UKC

https://uk.yahoo.com/news/gps-could-charge-for-appointments-top-economist-s...

What would you do if your GP started charging for appointments?

Go to A&E to be seen, like many people have to do now, as they can't see their GP because they are hiding behind the Covid barrier?

9/10 it costs me about £9 in perscription charges whenever I see my GP, so if the appointment fee included any necessary prescriptions then i'd not be totally against it. Especially if it reduced the number of timewasters and therefore made it easier to actually get an appointment.

That said, fundamentally I think the NHS (including eye and dental care) should be completely free at the point of need, so am NOT in support of the idea of charging.

Dental fees have been paid since the late 40s. It was too expensive for the NHS to cover that cost even back then.

And we only need to look at people's teeth to see how well that's gone. :-P

I think people should have the option of paying. I would if it was <£50.

The NHS was only created so that the UK could have a healthy fighting force back in the day.

NHS eye test is £25 and about the same for a dental checkup.

NHS gives opticians a fee of £21, but it costs the optician about £50-60 to perform it.

Why does it cost them so much, once they have all the amazing modern optical gadgetry installed? How can your figure of £50-60 possibly be correct?

Running a clinic with the all the overheads of the equipment/maintenance, salaries (including locums at £350 a day), insurance, etc is an expensive game. Remember that some of that "chair time" is taken up not even getting an NHS or £25 (or whatever) private fee, by stuff that doesn't make money like contact lens check-ups.

People in the UK are insulated from the real cost of healthcare and hence have no idea.

£50-60 sounds pretty good for a full examination from a professional using some expensive kit. 

An eye test is about 45 minutes. My physio charges £55 for an equivalent session, and all he has is a posh bench/bed thing.

But surely nobody is suggesting that patients pay for the full cost of NHS treatment?

It would be a mix of pushing people to A&E or leaving it dangerously late at which point whatever they have might be untreatable.

Might deal with some hypochondriacs but unlikely to be helpful

if they did it would certainly rapidly increase mortality and reduce life expectancy as it would be the over 40s who would take the brunt

perhaps that is the key to the housing crisis

Quite, what do garages charge per hour.. 35-50 pounds isn’t it?

Cheers

Toby

No. Obviously.

But it might kill off some of the poor and 'unproductive' members of the population. I'm sure the likes of JRM will be all over it.

I've attended many an elderly corpse because they were too polite to trouble their GP's during the last couple of years. Can you imagine an elderly relative of yours too afraid to contact their GP with an ever lengthening list of ailments and the worry of spiralling fees?

IIf you can find a garage charging <50 per hour, you are doing well. My main dealer on Teesside charges 160........

Probably to buy cleaning product to polish their spurs?

I think it would be fairer to have a charge for a course of NHS treatment paid on the first GP visit than an arbitrary prescription charge of a tenner if you need 50 quid's worth of pills but nothing if you need £20K worth of operation and follow up care.  It would also enable forfeit of the charge for not attending without cancelling.

Once again this sounds good in principle but everyone forgets about our good friend Unintended Consequences. 

How much in time and money do you think it would take a GP surgery to process all the paperwork and payments to manage this? If you have ever had (even minor) treatment in the US you would be staggered by the amount of form filling just to get through the door. Having to potentially means test and process invoices is I'm sure not going to help and just tries to fix demand rather than sort out the real problem which is supply. 

Then patients. Already the poor are at disproportionate risk of poor health outcomes because of a whole range of socio-economic factors. Charging for access to healthcare would surely exacerbate that. 

If you don't care about poor people, just consider that there is a £ value attributed to the cost of each early death to the UK economy which ultimately will affect you even if it's just the value of your pension in the long run. We all have a vested interest in a healthy, educated and safe population. 

That's unworthy of you. People can't see their GP because there aren't nearly enough GPs and they're not getting any younger.

People are having to wait for hours and hours for an ambulance too, how would you like it if a GP popped up on here with a pet theory that the problem is basically just you not trying hard enough?

There seems to be a misunderstanding about GP availability which has been terrible for many years in many areas, way before COVID. Locally, to cope with the numbers (a legacy of, rather than caused by COVID now) telephone triage is still being used to cope with the number of interactions, and certainly you can see a GP in a few days. So in that sense it seems to be working better than previously when you could book weeks in advance or ring at 8:30 and try to get in on the day.

Do I believe that telephone triage is as good as a consultation - NO. And do we need more GPs - YES.  But, it is all part of the bigger problem and social care, cancer medicine, the ambulance service are all in a poor position. I had surgery on the 17 March 2020, the penultimate week before the hospital changed to the early COVID rules. I wonder how many others are still waiting, have needed multiple GP appointments or that have ended up in A&E. I am exceptionally grateful for this.

Whatever your politics we should spend a lot more money on the NHS, but I would charge people for missed appointments without notice every time.

I know it's not quite the same, but this is how it works in most other countries. Here in France, if I want to see a GP, I book an appointment online (generally getting one within 2 weeks), go and see them, then pay them €35 before I leave. We have health insurance which then repays me. If I want a quicker appointment, I pick up the phone and ask, or search for another GP locally with spaces. I miss the NHS for some things, and I was well looked after by them for 40 years before moving to France, but the French system is generally much better. 

