'No longer will wealth be an advantage nor poverty a disadvantage. Healthcare will be provided free of charge based on clinical need and not on ability to pay,' declared Nye Bevan as he launched the NHS 66 years ago.
At the RCN Congress on 16 June 2014, a resolution was proposed to introduce a minimum £10 charge for general practice appointments, including appointments to see a practice nurse or nurse practitioner.
The debate was proposed by Andy McGovern, a hospital nurse who works in quality improvement in East London. 'I had initially submitted two proposals to the Congress, this one and a general one around funding in the NHS.
'From past experience sometimes it is better to discuss something that might have a negative impact as it can improve the quality of the debate. The quality of this debate was good, but the outcome was unsurprising.'
The majority of delegates (91 per cent) voted against the proposal. The failure of the resolution and the tone of debate reaffirmed that nurses firmly believe the NHS should remain free at the point of care.
However, 'Given that 40 people out of just under 500 voted in favour of [charges], it would have been interesting to hear their views as well,' thinks Mr McGovern.
'Charging patients for GP visits is a controversial issue - one that goes to the heart of what the NHS is and should be,' says Peter Carter, the general secretary and chief executive of the RCN.
Currently only 8.4 per cent of the total NHS budget is allocated to primary care. Peter Carter, alongside a number of other healthcare leaders signed a letter, printed in The Times on 7 July, calling for a national conversation on how the NHS is funded. The nine signatories included Maureen Baker, chair of the RCGP, Jeremy Hughes, chief executive of the Alzheimer's Society and Sir John Oldham, who chaired the Independent Commission on Whole Person Care.
'The future funding of the NHS is shrouded in uncertainty and we need clear direction from our politicians about the way ahead so that clinicians and commissioners can plan for the future,' says Mr Carter.
'As the general election approaches, the public needs to know where the parties stand on this vital issue.
'Nurses are passionate about protecting the health service and its founding principles but they know that it faces challenges, that its finances are finite and so they will continue to address the difficult questions,' he added.
All of the nurses who contributed to the debate were against the proposal for similar reasons. The first was that to charge for care goes directly against the founding principle of the NHS, which was to ensure that everyone could access free healthcare.
Food or healthcare
A common theme of speakers opposing the proposal was that people at the lower end of the socio-economic scale would be unable to afford appointments. This would create greater health inequality between those who could afford a GP charge and those who couldn't.
Many nurses raised the view that this would result in widening health inequalities between affluent communities and those on lower incomes.
Heather Henry, an independent community nurse and co-vice chair of the NHS Alliance, says that her experience of working with disadvantaged families has made her 'shudder in horror' at the thought of charging for GP consultations. 'Some of the families I work with live in such poverty that they struggle to provide food for their children and the thought of a £10 charge would deter them from accessing GP services.'
Included in the proposal was that some groups would be exempt from paying the charge, such as those with low incomes, the vulnerable, the elderly and children.
Ms Henry does not believe that these exemptions would be satisfactory. 'There's always a lot of confusion over things like that. People lead such chaotic lives in disadvantaged communities. They may not understand a GP charging system and just keep away.'
Ms Henry also suggested that ensuring all patients attend regular screenings could become more challenging if there were fees for consultations. 'If there was a charge for screening...those hard-to-reach and disadvantaged populations...may be deterred by the fee.'
'For patients with long-term conditions, such as asthma or diabetes, if the practice nurse asks the patient to come back in a few weeks or months, the number of visits and the cost to the patient will all add up,' she says.
This would likely lead to the NHS incurring the cost of patients presenting with more severe problems later on.
Appointments like gold dust
Nurses opposed the idea of charging for consultations because it was already difficult to get GP appointments. Dave Dawes, managing director of Nurse First CIC and a member of the RCN North West branch, introduced the debate saying it was 'easier to get a ticket for Glastonbury than it was to get a GP appointment,' with many practices running the system that requires a patient to call for an appointment in the morning.'
If patients cannot get an appointment with general practice and are feeling anxious about their health problems they might attend A&E instead. There are already concerns around the number of people that unnecessarily visit A&E for problems that could have been dealt with in primary care. According to research from Imperial College, London there were an estimated 5.8 million A&E attendances last year after patients where unable to get appointments at their GP practice.
