View from the ground, by Dr Rachel Hooke

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Dr Rachel Hooke

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There has been much debate about the possibility of charging for doctors’ appointments, particularly for seeing the GP. Advocates claim that it would reduce general workload and consultations for trivial and inappropriate problems, such as dental issues. Charging could free up capacity and reverse the trend of having to wait weeks for the next available routine appointment, compensate for Did Not Attends (DNAs), and make people realise the value of being given a professional opinion. It is pointed out that dentists’ and optometrists’ appointments have long been chargeable for many adults and that people have come to accept this.

Arguments to the contrary are based on the belief that charging could deter those most in need from seeking help. There are relatively few people left who remember trying not to ‘have the doctor’ unless it was absolutely necessary because of the cost, before the NHS was instituted 70 years ago. It could be said that we do not want to see a return to those days. There are also public health implications, such as the spread of communicable diseases if people are reluctant to attend for them, and poor uptake of screening. Women could potentially bear more of the burden if they have to pay for contraceptive or pregnancy appointments. The administration of a charging scheme could consume more resources than income generated.

Also, how would charging affect safety-netting and using time as an aid to diagnosis? If a patient pays to see a GP who asks them to re-attend if necessary, then the patient may not bother if they have to pay a second time. The concept of one issue per consultation will disappear, as patients will want to get their money’s worth by airing all their ailments in one go. Consultation lengths would have to be set beyond 10 minutes. Patients could become even more demanding if they are paying directly for a service. They may not be happy to leave without a prescription, a sick note, or a hospital referral. Simple reassurance and advice on the nature of self-limiting illness will no longer be acceptable and could be interpreted as ‘being fobbed off’. There is already a culture of ‘we pay your wages’ (in the form of taxes). An elevated sense of entitlement and ‘something must be done’ could ensue. Complaints could rise, along with requests for refunds if patients feel that they have been dealt with inadequately.

The public could be tempted as an alternative to seek free advice from pharmacists, who already claim to be struggling with relatively poor recompense for this service. Patients may attend the emergency department for conditions at extreme ends of the spectrum­—minor illness versus an emergency presentation of advanced disease, neither of which is desirable. Indeed, this would be counter to some hospital initiatives to reduce emergency attendances for illnesses that could or should have been picked up and treated earlier. With long-term conditions that were once managed in hospital now being deployed to GPs, patients may resent paying for follow up that would previously have been free in secondary care.

It is possible that telephone triage could remain free and weed out patients who do not need to visit in person nor incur a fee. However, many doctors are cautious about giving advice or prescriptions without actually seeing patients in person. Furthermore, practice administration systems and processes might need to be tightened up. For example, as a patient myself, I received a letter recently from my local surgery asking me to ring to arrange a telephone appointment to discuss some results. A questionnaire was enclosed, which, bizarrely, I was asked to fill in and bring ‘to the appointment’. You could not make it up. No doubt this was a hangover from a time when all appointments were face-to-face and telephone consultations were not formally established.

Any new system can have unintended consequences, no matter how noble the aims. I can remember, at a university interview nearly 30 years ago, suggesting that the introduction of private fees for eye examinations might risk problems such as glaucoma or detached retina going undetected. I am not aware of any evidence that this has occurred on a widespread basis, but we would not necessarily know.

One way to circumvent difficulties would be to retain free appointments on the NHS for certain sections of society such as children, the elderly, pregnant people, those on low incomes, the homeless etc. There could also be exemptions for people with certain long-term conditions or infectious diseases. However, as with prescription charges, this could result in a relative minority actually being charged and the whole exercise being more trouble than it is worth.

Dr Rachel Hooke

Freelance Medical Terminology Trainer, Leicester