2014 the year of the co-payment: lessons from the NHS

What can we learn from the UK’s recent experiments in primary health care about co-payments, economic incentives and the impact of creating barriers to access? Margaret Faux, from the University of Technology, Sydney, outlines some important messages for Governments and policy makers wishing to head down the same path as the National Health Services.  She writes:  

This year two of the best among the developed world’s health care systems, our own Medicare and the National Health Service (NHS) in the UK, have engaged in co-payment debates in attempts to shift responsibility for rising health expenditure to consumers. The fate of Medicare co-payments is as yet unknown, but if there is a lesson to be learnt from the NHS experience it is this: when barriers are imposed at the entry point to a health care system, there is no gentle ripple effect; it’s more a house of cards effect.  And just like the political administration in the TV series of the same name, the British government was happy to stand by and watch the NHS tumble.

Whispers of the Abbott governments co-payment plans were appearing in the Australian media last Christmas and, just as the NYE clean-up was coming to a close in London, so too were co-payments hitting the headlines in the UK, where a survey of 800 GPs had apparently found that one third supported a proposal for co-payments to be introduced into Accident & Emergency (A&E) departments. The subsequent attacks on both the NHS and the GPs working within it began with this headline:

 “GPs propose £10 fee for A&E to deter the ‘worried well’”

The next day a representative of the UK patients’ association hit back placing the blame squarely on GPs when she said:

“If GPs hadn’t dumped their responsibilities on A&E the crisis wouldn’t have happened. Presumably ambulance crews would have to stand by until a patient could find their purse.”

The ‘dumping’ referred to resulted from changes introduced in 2004, which created an access barrier at the entry point to the NHS. It was not an access barrier in the form of a co-payment, but instead a time-based access barrier. The government had introduced reforms which allowed GPs to opt out of providing after hours care and, not surprisingly, they all did. So when patients were no longer able to get timely appointments with their GPs, they had little option other than to attend A&E departments, which were already under resourced and therefore struggled to manage the increase in demand. By the end of 2013 they were in crisis.

There was a suggestion that the NHS co-payments would be refunded if the A&E attendance was necessary, but there was no indication as to who was going to decide what was necessary or who would be responsible for the administration of it all. And then came the, now familiar, questions of who was going to collect the cash, swipe the credit cards, process the refunds and balance the books. And what if a credit card bounced or the patient couldn’t find her purse, what then? Would the patient be turned away?

The situation worsened for the embattled GPs when they were found to be moonlighting in A&E departments on the weekends (rather than opening their own practices) where lucrative deals were on offer:

“Family doctors are earning thousands of pounds working night and weekend shifts at stretched A&E units, it was reported. GPs are being paid up to £1,500 a shift as they help crisis-hit casualty departments cope with soaring numbers of patients, the Daily Mail said. Four out of 10 accident and emergency departments are hiring family doctors, who are already paid an average of £104,000  per year.”

Unlike Medicare’s fee-for-service structure, the NHS is a capitation system which is free at the point of use. But on its 65^th birthday in 2013 it was in trouble. In 2012 the Health and Social Care Act (the Act) had been introduced to remedy some of the long standing administrative inefficiencies which had lead to its present woes, and specifically, the Act abolished the primary care trusts and strategic health authorities, who used to administer the buckets of money allocated to medical practices under the NHS’s capitation design. These organisations were replaced with new structures including Clinical Commissioning Groups (CCGs) and Commissioning Support Units (CSUs).

The CCGs comprised GPs, who were given the money and the responsibility of deciding how it should be allocated. These GPs essentially became finance managers who would procure and contract approved NHS services. But with no formal training in business or finance, it was to be expected that the GPs would need to call on assistance and support from the CSUs from time to time for advice and support concerning how to responsibly allocate such large sums of money. The CSUs were designed for this purpose as they had the finance and management expertise, or so the public were led to believe, until on January 4^thThe Times reported:

“Health chiefs spent £10 million on advice for their own advisers as part of a £40 million management consultancy bill to implement the Government’s NHS reforms”.

 “Figures released to Parliament reveal how the hundreds of new bodies which took over running the health service in April immediately began spending millions on help from consultants. Singled out for criticism were the 18 Commissioning Support Units (CSUs), created to advise the GP-led groups now responsible for buying services for patients. These in-house consultancy units spent £10 million on external management consultants in the six months to September”.

A representative of the patients association said:

 “…[CSUs] are there to give advice and support, yet they are buying people in to give advice and support on how to give advice and support. This sort of expense is totally unjustified”.

In a final embarrassing turn, it was discovered that the advisers, who had been hired to advise the advisers on how to advise, were former senior NHS executives who had recently received redundancy payouts of up to £600,000 from the NHS as part of the re-structure. They had jumped straight back onto the NHS merry-go-round being rehired as consultants to the CSUs to pocket yet more NHS funds.

Five months later, a review of 3000 patients conducted by the UK College of Emergency Medicine found that only 15% of patients could have been treated in the community as opposed to the 25% previously proffered by the NHS in support of its A&E reforms.

Our government would do well to heed the warning that access barriers imposed on primary health care will inevitably create pressures and costs somewhere else in the health care system. Because patients will continue to fall ill outside of business hours and on weekends and, being the inconveniently imperfect diagnosticians that they are, will also continue to sometimes get it wrong, and will attend the GP or A&E when it probably wasn’t necessary.

We should be thankful that despite the Federal Government announcing it will allow the collection of co-payments in public Emergency Departments (ED), our State Premiers have so far showed opposition to this move. But if the co-payment plan goes ahead, and patients pour through the doors of ED to avoid the $7 fee as is predicted, they will each clock up an average flag fall cost of $398 per presentation. 

A total disaster looming? “You might very well think that; I couldn’t possibly comment” (Francis Urquhart, House of Cards, UK series)

Margaret Faux is a lawyer, the founder and managing director of one of the largest medical billing companies in Australia and a registered nurse. She has been involved in Medicare claiming for 30 years and is a research scholar at the University of Technology Sydney examining the interface between Medicare and medical practitioners.