Charging for Healthcare – Closing the Doors on the NHS

I initially wrote this post for Pulse Magazine, with an audience of GPs in mind, so please forgive the fact that it sometimes slips into jargon. The debate on healthcare for migrants is not something just for GPs to consider, however, as it affects us all. How we care for those who arrive in this country from abroad says a great deal about our nation, and we should all have a voice in the discussion. Here is the post:

I don’t know about you, but I’m swatting up on public health and maternity care – it might seem an odd combination, but it looks like we’re going to need it. The Department of Health – renowned for its undying faith in the virtues of general practice – has decreed that only primary care will remain free at the point of delivery for non-EU migrants, while A&E and secondary care will be withdrawn behind a solid pay wall. This is seen by some as a U-turn, bowing to concerns that charging for all medical care could lead to serious threats to public health, such as outbreaks of TB – as has already happened in Spain.

The Department of Health has reassured the public by stating that, in keeping GP consultations free, everyone will have ‘initial access to prevent risks to public health such as HIV, TB and sexually transmitted infection.’ That’s all right then. There’s no statement, of course, about what is meant to happen after this initial access. When I’ve made my initial assessment that the impoverished patient sitting before me could well have TB, can I order a chest x-ray before I obtain their credit card details? And when the report of a cavitating apical lesion arrives on the fax machine, should I brush up on treatment regimes for mycobacterial disease when my patient informs me that he can’t afford hospital care? Perhaps I should learn bronchoscopy and start offering it as a minor op? Oh, but they plan to charge for that too, don’t they? Oh well, it’s not like TB is making a bit of a come-back or anything.

Then there’s maternity. Apparently no-one will be turned away, but they will be charged. How does that work then for a pregnant woman with no money? Cross your legs until you’ve saved enough? Visit Wonga and ask for a labour day loan? Or try a home birth with a cost-free GP and hope you find one that’s been around long enough to remember how to do it? Even if the moral argument doesn’t grab you, it makes poor economic sense – obstetric catastrophes are very expensive as well as tragic.

The thinking behind this, of course, is that the NHS is broken (it isn’t), and so-called ‘health tourists’ are the cause (they aren’t). The real reason, however, is more ideological. Read the DH document in detail and you find a recurring argument that goes something like this:

We’ve considered Situation X; we recognise there are moral and ethical difficulties, but we are going to charge anyway because the Hard-Working-British-Tax-Payer can’t put up with the idea that someone, somewhere might be getting a free ride.

The document makes a clear distinction between medical tourists (those who choose to travel for better health care, but are willing and able to pay for it) and health tourists (those who have health needs but cannot afford to pay for it). They want to encourage the former (the rich), while denying healthcare to the latter (the poor) – how very like this Government.

Now I’m not that keen on people being able to take cynical advantage of the NHS, but neither do I wish to see the most vulnerable in our society shut out of receiving healthcare; the new rules will apply to asylum-seekers – many of whom have genuinely fled from horror to the safety of our more tolerant society – and even people who have become victims of human trafficking may have to pay; the Government is still consulting about this, and is clearly stuck with how to identify the ‘worthy’ immigrant from the ‘unworthy’ one.

It will not be long before doctors will have to decide which is the higher calling on their professional duty. When faced with a sick patient – not quite an emergency, but not something to ignore – will it be Government policy that will prevail? Or the urgings of a hospital manager desperate to balance the books? Or should we insist that, whatever the political will we are up against, our duties are laid out by the foundations of our profession as laid down in the World Medical Profession declaration of Geneva:

I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient.

Or our own GMC:

MAKE THE CARE OF YOUR PATIENT YOUR FIRST CONCERN; Protect and promote the health of patients and the public; Respect patients’ right to confidentiality; Never discriminate unfairly against patients or colleagues.

Or the United Nations Human Rights Treaty:

States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services; abstaining from enforcing discriminatory practices as a State policy.

When these charges start to bite doctors will be faced with dilemmas on a daily basis. Do we do as we are told, and turn away patients whom we know we can help on the basis of their nationality, or do we consider something more radical? When Iona Heath reflected on the above statements recently on Twitter she had no doubt which was the right way for the profession to act, and recommended civil disobedience. Are we brave enough to follow her lead?

The Burden of the Elderly

Baroness Warnock must have known that she was brewing up a storm when she suggested that people with dementia may have a moral ‘duty to die’ because of the burden they place on their families and the state. One wonders why she did it – not for the publicity, surely? The most compelling argument against legalised euthanasia is the concern that vulnerable elderly people will feel obliged to consider ending their own lives out of worry about being a nuisance – whatever Baroness Warnock’s motivations, it is quite chilling to see it argued in print that they would have an ethical obligation to do so.

