Intended for healthcare professionals

Views And Reviews No Holds Barred

Margaret McCartney: Charging patients won’t solve the NHS’s problems

BMJ 2017; 356 doi: (Published 06 February 2017) Cite this as: BMJ 2017;356:j611
  1. Margaret McCartney, general practitioner
  1. Glasgow
  1. margaret{at}

It’s back: let’s charge patients for GP appointments. This idea floats to the surface every so often, like steatorrhoea. Think tanks propose it like clockwork, and then up it bubbles into headlines.12 GPs are surveyed, some of whom think that it will get rid of “trivial” consultations.3 Others say that it will balance the books.4

Now we have the leader of a local medical committee proposing charges for any routine appointments done outside office hours.5 In Northern Ireland the stress on primary care is now so great that it may become an entirely non-NHS, private enterprise in which most people have to pay for appointments.

As a solution to the rising pressure on the health service, the idea of charging patients for appointments is misguided. The RAND studies of US healthcare in the 1980s showed that, under randomised conditions, people who had healthcare under cost sharing insurance models behaved differently from those receiving free care. The cost sharing insurance models reduced poor people’s access to care: those who had to pay saw their doctor less frequently, whether they required low or high cost interventions.6 In the Republic of Ireland, where most of the population have to pay to see a GP, fewer people see one when they have a medical problem than NHS patients in Northern Ireland.7

Allowing people’s access to money to equate to access to healthcare reinforces the inverse care law, which the NHS should have subverted. For those who can afford to pay for care it lends itself to overdiagnosis and overtreatment, turning some people into patients when they don’t need to be. For those who can’t afford to pay, it prevents them from receiving the care they need.

Allowing people’s access to money to equate to access to healthcare reinforces the inverse care law, which the NHS should have subverted

Then there’s the bureaucracy. When my children and I visited an NHS dentist the other day it necessitated eight signatures from me, 12 bits of paper, and the same amount of time spent in reception filling in forms as sitting in the dentist’s chair. Do we really want to waste more money and time in creating, managing, and checking entitlements and credit card numbers?

The problems facing general practice need solutions that provide stable and sustainable funding, not ill conceived proposals such as charging patients for appointments. If we lose primary care, we will lose the NHS. But that failure would be a political choice, not an inevitability.



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