worried well. Patients who cannot afford to see a GP simply attend free emergency departments.

General practice receptionists gain the additional work of collecting fees, and practices often have to use debt collection agencies.

Conflict of interest

Copayments introduce a conflict of interest for GPs wanting to offer equitable and excellent standards of care to all their patients while protecting their income. Most UK GPs are self employed contractors working for a practice owner on a fee for service basis at around 55% of total fees.

Without patients there is no income. Apply discretion and don’t charge a copayment fee, then you subsidise the patient out of the practice’s and your own income. Poor people, mentally ill people, and people with chronic diseases and disabilities are inevitably adversely affected by copayments.

We should keep the NHS free for all at the point of access, not for sentimental or historical reasons but because it makes good economic sense, is better for healthcare outcomes, reduces bureaucracy, and allows for innovative ways to match supply and demand in general practice.