Can user charges make health care more efficient?BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3759 (Published 18 August 2010) Cite this as: BMJ 2010;341:c3759
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Thompson et al have drawn upon an impressively wide range of evidence in their review of user charges for healthcare in Europe.1 However I question some of their conclusions. Firstly, while I agree that the efficiency argument for broad user charges- that is, using them instead of tax financing- is unjustified, the significant resources which appropriate charges could generate to support high value care should not be dismissed.
The authors provide extensive information about how charges are being refined to reduce low value care elsewhere in Europe, but then conclude that the United Kingdom (UK) does not need this strategy because it is using some others. Presumably, by the same token, France could ignore the potential of pay for performance because it employs user charges. To reduce low value care, health systems need to use every available and effective strategy.
User charges for prescriptions already exist in the UK, and raise about Â£1 billion annually. A limited review of exemptions from prescription charges in England is underway, and cancer patients have recently been exempted,2 while the devolved Governments in Wales and Scotland have eliminated and reduced charges respectively.3;4 If they do continue, prescription charges would benefit from reform, to avoid the need to claim exemptions. The current income limit for free prescriptions (which was Â£15,276 per family via the Tax Credit system) is so low that adverse health impacts such as those described by the authors may be occuring in those with below average incomes, but above the current income limit for exemption from charges. Moreover, there is little theoretical justification for prescription charges, as prescriptions are initiated by doctors, not patients. So where else can Â£1 billion be found?
The only logical service for which to institute user charges is patient-initiated direct access to primary care, including both A&E and GP attendances to avoid perverse incentives. Over the period 1995-2008 the consultation rate per person year (all staff) in general practice increased from 3.88 to 5.45, a 32 per cent increase, from an England estimate of 188,000,000 consultations in 1995 to 276,000,000 in 2008 (see Figure below).5 Over the same period, the age-sex standardised consultation rate for all staff and all locations increased from 4.31 to 5.57, despite a fall in home visits from 0.28 per person year to 0.12. GP and other practice staff have increased, but more slowly, and this increase has now ceased.6 Meanwhile, A&E attendances increased from 12.5 million to 18.8 million, and there has also been growth in contacts with new NHS-funded providers, for example calls to NHS Direct.7 Thomson et al concede that " a charge could remain for low value care, but if care is indisputably of low value, why provide it at all?" Unless they are suggesting that walk-in primary care should be withdrawn, strategies are urgently needed to reduce low value primary care and A&E attendances. Carefully-crafted user charges should be considered as one such strategy.
Trends in estimated practice consultations, new A&E attendances, and GP and practice staff, England
(1) Thomson S, Foubister T, Mossialos E. Can user charges make health care more efficient? BMJ 2010; 341:c3759.
(2) Department of Health. Prescription charges for people with cancer and those with long term conditions/Implementing prescription charge exemption for people with long term conditions. Department of Health website 2010 [cited 23/3/2010]; Available from: URL:http://www.dh.gov.uk/en/Healthcare/Medicinespharmacyandindustry/Reviewof...
(3) Hart E. Free prescriptions helping to improve health in Wales. Welsh Assembly Government 2010 [cited 1/7/2010]; Available from: URL:http://wales.gov.uk/newsroom/healthandsocialcare/2010/100330prescription...
(4) The Scottish Government: reduced prescription charges. The Scottish Government website 2009 [cited 23/3/2010]; Available from: URL:http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/Health-Costs/pres-...
(5) Hippisley-Cox J, Vinogradova Y. Trends in consultation rates in General Practice 1995/1996 to 2008/2009: Analysis of the Research database. Information Centre for Health & Social Care website 2009 [cited 20/3/2010]; Available from: URL:http://www.ic.nhs.uk/cmsincludes/_process_document.asp?sPublicationID=12...
(6) Information Centre for Health & Social Care. NHS Staff 1997 - 2007 (General Practice). Information Centre website 2008 [cited 25/3/2010]; Available from: URL:http://www.ic.nhs.uk/cmsincludes/_process_document.asp?sPublicationID=12...
(7) Department of Health. A&E Attendances Timeseries. Department of Health website 2010 [cited 25/3/2010]; Available from: URL:http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/@sta/@perf/documents/digitalasset/dh_113249.xls
Competing interests: No competing interests
This paper's analytical framework for understanding the impact
of user fees is useful for developing country health systems.
However, I would note that for developing countries with weak
public delivery systems - user fees in public clinics are
associated with higher output (from a mix of staff
incentivization and the production benefit of having the extra
resources available in the clinic). For those health systems
settings, to determine what will happen to use of services
when you reduce user fees, you have to additionally take into
account the impact of the decrease in supply for high and
medium value services. This supply reduction could potentially
dominate the effect of the increase in demand due to the lower
prices paid by users.
Mead Over discusses the appropriate way to analyze the impact
of user fee reduction in this blog entry at the Center for
Global Development's Global Health
Competing interests: No competing interests