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The doctors' dilemma
It would not be a lamentable necessity at all, but an excellent thing, if patients had to pay directly for medical attention.
There seems to be something infectious in the air about thinking the unthinkable; everyone seems to be doing it. Even doctors are trying it. At the annual general conference of the British Medical Association in Edinburgh on Monday, members agreed in principle to consider new ways of funding the NHS, other than taxes and prescription charges. They have carefully left their options open and avoided being too specific, but what they are really expressing is something remarkable: a clear loss of faith in the possibility of a free, universal national health service. What they are talking about is making people pay individually for treatment, one way or another.
No doubt many of them feel bitter regret at this revolutionary thought. (Many of them appear to be confused as well, because they voted earlier for a motion which appears to be directly contradictory, demanding that the Government should fund the NHS entirely out of public money, "with no assumption of efficiency savings or private money".) No doubt many doctors are only bending, with great reluctance, to the harsh winds of economic necessity.
After all it was, as one of them said, "putting a stake through the heart of the welfare state"; and Dr Sandy Macara, chairman of the BMA, urged members to vote against the proposal, saying the NHS could perfectly well be paid for by the taxpayer, with only "a miserable pounds 17" more from each person. (It is also worth noting that a doctor arguing in favour of payment for doctors' visits claimed that it would raise half a billion pounds a year.) But this is the voice of the boy with his finger in the collapsing dyke.
The time has come not only to think the unthinkable, but also to believe it, and to start to think differently. Actually it would not be a lamentable necessity at all but an excellent thing if patients had to pay directly for medical attention. The fact that people have not had to pay all these years, but have regarded doctors' and nurses' time as free, has actually been a disaster for the NHS. The illusion of a free service has been wasteful, demoralising and counter-productive from the point of view of doctor, patient and taxpayer, and even, arguably, from the viewpoint of health administrators.
Anyone who pays for private treatment will know that the relationship between doctor and patient is radically altered for the better by the existence of a fee; parting with money tends to concentrate the mind. It sets up a powerful sense of personal obligation on both sides. Doctors have to provide a service patients think worth paying for, or they will go out of business. Equally no one with any sense will spend hard-earned money on a visit to the doctor unless he or she feels genuinely ill, and unless the excellent advice now available from pharmacists, and the passing of time, have not solved the problem, as they often do. People who pay the enormous fees of private GPs think long and hard before making an appointment, and find it quite astonishing how effective self help can be.
The other side of the picture is the frivolous abuse of the NHS, which is a direct result of people perceiving it as free. All doctors have outrageous stories of patients wasting their time, demanding visits even for sore throats or shampoo in the eye. Dr James Le Fanu tells of a middle-aged woman with asthma who called her GP for treatment at midnight; as he left she thanked him for coming, saying "my drugs are in my daughter's bedroom, but, I did not want to disturb her as she was fast asleep".
Night calls have risen fivefold in the past 25 years, and doubled in the last three, not because people are sicker, but because they are much less respectful of the doctor's time, which of course costs them not a penny. Not surprisingly GPs have become seriously demoralised.
The same goes for the ambulance service, which can offer equally outrageous tales of waste. In one station alone in one month emergency ambulances were sent to a young man who did not know how to remove his new contact lenses, a man who had been bitten by a stag beetle, a man who had stubbed his toe and broken a nail and a woman who had lost the string of her tampon.
What is more, highly equipped ambulances are regularly wasted by police, hospitals and local authorities as sources of "free" transport or of "free" low level community care, such as putting old people into bed. Not surprisingly, you cannot now count on an ambulance in a real emergency; only 66 per cent of calls are answered within 14 minutes.
So casual have many people become about the value of treatment, that many patients do not bother to turn up for hospital outpatients and consultants' appointments, and do not even bother to cancel. Considering that it takes many months to get one of these appointments, this is not only wasteful and disruptive, it is also unfair to sick people further back in the queue, and very demoralising to administrators. Frivolous patients might feel entirely differently if they were to lose a significant sum of money for wasting the hospital's valuable time, as private patients do when they fail to turn up.
It is not only patients' attitudes that can be damaging to the NHS. Doctors and nurses and other medical staff may find their attitudes subtly undermined by the knowledge that treatment is apparently "free". It is only human nature to treat with greater deference a customer who pays; a customer who had not paid, except in the remote sense of being (perhaps) a taxpayer, will sometimes be seen as lucky to get anything at all. Some patients seem to share this view, and feel unduly grateful for inferior service and oddly uncritical.
Certainly that is my experience of prevailing attitudes in the NHS, and certainly NHS patients are often treated in a casual way that would drive private practitioners straight into bankruptcy. All too often they are made to wait about ceaselessly; they see a constant stream of different doctors and their operations are frequently and brutally cancelled. This is not new, and not necessarily anything to do with the supposed cuts. It has to do with a prevailing culture that has horrified me all my adult life.
There cannot be a sense of value without a direct sense of cost. Equally there can be no personal sense of waste, without a personal sense of cost. So, far from the betrayal of an ideal, the single most effective reform of the NHS, the simplest way to cut back waste, queues, abuse and hypochondria, and to make way for those in real need, would be to make people pay, directly, part of the cost of each appointment. Of course there are many vulnerable people, who cannot and should not have to pay. But the rest of us might find we were buying, at low cost, a much more efficient service for everybody.
The Daily Telegraph | Wednesday, July 02, 1997
