Should the NHS ever charge extra?

(51 Posts)
Jac1978 Wed 20-Mar-13 15:23:37

NHS bosses have suggested charging for out of hours GP visits and for hospital meals to try and raise some much needed funds but is this the right way to go about it? Would it be better to charge those who abuse the NHS instead eg people who miss appointments or repeatedly end up in A&E drunk? Or would this be the start of privatisation when we all pay our national insurance for a completely free health service? How would you save money?

WestieMamma Wed 20-Mar-13 17:48:19

I'm in Sweden. We have to pay around £10 per doctor's visit, more if you miss it, and £8 for nurses/physios etc. We also have to pay approx £15 per night for hospital stays, although it varies from hospital to hospital. There are lots of exceptions eg children, pregnancy related appointments, routine vaccinations/screening, and once you've paid a certain amount (around £100 I think) in a year you're totally exempt for a year.

scarlettsmummy2 Wed 20-Mar-13 17:51:29

The Sweden model sounds excellent. I also think people that injury themselves whilst drunk should be charged. Nothing annoys me more than taking a sick child to A and E and having to wait while staff deal with drunken idiots. Obviously alcoholics are an exception but young guys fighting on a Saturday night are totally unacceptable.

Wishiwasanheiress Wed 20-Mar-13 17:52:36

I'd prefer to pay for missed appointments but no idea how u would do it.

wonkylegs Wed 20-Mar-13 17:54:24

In principle i would agree if it were not for the fact thatI keep on getting letters from the hospital telling me off for DNAs for appointments they have never told me about in the first place!angry so I would be wary of a system that penalised me for their mistakes. The hospital in question is lovely and brilliant except where paperwork is concerned where they are absolutely atrocious. DH worked there for a bit and got annoyed with the chaotic nature of the admin & management. He complained that it often made the running of his clinics nigh impossible.

foxrivereight Wed 20-Mar-13 17:55:10

Mmm interesting topic . I think maybe charging for missed appointments is something to think about . We have to wait about 2 weeks for gp appointments . It annoys me at the fact that the fortnights booked appointments won't all be kept and my DCs could have used it .

Rhianna1980 Wed 20-Mar-13 17:57:09

Charge missed appointments
Charge drunk relates injuries.

I quite like the sound of the Swedish model Too .

stretch Wed 20-Mar-13 18:06:51

The problem is, where would it stop? First missing appointments, drunk-related injuries..smoking related diseases...obesity related diseases...addiction....OOH appointments...ambulance 'wrongly' being called out....

I don't disagree as such, just don't trust this government an inch not to take a mile.

3littlewomen Wed 20-Mar-13 18:07:21

Here in Ireland we pay €50 approx to see our GP, and I can usually get an appointment the day I phone. We pay about €100 per night in hospital.

All maternity care is free. I don't mind paying as you do question if you really need to see Dr. Families on low income get payment exemption

NotAnotherPackedLunch Wed 20-Mar-13 18:12:40

Charging for missed appointments sounds ok, but I wonder if a disproportionate number of missed appointments are MH appointments where the patient may be in no state to attend the appointment or to pick up the phone to cancel. I think a lot of consultation regarding exemptions would need to be carried out before introducing a scheme like this.

ParsingFancy Wed 20-Mar-13 18:15:48

Not much point giving people hugely expensive treatment in a hugely expensive hospital bed, and neglecting the really cheap bit of their treatment: basic nutrition.

What on earth would you do with someone poor who scrimps on meals to save money in hospital? (Bear in mind illness is expensive - they're unable to be at work, may need to pay childcare, family have transport costs to see them, etc.)

AThingInYourLife Wed 20-Mar-13 18:17:44

The Irish system is fucking hideous and plenty of families don't take their sick children to the GP because they can't afford it.

And no, they should not start charging for OOH care to create easier profits for private contractors.

As for all the moralisers calling for the withdrawal if medical treatment for people who are injured when they've been drinking - words fail me.

