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The Maynard Doctrine: Time for user charges in the NHS?

Professor Alan Maynard explores whether the Coalition’s ideology is guiding health policy towards the introduction of more NHS user charges.

The Coalition’s attitude towards the NHS is a mixture of right-wing ideology and optimism that market-orientated reform will be the salvation of the service.

If the latter fails, the ideologues will inevitably pursue their goals by advocating changes to the funding of the NHS. This will be presented as the ardent efforts of concerned policy advocates seeking to “save” the NHS!

With most policy wonks focused on the current reforms, there is a clear risk that further fundamental changes in the NHS will be neither mentioned nor analysed before they are hastily presented as faits accomplis by the Coalition.

This is clearly the case with user charges. Should they be used to complement further tax finance of the NHS?

Here come the policy zombies
Professor Robert Evans of the University of British Columbia has likened the re-cycling of proposals for user charges in health care to zombies: however much advocacy of patient participation in healthcare is ridiculed and rejected, it pops up again as some 'bright' policy wonk rediscovers its alleged virtues!

What are these alleged virtues?

Firstly, user charges offer politicians a nice way of avoiding tax increases or deficit financing i.e. they shift part of the cost of the NHS from the Treasury to private households. This, in a period of imposed and extreme (and potentially sustained) austerity, may appeal to many in Whitehall Village and the media.

Thus: user charges are a tax on the ill. Do they make users more conscious of the costs they impose on healthcare systems? If so, does this greater awareness of the opportunity costs of healthcare consumption make patients more economical in the use of scarce resources?

The Rand insurance experiment in the 1970s in the USA showed that the use of charges reduced utilisation by patients. But did such changes in patient behaviour save resources over the longer term?

The drawbacks of charges
The alleged merits have to be set against the problems with user charges. Who uses healthcare services? The major users are the elderly, often individuals with complex and multiple chronic diseases. Some of these folk may be quite affluent. But how can they be distinguished from the less financially well-endowed without costly means-testing?

If healthcare services are used inefficiently, do user charges represent the best solution?

What is meant by inefficiently? One popular definition in the red-top media seems to be individuals presenting with no observable deficiencies in their health status. Are they lonely and in need of psychological therapies? Are they being poorly diagnosed? Just how many, for instance, GP visits are in this way “unnecessary”?

Answers we know not - because the primary care system does not collect adequate performance data! Without better evidence, there is a risk that patients will be dissuaded from using healthcare in a timely fashion by charges.

The probable consequence is that when they seek care later, they will be more costly to treat with poorer outcomes e.g. delayed presentation and diagnosis for cancer means outcomes are worsened.

Charges - already with us
Currently, the major healthcare charge for patients are for  prescriptions. Here there are major exemptions to charging: the elderly. pregnant women, those in receipt of social security, and children do not pay. This means that most prescriptions are free.

How long can this last before the user charges zombie once again bursts its tomb and emerges in the policy debate? When it does, do bear in mind the words of Robert Evans and colleagues who have reviewed this literature as part of the ongoing policy debate in Canada:

“In the present structure of healthcare delivery, most proposals for 'patient participation in healthcare financing' reduce to misguided or cynical efforts to tax the ill and/or to drive up the total cost of health care while shifting some of the burden out of government budgets”.