Image: Andre Popov/

Should we worry about the rise of fee-for-service general practice?

Paying for GP services is back in the news. New models of private health care are being launched, and commentators are calling for NHS patients to make co-payments to visit their GP. With the NHS under attack from all sides, is this just more evidence of the softening up of the public to accept privatisation? Or should we be more open to considering paying for health care?

One new entrant to the market is entrepreneur Eren Ozagir’s online GP consultation service Push Doctor, which has just appointed a PR agency to help “transform the choices people make about their health care”. For £25, Push Doctor offers a ten minute video-consultation with a doctor who can provide advice, prescriptions and sick notes from the comfort of your own home. Everything, in short, apart from a physical examination. In the light of media scare stories about how NHS GPs are struggling to cope, with patients facing long waits for appointments, this is an attractive offer. I don’t have to hang on the phone for hours at 8.30 on a Monday morning hoping to get an appointment before they all go; I don’t have to persuade the harassed receptionist that I really do need to see the doctor; I don’t have to face that demoralising wall of ‘Switch off your mobile phone’, ‘Do not miss your appointment’ notices in the surgery. I don’t have to feel guilty that I am using precious NHS resources on my trivial problems. Instead, I get to be treated like a valued customer, and at my convenience.


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So does it matter if people like me are enticed away to private GPs?

In principle, free, universal and good quality primary health care is in everybody’s interests. It is good for health, good for equity and good for society. Paying fee-for-service is more likely to get me what I want – but a collectively managed service is more likely to provide what I need, and more importantly perhaps, what is in the interest of the public health. That might mean no antibiotic prescriptions, or a cheaper generic drug than the one I ask for. And it works. To date, the NHS has been one of the world’s most efficient and effective systems for delivering health care. If we all use the NHS, we all have a vested interest in making it function well, and in paying for it through taxation.

A growing private GP sector potentially erodes this communal responsibility. If I pay for a private consultation, I get the promise of a more customer-focused service. Shifting some care out of the NHS may also reduce demand on an over-stretched service. But it also starts to signal that NHS services are for those who can’t afford anything else.  If those of us who can afford to go private no longer use the NHS, this potentially drives a wedge in our commitment to paying for the system through taxation. More insidiously, it gets us all used to the idea of paying directly for health care.

The endless trickle of stories vilifying NHS provision serve to soften up the public to privatisation by highlighting the downsides of collectivised health care. They also shift the moral frame; if patients are simply consumers, it’s acceptable for entrepreneurs and shareholders to make profit from ill people. Should we, then, resist all fee-for-service initiatives as simply more evidence of the current government’s efforts to demolish the NHS through privatisation?

Perhaps. But it’s important to remember that there is a long history of fee-for-service primary care in the UK, pre-dating the current NHS crisis. Although the private GP sector is small , it is telling to look at who uses it. Those going private have generally been neither the rich, nor the insured – many private insurance packages only cover post-diagnostic care. Thirty years ago, for instance, Nicki Thorogoood described why low-income Black women in London used private GPs, despite being eligible for NHS services – in part to ‘buy some equality’, in transforming their relationship from ‘patient’ to ‘client’.   More recently, similar incentives were identified by Dorota Osipovič, who writes about how Polish migrants paid for private services not just because they have limited knowledge of how to access the NHS, but because they actively choose culturally familiar doctors who offered the kind of service they wanted.

In short, paying changes the relationship between provider and client.

So does that mean that charging within the NHS would improve care? Debate has resurfaced about whether NHS patients should be asked to contribute directly to costs when they visit their GP through co-payments.  However, rather than being offered as a way to shift the balance of power back to patients, this has been largely discussed as simply a response to the financial crisis. One contributor to the BMJ, for instance, argued that rising health care costs left no alternative but to charge co-payments for GP visits: they would contribute much-needed resources, and deter trivial visits.

Luke Allen has robustly challenged the credibility of these economic arguments. First, patients are often unable to judge what is and isn’t trivial. Second, the costs of collecting fees can outweigh the income. Perhaps most importantly, charging fees is inequitable: it hits the most vulnerable and sickest hardest. Those who can’t pay are then reliant on other services such as A&E departments, which are free at the point of delivery, but more expensive to provide.

If the economic arguments for co-payments for GP visits don’t stack up, neither do the consumerist ones. In an overburdened system, a small contribution is unlikely to change the relationship between doctor and patient. Co-payments risk combining the worst of both collectivised and fee-for-service systems.

Perhaps the most insidious effect of current attacks on the principles of the NHS is that they undermine our ability to be critical of the former. One well-recognised risk of collectivised systems is the lack of power patients have. This is why services like Push Doctor – and other fee-for-service GPs – are so appealing. We need to defend the idea of the NHS vociferously – it is in everybody’s interests – but we also need to consider more carefully why patients might choose alternatives.