It'll never happen.

GPs aren't and weren't hiding behind any Covid barrier.

We seem to be discussing this as if it was a reasonable suggestion. It is simply another move to privatise the health service. There will be large US health providers who are over the moon that their lobbying has been so well received.

If people want to pay for express GP appointments then there is always BUPA. Oh, except they dont really do a GP service and many of the medics are also NHS medics. So going private is often taking resources away from the NHS.

A more long term solution might be that we train medics, but forgive their student loans after X years working for the NHS. We would be increasing the supply of professionals, rather than poaching them from different areas or countries.

Long term thinking (5+years) is not high on the current governments agenda, as they stumble from crisis to crisis week by week. Which is why these dubious ideas of 'privatisation will fix everything' are so appealing. No doubt if, as an MP, you champion the idea, you can get a nice directorship with them after you leave office.

We did that one in Germany, €10 first vist per quarter (A&E the same).  8 million hours per year extra admin work for the GP's practices, no reduction in patient visits (the poorest stopped coming, those that had paid came more often) and the idea was dropped after eight years.

Time, skill, training, overheads staff wages etc etc.

Same as Vets, dentists and most other professionals.

Surely the elderly and those on benefits would continue to get services for free?

Such a sad story though and tragic that people with genuine need of help feel unable to ask for it.

That reminds me, I had a letter out of the blue from the hospital's oral clinic the other day, notifying me that I have telephone consultation on such and such date.

This is following a failed molar extraction which left part of the tooth and roots behind... over two years ago. 

I've managed to whip the leftover bits out myself but it'll be interesting to hear what they have to say.

Is the French system generally much better because it has more money spent on it and has better patient care. I don't think the €35 spend to see a GP is why its better than the NHS.
 

I thought the NHS was meant to be 'free' to all.

If the government wanted to help the NHS it would fund it better. Instead of giving loads of money to there mates.

Christ on a bike.  The state of this thread.  Dripping with hyperbole and a fair amount of utter bobbins. 

How you get from an economist (that nobody cares about), reported on Yahoo, suggesting we think about a token GP payment, to privatisation of the NHS to the US is beyond me.

Some facts:

- GPs ae PRIVATE, for profit, providers already.  They are not NHS employees.  They have a contract for services that their highly skilled union played a blinder on a few years ago (QOF and out of hours for example) but has been eroded a bit since.  They still want "more" for anything they can define as "new", which isn't healthy for the system, but is understandable since...

- A decade/15 years ago the average footfall to GPs was ~3/year/person; in many areas it's now ~6.  That is a large part of what has driven shortened appointments.  It has also driven practice mergers for efficiency, together with a demographic wave of single-handed retirements.  In general, larger practices have better outcomes - there's better peer review, less professional isolation, more sensible use of overheads and premises, and usually a more professional approach to managing the flow of patients and the business.  Did I mention these are private BUSINESSES?

- GP workload has also been impacted by the erosion of the partnership model.  Many new doctors don't want to take on the responsibilities of a partner (regulatory and business), and the shortage means that they can earn well as a salaried GP or command excellent locum rates (£110/hour round here), and still have a great pension, flexibility, and very little of the surrounding headaches.  Add to that the cost of buying into partnership often includes a share of premises, so someone a new GP moving to their first long term role needs to find a house AND put up for a share of premises.  So fewer doctors, fewer, partners, a stricter regulatory environment, double patient pressure, less profitability.  All looks less attractive, so more and more practices are in a downward spiral - the insufficient new doctors there are don't want to go somewhere that's 3 people short and having to work 7/7.

- Add Covid, and GPs needed to avoid illness at all costs.  However, some very important things have stopped happeneing - blood pressure monitoring of risk patients has fallen from c.80% to around 50%, and has now recovered to mid 60%s.  1.2m risk people are not getting monitored.  Watch the strokes numbers down the line...  Of course, some GPs have simply abdicated - everything gets referred to the hospitals, and we all know about the waiting lists now.

- Around 30% of consultations result in reassurance or advice only.  Many of these people don't need to see a GP. Just as ~30% of A&E attendances are completely unnecessary.  I don't know the figure for ambulance disposition, but doubt that it's lower.  People are less comfortable managing their own health, and more prone to internet-induced concern.  There is also a huge consequence of the politicisation of the NHS (which has become a central football at every election and prodcues someof the dog-whistle nonsense in this thread) - people feel they have paid for it and they're entitled to use it.  Being free tends to exacerbate that.

Where does payment then fit?

Every time someone shows up at A&E it costs c.£150; a GP perhaps a third of that.  20-40% of that demand is inappropriate.

Prescription charges exist - but >80% of scrips are exempt (kids, pensioners, cancer, etc. don't pay, but are the biggest consumers by far).  Often the product is cheaper than the processing cost.

Dental charges exist after childhood, and dentists (also private, for profit, businesses) have managed to convince an enormous swathe of population to be private clients (try finding an NHS dentist if you doubt).  The dental contract needs to require a proportion of units of dentistry to be NHS, but that's another story.  Again there is an exemptions list for dental charges.

