There are, according to the Daily Mail, over 10m people who are short of their normal GP service. This is an inexcusable dereliction of duty in a civilised society. Poor manpower planning, poor politics, unequal educational opportunity and standards, and poor funding are responsible, along with the decentralisation of control (devolution) in a system where doctors are free to move. Don’t forget that, as it implodes, you can go abroad for treatment.
The Nuffield Trust reports on the uncertainties which will follow after Brexit. Staff shortages, drug supply chain problems, are just two. The structure of Social Care may break down as it is dependent on overseas staffing. But whatever shortages there are now will be worse after Brexit. GPs are an international commodity and can take their skills overseas. Most of the former British Empire and Commonwealth countries are also short of GPs, so there is a ready market waiting for newly qualified, or disillusioned GPs.
This temptation to move abroad also applies to consultants whose pension rules make it unproductive for them, however keen they are, to reduce waiting lists. James Phillips for Professional Pensions reports: Pensions tax issues leading to longer NHS waiting lists
The Kings Fund reports on the Health and Social Care system, and its threatened breakdown.
In my own area there is no “choice” (West Wales, Hywel Dda) so that if someone needs a “greenlight laser” they will not get referred. Older fashioned TURP (Transurethral resection of the prostate) has far more side effects and is far more intrusive, with slower recovery times. Consultants in Hywel Dda will not refer for this treatment under the Welsh Health Service, as the money would move with the patient and Hywel Dda would lose cash. There are plenty of other examples of improved care but they are always concentrated on cities, and rural citizens will get them less. In England, provided patients are prepared to wait and to travel themselves, “choose and book” (e.g. Cumbria) allows them access. This does not apply in Wales.
Yes, it would be a good idea to recruit retired GPs, and many like myself would help out, but there are issues around medical indemnity and speed, and most of us would want to see the system founded on a financial rock rather than the quicksand of today.
|People across Greater Manchester say they struggle to get GP appointments; “It really is a disgrace for those who genuinely need to seek medical advice urgently”|
I still get e-mails advertising jobs in other countries with far less bureaucracy, more clinical freedom, and less intense time pressures, and a far greater income. It is this we are competing with. The only answer is to agree with all our G8 countries that we train more than enough doctors.
There is still little Private Practice option in General Practice, but this will change. As delays for serious symptoms become intolerable and all the ruses the experienced use to gain access fail, Private GP, like Private Dentistry will emerge..
The reality that Health and Social Care are not either of them free, has not sunk in to the politicians yet. We cannot have “Everything for everyone for ever” and for free, and in their denial, both houses thus conspire to avoid the important debate that Mr Stevens called for on 4th June 2014, almost exactly 5 years ago. If Social Care is means tested, why not Health Care?
The unedifying spectacle of two potential leaders trying to bribe 160,000 older and richer people who happen to be their members, is the reality of todays politics. No wonder so many people dont vote. We need an honest party to speak “hard truths” to the nation. NHSreality believes the first party to do this, and be understood as honest and working for the overall good of us all, fairly, will eventually win a landslide. It will also win the hearts and minds of the medical professionals….. and they are trusted, and speak to many people daily.
Our political (moron) representatives need to permit commissioners and trust boards to ration overtly, so that their citizens know what is not available. Initially this will have to be by post code, but national guidelines from NICE would help. Eventually, for those services and treatments that none of us can afford, cancer and big operations for example, there can be a National Health Service again, and for cheap and cheerful, high volume low cost services, we can have local post code rationing if we still want it…
and the Guardian today also reports the Peers asking for an extra £80m for “vulnerable elderly people”.
How long will the UK citizens put up with untruths? How long will it take for the proper debate to begin? The Economist recognises rationing, Enoch Powell in “A new look at Medicine and Politics” recognised rationing in 1966. We cannot go on without knowing what (for us) will be unavailable. It is surely a human right to be able to plan for your own health, your family’s health, your death, and illnesses. No wonder citizens are getting more and more angry..
If we want to win the cooperation and hearts and minds of medical staff we need to find out the truth about what they think. BMA conferences full of retired and burnt out doctors may reject the “long term plan” but there is no link with the doctors at the coal face.
