Sep 15

Three Tier NHS?

Tag: Ambulance,BMJ,JournalKal @ 12:05 am

Another post from the series I wrote for the BMJ, these are less funny than my normal stuff and *designed* to make people argue :)


Obese, but not morbidly so, the CVA had left her with no movement down her left side. When we arrived she was lying on a mattress on the floor, a spreading puddle of urine under her..

“I just can’t get comfy…my back hurts.”

We advised her on painkillers, helped shuffle her back up the bed and suggested that perhaps she might like to come to hospital?

“I’m not going back there. I only came out today.”

I looked around the foetid room, the bare mattress, the plastic bucket of faeces on the floor.

“Did they not arrange nursing care for you?”

“Well, they said they would, but nobody’s been round.”

“And they let you come home like this?”

“Oh no, they said I shouldn’t, but I didn’t like it in there. They were giving me drugs. I signed myself out.”

“Against their advice?”

“Yes. My husband helped me into the taxi.”

He’s at my shoulder, frothing.

“It’s a disgrace, the way they’ve let her come home.”

She gestured around the room.

“You can see the state of the place, what am I meant to do?”

I bit my tongue.


“He’s shit himself.”

Indeed he had. Nineteen and drunk, you might well, but he’s fully conscious and walking. I prescribe a lift home, a roll of Andrex and a shower. His father disagrees.

“But what if he’s sick in the car? What about the seats? Take him to hospital. I’ll pick him up when he’s sober.”

The NHS was developed to provide free, accessible health care for all. It is, in principle, how health care should be run. Our patients don’t fret about their insurance, or the bottom line. They can worry about getting better.

Sure, the waiting lists may be longer than we’d like, both on the surgery lists and in the waiting room, but we’ll get to you every time, gratis.

We’ve heard plenty about private health care encroaching on the state’s own provision. The debates surrounding “top-up” fees are fierce and always conclude with someone bawling about a “two-tier” system.

Well here’s an idea.

How’s about a third tier.

For those who abuse the system.

We in the NHS will deliver you free health care, accessible to all, at any day or night. We’ll come to your house, we’ll involve you in our clinical decisions, we’ll give you a voice in your care. We’ll do it to the best of our abilities, with the best equipment we have. All for free.

In return, you respect the state’s provision, if you fail to do this, you lose the privilege.

As motorists, we pay an extra premium each month to cover uninsured drivers involved in collisions.

We recognise that the innocent victims of their irresponsibility do not deserve to be out of pocket due to someone else’s callousness or criminal activity.

And when you’re found to be operating a motor vehicle without insurance, you’re reported to the Procurator Fiscal

If employed, we all pay National Insurance. We recognise that our NI contributions go towards funding the percentage of the NHS that cares for those patients who do not pay contributions, through being out of work or otherwise.

But when we find “uninsured” patients who demand ever higher resources from the Health Service, who phone ambulances because they don’t want to risk their upholstery, or check themselves out of hospital against advice with no thought to how they’ll continue their daily lives, then demand the emergency services and A&E haul them out of a problem of their own making?

Is it time we had a third tier for these people? We let the rich top-up their treatment with privately obtained treatments, why not issue bills to those people who waste resources through their own actions, stupidity and flagrant irresponsibility?

“Free health care for all”?

That would be nice.

Right now I feel I’m paying an awful high price.

23 Responses to “Three Tier NHS?”

  1. Sasha says:

    Acht you should have left her and told her to clean her messy ass up! Moaning about getting prescribed drugs that were a neccesity with her care within the hospital, i hate people like that! Unemployed manky shits! I hate the fact that i pay for them to sit on their arses all day! The health service is strained enough without pettyness from people like that! Grrr!

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  2. Cannonball Jones says:

    Sounds nice initially but I can’t get behind that. Going down that road leads to a third tier in ALL emergency services. No police protection for people who continually fight on the street. No fire service for people who leave the telly plugged in when they go to bed. No coast guard for people who go out in dinghies without life preservers or mountain rescue for those who attempt Ben Nevis in flip-flops and tank tops. Just doesn’t work for me. As much as I’d love to see these folk taught a lesson it’s just too harsh.

    Unfortunately being born a fuckwit doesn’t mean you don’t deserve help.

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  3. Ben Yatzbaz says:

    I’m with you all the way on this one Kal! Posted something similar a couple of months back. You may wish to have a read and maybe look through the comments too… Some interesting ideas.
    http://insomniacmedic.blogspot.com/2009/07/waiting-time-or-wasting-time.html

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  4. Nickopotamus says:

    It would be lovely to be able to say “You’re abusing the system – that’ll be £230 please” for every inappropriate callout. However, it raises the problem of firstly deciding what’s inappropriate, and secondly the people who will actually be bothered by the idea are the nan downs etc that do need an ambulance.

    More seriously, this could be applied quite easily to HCPs. OOH docs who call urgents, or even Reds, just to get patient’s off their hands? Say if the crew and hospital agreed that it was a pointless admission, they could charge the doctor for the cost of the job. Would make the doctors think twice before ticking admit, and save not only that patient from the risks of transport and hospital acquired infection but also more people by leaving an ambulance available…

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  5. Tom says:

    I would dearly love to supply a pithy observation about this post, but I can’t.

