Care before cash

First let me make two things clear.

1. I have no issue at all with the quality of service at our A&E department. Compared with the lengthy waits and harassed staff at NHS emergency departments it's a real pleasure to experience the high standards and the timeliness of the care at the PEH.

In fact in some ways I wish they were a bit busier.

2. Nor do I have a big issue with A&E charging the same for a consultation as one of the three private primary care practices although I think it should be reviewed. The policy means it's quite expensive to go to A&E on weekdays, but becomes rather eye-watering in the evenings or at weekends.

My issue is far more with the additional charges now elicited for 'extra procedures' from patients forced to go to A&E when they have a really pressing medical need. Surely this is a significant move away from the traditional approach of simply matching the cost of treatment at A&E to that at a doctors' surgery?

If you go to your GP and they decide you need more specialised treatment they will either refer you to the MSG or the PEH at which point it becomes free at the point of delivery. By contrast if you get rushed to A&E after some sort of accident you could now rack up fees of many hundreds of pounds which for many islanders is just plain unaffordable. It almost takes us back to the bad old days before secondary care was covered by a compulsory States insurance scheme. I well remember all the times when low-income families were devastated by unexpected medical bills.

I know that HSC will say that the current scale of charges is just a simplification of the last one with no real increases. They may be right, but both the current system and its immediate predecessor represent a quantum leap in the potential cost of a visit to A&E from what went before.

For donkey's years the consultation was all you paid for and any treatment flowing from that initial assessment came free. Now, by contrast, if you need treatment following a Sunday visit to A&E you might need to take out a mortgage.

I have heard the Health president making the point that A&E loses them money rather than turning a profit as if that was proof that the charges are equitable. I beg to differ. There was always a cost to providing an emergency department and so what? It simply does cost money to provide health services and not everything has to be run on a commercial basis.

The irony is that the motivation for the States to take the operation of A&E in-house from its previous private providers was a consultants' report suggesting it could be provided much more cost-effectively that way. If so why on earth are the punters now being squeezed for much more money than they used to be?

In fact I even question the policy of making the charges for A&E consultations the same – at whatever time of the day – as private GP consultations. I understand the logic behind the policy which has existed since I first served on the old Board of Health back in the 80s. The argument goes that if A&E is any cheaper than GP surgeries it will rapidly be overwhelmed.

Anyway if lower charges led to a busier department would that really be such a bad thing? I presume most of the costs of the new in-house A&E department are fixed, salaries and so on, so if they charged a bit less, became much busier as a result, and thus generated more income then the whole set-up may prove to be less of a strain on the health budget.

That said, my main concern isn't about the business model or the cost but far more about the impact on low-income islanders needing to access the service. To their credit, HSC has realised that the unaffordability of primary care is a massive social issue facing the island. It is. Perhaps one of the biggest and most intractable. The irony is that in the A&E department they have one lever which could help in a small way to resolve that situation but instead the current charging structure does quite the opposite.

I end on a personal footnote. Some time ago I had reason to visit A&E at a weekend because of infected wounds on my leg. I knew the bill for the consultation would be north of £100 but I was stunned to also get an additional bill of nearly £70 for a minor procedure. As the only treatment I had received was a prescription for penicillin and two large plasters I questioned this supplementary bill and it was dropped.

Fine but I suppose my point is that a less assertive person – or a better insured one – would simply have paid up without questioning this extortionate charge. I was left with the uncomfortable feeling that A&E had a policy of income maximisation which sat uncomfortably with what should be an ethos of care before cash.