Wednesday, 11 September 2013

Doctor, It Hurts When I Do *This*.............

It is claimed by the medical experts that patients who visit the doctor unnecessarily amount to about 20% of overall patients, and that this costs around £2 billion of taxpayers' money.  So here's a poser for the day; how do we drastically deter people from visiting the doctor when they needn't have done so (people with colds, coughs, sore throats, etc), but without imposing a mandatory financial charge that would penalise other patients?  Imposing a mandatory charge of, say, £15, but then reimbursing those who weren't deemed to be making appointments unnecessarily is problematical, not least because the administration charges may end up costing more money than the policy saves.
This interview with the Self Care Forum Board member Dr John Chisholm gives insight into the misapprehension some GPs seem to be under, where they want to educate people to manage their own ailments by being mindful of using the NHS at the point of need, not demand.  Of course, GPs are right that this needs to be done, but they seem less focused on the cause of the problem, which is that it is against people's interests to put need before demand, because the system encourages people to take full advantage of what is on offer.  That is to say, the square peg shape of the NHS "free at the point of delivery" does not fit in the round cultural hole of demand-led preoccupations that govern people's incentives to be responsible.

This ought to be fairly basic stuff for the Government's Department of Health. One of the golden rules of economics is that with decreased prices you'll see an increase in demand. For example, if next year all music festival tickets went on sale at 20% of their retail price, a heck of a lot more people would want them. Hence, if doctors see their patients for free, then patients have very little incentive to be responsible. In wanting people to focus on 'need' not 'demand', doctors are asking people to be far more rational than they actually are, by acting against their own interests.

Here's a slightly more extreme illustration to highlight what GPs want the public to do. Suppose the Government nationalises every supermarket in the country, sets the price of all food and drink to zero, and tries to encourage people that they should only take the food and drink that they 'really need', not all the food they want.  No such encouragement would see those aims achieved. Not only would people struggle to distinguish between food and drink 'needed' and food and drink 'wanted', they'd have no incentive to be responsible eaters and drinkers, as all food and drink would be free.  In fact, if sustenance had been paid for by taxpayers' National Insurance, many would over-consume to ensure they're getting their 'fair share' commensurate with what they'd paid in.

At a less extreme level this is what is happening with the appointment profligacy we are seeing in GPs' surgeries. I'll be frank though; it could be that there is no easy solution to this problem, particularly if the administration costs outweigh the success of the policy.  Maybe the £2 billion lost in 'irresponsible appointments' time is the price that needs to be paid to ensure that the remaining 80% of doctors' patients do not pay a fee for what are genuine illnesses that require NHS time. Or maybe there is a solution that has low administration expenditure but at the same time avoids the imposition of blanket costs (either financial, or some other kind) and retains the 'free at the point of delivery' ethos for which the NHS is so ubiquitously renowned.  If you have any suggestions for a possible solution, I’d be interested to hear them.

EDIT TO ADD: I sent this off to my local MP, and here is the response I received:

Dear Mr Knight,

Thank you for your email regarding NHS costs. You make some thoughtful points.

I understand the pressures faced by GPs, who are facing increased demand for their services, and agree that it would be preferable for people to use their GP only when necessary. I have written on your behalf to Ministers at the Department of Health for their comments on the points you raise and will return to you with any response I receive.

With best wishes,


Let’s see if I get anything thought-provoking from the Department of Health by way of a response.

* Photo courtesy of