Patient charges have featured in the British press in recent weeks after Malcolm Grant, the head of NHS England, raised their spectre last month.
Until recently I was undecided about patient charging. There’s mixed evidence and obvious downsides, but health spending is a bottomless pit, and £5 judiciously applied here or there seems like a good way of partially filling that pit and discouraging every no-show or vexatious and petty query of the worried well.
And then last year I moved to the US and am now experiencing first hand the impact of “co-payment” as we like to call it here (charging would, I assume, be vulgar).
I don’t think it betrays any major patient confidentiality or parental contract to reveal that a few weeks ago my son had earache. It was probably just a minor infection, but as the day went on so did his distress and with no otoscope to hand and the usual paediatrician closed for the weekend, we were redirected to a hospital just a short walk from our apartment.
A brief consultation later saw us leave with an infection confirmed and prescription in hand—a very straightforward, minor experience.
Two weeks later, however, we received our bill. The cost of the three minute consultation to confirm an ear infection was $1,100, prescription not included. Our insurance will cover $900 of that and our personal co-payment (charge) is $200.
The experience seemed instructive on a number of levels. Firstly, I knew the US was by far the biggest spender on healthcare in the world, but had no idea quite how much an individual visit like this really cost, either to the hospital, or insurer, or patient. I suspect few outside the US would know this either.
Secondly it made me realise I had no idea of the individual cost of emergency hospital visits in the UK. A short wade through some pretty patient unfriendly data tables later I can confirm that by comparison, the NHS payment by results tariff for a simple emergency visit in 2013-14 would have been between £58 and £78 depending on the type of hospital—around one tenth of the cost. And incidentally, it would be the same tariff code if one were to turn up at the hospital dead—code VB09Z. So now you know.
But the most impactful result it had was a personal one—if the same situation were to reoccur I would not seek out treatment, but tell my son to live with it, and accept possible risks of perforation etc, until we could get to somewhere cheaper.
The reality of the world is that we all have our price. Depending on everything from income to outgoings and simply how unkind we are willing to be to our children, one man’s $200 is another man’s £5.
And that’s the bottom line—any patient charge will impact access to patient care for some people and sometimes merely because they are born to tight-fisted parents.
While recent campaigns have raged against the Section 75 regulations of the Health and Social Care Act and the perceived privatisation they may or may not induce in the NHS, nothing within them would so certainly introduce a multi-tiered system of patient care as the introduction of patient charges.
For better or worse from a payer’s view, in my personal case, the introduction of patient charges has changed my use of healthcare services overnight. Such a move to charges in the UK may or may not deter inappropriate use, it may or may not limit vexatious complaints, but as sure as death and taxes it will mean an individual’s financial status, as much as their need, affecting their use of healthcare. It would fundamentally change the foundations of the NHS.
Edward Davies is US news and features editor, BMJ.