Call to reform NHS charge system

Most NHS prescription charges in England should be scrapped and applied to "ineffective treatments" instead, NHS public health chiefs say. The Association of Directors of Public Health said rising demands on the NHS will lead to more rationing.

Their president, Dr Tim Crayford, said: "If NHS charges should be applied at all, they should be applied to relatively ineffective treatments." He gave tonsil removal and varicose vein surgery as examples. But he also speculated about the feasibility of allowing more serious procedures, such as cataract surgery and hip replacement operations, to remain free in all cases. "Medicine and treatment that people need for health reasons should be free. But where there's little proof of clinical benefit, the use of such treatments would reduce more quickly if they had a price tag attached," Dr Crayford added.

Doctors' representatives said more NHS care should be rationed, but they were against charging.

Dr Crayford, president of the association, which represents NHS trust public health directors across the UK, said since 1998 spending on cataracts had increased by 40% to £200m, while the cost of hip operations had risen a third to £300m.

"What is wrong with asking people to contribute for some care which is not life-saving - much as we do with dentistry? For operations such as cataracts and hip operations we need to decide at what point in people's lives these operations should be done. The association is calling for a debate on issues such as this to allow the public to decide how the NHS's limited resources are spent. If the public agree a threshold what about people below the threshold? Our argument would be that below that threshold they should be allowed to contribute towards the cost as they would with a filling. The thing with hip and cataract ops is that they have become more common as waiting lists have fallen and surgery improved, so we have to ask ourselves is it better if patients are asked to wait until their level of pain or blurred vision is more acute. The NHS will not be able to do everything in the future."

Dr Crayford also said the health service was currently carrying out a small proportion of care which had little medical benefit. He said procedures such as certain types of plastic surgery, orthodontic surgery, and varicose vein surgery should not be widely available in the future. "As the elderly population grows and more medical breakthroughs are made, it is clear we are going to have to think about what the NHS is there for and what it is providing."

The British Medical Association is currently drawing up proposals about what the NHS should be providing and will discuss the issue at its annual conference later in the year. Jonathan Fielden, chairman of the BMA's consultants committee, said it was an important debate. "The NHS is already rationing procedures - cosmetic surgery is not carried out on the NHS, and the drugs which are used are restricted. There needs to be a public debate about what a comprehensive NHS means, which services are available, and which aren't. For example, should the NHS be doing work which is purely cosmetic, or of little clinical value? But the question is how far do you go? If you include hips and eyes I think you are breaking with the traditional values of the NHS, I wouldn't agree with that."

But Professor John Appleby, chief economist at the King's Fund health think tank, said: "I do not buy into these doomsday scenarios. How much extra demand is there going to be on the NHS? I don't think there are any miracle drugs in the pipeline and as for the people living longer, what matters most is how close you are to death, not how old you are. We consume the most health resources in the last year of life whether that is at 50 or 80."

Professor Appleby also said it was likely there would be public appetite to increase the amount spent on health to keep pace with increasing demands.

Nigel Edwards, director of policy at the NHS Confederation, said: "The issue is quite rational; after all, care is already rationed and we already make a contribution to dentistry, but it is a very emotive and political subject. In the end it is going to have to be decided by a public debate and it will be the public which should decide what the NHS does."