Similarly opticians.  Adult charges, lots of private provision.  Most made money on selling glasses (and pharmacists; shampoo).  The idea they do it below cost is wrong - you need to look at the customer value

So right now, well over 90% of what the NHS does is co-paid and performed by private providers...and has been for decades.

Many countries use co-pay for primary care.  Some have refundable co-pay for hospital care.  There's really no evidence that it leads to worse outcomes - I'd rather use (and work in) the Swedish or German co-pay environment, than the NHS.  Financially it tends to be +/- breakeven, although there are so many extra bits and bobs claimed for payment by GPs already (vaccination for example) that the additional process isn't likely to be onerous.

Personally, I don't think it's the way to go in primary care, but it's really not a heinous concept in itself.  The private nature of the GP contracts is no longer fit for purpose.  A refocus on health and illness prevention is needed, and it might be better to encourage some hospitals to take on some primary care contracts...

Fully agree - but there are numerous reasons why I prefer it. Each medical profession is run independently, so if you need an appointment with a dermatologist, or physio, or podiatrist, you just book and go, generally very quickly. When I injured my shoulder climbing, I first went to the GP for referral, had an x-ray within a couple of days, an arthro MRI a week later, and saw a consultant a week after that. I was astonished. 

I also dislocated my ankle climbing in the forest a couple of years ago - 2 ambulance crews turned up, who decided I should get air lifted to hospital - 2km to the hospital. At hospital, I had scans, x-rays, an operation, 2 days in a room on my own, then at home I had a nurse come by every day for 6 weeks to give me a blood thinning injection, then 6 months of physio. It seemed that everyone wants to get an invoice in for their work, which was fine by me as I got well looked after. 

Again, everything is covered by health insurance, and if you are a French resident without insurance you are still able to claim back nearly all costs though the equivalent of national insurance. The advantage here is non-residents pay, either cash or via their travel insurance, so the system is not open to abuse. 

Maybe it is just me having good experiences...

I don't disagree with you. I have heard that the postnatal care is a lot better also in France.

I'm in France too and the care is far superior at every level that I've experienced (GP, physio, eye surgery, MRIs, A&E broken leg twice) however:

1. I'm in a relatively affluent rural area, if I was in central Paris or Marseille it might be quite a different experience.
    
2. There a lot of social charges taken from my salary every month (my payslip goes onto two pages of A4) to pay for this - it's not just the (25€ in my case) up front payment. Ultimately the government has to tax and spend at adequate levels to fund the service structure costs otherwise nothing else will matter.

Most first line healthcare here has to be paid for. Government subsidise GP visits by ~£16 so they tend to cost the patient £45. Prescriptions are £4.30 unless you're a pensioner or on benefits. A&E costs, so a kid going in for a hurt ankle is £130. People with no money can get means-tested grants to cover dental & GP treatment.  Second line treatment is free, so if your GP refers you to a specialist and you then need an op the specialist and op is free.  Specialist care is generally provided by a private healthcare group called the Medical Specialist Group who are contracted by government to provide the service. So when you go to hospital for a replacement hip the doctors & surgeons are generally employed by the MSG and the nurses employed by government.

End result - people don't abuse the system like they do in the UK, but also aren't open to horrendous second line treatment costs. It seems to work well, although the GPs and MSG are often accused of profiteering. There is also the aspect of the same MSG staff providing private ops and cries of 'Why do I have to wait months for a new hip when I can pay money and jump the queue to have the same job done by the same surgeon?'

I'd beg to differ. Purely anecdotal, but it's still telephone consultations only round here. With one notable exception, (he's a top bloke), the GPs have handed over touching, or even been in the same room as, patients to the practice nurses and the local pharmacist.

Really?

I have had cause to see my own GP over the last couple of years and had to jump through unfathomable hoops such as entering the building through a hidden back door.

But the same GPs were happy to send me out in my "big yellow" van with nothing more than a sandwich making pinny and simple mask to have eyes on the patient.

GPs put up their shop shutters from Day One and aren't going to be taking them down any time soon. Me thinks the GPs protest too much, my lord.

Not really true. Maybe that was an added bonus but things like having a healthy workforce for an economy that was basically screwed without the stimulus of the war were far more important. Not to mention a general sense that poverty, want, illness and ignorance were bad things anyway. 

Have a like. That's a very informed reply.

Do you know if there are any incentives to bring more people into the profession and on better terms? From what you've said there are lots of hurdles for junior GP's.

If they charged for appointments I would be even more reluctant to see them than I am now.

Things that could be caught early would be missed until it was too late. Is that lump cancer or something benign? Let's wait till it hurts.

That was really interesting to read and I learned quite a bit.

Thank you.

Plus a certain fear about communism which was, at the time, still appearing as a semi valid alternative. When the fact that the country had a large number of combat veterans it was generally seen as a good idea to ensure that it didnt appear overly appealing.

You could always cancel and then somebody else could be seen a little bit quicker.

I beg to differ. It was noticed that the overall health of the British soldier in the trenches, mostly in the First World War and Second, was shocking. It was this main observation that the NHS was first thought up to ensure future generations of healthy candidates for the Armed Forces.

