Why A+E fees are a despicable idea

With the average time patients spend in A+E rising and ambulances left queuing up outside for hours, it’s no wonder we’re trying to think of ways to ease the deluge of emergency presentations to hospital.

But one particularly bad idea keeps coming back time and time again – the idea of charging people who turn up with ‘inappropriate’ problems.

This morning it was the turn of the Northern Ireland health minister to float the proposal, targeting people who ‘abuse’ the system by having the temerity to turn up under the influence of drugs or alcohol. England is no stranger to the suggestion either.

I want to list the main reasons why this idea is at best misguided and at worst malicious.

Firstly and most importantly any fee for attending A+E, or any health care service for that matter, is a tax on the sick. The NHS was built on the founding principles that health is a right not a privilege and that no one should have to pay one penny more in sickness than would have had to in health. Sickness and disease are burdens to be accepted and borne by society, not cast onto unfortunate individuals.

Some might say that only charging people who ‘abuse’ the system or ‘bring their illnesses on themselves’ abrogates this moral duty. But I don’t think such a group is either easy to define or deserving of such spite.

So many of the patients I see labelled ‘timewasters’ are in reality the most deserving of care. They often have complex social, emotional and medical needs as well as substance misuse problems over which they have very little control. Society has frequently failed outright in providing them education, a safe and happy childhood, housing, employment and a stable emotional life, but instead of holistic intervention and understanding we are now suggesting charging them for seeking help in the only way we ever taught them – with desperation. Such a policy demonstrates nothing but the most basic misunderstanding of our most vulnerable patients.

Furthermore, how many illnesses which people ‘bring on themselves’ are we more than happy to treat for free? A broken leg from a skiing accident gets you top notch free orthopaedic care, even though you knew it could happen when you booked the holiday. Smoking for 20 years gives you COPD but there’s still an NHS bed for you if you need it when the winter chest infection season starts. But if you’re difficult to emotionally relate to, you keep coming back and have difficulty following advice, all of a sudden it’s your own fault and you should learn your lesson.

No one turns up to A+E for fun. We need to address the problems of difficult patients more thoroughly, not bat them away with a fine for being so bothersome.

There are numerous secondary reasons why charging people for medical services is counterproductive. People who are genuinely unwell will decide not to turn up for fear of it being labelled inappropriate or expensive, as the US know only too well.

The cost of implementing a system to charge so-called ‘abusers’ of healthcare would in all likelihood cost far more than it would earn, especially bearing in mind the track record of NHS IT projects, and almost by definition would target the very people who are least able to pay the charges anyway. Many also fear it would also represent the thin end of the wedge towards universal charges – something I wouldn’t put past this government.

All in all, a frighteningly frequent proposal which shows just how badly some people understand our more challenging patients and just how little they really want to help them. I hope I never see it suggested again, though I’m completely sure I will.

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About Alex Langford
I am a psychiatry trainee based in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

One Response to Why A+E fees are a despicable idea

  1. Judy says:

    great piece

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