Policing access to primary care with identity cards

Doctors are familiar with ethical dilemmas. The tension of irreconcilable imperatives is a permanent feature of most of our working lives. For example, our professional ethics teach us to treat patients according to need, but in the context of a publicly funded service, resources will always be insufficient. The introduction of identity cards, dovetailing with plans to change the regulations governing eligibility for free NHS primary care, are nevertheless likely to intensify these dilemmas for general practitioners and some hospital doctors.¹,²

Eligibility to free health care is quite properly a political question, to be decided by due democratic process. Crudely speaking, the NHS is a giant national risk pool—an insurance policy—and those who have not contributed, to the extent of their means and ability, should not draw on its reserves. We are properly indignant at those affluent foreigners who visit the United Kingdom because they do not wish to claim on their own private health insurance. NHS trusts also have a legal obligation to ensure that only those eligible for free care receive it. Yet the current proposals seem likely to present huge problems to primary care clinicians and staff and to cause unnecessary distress to vulnerable and isolated patients.

Identity cards are expected to make it easy for healthcare providers to establish eligibility to free health care. Although the details have yet to be worked out, the government's consultation paper, published in April this year, creates powers to make the provision of health services dependent on the production of an identity card.³ General practitioners may therefore be forced to deny treatment to patients who do not have a card or whose card declares them to be ineligible.

Consider this scenario. An asylum seeker with insulin dependent diabetes has recently had her claim for asylum rejected. She attends her practice, where she is told that she is no longer eligible for free prescriptions. She has no money and therefore cannot afford to pay privately. The practice therefore has to inform her that her only option is to wait until her situation becomes an emergency and to visit the local hospital.

Such a situation could well become familiar; it raises a number of issues. The conflict between the desire to care for the pressing needs of the individual and the duty to assess eligibility on objective criteria will be distressing for all concerned. To treat a patient in a diabetic coma in hospital is also far more expensive than to provide maintenance doses of insulin. If the justification for denying treatment is primarily financial, what sense would such a decision make? What if antenatal care was required? Or treatment for pre-metastatic cancer? Or post-traumatic stress disorder? To this has to be added the real complexity of assessing what actually constitutes emergency or immediately necessary treatment. An emergency is often the result of a process of illness and, as with the patient with diabetes, intervening early is usually more cost effective. Besides, “emergency” and “immediately necessary” are remarkably slippery categories, and such decisions can often be made only after the patient has been seen and assessed by a doctor. Competing interests aside, the potential for acrimonious disputes between patients and staff is also obvious.

We used the example of a failed asylum seeker deliberately. Behind the changes to eligibility and the introduction of identity cards lies, among other things, the desire of the government to appease perceived public wrath over immigration. The difficulty here, however, is the shortage of data. We are awash with anecdote about abuse of public services, some of it maliciously driven, but real evidence is extremely patchy. We have heard, again anecdotally, that the government is undertaking such research. Surely the evidence should be assessed before decisions are made. The new scheme might cost more to implement and police than the current situation, and a lot of distress will be caused in the process. The onus should be on the department to show the cost effectiveness of the proposal. Surely we should aspire to evidence based decision making in public policy as much as in health care.

The changes also raise questions about equity. The proposals to tighten the rules for eligibility create provisions to allow general practitioners to make private charges for the provision of primary medical services to patients who are unable to prove eligibility to free care. The government says that this will provide practices with local freedom and flexibility. It could also create an inequitable service, with different practices having very different thresholds for emergency and immediately necessary treatment.

In the end, denying treatment to those who can catch the next flight back and take up their albeit expensive health care at home is one thing. No harm has been done, and an abuse of scarce public resources has been prevented. Refusing treatment to a destitute failed asylum seeker, with only forced repatriation to a failed state to look forward to, is another matter. Ethically this is the crux. As in everything else, doctors no doubt will be divided over identity cards. Many will look forward to a simple and accurate method of assessing eligibility, provided its costs do not exceed its goal, and it does not further burden general practitioners with bureaucracy. As gatekeepers, general practitioners are accustomed to husbanding the scarce resources of the NHS, and this might look like a logical extension of their role. Others will want to play no part in such a system. If identity cards do go ahead, however, and general practitioners are asked to determine eligibility, then it is vital that some discretion, some necessary minimum of humane flexibility is encouraged. Without it, this could be one ethical conflict too far.