I'm not a dentist so I'd like someone who's qualified to check my handiwork and sign it off if it's not too much trouble.

Someone thought separate 'funding streams' for a multitude of condition initiatives would be a great idea.

Of course, it just meant wasting money both within every GP practice to manage the application and administration of these schemes, and matching waste within the NHS to process the claims.

Rather than simply increasing the existing payment per patient, and an education/promotion campaign.

And it meant that if you went in with a sore knee, you got tested for asthma, as that was one of the big drives...

Thanks.

The transition from medical school to the NHS is a mess.  Where to begin?

We subsidise medical school to the tune of ~£40k/year, but make no requirement for doctors to work in the NHS subsequently.

There's a nasty "closed shop" approach to who, where and how training is done - several universities would like to train doctors but the club won't let them in.  So not enough polaces to start with.

Attrition at medical school is c.10%.  That's hugely wasteful.  A combination of abysmal support in the universities and some misfits (pushy parents etc.)

The survivors enter FY1 and FY2 and we often treat those doctors really badly - exposed beyond their competence, over-stretched, under-supported (by consultants). At the end of FY2 there's another tragic attrition step - a further 10% although the numbers are hard to process cleanly.  They go abroad, to industry, or leave the profession.

There's a profound mismatch between the way Health Education England and the Deaneries operate specialist training, and the current and future needs of the service.  Popular and highly competitive specialties such as ophthalmology have a fixed quota, to try to drive people into less popular specialties (psych, geriatrics, GP), even though we have a national shortage of Ophthos...and so people do FY3 and FY4 to try to get in.  There is utter disconnect between the cohort sizes and known demographic trends for demand.

Junior doctors waiting to get into specialist training do locum work in short staffed areas (like A&E)...and it's hard to build a high performance culture if everyone is temp.

Whilst queuing, pay is static, and some get "forced" into specialties they didn't really want to do, which isn't great for them or patients.

Although it's improved a bit in the last few years, we still don't adequately recognise out of hours work.  Why do a 24/7/365 rota in A&E when you can do 9-5 Monday-Friday in path?

Having finally got trained, consultants often develop private practice...and frequently are unavailable for NHS work because BMI is more lucrative.  They manage to do 5-6 hips/knees in a private list; but only 3-4 on the NHS - there's little incentive for productivity (although the private cases are always the more straightforward for other reasons). 

Meanwhile the services have shortages of doctors.  Waiting lists grow (irrespective of Covid).  The NHS reinforces the perverse incentives by paying royally for catch up sessions on bank holidays etc. (think £5k+ for a day).  Doctors are recruited from overseas (ethically questionable in the time of a pandemic).  There's a major pending issue of forthcoming retirements, especially in primary care.

Against that backdrop, the way Juniors are forsaken is an absolute travesty.

Good to read from somebody who works in it and has figured out the flaws.

Do you think the recent proposal to switch GPs to being centrally employed by say the local NHS Trust has legs to it?

In what sense?

Will it be tried?  Almost certainly.  There's a level of desperation that requires some sacred cows to be slain.  The risk is that it's a haphazard and poorly executed cull.

Will it be successful?  Yes and no (just my view, obviously).  Executed well and with doctors that actually want to make things better, it could be amazing.  Poorly "done to" doctors that don't want to change it'd be a disaster.  Some very high quality practices are really there because the partners are passionate, engaged, selfless people...and work very, very hard indeed.  The risk is that if they're moved into an employee model they'll get a bit of the 9-5 disease.  It's the main opposition argument from the GPs (those that like the partnership model).

Personally I think the balance is in favour of a change to a more directly employed model, for at least a portion.  I believe the majority of GPs want to do the best job for their population and, especially the newer/younger ones, want to see more prevention and health promotion.  The sense of the support of being in a larger organisation (and no building/goodwill to buy into) may make people less reluctant.  It might even erode some of the us/them between consultants and GPs.  It'd certainly stop some of the nonsense cost (like two reception desks for 2 practices in one health centre).

exactly, this proposal creates an existential threat to many

The truth is that the NHS was demanded by the population - after the privations of the 1920s and 1930s and 6 years of war politics had completely changed and there was huge demand from the population.  I'd like to remind people that young women of my Grandmother's generation it was by no means unknown for a wedding gift of having teeth extracted would be made to a new bride to avoid dental troubles and unaffordable bills.  Health problems could be disastrous for the working classes as there was no health service.

The post war Welfare State was not motivated by the need for troops but the need for a modern society and total reform.  Thank God

If there is a story of health and troops it was that medical care made a huge difference in WW2, particularly the availability of antibiotics for the first time.  From a welfare point of view Montgomery was famous for having insisted on dental care being available for front line troops as he considered them combat ineffective if distracted by toothache.  A very modern attitude, but then he came from a very unaffluent background and unlike most of his officer contemporaries had no private income to supplement his military pay.

Building with ongoing costs, reception costs, repayment of capital on all that amazing modern optical gadgetry, service contract on all that amazing modern optical gadgetry, paying an optician. At least opticians generally don’t earn as much as dentists.

