Is the NHS in crisis? 2) Demand, rationing and charges

This is the second in a series of comments on key issues in the NHS. They don't represent an agreed or formal position of SSONHS but are a collection of thoughts broadly consistent with views across the group's point of view.

We hear a lot about the rising demand on the NHS - to do with demographic changes, more advanced diagnostics, more technological treatment, rising expectations etc. We also hear from people on the front line increasing resentment at what they perceive as abuse - something which leads some NHS workers in the most vulnerable areas such as GP surgeries and emergency medicine openly to canvas the idea of charges (either generic or linked to causal factors such as alcohol). Even more punitively the call to exclude people such as smokers or who are obese from treatment until they change their lifestyle is gathering more adherents.

As with funding crises, fears about demand have a long history. On the first day of the NHS one group of doctors and healthworkers in Birmingham barricaded themselves into their clinic, only to find, when they peeped out, an orderly queue of mothers and babies. But demand was much greater than expected, not just for medicines, but for aids like cottonwool (rationing was still in force). People place their hopes in medicines. There are also the abusers, the careless, the thoughtless and those who think they are entitled to get something back for their taxes, just like people who bump up their insurance claim if they have been paying premiums for years.

Austerity has its own answer to the demographic change. Life expectancies for women aged 65, 75, 85 and 95 all fell in 2012 compared with a year earlier, the first slip in all age groups in nearly two decades. There was also a small drop in life expectancy for men at ages 85 and 95, while longevity for men in the two younger age groups stagnated, according to a Guardian report referring to Public Health England. Although the figures for 2013 did not show any further falls, the life expectancies for men and women aged 85 and 95 failed to recover to 2011 levels, which were the highest to date. This looks like one gift of the Coalition's austerity programme - to manage demand by killing people off earlier especially if they are no longer in the workforce. If the Conservatives are elected they promise to make things worse. Apart from the cuts they also threaten in their manifesto impose benefit sanctions on people who won't accept recommended medical treatment.

Debates over priority for treatment are complex but nearly all the electoral talk has a victim-blaming edge to it. Rationing by severity of condition and predisposing behaviour are one tack - already introduced by some CCGs. But lifestyle issues are not just down to individual decision. Apart from restrictions on budget (so that the poor always have the poorest choices) health-affecting lifestyle choices are driven by commercial interests - especially the tobacco and alcohol industries, soft drinks manufacturers and the purveyors of fast food. At one stage it looked as if the Tories were actually going to stand up to the brewers, distillers and supermarkets by introducing minimum pricing. But then the public health researchers (principally from the University of Sheffield) who had shown the positive effects of this were frozen out of the Department of Health which set up meeting after meeting with the manufacturers. We also know that poverty and austerity ensure that the proportion of junk food consumed is much greater. One million people are using food banks but the only food available there is prepacked or processed with healthy options restricted.

We've heard over the last few years that fewer young people are taking addictive drugs and (until vaping got going) smoking. It is very likely that some of this was due to the Healthy Schools movement (eventually partially funded by the Labour government) which grew rapidly from 2006 but was then largely sabotaged by the Coalition's drive towards Academies. There is a huge amount of potential work to be done here but it threatens significant sectors of economic activity with access to powerful lobbyists.

So what about patient charges? Dr Mark Porter from the BMA (an opponent of the Health and Social Care Act and of charging) recently raised the spectre of extended charges (which currently raise about 1% of NHS income). The Coalition has already strengthened hospital charging mechanisms for overseas visitors and migrants (e.g. the new pre-entry charge for temporary migrants) which it was considering extending to primary care. This move was 'deprioritised' before the election. There is apparently intention to undertake an independent Major Projects Authority review into the impacts of charges on vulnerable groups - which could be a foundation for extending charges more widely. If current coalition policies continue, it is quite likely that the issue of potential primary and A & E charges will be put out to further public consultation in the autumn and this could include all NHS services inside and outside hospital as well as those commissioned from outside providers.

There is no doubt that charges totally undermine the basic concept of the NHS as a universal service. All of us will know people who have not taken up prescriptions, particularly for longer periods of treatment, because they cannot afford them, or people on low incomes who have had to cancel even dental checkups because there is no money that week for family food. It was shocking to read recently of the increase in DIY dental kits, including tooth extractors. Would everyone be charged (the £10 per GP visit for example) or would there be a vast range of exemptions? If only selected groups were charged (e.g. people with alcohol problems) who decides whether a charge is appropriate. And what is the difference between an alcohol-related injury and a sports one? How much would it cost to administer a charging system. And how much would it cost in terms of delaying diagnosis and treatment? There is no evidence to suggest that charging would not cause and cost much more than it might save.

Demand needs to be managed but in other ways - and it is possible to rethink the whole way in which people access the NHS. Technology may be part of the answer but making basic advice more available is also important. Meanwhile people are being blamed both for worrying too much about their health and for neglecting worrying symptoms - something for which they could get penalised.

The development of more community based health services is probably one part of the answer. Charges and sanctions are definitely not - another reason to try and ensure the Tories don't get back into power.