Every couple of months, some prominent media personality suggests people should pay upfront for more of their healthcare. This is not, the pundit usually hastens to add, to fund the service, but to discourage people from using it frivolously. Suggestions range from £5 to see your GP to £100 for an inappropriately-called ambulance.
On days when we’ve dealt with someone casually misusing the NHS – and yes, I have known a patient to call an ambulance for a broken nail, and I’ve worked in the A&E where a mother arrived demanding that staff clean dog poo off her child’s foot – it’s very tempting for healthcare staff to agree.
The management-speak term for this approach is ‘demand management’. It’s a polite way of saying that making it harder for people to access healthcare will put them off, and maybe they’ll get bored and go and do something else.
There’s considerable truth in this, and as the ratio of demand to supply in the NHS rises to ever giddier heights it’s an approach that can look tempting. Cutting services completely always generates unfavourable headlines, whereas merely making them a little harder to get at is less dramatic.
And it doesn’t even have to involve a monetary transaction: there are plenty of more subtle ways to stop those inconvenient patients turning up demanding care. But the trouble is, the people we discourage are not the frivolous, the ‘worried well’, the over-entitled: more often than not, they’re the people who need our care most of all. This is no less true when the chosen ‘demand management’ strategy is non-financial.
In my current community paediatrics placement, parents of children needing therapies, hearing tests or parenting support receive a letter. Their child has been referred for (as the case may be) speech therapy. If they would like to take up this offer, please will they reply to the letter within a fortnight? Otherwise, they will be discharged.
Then, if they like, they can start again at the beginning of the lengthy referral process, and see if they do better next time. Or they can fall off the service’s radar completely.
For the sort of people who make health policy decisions, or who provide health services, this sort of thing wouldn’t be a problem. Of course we’d answer the letter, arrange the appointment and make sure our child got the help they needed – it’s simple. Only it’s not so simple if you don’t speak English, or you do but you can’t read very well, or you have your own undiagnosed learning difficulties, or your life is just so chaotic and difficult that an extra letter to answer feels like an insurmountable challenge.
And guess whose children usually have the greatest need for support? It’s not the sons and daughters of health service managers.
That’s why my recent clinic included a boy with wholly incomprehensible speech who, at seven years old, has never had his hearing checked. That’s why I regularly see nonverbal, profoundly autistic children who have not yet got around to ever seeing a speech therapist. That’s one reason children of poor, or poorly-educated, families persistently do less well than their prosperous peers.