Yes indeed. A good insight for anyone unfamiliar with the reality of pre-welfare state Britain is the excellent book "Harry's Last Stand" by the late Harry Leslie Smith. A word of warning though: there aren't many laughs in it.

Every day is a learning day.

Cheers.

The truth is that a centralised wartime economy showed to all the many benefits of a healthy population, and universal healthcare. And 'all being in it together' meant understanding the need to support each other (those bombed out of homes, the wounded and families of those killed and wounded) led to a call during the war, for a welfare state in a better, postwar world.

The background of working classes and medicine can be discerned in the books of AJ Cronin, set pre WW2.

As Wercat has pointed out this wasn't a principal motivation for the formation of the NHS. But earlier wars did have a role in creating a climate in which state intervention and eventually a national service were seen as more acceptable. The Boer War was a much bigger challenge than expected, and the ill-health and malnutrition of military recruits was  a major part of the problem. That led to increased government intervention, particularly from the Liberal government of 1906. There was a similar response after WW1 - this all contributed to an acceptance that the state should have a much bigger role in public health. 

“Homes fit for heroes” is a good example of a slogan linked to this and the huge boom in social housing after both world wars.

His novel 'The Citadel' is oftens cited as a contributor to the founding of the NHS because of its portrayal of the shambolic state of UK healthcare. I'm not sure how much of an impact it actually had but he did work for several years for the Tredegar Medical Aid Society, which was a key model for Nye Bevan's conception of the NHS. 

Another slogan that springs to mind is “And now win the peace - Vote Labour”. 

I would have agreed a while ago

However (and caveat this is clearly one surgery, but I know a few others with similar experiences) increasingly now when you ring up its telephone only....the other week I actually wanted to see someone F2F so they could examine ref. an ongoing issue I had done telephone for before......answer from reception was all the GPs are working from home today, similar story the next day when I rang up.

There is no option to book in advance (it could have waited a day or so) so you either accept this or ring up again the next day etc. (normal 30 minute telephone queue, which is fine I can leave it on in the background) and hope there is a GP actually in the practice that day who will see you F2F.

I am supportive of telephone consultations as a way of getting through the queue of people more quickly, but there should always be some F2F provision available where required IMHO.

 

Telephone or via what’s app or other video means?

Oh right, my mistake then. I hadn't realised it's actually GPs that run the ambulance service and have responsibility for providing you with PPE.

   When Lil’s husband got demobbed, I said—
I didn’t mince my words, I said to her myself,
HURRY UP PLEASE ITS TIME
Now Albert’s coming back, make yourself a bit smart.
He’ll want to know what you done with that money he gave you
To get yourself some teeth. He did, I was there.
You have them all out, Lil, and get a nice set,
He said, I swear, I can’t bear to look at you.
And no more can’t I, I said, and think of poor Albert,
He’s been in the army four years, he wants a good time,
And if you don’t give it him, there’s others will, I said.
Oh is there, she said. Something o’ that, I said.
Then I’ll know who to thank, she said, and give me a straight look.
HURRY UP PLEASE ITS TIME
If you don’t like it you can get on with it, I said.
Others can pick and choose if you can’t.
But if Albert makes off, it won’t be for lack of telling.
You ought to be ashamed, I said, to look so antique.
(And her only thirty-one.)
I can’t help it, she said, pulling a long face,
It’s them pills I took, to bring it off, she said.
(She’s had five already, and nearly died of young George.)
The chemist said it would be all right, but I’ve never been the same.
You are a proper fool, I said.
Well, if Albert won’t leave you alone, there it is, I said,
What you get married for if you don’t want children?

[from the great poem of Modernism'The Waste Land', 100 years old this year]

Are you sure there wasn't a practice covid outbreak at the time? Happened to quite a few practices where multiple GPs test positive and have to work from home, so very limited or no facility to offer face to face appointments.

​​​​I find this interesting can you elaborate? How does the loss of a person who is a significant net burden on society with little to no hope of that ever changing have a £ cost to the UK economy?

Surly GDP per head would go up as we killed off the poorest as they are not just not contributing they are negatively productive, as in it takes others having to work and pay taxes in order to sustain them.

All I can think of is perhaps the costs of looking after their children if they are still under 18 and need state care. Although as we are looking at people dieing due to not visiting GP's due to a charge, I suspect it'll mainly be the older poor effected so not a major issue with child dependants.

Lovin your work.

A valid point, there could have been - if that was the case probably would have been useful/in their interest to relay that fact 

Its not a proposal, it's an economist spouting on yahoo.

And dial down the hyperbole - it doesn't.

I can only imagine you're drunk and taking the piss or otherwise mentally unbalanced. 

Being low paid doesn't equate to "being a burden on society"

Something like 45% of UK households take more out of the system than they pay in. This doesn't make them "a burden on society" either. They are society.

Quite so.  We only recently had a powerful reminder about who a lot of the 'essential key workers' who keep society functioning are, and an awful lot of them are shockingly poorly paid. 

Given the way things are going those who are struggling to make ends meet now will be finding it harder still pretty soon. The poor are getting poorer and the 'just about getting by but not what you'd call yer actual poor' are on the brink of slipping into poverty too.

