Should patients pay to see their GP?

Should patients pay to see their GP? Two doctors debate the issue in The BMJ.

Charging patients for GP consultations could raise much needed funds for the health system, argues David Jones, a foundation year two doctor at Worthing Hospital.

The UK NHS prides itself on the mantra of free healthcare at the point of service, but with ever increasing costs and demands “we need fundamental change to ensure its prosperity and longevity,” he argues.

In Australia, a standard consultation is typically about £10, with the remainder paid by the government. “No one sees this as unethical - it is the norm,” he writes.

He points out that people in the UK who can afford to already pay towards drug prescriptions and dentistry, “showing that the public accepts that an entirely free healthcare model is not sustainable today”.

Vulnerable groups, including children and elderly people, would be exempt from charges, similar to the existing prescription charges exclusion criteria, he explains.

He adds that charges may offer other benefits, such as a reduction in missed GP appointments, patients taking more personal responsibility, leading to fewer visits with conditions that they could manage themselves, greater service availability, and shorter waiting times.

The argument that charges would deter the sick from seeking help doesn’t stand up, he says, as in Australia annual GP attendances per person are comparable to those in the UK.

“Copayments would not be a vote winning strategy for politicians, but 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,” he concludes.

However, Nancy Loader, a GP partner in Suffolk, worries about increased overall cost and harms to patients.

Extensive evidence shows that strong primary care led health systems, free at the point of access, are associated with improved health outcomes, increased quality of care, decreased health inequalities, and lower overall healthcare costs, she writes.

She explains that in countries that have introduced copayments, governments “end up reimbursing, capping, and waiving the copayment to reduce health disparities”.

For example, New Zealand and the Irish Republic, where patients have always made a co-payment to GPs, “it has interfered with initial access to care and deterred preventive care measures, resulting in greater health spending in secondary care,” she writes.

Charges can also deter patients from seeing the GP as advised after medical or surgical discharge from hospital, she adds. 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.

She points out that patients who cannot afford to see a GP simply attend free emergency departments instead.

“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,” she concludes.