ParsingFancy Wed 20-Mar-13 18:21:17

I know, since we're desperate for income, we could pay for drunk injuries by increasing tax on alcohol. Including beer.

Oh, wait... hmm

In principle I think it's a good idea but you have to keep it simple or the administrative costs will rocket. That means avoiding judgemental charges - was it the patient's fault he was injured, how much did he have to drink? Impossible.
On the other hand a nominal sum for a GP appointment and modest hotel charges for hospital stays seem reasonable.

Hospital transport is also huge drain on the NHS. Free transport is provided to and from hospital for many, many patients regardless of means.

ParsingFancy Wed 20-Mar-13 18:26:24

Er, some people can't afford to stay in hotels...

I don't mean that literally.
I mean a small charge for food during overnight stays.
And as always those on benefits could be exempt or pay less.

ILoveMimislabel Wed 20-Mar-13 18:32:39

The nhs is free to all and should stay that way ! I work in the nhs and there are many faults with the system but that it is free is not one of them! Starting charging for certain things is slippery slope to the American way ! Not enough money to be treated ? Do you really want that ?

Whorulestheroost Wed 20-Mar-13 18:38:33

That's a difficult question. I am a district nurse and see lots of people abusing the system. Not complying with treatment, calling us out over nothing (repeat offenders), people who could easily do their own eye drops but insist on a nurse visiting 4 times a day. BUT the worry would be that people who genuinely needed a service wouldn't use it because if the cost. There are a lot of older people who have no conscience in over using the NHS as they feel have paid in all their lives and deserve something out of it.

Whorulestheroost Wed 20-Mar-13 18:41:11

What about things like continence pads? The nhs spends millions on these - should this come out of an over stretched budget?

AThingInYourLife Wed 20-Mar-13 18:51:11

Definitely no continence pads for people who piss themselves because they are drunk.

Or people who wet themselves laughing. Fucking pay for your own humour-related wee wee accidents.

Having fun is a choice!

Whorulestheroost Wed 20-Mar-13 19:03:17

But people who wet themselves laughing have stress incontinence same as when you laugh & sneeze!! People with peg feeds have their feeds supplied on prescription and also those with coeliac disease are able to get food basics on prescription. Are these items medicinal? Should they be paid for by the NHS? It's hard to know where to draw the line.

edam Sat 23-Mar-13 19:54:17

Yeah, right, the out of hours service is a disgrace and has been a disgrace for a long time and they have the cheek to suggest charging for it. Jeez. NHS managers know OOH is a mess. People have died because OOH is a mess. Some providers only bother to employ one doctor to cover huge parts of the country - I think the whole of Cornwall had one out of hours doc at one point.

edam Sat 23-Mar-13 19:57:16

And wonky's right that missed appointments are often NOT the fault of the poor darn patient. MIL is getting increasingly confused and the hospital are writing to her with appointments, even though there's no chance she will understand, retain and use the information. SIL has pleaded with them to at least copy her in on appointment letters, but no joy. We just have to hope that when dh and SIL go round they manage to find any letters MIL has tucked away God knows where. (MIL gets five carer visits a day but really needs to be in a home, but the bureaucracy of SS doing assessments, hospital doing assessments and the potential home doing assessments and then finding a place is never-ending.)

scaevola Sat 23-Mar-13 20:01:01

My friend kept getting "naughty naughty you've missed XYZ antenatal appointment/scan" letters - even though she's had a miscarriage and ERPC in the same damned place as was sending the letters.

The admin just isn't up to this.

And I think it's wrong anyhow.

tribpot Sat 23-Mar-13 20:04:17

I'm not sure I understand the rationale behind paying for OOH treatment, except that many people use it who don't really need to (depending on who defines 'need', obviously - the worried first time mum? The confused elderly person? The chronically ill patient whose pharmacy didn't deliver the right quantity of pills? Have had to do that one twice). Equally many people make appointments with their GP which are unnecessary and that costs money too. So ... why is OOH different?