I'm just trying to understand what the guy is saying, I'm assuming he's correct in that there is a cost but I can't see how so looking to grow my knowledge if he's indeed correct. I understand that generally more workers equals a bigger GDP, see China, but more non workers I'm not so sure about. 

I guess it depends what we are defining as poor, in my example above I'm talking about the long-term unemployed. Perhaps he was talking about the low paid workers in which case he'd have a point. As you said a large chunk of people over thier lifetimes pay in less than they take out (does this account for inflation btw?) But if they are working and those jobs are needed then they are producing, just their lives are just state subsidized I guess with the solution being to pay them more in the first place.

There is a problem with there being too few GPs for the population but I see having to pay for a GP appointment as helping to hasten the end of the NHS.

I have mentioned this before but I urge anyone who is interested in what is happening , and has already happened, to the NHS to spend about 20 mins watching this from 2014.

youtube.com/watch?v=Cz5dl9fhj7o&

Dave

It’s some ways it is similar to the aims for covid testing - if large percentages of tests are coming back positive then you are almost definitely missing cases. Similarly if every GP appointment resulted in treatment then I’d suspect that means serious stuff is being missed. What percentage of advice outcomes would you see as acceptable and why?

Compared to what/when? Are there comparable statistics that account for any changes in population demographics (especially age), increased availability of health information, and whether advice visits reduce subsequent treatment costs?

I think jimtitt’s reflection above is important here. There’s a number of case studies where introducing small charges for things like healthcare or late pick ups at schools paradoxically makes the problem worse. When it’s free at the point of use people feel some responsibility to not abuse the system;  that largely disappears once you’ve made a direct payment for a service. You’d probably see a reduction in visits from those who genuinely can’t afford it (and often most need it), but I think that could be dwarfed by an increase in visits from people who have paid.

Just wow. Even if you don't know, you can surely see that letting the poor* die in the street isn't the way most well functioning societies operate. 

A quick Google shows this. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6790234/

I guess I'm 'the guy' you mention and I guess what  I was getting at was that even people on the lower end of the economic spectrum are vital parts of the economy over and above their actual wages. 

You're talking about the non working poor as of we would benefit from some kind of purge. I had a lot more to write but just decided it's not worth the thumb ache.  

*However we define this. 

If we exclude any moral case and just take a pure cost benefit money analysis from a state point of view about letting the non working poor die early. 

It's a cost because if someone is sick to the point that they are at deaths door then someone else is looking after them. If the state provides the care that is a direct cost to the state. If the state takes a short term view and denies the care then relatives will have to withdraw themselves from economic activity in order to provide the care.

A healthy population can engage in economic activity so it's a benefit to the state to keep the population healthy.

clearly critical, but I'm not sure it needs one to one doctors appointments etc.. eat better, exercise more. Two basic message that would improve the health of 90+% of the population. It's just a question of how you deliver the message. 

And the NHS doesn't help itself either. From the BBC today: feeling uneasy or a bit sick? Better call 999! I mean, for f*cks sake, where's the joined up thinking? 

https://www.bbc.co.uk/news/uk-60358296

Improving general health has little to do with preventing disease or don't vegan yoga practitioners get cancer, arthritis, Parkinsons disease, dementia, cateracts etc etc? Some effect for some things for sure but 90%?

Heh.

I saw that. While I kind of agree with the general message, even as a relative newb I've already been to a good few patients with chest pain that should have sought help a couple of days earlier, that list of vague symptoms.......isn't particularly helpful at the moment.......

Chest pain, absolutely, but feeling a bit sick? A vague sense of unease…ring 999? It’s not like there aren’t other options. Wouldn’t 111 be more appropriate?

I'm in no way suggesting a better diet cures everything, but obesity and poor nutrition is linked to so many illnesses. Even exercise alone has multiple physical and mental health benefits. 

There are more contentious studies about gut bacteria, links to mental health etc.. but there's no doubt eating less processed or more fresh food, plus moderate exercise 3 or 4 times a week is highly beneficial.

90+%, I was referring to the numbers of folk eating badly, not exercising and over weight. Just looking at the clothes rail in a normal shops shows most men must be 36, 38, 40+" waists. 

Of course! Kind of what I meant by the list of symptoms not being particularly helpful. 

Let’s say 100 people find lumps that they think could be cancer. They aren’t certain, because they aren’t medically trained. Is it better (and cheaper long term) for all of them to go get checked by a professional, or for them to wait until they are certain that they have cancer before contacting their GP? If the former, then we have to accept that some appointments for people who don’t need treatment are a necessary cost of better overall health outcomes.

It’s also important to remember that in some cases the advice, which is being framed here as indicative of time wasting, will be along the lines of “this could be serious but we aren’t sure. If X happens you need to get back here pronto so we can act early”. That doesn’t sound like a wasted appointment to me either. 

111?

"Hi I'm feeling bit sweaty"

"Do you have a sense of unease?"

"Yes actually.. I just had to run away from a dog"

"Do you have any chest tightness?"

"Well yes, my chest is feeling a bit tight after that run"

Outcome: 999 response arranged

You are making me chuckle 🤣

Hehe. I know we all thought the same thing :P

Don't forget now that you are breathing a bit more quickly from running away from that dog, you now have ineffective breathing.