Not only is devolution a failure (certainly in Wales) but the 4 different systems allow different language of obfuscation, different methods of rationing, and outcomes. The anger will be the same.
Enoch Powell 4 Supply and Demand – Rationing Minister of health for 3 years 2nd Edition 1974
Toni Hazell 28th June in GP mag: Here are two potential problems with primary care networks. Huge hurry, and who takes responsibility?
The BMJ publishes “Doctors spurn NHS long term plan”, ( BMJ 2019;365:l4392 ) at the Annual Representatives Meeting, which reflects reality. The profession has not bought in to it. It is not founded on a financial or philosophical rock. Without the honest discussion that Mr Stevens called for we can get nowhere. So it’s going to get worse..
Doctors at the BMA’s annual representative meeting have expressed strong doubts about NHS England’s strategy for the next decade, published in January.1
Representatives voted overwhelmingly against a part of a motion proposed by the Wigan division that the meeting, being held in Belfast this week, “welcomes and supports the aims and initiatives of the plan.”
Tom Dolphin, a consultant anaesthetist and member of the BMA Council, proposing the motion, compared the NHS Long Term Plan to a “sketchy unfunded wish list for the NHS.”
He said, “The plan has two major problems: workforce and finances.” He described as “vague” and as lacking identified funding its proposals to shift care from hospitals to the community, to focus more on prevention, and to rely more on digital technology.
“It could have been good, but there’s no detail, too many big reforms, and nowhere near enough money,” he added. “It’s doomed to failure. The government needs to think again.”
A majority of representatives voted in favour of parts of the motion that the plan’s ambitions were largely unachievable because of underfunding and that “the reforms and structural changes proposed are not in the interest of the NHS.”
Without an adequate workforce strategy, the plan would precipitate a greater crisis in this regard, they agreed.
Delegates voted for parts of a different motion that opposed funding cuts imposed through efficiency savings, shifting care from hospitals to the community without a concomitant increase in resources, and the long term plan being a route to a market driven healthcare system.
The motion had been proposed by the retired surgeon Anna Athow, of Enfield and Haringey division, who described the plan as a “business prospectus in code.”
She said, “It is an anti-NHS plan, which is not care according to clinical need but the road to American market driven healthcare.”
But delegates did not agree with part of Athow’s proposal that GP surgeries joining primary care networks could lead to competitive tendering of contracts for integrated care providers. Integrated care systems, she had claimed, would be incentivised to cut care. “These are the principles of the American accountable care system,” she said, which could be run for profit. “The big productivity savings are to come from NHS staff as local ICS workforce boards develop strategies threatening national terms and conditions . . . Skill mix reduction is mandatory, with trained staff replaced with untrained staff.”
George Rae, a GP, was more positive, saying, “In general practice at present we can’t survive without a shift of certain care to other healthcare professionals.” He said that the long term plan did away with aspects of competition and that integrated care organisations needed to be NHS not private bodies. “Let us not throw out the NHS plan with the bathwater,” he said.
Just as Wales cannot afford (without central intervention from Westminster treatment for North Wales patients in CHester. ( Solved by Loan or grant we wonder?) the services their patients need, Warrington and Horton are trying alternative methods to ration by encouraging purchase schemes. They forget that the average DGH has more complications than a private hospital, and if you are paying you might as well ensure safety, quality and a consultant of your choice. (The default operation consent allows any of the team to do your operation). Quite rightly, Helen Salisbury questions whether there us anything that can be done to stop the financial decline. If the 4 health services are to remain free at the point of need, (as opposed to want) we need to ensure that need is not defined by the patients themselves! Now it would be interesting if Chester patients were to demand care in Wrexham, but with longer waits and lower standards this wont happen. Wrexham would be delighted as the money moves with the patient. Chester and Oswestry will have two waiting lists, one for Wales, and one for England.