My surgery is being urged by the patient group, including by me, to consider penalties for repeat offenders who Do Not Attend (DNA). They are extremely reluctant to do so - I suspect for some of the reasons given above. MH and other vulnerable patients whose lives will be made worse if they feel pressurised about poor performance - and the downward spiral only increases costs on the NHS anyway. I have a feeling (although they haven't said it) that they rely on a certain percentage of DNAs to make sure they can get through the day's appointments without massively overrunning. A bit like airlines overbooking flights.

So in the traditional time-cost-quality model, if costs can't increase and (obviously) quality can't decrease, that only really leaves time. Longer waiting times in order for hospitals to do more private work? (Although god knows there's plenty of spare capacity for private work already, they're called 'weekends').

edam Sat 23-Mar-13 21:09:09

Tribpot, they may well be extremely reluctant to do so as it's probably illegal. Although the dog's breakfast health bill did originally include the outrageous ability to impose charges, I have no idea whether they made it through all the shenanigans... but I imagine any surgery trying it would find itself on the front page of the nationals very quickly.

And yy, surgeries do rely on a certain proportion of DNAs to make their workload more manageable.

tribpot Sat 23-Mar-13 22:23:37

edam - yes, I think the sanctions discussed were around the patients being taken off the surgery's books entirely, or at least not being allowed to book appointments but instead having to come down and wait for a free slot to open up. Nothing financial.

Equally I would quite like to charge my surgery for wasting my time as well - DH was called in after a pre-op assessment at the hospital revealed a problem with one of his blood results. GP summoned him in (in the snow, in a wheelchair) to tell him to have some blood taken and to come back in a fortnight. Two more appointments (see above) just to get the blood drawn and the results discussed.

This is the double-edge sword of trying to charge; if NHS Direct say to go to OOH and OOH charge me to tell me to go to A&E, do I get a refund from NHS Direct?

Erebus Tue 26-Mar-13 20:51:58

Where I work, the majority of DNAs are of 'working age' men. In one place I worked, they'd deliberately double book the 8am appointment for 2 patients with the same condition 'requiring' investigation in the pretty sure knowledge that one of the appointees wouldn't show. We were rarely wrong.

Erebus Tue 26-Mar-13 20:54:51

My idea would be to set up a 'please explain' unit, for just a year (unknown to the public!) where every NHS appointment DNA'ed by a 'working age' patient would be sent a 'bill' with a chance to explain why they hadn't attended. You'd get Booker Prize winning fiction written in response!- You'd be let off the 'fine' on this occasion... but I bet that within a year, the Message would be Out There that 'You DNA, you pay'.

CabbageLeaves Tue 26-Mar-13 21:05:13

I work in the NHS. We spend extra money trying to attract people to engage with healthcare. We target groups who are both poor attenders and at risk. These are also the sort who DNA, cancel at the last minute etc etc

I do find myself thinking its nuts tbh and we should make people responsible for their own health. Don't chase ...and spend that money on those who want healthcare. We act like a nanny trying to cajole 'better behaviour' from naughty children.

People know smoking and alcohol will affect their health. It's their choice. Treat them like an adult capable of making a choice

I strongly suspect the people who would be affected most by fees and penalties would be parents, old people and people with disabilities. Please don't let this happen sad

tribpot Tue 26-Mar-13 21:36:01

Cabbage, I think the argument is about whether the cajoling is preventative. Some money spent chasing a relatively well smoker might result in that person not developing a more serious (read: expensive) condition for which the NHS picks up the tab later.

But equally as you say, the cost of targeting reluctant patients is that the not-reluctant ones have to wait patiently (no pun intended) in a queue.

CabbageLeaves Tue 26-Mar-13 21:52:55

I can see arguments for and against but I am pretty sure (only personal experience) that you cannot make a person engage unless they want to. So...extend the offer then forget it

To spend money on charging for hospital meals and 'hotel' fees for people who are sick (possibly losing wages) with no choice about their health ...and not enjoying that food and hotel experience...whilst spending money on someone who drinks and smokes more than the DoH thinks is safe is just skewed.

