It was interesting to see the UK media discussion around the Co-Funding and Co-Payment Bill which was put before the House of Commons for its 2nd reading last week. The Parliamentary webpage describes it as “a Bill to make provision for co-funding and for the extension of co-payment for NHS services in England; and for connected purposes,” co-payments being things like a £7 charge to visit the GP. It is a private members bill, which in the arcane bureaucratic UK legislative system, means that there are only 5 days in any given parliamentary year that they can be tabled and debated in an allotted 5 hour period. Last Friday, much of the time was taken up with discussion of a parental bereavement bill so the co-funding and co-payment bill was not debated, it was ‘talked out’. I’m not a constitutional lawyer, but my understanding is that this does not mean the co-funding and co-payment bill has gone away. Rather, the process can function to keep it ‘on the table’ so to speak, and according to this commentator, it’s been re-tabled for discussion on 15thJune. As such it is still a clear and present danger that co-funding and co-payment could be introduced into the NHS.
However, it seems that even the MP who proposed the legislation, Christopher Chope, did not expect the legislation to be successful. The Mirror reported that Chope was ‘attempting to spark a national debate on the issue’ and for it to be included in the next Conservative Party election manifesto. The intention, according to the Mirror, is to extend NHS charging out from dentistry, eye tests and prescriptions to things like GP appointments and hospital procedures. Putting parliamentary process aside, I want to consider what the implications of a system of co-funding and co-payment would be for people in the UK (and trust me, they’re not positive).
Much of the impetus for increased levels of co-funding and co-payment in healthcare systems is driven by appeals for the need to reduce what are termed ‘frivolous demands’ on the service. Co-payments, it is argued, will encourage responsible use of services, where responsibility is codified as people being far more likely to hesitate in calling on a service if they are required to cover some or all of that cost themselves. According to Kiil and Houlberg, typically co-payments reduce the use of prescription medicine, number of General Practitioner visits, and use of ambulances. However, and importantly, they also found that “individuals with low income and in particular need of care generally reduce their use relatively more than the remaining population in consequence of co-payment.” Even the imposition of a nominal charge could have severe public health implications for issues such as the spread of infectious diseases. In this case, the judgement of what would be a ‘responsible use of services’ becomes harder to make. If economic barriers prevent sick people from accessing care, and in turn, leads to them spreading further infection, a system intended to save on healthcare expenditure would perversely be leading to increased costs. Think of the wider cost to the economy of 5 days lost employment as a local SME has to close due to a flu epidemic amongst the 25 low income employees because of their inability to cover GP consultation and increased prescription costs. And if we put costs aside there is also the likely increase in suffering, disease and mortality.
Consider now an example of a country that has abolished a system of co-payment. Recent longitudinal evidence from Zambia, where co-payments were abolished in 2006, demonstrates that, following abolition, overall use of the system increased more for individuals from low income groups. But also that whilst the proportion of individuals incurring any medical spending reduced, the total average spending did not change, and that these effects were sustained over the long term.
Even economists agree there are political costs for systems of co-payments and co-funding. Those political costs are that increased systems of co-payments create inequities, and create barriers for access to healthcare. Besides, they are limited in their effectiveness at constraining cost because most patients have limited choice over what happens to them (in an economic sense). “Most ‘cost-containment’ efforts focus on minor, front-end costs rather than addressing major, back-end costs.” Of course, it is these back end costs that would affect the highest degree of savings for the NHS.
But, sadly, these issues are not new either. Tudor Hart, writing in the Lancet in 1971, set out the Inverse Care Law. This was the argument that “in areas with most sickness and death, general practitioners have more work, larger lists, less hospital support…than in the healthiest areas”. Invariably, those areas with more sickness and death were lower income areas, and the healthier areas were higher income areas. Titmuss, writing in 1968, stated
“We have learnt from 15 years’ experience of the Health Service that the higher income groups know how to make better use of the service; they tend to receive more specialist attention; occupy more of the beds in better equipped and staffed hospitals; receive more elective surgery have better maternal care, and are more likely to get psychiatric help and psychotherapy than low-income groups- particularly the unskilled.”
This is still the case 50 years later.
Yet despite this overwhelming burden of evidence, about inverse care laws and social class gradients, about the negative impact of poverty and disadvantage on morbidity and mortality, despite all that, it remains possible in 2018, for Conservative politicians to blame poor people. So, it seems that in 2018 ‘victim’ blaming is alive and well. Talk of the need for co-payments and co-funding to limit ‘frivolous demand’ reflect wider political prejudice towards people living in poverty. It marks another attempt to make them individually responsible for their poor health status. It functions to background the enduring and intergenerational effects of structural inequalities. These are well documented and have a fundamental impact on quality of life and life expectancy. In this context, it becomes clear that the driver of this proposed reform is not one of economic sustainability, but rather it is a neoliberal politics of blame writ large. The principle of the provision of universal healthcare, free at the point of need has been a fundamental influence in reducing the detrimental impact of the social reproduction of poverty and inequality in the UK. Any return to a system of co-payments would mark the fundamental death knell of that system.