Since its foundation, the NHS has been committed to providing treatment according to clinical need. The distinction between want and need is important—there may be treatments that patients want but don’t need, such as cosmetic surgery. In these cases, they have to go to the private sector and pay up front or through insurance. This is set out in the first two points of the NHS constitution,1 which state that the NHS provides a comprehensive service, available to all, and that access is based on clinical need, not a patient’s ability to pay.
This week Warrington and Halton Hospitals NHS Trust was in the news for its published list of charges for 71 procedures.2 This is not entirely new: starting with an initial offer of varicose vein surgery in 2013,3 the scheme was relaunched in September 2018 with a hugely expanded list of procedures and has only now hit the headlines. This list appeared under the banner “My Choice—by the NHS, for the NHS,” next to the NHS logo. This is very confusing and would leave many people asking, “Is this an NHS service or not?” The list included prices for cataract surgery (from £2251 (€2523; $2872)), knee replacement (from £7179), and hip replacement (from £7060), all of which are beyond the means of most people served by these hospitals, given Warrington’s high deprivation.4
The justification given by the trust is that these procedures have been limited by NHS commissioners.5 Operations on this nationally generated list were initially referred to as “procedures of limited clinical value” and are now “criteria based clinical treatments.” If patients don’t meet the criteria but still want the surgery, they will have to pay.
This makes a mockery of the NHS constitution: either patients have a clinical need, in which case they should receive timely NHS care, or they don’t need the surgery, in which case it’s not in their interests to have it, and it shouldn’t be done by the NHS.
What this programme reveals is that access to procedures with a proven track record of safety and efficacy, which patients need in order to see clearly or move comfortably, is being denied. The “criteria” for many patients are increasingly stringent: the Royal College of Surgeons raised the alarm in 2017 about restricting hip and knee surgery on the basis of arbitrary pain and disability thresholds rather than clinical assessment.6 And cataract guidelines from the National Institute for Health and Care Excellence explicitly state that commissioners should not restrict access to surgery on the basis of visual acuity,7 yet that’s what happens to patients covered by over a third of clinical commissioning groups.8 These decisions are not about optimising outcomes for patients but are a reaction to inadequate funding, requiring patients to be significantly visually impaired or disabled before they’re treated.
Even more worrying is that an NHS trust is explicitly offering a two tier service, with earlier treatment if you can pay. We should resist this transformation from a single, comprehensive system, where all are treated equally, to one where rich patients have rapid access and poor patients struggle to be referred and then languish on waiting lists. Bevan must be turning in his grave.
Wrexham.com suggests the problem of Welsh patients being seen in Chester is resolved. What nonsense. The financial solution is opaque indeed… and will be so for the foreseeable future.
A new look at Medicine and Politics: chapter 4 – J Enoch Powell 1966. We have invented many more since Enoch Powell’s day, and the latest from Warrington is how rich or poor you are…
The answer for this post-code lottery is for GPs to send all their patients elsewhere. Since the money moves with the patient, Warrington and Horton will get none.
METHODS OF RATIONING
The preceding pages have been devoted to examining how the medical profession is affected by the system that has been adopted for the purchase by the state of a certain quantity of medical care outside the hospitals. That quantity, as already explained, is indirectly fixed by the remuneration the state offers, which determines in the longer run the number and quality of those contracting to provide that care.
Thus, outside as well as inside the hospitals the figure on the supply side of the equation is fixed at any particular time by those complex forces that determine the state’s decisions on expenditure. With this figure demand has to be brought into balance. Virtually unlimited as it is by nature, and unrationed by price, it has nevertheless to be squeezed down somehow so as to equal the supply. In brutal simplicity, it has to be rationed; and to understand the methods of rationing is also essential for understanding Medicine and Politics. The task is not made easier by the political convention that the existence of any rationing at all must be strenuously denied. The public are encouraged to believe that rationing in medical care was banished by the National Health Service, and that the very idea of rationing being applied to medical care is immoral and repugnant. Consequently when they, and the medical profession too, come face to face in practice with the various forms of rationing to which the National Health Service must resort, the usual result is bewilderment, frustration and irritation.
The worst kind of rationing is that which is unacknowledged; for it is the essence of a good rationing system to be intelligible and consciously accepted. This is not possible where its very existence has to be repudiated.