You now get priority for a Big Yellow Taxi over that poor old dear who's been on the floor for six hours with a broken hip.

Yep, if you mention chest tightness that's what'll happen but read the BBC headline "call 999 for lesser known heart attack symptoms". Chest discomfort is the number one, best known heart attack symptom.

Yeah, I know but consider that we only see all the crap 111 sends our way. What we don't see is the shit tonne of crap they deflect (full disclosure: a mate has just finished a 6 month stint as a 111 para).

lumps... I'm talking about blatantly obvious health advice, like lose weight you're clearly 20kilos overweight, it shouldn't need a doctor to state this. 

I'd hope everyone with a lump, anywhere, seeks medical advice asap. 

Ditch 111. Return to medical professionals on the phones deciding what to do from the initial call.

But wait they tried that.

The 111 phone service reduced that medical phone service by a whopping 75%.

Can firmly kicked down the road to other services now thoroughly emotionally and physically spent.

So I added 20kg to my weight and the NHS calculator told me to see my GP for help and advice.......

But “seeing the GP” in that scenario could be seeing a nurse or other person well suited to delivering dietary advice. (Or at least it should be)

You're preaching to the choir, but there simply aren't enough medical professionals to cope with current levels of demand and rather than asking the public to employ common sense, the BBC are reporting that the NHS want them to ring 999 for even low level symptoms.

It only says see a GP, who I would hopefully assess ones condition to undertake a diet AND check one has no underlying condition which is causing the overweight in the first place, it's not always gluttony and laziness. That is their job, not some half-trained assistant down the local chemists which appears to be the NHS's desperate solution.

Perish the thought that our 'frequent flyers' use this script of buzz words to get free fix.

Hi, whilst I think a lot of what you have said is absolutely right some is I think a little bit wrong.

The majority of NHS consultants do no private work at all- but get paid a fair bit less than GPs, but have done longer training, get worse pensions and do on call for decades. But I suspect that this is of no interest to anyone, unless they actually want to have consultants.

The vast majority of medical school graduates pass and go on to work in the NHS. However, the demographic shift in medical school entry- to way over 50% women has had an impact on the whole time equivalent output. That is just the way it is (I am just stating a fact rather than suggesting that this is in any way wrong- my other half has worked part time for the last 20 years) and many of the male trainees are also opting to work part time, which is actually good.

Trainee doctors have never been paid so much, for such short hours and for such little responsibility- but undoubtedly they have never been so miserable. Why? I think because the 'firm' model of training has gone in which there was a much tighter relationship between seniors and their trainees. People took an interest. 

The 'catch up sessions' at £5k a day- I don't think so. Slightly less than £500 per half day before tax.

Getting to the actual point of the thread. Paying to see your GP would be awful. It wouldn't change a thing and would be to the detriment of the poorest. Very oddly in the UK that means working couples with children in low paid jobs. (Who knew?)

But in the UK we are totally ignorant of how much healthcare actually costs, it is so much more than one person's time and or drug costs. This is all set out nicely for you if you take an animal to the vets. (Of course vets have a massively subsidised education- but nobody complains that they all go into private practice, similarly dentists).

I think it would be helpful for every contact with the NHS to result in a brief letter to the patient they take away. Who you saw, what the problem was, the treatment, some written health advice for that condition, follow-up arrangements and the approximate cost. Absolutely not as a prelude to privatisation- just so people know. I don't think anyone has any idea of what this might be.

In early 1994 I was working in AED in North Liverpool. A young man with no impairment of his faculties had called an ambulance because he had a papercut to the back of his hand. We put a plaster on it. the previous night thousands upon thousands have been murdered in Rwanda. I have never felt so pointless or frustrated. I did mention this.

So presumably you’d agree that a proportion of appointments resulting in advice rather than treatment/referral isn’t necessarily indicative of  a problem?

 I’m not suggesting that the best use of a GPs skills is reminding people to eat 5 a day and exercise. Only that “advice” does not equal “this person is a time waster”. 

I'd suggest a doctor is over qualified to advise someone the reason they are overweight is because the furthest they've walked in 30 years in 500m.

On the other hand one hopes a doctor can diagnose thyroid problems or Cushings syndrome etc (or can refer the patient to someone who can). Not just make sweeping generalisations about the next fat person that walks through the door.

Although there is also a crisis in French healthcare with regions having a serious shortage of family doctors.

French healthcare is / has been a bit odd. Your GP can / could prescribe a Spa. And when my eldest son went to a French GP in December he had to pay €50 cash and was then prescribed some amoxicillin (fine) but also some paracetamol, cough syrup and steroid nasal spray. I suspect that expectations and possibly a fee for service model influenced the last 3 items. Likewise my brother in law's brother in law is a physician in Germany- he rails against over investigation- which is demanded by the private hospital model.

You’re gonna have to help me out; what does that have to do with anything I’ve said?

I'm guessing that the majority of the population have no idea the cost of their medical treatment, and why should they?

Its free.

However how about an experiment for the next six months to a year people are given a document recording the cost of their various treatments, obviously with no charge to be made but more an exercise in trying to show how much all this costs?

