Every couple of months, some prominent media personality suggests people should pay upfront for more of their healthcare. This is not, the pundit usually hastens to add, to fund the service, but to discourage people from using it frivolously. Suggestions range from £5 to see your GP to £100 for an inappropriately-called ambulance.
On days when we’ve dealt with someone casually misusing the NHS – and yes, I have known a patient to call an ambulance for a broken nail, and I’ve worked in the A&E where a mother arrived demanding that staff clean dog poo off her child’s foot – it’s very tempting for healthcare staff to agree.
The management-speak term for this approach is ‘demand management’. It’s a polite way of saying that making it harder for people to access healthcare will put them off, and maybe they’ll get bored and go and do something else.
There’s considerable truth in this, and as the ratio of demand to supply in the NHS rises to ever giddier heights it’s an approach that can look tempting. Cutting services completely always generates unfavourable headlines, whereas merely making them a little harder to get at is less dramatic.
And it doesn’t even have to involve a monetary transaction: there are plenty of more subtle ways to stop those inconvenient patients turning up demanding care. But the trouble is, the people we discourage are not the frivolous, the ‘worried well’, the over-entitled: more often than not, they’re the people who need our care most of all. This is no less true when the chosen ‘demand management’ strategy is non-financial.
In my current community paediatrics placement, parents of children needing therapies, hearing tests or parenting support receive a letter. Their child has been referred for (as the case may be) speech therapy. If they would like to take up this offer, please will they reply to the letter within a fortnight? Otherwise, they will be discharged.
Then, if they like, they can start again at the beginning of the lengthy referral process, and see if they do better next time. Or they can fall off the service’s radar completely.
For the sort of people who make health policy decisions, or who provide health services, this sort of thing wouldn’t be a problem. Of course we’d answer the letter, arrange the appointment and make sure our child got the help they needed – it’s simple. Only it’s not so simple if you don’t speak English, or you do but you can’t read very well, or you have your own undiagnosed learning difficulties, or your life is just so chaotic and difficult that an extra letter to answer feels like an insurmountable challenge.
And guess whose children usually have the greatest need for support? It’s not the sons and daughters of health service managers.
That’s why my recent clinic included a boy with wholly incomprehensible speech who, at seven years old, has never had his hearing checked. That’s why I regularly see nonverbal, profoundly autistic children who have not yet got around to ever seeing a speech therapist. That’s one reason children of poor, or poorly-educated, families persistently do less well than their prosperous peers.
The therapists and doctors I work alongside want, without exception, to do their best for the children we serve. They care deeply about helping people and most of them, even as the last-days-of-Rome atmosphere grows in the NHS, love their work. The opt-in letters are not their idea.
This is the way a struggling system has found to ‘manage demand’: to restrict the number of people receiving care to a number we can just about cope with. If that doesn’t always include the children in most desperate need, well, that’s just too bad.
The gradual erosion of the NHS is happening in ways that, to the comfortable middle classes, may not even be visible. But to the people barely coping with life, who need health services the most, what the socially secure experience as a barely perceptible inconvenience may, for them, become an impregnable wall.
Miranda Barry is a junior doctor. She writes under a pseudonym
I'm an educated articulate professional but I got managed off a waiting list by being offered an appointment for in patient treatment involving a general anaesthetic at only two weeks notice. As I couldn't get time off work at such short notice, and as I couldn't find someone to drive me to the appointment and pick me up afterwards (due to the GA) I couldn't do either of the two dates offered. So I was taken off the waiting list .
The NHS is one of this countries greatest achievements and if we don't stop the rot, then we will be reviled as the generation who just stood by and watched as the Tories destroyed it so they could line their own pockets!
Dear anon, that simply isn't true, we spend 2% of Gdp on overseas aid, the same or less than most other developed nations, this is our duty and is not directly correlated with funding the nhs.
Dreadfully sad that people think overseas aid, the EU or frivolous appointments are somehow the cause of the billions stolen from the NHS that we paid for. Victim blaming at its very worst.