In the hospital service probably the most pervasive, certainly the most palpable, form of rationing is the waiting list. The waiting list is a complex phenomenon in itself. One component can be likened to a reserve of working materials: if the hospital resources are to be continuously used, there must be a waiting list. The simplest case is that of a consultant available (let us suppose) during a two-hour session. If there were no queue in the outpatient waiting-room, there might be gaps between one consultation and another when the consultant would not be productive— not, at least, in that sense. So it is always arranged that there shall be plenty of people waiting when the great man arrives, so that there is no danger of the expensive mill even momentarily lacking grist. Similarly, if the capital and resources represented by operating theatres and their staffs are to be intensively used, there must be, so to speak, a cistern from which a steady flow of cases can be maintained.
This element of the waiting list is only incidentally a rationing device, though even here time is serving as a commutation for money: a consultant in private practice can accept the discontinuity of work implicit in a good appointments system, because his patients are in effect buying his waiting time as well as his consultation time or, putting it another way, the patient finds his own time worth more to him than the consultant’s.
Waiting lists, however, normally exceed the minimum related to full employment of the medical resources. They are then directly rationing in their effect. For example, they ration demand for the more able, experienced or celebrated advice and treatment compared with the less: the waiting lists of consultants in the same department of a hospital can differ greatly in length. It is sometimes said that consultants regard a long waiting list as a status symbol and preserve it with the same care and pride as an Indian would a string of scalps. Certainly, consultants are very possessive about their waiting lists. But the taunt is as uncomprehending as it is uncharitable. There has to be some differential rationing for different qualities of an article, and if not price, then, for example, time: better surgeon, longer wait, and vice versa. No wonder consultants, family doctors and patients too resist equalisation of waiting lists, which would mean that rationing by time would have to be replaced by some even less rational or intelligible form of rationing, such as rotation or the initial/letter of the surname.
Generally, the waiting list can be viewed as a kind of iceberg: the significant part is that below the surface— the patients who are not on the list at all, either because they are not accepted on the grounds that the list is too long already or because they take a look at the queue and go away. Naturally, no one knows how many these are. Indeed, the very question is rather absurd, as it implies some natural, inherent limitation of demand. But the part of the iceberg above the water is doing its work, directly as well as indirectly, by attrition as well as by deterrence.
It might be thought macabre to observe that if people are on a waiting list long enough, they will die— usually from some cause other than that for which they joined the queue. Short of dying, however, they frequently get bored or better, and vanish. Here again, time on the ‘waiting list is a commutation not only for money— measurable by the cost of private treatment with less or no delay— but also for the other good things of life. It is an interesting phenomenon of the waiting lists for in-patient treatment that at the holiday season and around Christmas time it may be necessary to go quite far down a lengthy waiting list to get patients willing to accept the long-awaited treatment in sufficient numbers to keep even the temporarily reduced hospital resources fully employed.
I cannot but reflect sardonically on the effort I myself expended, as Minister of Health, in trying to ‘get the waiting lists down’. It is an activity about as hopeful as filling a sieve, although this is not to deny that some of the measures applied and pressures exerted might conceivably have had some useful side-effect in improving, in a slight degree, the direction of effort. There were the circulars enjoining such devices as the use of mental hospital beds and theatres, or of military hospitals. There were the stiff cross-examinations of staffs and hospital authorities in the endeavour to discover what contumacy might explain their continued non-compliance with the official exhortations. There were the special operations to ‘strafe’ the waiting lists, urged on the fallacious ground that a stationary waiting list is not evidence of deficient capacity— otherwise it would lengthen —but of a backlog which, once ‘cleared off’, ought not to be allowed to recur.
Alas, the waiting list that melted under an assault of this kind was back again to normal before long. There were always special, local and temporary explanations that could be cited, such as a sudden coincidence of staff off duty through leave, sickness or change of post. But all too evidently the causes at work were general and deep-seated. There was a mean around which the figures fluctuated, but that was all. Naturam expellas furca, tamen usque recurret: though you drive Nature out with a pitchfork, she will still find her way back.