Someone once said to me that the NHS was set up to provide healthcare for those who were deprived but now is increasingly providing care for people who have excess food, drink etc

flatpackhamster Tue 26-Mar-13 21:57:17

ILoveMimislabel

The nhs is free to all and should stay that way !

Well it isn't, it is? It's 'free at the point of use' but it costs a bloody fortune.

I work in the nhs and there are many faults with the system but that it is free is not one of them! Starting charging for certain things is slippery slope to the American way ! Not enough money to be treated ? Do you really want that ?

Starting charging for things is the slippery slope the system they all use on the continent. France uses the same system as Sweden. Germany uses it. But apparently it isn't good enough for the NHS? Since when was our healthcare so amazing that we can't learn from abroad?

I'm sure that they aren't stacking the dead geriatrics like cordwood in the way that they are in our hospitals.

TheFallenNinja Tue 26-Mar-13 22:18:22

Can you imagine the cluster fuck if they suddenly had to manage a retail operation.

Cut the waste, cut the cost.

CabbageLeaves Tue 26-Mar-13 23:00:33

Waste. Hmm. I manage the budget for my dept Equipment costs anything between £26000 and a million quid.... Medical devices implanted into patients cost £7000. I don't think people realise quite how expensive their healthcare can be.

How many retail outlets provide interpreters for customers? The demands on the NHS are different. I really don't think people have a grasp of inherent costs such as drugs, equipment etc

Waste... I can't deny that there is waste. I really would like to think I run a very patient focused, cost efficient service. That is honestly my goal. What stands in my way is bureaucracy which is often driven by politicians keen to demonstrate our fantastic the NHS is... I waste time on that rather than giving patient care. Having said that my dept is performing very successfully so we have a light level of supervision and lots of trust.

In many ways a privatised service would work well for some, less so for poorer patients. From my pov it couldn't harm. Our budget is so efficient that there really is nothing to trim unless you reduce the service! Private companies provide the same service in parts of the country. NHS depts out performed them for same cost last year.

ParsingFancy Tue 26-Mar-13 23:55:02

The NHS wasn't set up to provide healthcare for the deprived, though. It was set up to provide healthcare for the nation, rich and poor, according to medical need not according to ability to pay.

And the rich included those with gout and alcohol and drug-related problems.

There are a lot of myths being created about "Oh, the NHS has changed in purpose and lost its way," to soften us up for things that really would be changes in the NHS's purpose and ability to deliver.

CabbageLeaves Wed 27-Mar-13 07:35:41

Well... 1) I'm against charging because I don't think it will improve healthcare and 2) my point was that when the NHS was formed : the health service will be available to all and financed entirely from taxation, which means that people pay into it according to their means. So those who couldn't previously afford it now had healthcare. Yes everyone accesses it regardless of wealth

I still think current economics mean the health service should examine some of it's goals and put care of the sick first: that includes giving healthcare to those injured during risky activity whether sport, party, booze or drugs

I would however like to see whether there is any evidence to suggest that it's cost effective to spend time trying to change people's lifestyles. So offer lifestyle change support but spend less time trying to reach out to those who don't want help.

Help those who want it

WannabeWilloughby Wed 27-Mar-13 07:49:53

If they started charging for hospital stays, they would need to rethink car park fees. I bet many people couldnt afford to pay to park at hospital and also pay for an appointment there.

Do you pay for prescriptions in Sweden too? (don't mean that in a rude or confrontational way, just genuinely interested if you just pay for your appointment and that covers everything or is medication separate? iyswim).

tribpot Wed 27-Mar-13 07:54:45

I agree, CabbageLeaves. There appears to be a belief that it is more cost-effective to reach out to people before their health deteriorates, to prevent them from presenting with unmanaged and more serious conditions later on. When treatment can't be denied, i.e. we tried to stop you smoking, you didn't, now you have lung cancer.