'I think the whole way people book GP appointments needs a radical overhaul but charging is not the answer. Having to ring in the morning for appointments is a badly managed system,' Mr Dawes says.
Ms Henry agrees: 'We already have problems relating to GP appointments and a lot of people going to A&E. I think charging for GP appointments would compound the problem.'
The difficulty of getting GP appointments is likely to be a direct result of the recruitment problem across general practice. 'Perhaps they could use practice nurses more, by increasing their powers to prescribe and enabling them to deal with more complex conditions, so that they can see a wider variety of patients. We need to look at redesigning the way that general practice works from a patient's point of view rather than for the convenience of GPs.'
Debate on funding
Despite proposing the resolution for debate, Mr McGovern doesn't believe that charging for GP consultations is a good idea. 'I had wanted to start a debate about funding in the NHS as it is clear that there is not a lot of money left and I wanted to question what will happen after 2015. Charging for GP consultations is one way to address the lack of money but I think that there are other ways.'
'There is not enough money in primary care, commissioners do not have sufficient resources to spend on secondary and tertiary care and given how complex treatments are these days, more money is needed.
'Perhaps we could look at the cost of drugs and whether there is any way that we could trim some money from the resources budget and put that back into direct patient care.'
Jeannett Martin, regional director RCN South West, says that it isn't necessarily true that the NHS doesn't have enough money. 'There has been a significant waste of money within the NHS. For example, the government spent £3 billion on a complicated and unnecessary restructure that no-one wanted. Hundreds of people were given redundancy payments as a result of this restructure and many were re-employed soon after. Last year the government took £2.2 billion from the NHS and gave it to the Treasury to be used towards the deficit. Those billions of pounds could have been used to build up services in primary care,' she says.
An alternative suggested during the debate at the RCN Congress would be to charge those who 'do not attend' appointments (DNAs). The theory is that people would be less likely to miss their appointments without warning if they incurred a charge for not attending. However, Mr McGovern says this would be very difficult to implement and monitor.
Ms Martin says that instead of introducing charging for DNA's when some people will often have genuine reasons for missing appointments, other services or systems could be used to minimise the numbers of missed appointments. 'Some organisations now have the facility to send an automated text reminder to patients asking them to cancel and reschedule their appointment if they can no longer make it,' she suggests.
Some people believe that charging for GP appointments would increase the value of general practice and deter people from missing appointments.
However, Mr Dawes doesn't believe that charging for appointments would increase the value in people's minds. 'I think it's a silly idea that you can make people emphasise the value of something by charging for it. There's lots of things in society that have value and we don't directly charge the end user.'
Ms Henry thinks that by educating patients and making them less reliant on healthcare professionals the numbers of patients accessing general practice could be stemmed.
'We've created a dependency amongst people, so that as soon as anything goes wrong you take yourself to the GP or A&E. We need to educate patients about the appropriate use of services and understand the causes of why people attend general practice.'
The NHS celebrated its 66th anniversary this month. It seems that nurses are still resolutely supporting its original purpose of providing healthcare for the population free at the point of contact.
However, as the topic of funding and resources in the NHS is never far from the headlines, many believe a national conversation is needed to ensure that the services are adequately supported with the money that is available.
Despite the fact that the vast majority of nurses and healthcare professionals, along with health secretary Jeremy Hunt, are opposed to charging for primary care consultations, a minority did vote in favour of the proposal. With so many loud voices against the proposal, those who believe that this may be a good idea, are either afraid to speak up, or cannot be heard.
All views and ideas should be considered if the NHS is to remain true to its founding principles but while accommodating the ever-changing health needs of a 21st Century population.
Many nurses who took to the podium at the RCN Congress echoed Nye Bevan's words. The speakers expressed pride in the NHS and that they did not want it to change from the values and principles that it was founded it on. One speaker encapsulated the general feeling: 'We have the best healthcare system in the world and we would be going backwards if this was implemented. I don't care what any other country in the world does, I'm proud of our NHS and I don't want it to change from its values and principles that Nye Bevan founded it on.'
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