Yes its a paper exercise that would add extra costs to the NHS but as an educational tool to make people better informed about how much all this costs, would it be a good experiment?

When my other half got sepsis about 12 years ago, I did a little digging around at how much it cost her to be in hospital for two and a half months. Even with my back of the fag packet calculations I came to in excess of £100,000. If I had received a bill, it would have bankrupted me/us.

This is not counting the cost of the damage to a dialysis machine when regaining consciousness and suffering ICU Psychosis, after being intubated for two and a half weeks on some seriously powerful meds in a silent environment with beeping machine alarms sounding all over, thinking that she was attached to a bomb.

Just a thought.

Is that true for women as well? There has been a lot of publicity lately to the effect that the symptoms for women can be other than chest discomfort.  It's a bit confusing.

Yep.

Women can present with abdo pains or something like indigestion. Its all very subtle and can be missed by even the best medics.

These can be silent heart attacks.

what proportion of obesity isn't caused by lifestyle?

or, perhaps the person who is relatively active, eats ok etc.. but is still obese should get the doctors time, those who've done nothing to help their own health for 30 years can get the truth off the nurse? 

you spoke about maintaining health, prevention... i said maybe telling people they are obese and need to eat better, exercise etc isn't best use of doctors time... then you started off about 100 potentially cancerous lumps and so on. 

Doctors appointments need triaging by nurses, not receptionists. Young unhealthy people need the blunt truth now, before they have multiple conditions in their 50, 60s etc.. 

And who's going to do this without incurring the wrath of social media?

You can't tell people the blunt truth unfortunately. It results in complaints and every complaint takes several multiples of a single appointment duration to respond to. 

You're correct, so funding on treatments for obesity related conditions etc will only increase. I've an obese relative, 41years old, had weight watchers on prescription because mild bipolar effects their weight, they do zero exercise, eat appallingly, have no issue accessing cocktail bars and takeaways... they've already had an operation on their back which they try to convince family members is because they are so active it's worn out. I despair and see no solution. 

Well I have just had a text from the NHS reminding me that if I do not turn up for an appointment on Monday it’s a waste of £160.

So it’s something they are already doing!!!

my local GP and dentist also tell  me this info .

I think the NHS could do better on this. An ongoing campaign to remind us that it's OUR NHS; we own it, but that means we're also responsible for it. The decisions we take today will affect the treatment we - and our friends, and our children - will receive tomorrow.

I understand why and respect the fact that medical staff can't do this, it doesn't mean the organisation can't. 

How moronic would you have to be to introduce a system that punishes the poor and chronically ill? Raise taxes all day long if you need to, but keep healthcare free at the point of use. Do we even have to talk about the thin end of the wedge?

Jeezus. I suggest those with the means and the inclination could help to bolster the NHS and this is the reaction. This says more about the button clickers than myself...

Similarly  a highly trained paraprofessional can spot the folk who need to see an MD and who does not - Dr’s are not the be all and end all.

Many a nurse has stopped a doctor f*cking up as well.

Yep okay, “prevention” was a clumsy and unclear word to use in my first post. I was talking about there being advice that does require medical knowledge, as opposed to generic health advice, and that it can’t be assumed that all appointments resulting in “advice” were a waste of clinical time. I thought that I had clarified that sufficiently in my later post, but clearly not. We’re talking about different things. 

Re Vets - education is certainly subsidised, but not much more than many STEM subjects. 
 

Vet bills ve medical costs are pretty variable - eg we charge about 4.5k for a THR, the RVC charges about 14k for a mitral valve replacement (bypass etc) and those costs are not far off the ticket price in people. However a lot of day to day vet stuff is cheaper than the day to day human, and that’s reflected in vet/VN salaries.

You are quite right though that many peoples exposure to medical costs in the UK comes from vets, and often invokes horror.

Please. It really isn't a very sensible idea. Are we talking collection boxes on every GP reception desk?

"Will you be contributing to your treatment today, Sir?"

Even Exiled Scots seem to have this ability

What self-respecting free-market capitalist would do that when they can get the state to subsidise their workforce?

Yes, through taxation and the prescription charge. I suspect those with the means to pay, will already be paying through their taxes. People have options to pay more, it is called private healthcare.

having a nurse book appointments not reception staff would help, they can view their existing record as they speak then decide home, pharmacy, nurse, doctor, a and e, ambulance... always airing on side of caution. Yes, it takes up a nurse, but the saving of steering the patient in the right direction must be better for everyone?

Nurses and other medical staff used to work on the NHS Direct line. But somebody in power thought it cost too much so nurses were scrapped and replaced by non medically trained staff following a script, and the 111 service was born. Huge savings were made not having to pay such highly skilled staff giving medical advice.

Those savings are now somebody else’s nightmare in the NHS. 

Wasn't there a private GPs practice set up close to one of the big London stations a few years ago where busy commuters could opt to drop in for a fee (IIRC it was about £50 for a jhconsultation) thus saving them the hassle of taking time off to visit their local surgery at home? It sounded like a good idea at the time and patients were prepared to pay for it.

There are a more a few around Euston for example. Mind you a 20 minute walk will get you to Harley Street.