Perhaps this belief is based on long-term evidence, perhaps it is just a belief that the NHS has to try to afford this approach now before the time bomb goes off.

I understand the desire to prioritise health needs based on some definition of the patient's own willingness to participate in prevention and treatment, but it quickly becomes a moral maze. I'm quite sure if I worked in A&E, however, I would want to fast track the people on a Saturday night who are not there because of their own drinking, drug-taking and fighting!

austenozzy Wed 27-Mar-13 07:56:28

terrible idea. it would simply lead to a two tier health system in which the vulnerable suffer. and the nhs has enough trouble with existing admin without adding a complicated billing system into the mix.

Erebus Wed 27-Mar-13 08:16:35

Did anyone see that BBC programme last night on the NHS? I was rather surprised that in its opening programme, of 8, it put a degree of focus on the obese, the alcoholic, the time-wasters and the extreme old age- 4 factors that threaten the on-going existence of the NHS. It wasn't judgey, as such, and it also had the child/ren-with-cancer but only a touch of the child-birth thing which characterises so many NHS focused TV, ie the touchy feely, plinky piano accompaniment, "isn't the NHS grand?" -stuff, but which rarely focuses on the pointy end of several factors (given above) that impact on the ability of the NHS to go on being all things to all people.

Erebus Wed 27-Mar-13 08:22:53

Actually nozzy, the NHS has no problem with Admin at all! It's very good at it. It has tiers of management all admin'ing away; not because the NHS feels like it but because the government has Listened To The People and has demanded it.

Sadly, in every other walk of life, 'the vulnerable' suffer. Can't see it being any different to that. And, of course, you'd have to define 'vulnerable'. Some modern commentators define it as 'anyone with any sort of issue or problem'. We get to the point where no-one is responsible for themselves in any way because the majority of issues in life are as a result of something external to ourselves; it's how we choose to react to them that determines the outcome, but an awful lot of people seem to be like corks in a storm tossed ocean when faced with anything difficult, thus resort to risky behaviours. Then get classified as 'vulnerable' because they made unwise choices.

Trazzletoes Wed 27-Mar-13 08:34:04

I'm disgusted at the prospect of asking people to pay for their meals in hospital.

People don't stay in hospital for fun!!! Generally you have to be here for whatever reason! plus there's no way on earth I would willingly pay money for some of the stuff that gets served

Eating is pretty essential, and often even more important for sick people. People would end up not paying and not eating and leading to MORE health problems.

mercibucket Wed 27-Mar-13 08:41:22

i would be quite happy paying for food. i saw how it worked in france and that looked fine. those on benefits and children got free meals. the food was good quality, unlike nhs food

ParsingFancy Wed 27-Mar-13 08:59:06

tribpot, the focus on public health interventions is indeed based on evidence and there's a lot of work by health economists (internationally) and NICE in this area.

Eg paper here: The cost-effectiveness of public health interventions

As an NHS worker, I can see both sides (hopefully)

YY to the missed appointments, it is a total waste of NHS time/money.

But then we have the Josie Cunningham breast augmentation on the NHS story.
Hopefully the GP and surgeon who sent her for this (and bear in mind, it wasn't a post-mastectomy operation or anything like that.Apparently she has a congenital lack of breast tissue. But she had it done with the intention of being a glamour model. Doesn't she read any magazines? Look at the popular glamour models love. 99.99% are seriously pretty without all the make-up. You are not in that league)

Meals in hospital? Why not pay for them. You'd pay at home wouldn't you?

Missed appointments- I'm on the fence here. If someone is ill- as in , hospital ill or having to have the GP out, would you charge them? If their spouce was ill?