Not an overly fair representation. People not being able to speak the language is a different argument, however, those and those with learning difficulties have a large network that can support them including schools and school nurses and charitable organisations but to name 2. Before a barrage of abuse and questions of my " qualifications to comment, my son has profound and multiple disabilities, my wife works in the NHS and I am a school governor at a special school and chair of a charity, based from the same school. It is undoubtedly there will be innocent victims of such a scheme as in the article, however, it is time people start to take some responsibility and have a better understanding of the strains the service is under, don't take it for granted, cherish and respect the NHS.
The NHS needs to be managed by patients and clinicians working together. This government is trying to destroy it by stealth.Has anyone thought of polyclinics in the community as the first port of call for most problems?I went to A and E totally inappropriately, because they had an ECG machine, and primary care did not. A and E was overwhelmed, but it was having to deal with impoverished community care.
No its failing because it's haemorrhaging billions to private companies who are allowed to charge more for services than when the NHS provided them directly.
Just to say that ,given some abuses by "poor" people ..my impression is that the Middle And "Chattering " classes will always manage to get the best out of health and education services , one way or another
2 week opt in, what a nonsense! Opt in shouldn't need any limit as it doesn't cost anything. As described, just another waiting list clearing exercise. And yes, it does affect us GPs. It completely wastes our time.
Twas ever so - the inverse care law. Wonderful that colleagues are calling attention to it - it needs to be shouted from the rooftops.
And while on the rooftops a few words about 'Affordable housing' meaning houses for those who with a little extra help could get a mortgage, not people who are homeless, etc. Not yet diagnosed as 'alternative facts' but similar - perhaps 'alternative' policies to address todays problems arising from refusal to raise the taxes from those who can afford to pay to fund the welfare state than any civilised country should be.
As a retired GP I find it nonsensical to argue that people want health appointments and consultations unnecessarily. As one patient used to say, "I always love to see you - except in your surgery". Most people lead busy and quite difficult lives and to take time out for a health related appointment his demanding and disruptive. If something crops up, the tendency is to procrastinate hopefully, and think perhaps that it will go away but plan to do something if it has not gone in a fortnight. Then when it does not go, to think, "Well, may be another fortnight". Then after another fortnight they finally and reluctantly drag themselves to the GP. There always a tiny number of irritating exceptions, but shortage of supply, and not excessive demand is the problem .
It is only militant ignorance by politicians which makes it possible to rant about having given the NHS extra money, but will go and see the reality at the local hospital, will not accept that this country starts from an incomparably low position, e.g. fewer beds than any other OECD country. The country lost a quarter of all its hospital beds between 2005 and 2015 or again, this country spends less of its GDP on Health than any other in Europe, except for Turkey and Portugal .
NO, I do not want to be anonymous.
The NHS is grossly abused. Perhaps not by the majority, but enough to have brought it to the point of collapse. The problems are: free at the point of delivery, lack of overt rationing, a benefits system that rewards illness behaviour, free prescriptions, demand led rather than need led, a litigation culture that penalises doctors unless they over see, over investigate, over refer, and over treat, the medicalisation of life. We now have politics based medicine. It is a pity that some children who have feckless or otherwise disadvantaged parents are going to slip through the net. I have seen this happen in my own practice. It is a very difficult and litigation strewn road for children to be taken into care in these circumstances and even then local authority care is not a good option long term either. Unless an entire review of the NHS purpose and performance is undertaken we will continue to see efforts to keep to budget by fair means or foul. My point is that the NHS trying to be all thing to all people must cease.
Sure. But as Miranda admits, there is a lot of unintelligent misuse of NHS. How do we curb it? Coughs & colds strains & sprains don't need a doctor
Excellent article. Scary but true. I met a severley depressed woman the other day who burst into tears at the least provocation - there is no way someone like her could negotiate the process described. The "sorry but no" and blame the EU comments below display a disturbing lack of empathy, I really hope those people aren't caring for others