In a medical service free at the point of consumption the waiting lists, like the poor in the Gospel, ‘are always with us’. If at any moment of time they do not exist, they have to be re-invented, or rather they reproduce themselves effortlessly and automatically. Ministers come and Ministers go: the hospital service spends a rising fraction, or it spends a falling fraction, of the national income; but the ‘waiting list at 31st December’ in the Ministry of Health’s annual reports still stays the same, a reliably stable feature in an otherwise changing scene. On New Year’s Eve 1959 it was 442,519; on New Year’s Eve 1960 it was 475,643; I962, 474,353; 1963, 470,297; 1964, 475,863; 1965, (oh dear!) 498,972. And what had it been, pray, on New Year’s Eve 1951, back in those early, primitive days of the National Health Service? Why, 496,131.
At the same time, Ministers of Health are broadly truthful when they say that for cases diagnosed as urgent or critical the waiting list, practically speaking, does not exist. This is far from disproving the function and necessity of the waiting list as a rationing device. For one thing, ‘urgent’ and even ‘critical’ are not objective magnitudes; on the contrary, they are assessments that have already taken the volume of supply into account. In any case, there is no clear-cut dividing line between the ‘urgent’ cases, seen or treated at once, and the ‘non-urgent’ cases on the waiting list— or, as the case may be, not on the waiting list at all. The latter are squeezed down— or off— by the former. To point to the fact that no ‘urgent’ case goes untreated as evidence that supply and demand can be brought into balance without rationing is like arguing in a famine that because nobody dies of starvation, there need have been no rationing system.
A DOUBLE STANDARD
In the last resort the waiting list, or the queue in the general practitioner’s surgery, is one aspect of rationing by quality. In the days of the reform of the poor law and abolition of outdoor relief for the able-bodied, this used to be known as the principle of ‘lesser eligibility’. What are called the ‘deficiencies’ of the National Health Service— the large number of patients per general practitioner, the age and quality of many of the hospital buildings, and so on —are not deficiencies in the literal sense of the word, that the service falls short to a measurable extent of an objectively definable standard. They are those consequences of the quantity and quality of medical care being purchased by the state that help to equate the demand with the supply. The supply of medical care of all kinds through the National Health Service is rationed by forcing the potential consumer to choose between accepting the quality and quantity offered or declining the care offered. If he declines the care offered, he can either renounce or defer treatment altogether or he can endeavour to purchase it outside the National Health Service.
This is why it is absurd to declaim against a ‘double standard’ of medical care, inside and outside the National Health Service respectively. The standard inside is that which balances demand with the amount supplied by the state; the standard outside is that at which the supply and demand for medical care balance in the market, given the existence of the National Health Service. The standard in question is not necessarily one of purely medical treatment, if indeed the purely medical aspect of care can be divorced from the others. For example, it may well be that a patient acutely ill or gravely injured may be treated as skilfully, efficiently and safely in a National Health Service hospital as in an expensive private hospital or ‘nursing home— often, I would guess, more so. But the paradox is capable of rational explanation. The ancillary aspects of medical care— amenity, privacy, attention in convalescence, a degree of freedom, choice and individual self-assertion—may be valued no less than the essentials that affect life and limb. Indeed, they are sometimes valued more highly, surprising though that may seem. There can also be an element of pride, prejudice, snobbery— call it what you will— that values the identical article more highly when it is purchased than when it is received gratis.
The principle of lesser eligibility has always been applied, cannot help being applied in some form, wherever provision is gratis. It was applied before the National Health Service started in the voluntary and municipal (ex-poor law) hospitals and, indeed, from the beginning of time wherever medical care was rendered free at the point of consumption. Since eligibility is a form of rationing, we naturally find that it, like the waiting list, is also used to establish an order of priority. This is the reason why, for instance, the geriatric and long-stay mental hospital wards are, and have always been, the most ineligible in the service. The priority accorded to the demands of acute illness requires that rationing be applied more severely to the chronic.