Many times I phone people who have missed the appointment.
"Hello, Mr Smedley, this is XYZ Clinic, you had an appointment with us this morning.I'm calling to see why you didn't attend"
"It's tomorrow"
"No, it was today.I've got the clinic list here"
"No it's tomorrow.I'll get my card" <<mutters and rummages for card>>

"Oh. Oh, it was today. I thought it was tomorrow. Oh, see I'm not very well today <cough.>. I really need to be seen. I can come now"

No. You were well enough when you were calling me allsorts earlier for phoning.
The patients PHONE TO MAKE THEIR APPOINTMENTS.
They know when they are.

One day this week, I had 4 missed appointments in one day (20 minute appointments)

angry sad

Missed a bit with my rambling:

Hopefully the GP who sent Ms Cunningham for her breast op will be able to look their next patient in the eye and say "Well, I'm sorry Mrs Hodges, I cannot give you these tablets, N.I.C.E, guidelines etc, and the huge slice of the budget on cosmetic surgery"

Simple answer is no, i don't think paying extra will solve any problems, it will just create more.
People with children on low incomes, those with disabled children, the elderly, the single working people on low income and the disabled wont be able to afford to pay fees and their health & their children's health will suffer as a result. Its lunacy at it's worse

bridgetsmum Wed 27-Mar-13 11:57:46

As a British citizen who lives outside the UK, the one thing I really miss is the NHS and I think it should be protected as it is. Any form of privatisation should be strongly resisted. Watching the programme on BBC2 last night about the NHS made me very proud of the service and the staff. A guy who collapsed was within 2 hours having life saving surgery, his surgeon made the point that he paid taxes all his life and deserved that treatment.

Erebus Wed 27-Mar-13 19:15:25

Well, for me, watching that programme last night reinforced in my mind why the NHS cannot continue as it is!

I am not sure that 'any form of privatisation' should be resisted, actually. BUT the Biggest Problem with privatisation is that we only now one model of it in the UK, as in: Big Shot strides in with his 'management team'. This largely consists of wide boys and schmoozers. Suddenly the current team of properly accredited, experienced workers are replaced with one or two who'd meet that required grade plus a bunch of semi-qualified chancers, many with dubious qualifications (often from semi-existent 'colleges' abroad) whom the few properly qualified will be paid £2 an hour more to 'supervise'- the 'staff' will be paid less than ever. Meanwhile, the (few) top dogs in the company, and of course the owners, will be raking it in.

You, as the 'punter', won't necessarily spot a difference because you're not qualified to do so. The Xray scan which they do so thoroughly - 3 or 4 times, in fact!- Is actually one scan repeated over and over because they got it wrong. The doctor's report will invariably suggest another form of imaging or diagnostic test which- Guess what! They also control. Bear in mind you'll think you're protected from rogue operators because, hey! This is the NHS BUT what will actually happen is that the government will instruct the registration body , the HPC, to accept lower qualifications as their mates who've won these huge contracts will want cheap labour, won't they?

I worked in Oz in the 'NHS' and then in a funny set-up they have there where the service (Xray in that instance) was privately owned and run but which imaged NHS style patients, ie 'for free'. I was shocked by what I saw. It employed all sorts who wouldn't have been employable in the 'NHS'. The standards were dire. Because extra payment-boxes could be ticked, everyone got 'additional views'. Everyone was fired with additional radiation they didn't need- and every report said 'We recommend this patient is referred on for further imaging which can be accessed via... (US!)'. Which duly happened. And I cannot state that I'm sure golf trips for the referrers didn't 'feature' along the line....

SO- my point is, privatisation isn't necessarily a bad thing but it has to be morally, responsibly and accountably managed. I would readily concede that you'd be surprised how much 'better' care became (ok, ok, how much better people perceivetheir care to be!! Important distinction) were one to incentivise the staff by getting the patients to rate their service, and the staff to be bonus'ed accordingly!!

Chipstick10 Fri 29-Mar-13 22:39:41

The nhs cannot go on in its present form, it needs a massive overhaul. I think the Swedish model sound pretty good.

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