If the criterion for ending your life is that your continued existence carries too great a price for family and state to pay for, then it is a small step to apply these principles to the young as well as the elderly. After all, the main difference between a young, severely disabled person and an elderly severely disabled person is that the younger person will require care for far longer. The argument then starts to resemble the ideology of eugenics – Europe has been there once in the last hundred years, and once is quite enough.

There is no doubt that people with advanced dementia are a burden on their families and the state – they require a lot of care and support, we would be blind to the reality of the situation to argue otherwise. The key question, though, is this: should humanity be about avoiding carrying burdens in the pursuit of individual happiness, or is our humanity both defined and enriched by the fact that we choose to carry one another’s burdens?

You only have to talk to some of those who care for a loved one with dementia to know two things: caring for someone with dementia can be tough, and many thousands of carers would tell you that it is a burden that they gladly and willingly carry for as long as it takes. We should not romanticise the role of a carer, though. For many it is too much to juggle the needs of an elderly parent with dementia with the requirement to earn a living, care for the children and still find time to eat and sleep. People need help to do this. They need a society that is willing to step up to the plate, pay its taxes and prioritise the care of the weak and vulnerable as a key measure of civilisation. We need a government that doesn’t just berate families for allowing their elderly to become isolated, but creates an environment where those of working age are more able to achieve sufficient slack in their lives to be able to care.

Ultimately it depends on whether we see the weak and the vulnerable as an annoying drain on national resources, or the very stuff that society is there for; the grit in the oyster that creates a pearl as humanity finds its purest form of expression in the care of the vulnerable; the antidote to our sanitised, celebrity-driven culture that seeks to avoid suffering at all cost, and a reminder that how we care for one another is how our society should be judged.

Leave Them for the Poor and the Stranger

The Old Testament book of Leviticus may seem an unusual source for guidance to inform social policy, but there is wisdom in this ancient Hebrew book of the law that we would do well to consider, whatever our religious views. Hidden in the middle of the 19th chapter are the following two verses:

When you reap the harvest of your land, do not reap to the very edges of your field or gather the gleanings of your harvest. Do not go over your vineyard a second time or pick up the grapes that have fallen. Leave them for the poor and the stranger.

This was a clear instruction to the Jewish people that they were to live with a social conscience: that those with plenty should leave behind something for those in need, which includes both the poor and the foreigner.

In stark contrast, the political arguments from our Government are increasingly about taking the harvest right up to the edge of the field. There is an ideological fear that someone, somewhere might be getting a free ride, which leads to picking over the vineyard again and again to make sure that nothing is left for ‘free-loaders’, while the dual spectres of the benefits scrounger and the health tourist are used to stoke the political debate.

There are many formal policies already in place, such as the huge cuts to legal aid or the cap on welfare payments. Most obvious to GPs are the changes to Employment Support Allowance, with patients frequently left bewildered and desperate after an assessment by ATOS and the sudden cessation of their benefits.

Now we hear that there are to be changes to Job Seekers’ Allowance. Claimants will have to sign on weekly rather than fortnightly, and will have to wait seven days rather than three before their first claim – four days without income when you are already gleaning what you can from the edges of society. The poor are being squeezed.

As for the stranger, families are being split by increasingly harsh immigration laws, the spectre of a two-tier NHS was first floated by the Immigration Minister Mark Harper, who seeks to deny healthcare to newcomers from Romania and Bulgaria, and now the Health Secretary intends to make it a reality with his proposals to dramatically reduce access to healthcare for migrants.

Austerity, of course, is the justification in every case – epitomised by the plight of the idealised ‘hard-working family’ – but there are times when society has to decide what is right, and what is wrong. For many of these policies the financial gain to the Treasury is small, but the political will makes them appear a necessity. Do we want to live in a society that squeezes the margins so tightly that we ensure no-one ever takes us for a ride? Or might we just be willing to risk being taken for granted, leaving something at the edges for those who are in genuine need?

A society should be judged by how it cares for those who are most vulnerable. At first it might seem more expensive, but there are wider costs to bear when society gets tough on the poor. Poverty is closely linked with poor health, and increasing poverty with worsening health, while the health problems of the most vulnerable will have impact on us all.

When I look at these verses in the book of Leviticus, I can’t help feeling that the thinking behind them is as pragmatic as it is moral – if you marginalise the poor and the foreigner there will be a greater price to pay in the end.

This post was originally published in Pulse magazine (free registration required)