Two instructive contrasts outside the National Health Service will illustrate the rationing function which lesser eligibility performs in it. One is the striking contrast between the two forms of old people’s accommodation: the workhouse and the new-style old people’s home. The former was designed to meet a legally unrestricted duty to admit; the latter corresponds to a discretionary and highly discriminating right to admit or not to admit. Consequently the poor law institution had to ration by ineligibility, and still in practice does if it continues to exist, while the new-style home explores ever-rising standards of amenity and care under the shelter of a rationing system of a different kind. Similarly, the paradox of the relatively high standard of the subsidised local authority house, although it is subsidised, is explained by the fact that the demand is tailored to the supply by the discretionary waiting-list itself, and consequently the supply can be rendered in a relatively eligible form.
The fact that the necessity for these covert forms of rationing springs from the very nature of the National Health Service and not from any particular level of supply attained in it is borne out by ‘Parkinson’s law of hospital beds’, which asserts that the number of patients always tends to equality with the number of beds available for them to lie in. Thus, the ratio of hospital confinements to total births ranged in 1965 from as low as 53.8 per cent in East Anglia to 78.4 per cent in Wales—the national average was 69.8 per cent. Yet the pressure on maternity accommodation was at least as high in the latter part of the country as in the former. Again, the number of hospital beds for acute disease in the North-West of England is almost twice as great as in the South-East: in 1961 there were 3 per thousand population in East Anglia against 5.6 in the Liverpool region. Yet the pressure of demand, as evidenced, for example, by length of waiting lists, shows no comparable variation. There is, as has been said above, no reason to suppose that an increase in the quantity or quality of care provided by the National Health Service would reduce the need for rationing. On the contrary, every increase in eligibility must involve an intensification of the other forms of rationing, such as waiting.
It is unfortunate that the nature and the value of rationing by waiting and by ineligibility in the National Health Service are not recognised, at least by the professions. For these are the features that make it possible to avoid invidious discrimination in administering the service and, at the same time, secure a certain rational allocation of priorities. Instead, these features are treated as evidences of ‘inadequacy’ and as blemishes that it lies within the power of politicians to remove, given the insight and the will.
Martin Bagot in The Mirror updated 2yh June reports Warrington’s plans to charge 20K for a hip replacement. It would be cheaper and safer to go abroad.
It may seem an insignificant sum, at £5 per annum each to cover overseas visitors to the UK who need (or engineer) health needs, but this is just the thin end of the wedge. We need co-payments according to means as well as treatment according to need. The nature of the BMA means that it is manned by retired members (like myself) especially at conferences. Those at the coal face are never heard (No exit interviews) so the real feelings of the profession are out of step with the BMA. This adds further to the disengagement of the profession in the political process..… Some hospitals / trusts come clean (Leicester) and more need to do so. Of course professionals should feel uncomfortable with the administration of charging, so managers in both hospitals and GP must step up to the plate.
Bn’s health service is facing daunting challenges: an ageing population, closures of GP surgeries in remote areas and high rates of readmission, particularly for elderly patients who are insufficiently supported when they return home. Yet doctors at the annual British Medical Association (BMA) conference have voted to stop billing foreign patients for NHS care.
In a Britain of limitless bounty, no one could quibble with the idea of allowing visitors from abroad to use the health service without charge. Regrettably, ours is not a land of on-demand milk and honey. Costs have to be kept under control if the health service is to provide adequate care for those whose taxes pay for it.
Under the status quo, patients are entitled to free NHS treatment if they live permanently and legally in Britain. Two years ago Jeremy Hunt, then secretary of state for health, obliged hospitals to check visitors’ eligibility for free care and to charge patients who fail to qualify. Visitors from the European Economic Area are covered for unplanned treatment, provided that they have valid documentation, while those seeking care who live outside the EEA are billed upfront. Not all hospitals collect their debts with the assiduity they should, and some care is free regardless of who is seeking it, including emergency admissions and treatment for some sexually transmitted diseases.
Seen on a global scale, the system of healthcare is generous. If you break your leg skiing in America, one of the first things medical aides will demand as you’re winched away by helicopter, is whether you have health insurance. Yet the BMA, which represents 155,000 doctors, insists that charging tourists and migrants for care makes medical staff complicit in racism and talks irrationally about them becoming “border guards”. Critics argue that the set-up fails in practice, costs the NHS more in the long run and foreshortens lives. Doctors go into their line of work to heal, so the argument goes, not to enforce borders. They do not want to stay in the business of withholding treatment from sick and frightened people deemed unfit to receive it.
That approach ignores reality and common sense. The total budget for NHS England in 2018-19 was £126 billion. Figures on the scale of health tourism are vague and need updating, but they suggest that the problem costs the NHS as much as £300 million a year. In one case, a woman from Nigeria racked up an unpaid bill of up to £500,000 after giving birth to quintuplets in a London hospital. Hours before, she had been turned away from the US by border officials. The last thing the health service needs is to become a magnet for those unable to afford treatment at home but able to board a cheap flight to Britain.
Indeed, people eligible for free care in the UK but infuriated by low standards and long waiting lists are resorting to paying for private treatment abroad. According to the Office for National Statistics, flights out of the country for medical reasons rose from 48,190 in 2014 to 143,996 two years later. Women with endometriosis, for instance, who are awaiting NHS treatment, often in considerable pain, are increasingly seeking surgery abroad. Hospitals from Turkey to Thailand are offering “endometriosis packages”.
It is not unreasonable to expect the NHS to restrict its care to those who pay for it. Nor is it racist to expect hospital staff to enforce rules obliging international patients to contribute to their care. Medical treatment costs money. Far from scrapping upfront charges to foreign patients, hospitals should become more efficient at collecting payments when they are owed, while respecting the possible vulnerability of those the service has treated. Overseas visitors can use the NHS as long as they pay for the care they receive, just like the rest of us.
Sir, Charging migrants for care will not help to fund the NHS, as by the government’s own estimate “health tourism” accounts for only 0.25 per cent of the NHS budget, a tiny amount when compared with other costs (report, Jun 26, and letters, Jun 27). The people who will be hit hardest by this policy are long-term migrants who have been unable to regularise their status, asylum seekers trapped waiting years for a decision from the Home Office, and those people in the UK who do not have a passport. These are people more likely to be in precarious or low-paid work: they do not have thousands of pounds to pay for the care they need.
In practice the exemptions for particularly vulnerable people, and for treatment considered urgent, do not work. Research from the Equality and Human Rights Commission found that people seeking asylum were deterred from seeking care despite being exempt. We must not let the NHS become a place of fear that stops the most marginalised people in our society receiving the help they need. Instead we must ensure that the NHS remains open and free for all.
Dr Omar Risk
Newly qualified junior doctor, Oxford
Sir, In claiming that charges for foreign patients are racist, the British Medical Association has lost sight of the fact that foreign patients take up valuable NHS time and facilities at the expense of taxpaying UK residents. Although I understand doctors’ concerns about charging, there is a solution: allow the funds received to be retained by hospitals and surgeries without any devious clawback into the NHS system. This would be an incentive to collect the charges payable by foreign patients, and would provide additional income over and above budgets.
Sir, In New Zealand, everyone — citizen or visitor — who can pay to see a doctor does so, with appropriate provision for the indigent. Nobody here suggests that the medical profession is racist or connives at racism. The members of the BMA who castigate those who support payment by those who have made no contribution to the NHS might take note of a system that works well for all, whatever their status.
David Abell (ret’d GP)
Christchurch, New Zealand
Sir, I am a consultant medical practitioner with almost 40 years experience. The decision of the British Medical Association to offer up the NHS as the “casualty clearing station” for the entire planet underscores why I left the BMA 20 years ago. The organisation has been captured by political extremists and does not represent the average medic.
You cannot have a club (the NHS) with an expensive membership fee (my taxes) that then freely admits non-members.
Dr Michael Creagh, MRCP, FRCR
Sir, The doctors who oppose charging foreign patients for care need to be reminded that the organisation which pays their wages is funded by British taxpayers and is the National Health Service, and not the International Health Service.
Sir, Further to your leading article “Fair Care” (Jun 27), NHS doctors do not invoice patients. That is what managers are for.
Ret’d gynaecologist, London SE21