    The up-shot being that when I joined the ambulance service in the 1980’s, the current crop of brain donors calling on the service had not been born. Moreover, the attitude of the population then was to dial 999 only in dire emergency.

    Though I would love to see the morons dealt with, in reality, for many of the reasons set out in comments above, it will not come to pass, if for no other reason that in financially penalising the fools, ultimately the tax payer will have to foot the bill as in a lot of cases the abusers are not gainfully employed.

    Love the idea and site though.

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  6. Gigaflynn says:

    Hmmm…
    I agree with you in that mindless bumblefucks do waste a vast resevoir of the NHS’s resourses, because they can act however they want and know that someone else can clear up the mess later on, for free.
    so free healthcare is definately open to abuse.

    but where does one draw the line for such charges? I sure under our current stupid and feeble government they will just see this as a opportunity for more fund raising and idiotic target meeting: “£150 per fine, must make 20 fines a month”

    so I recon it will cause even more problems for the ambulance service, because should one paramedic have a really REALLY bad day and fines someone who perhaps shouldn’t have been, that paramedic will end up in court and the NHS probably sue’d for most of its yearly budget, followed by a gigantic public outcry.
    it’s understandable that this could occur, you guys work in an extremely stressful line of work.

    I personally think the answer is for the NHS to stop wasting so much of its money on admin and red tape, have the bare minimum of admin they can get away with, so that more money can be freed up to be spent on the sharp end of the NHS; the ambulances, their crews and call out doctors.
    if they had more funding, which was spent well and allowed these services to increase in size, the effect of the idiocracy we live in would be reduced.

    just my thoughts folks, feel free to disagree.

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  7. Chris Norton says:

    This is one of the best posts I have read in a long time. I am totally with you – people who discharge themselves and then complain about our service should have the service revoked. I am pretty certain if we used a yellow and red card strategy they would stop moaning pretty sharpish.

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  8. Mike Neal says:

    Nice idea. Non starter obviously.
    I would rather 100 of the “under class” be allowed to abuse the system than one gran suffer needlessly through fear of “getting into trouble”
    It used to piss me off looking out of the lab window across to the terminal care unit and see the terminal lung cancer patients sitting outside in their wheelchairs smoking. And seeing, over the years, the amputees with less and less limb, enjoying the fags that were fucking up their circulation.
    Still, can’t take a joke, shouldn’t have joined.

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  9. Fee says:

    Mmmmmm … tough one. I suspect that most right-minded people will be at least half agreeing with you. I have only ever phoned an ambulance once in a private capacity and rarely as a first aider. The appliance of common sense meant that mostly, I just dealt with the problem. The mindless fuckwits, however, do not have any common sense to apply. They also seem to have a sense of entitlement lacking in most of us (the ones actually paying for the service). My friend’s sister is training as a GP, and they routinely see patients looking for prescription paracetamol, for example, because they’re entitled to free prescriptions, whereas the rest of us just buy them. At less than a quid, they’re not exactly a luxury item.
    The NHS, and also the Welfare State, were set up as a safety net, to help those who couldn’t (not those who wouldn’t) help themselves. We’ve moved so far away from that basic principle I don’t know how we’d get back to it. Charging the drunks would be a great start, though, if only to spare the hard-pressed staff from Friday and Saturday night mayhem every week.

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  10. Zac Smith says:

    How about a mandatory £50 charge for using an ambulance (not calling one) waived in cases of genuine emergency.

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  11. Cath says:

    Interesting thought. Problem is, the people who abuse free care rarely have the money to pay a bill anyway. And I agree with comments above; it’d be hard to draw the line between abuse and real need for help. Should the stupid, drunken kid suffer because his father is an idiot? We’re only humans, humans are stupid and make mistakes sometimes. I’d hate to live in a world where you have to be perfect

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  12. Oliver Smith says:

    In theory it sounds like a good idea, but in practice it would be a terrible idea that would undermine the very founding principles of the NHS.

    I can understand your frustration at those who are wasting hospital and ambulance time; I’ve seen it numerous times while I have been sitting in A+E (actually ill I must add) only to see drunks around me who are probably just drunk and just need to go home and sleep it off rather than spend hours waiting in the hospital after a nice free taxi ride to A+E in an ambulance.

    What would help is if people were more honest so that they can be directed to the appropriate services or if they really want an ambulance that it at least turns up with the right category of call (and not racing round on blue lights putting loads of people at risk for chest pain that doesn’t actually exist)

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  13. Johndog says:

    Nice stir mate. Sense a job creation scheme here; poverty = ill health, so make poor people poorer by charging for those NHS resources someone (you?) decide are being abused = even poorer people = more ill health. Brilliant!

    Suspect a lot of those embra freshers we pick out o the gutter this week may well qualify in the top 2% academically. Fuckwits, underclass or drunk, discuss?

    Pedants point – NI contributions go straight into the general revenue mate; if they were set aside to fund the NHS we might have the resources we need to do the job. Like the cops. Or the saintly firies. OOps, political, bad dog.

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  14. Ross says:

    In principle the idea is sound, but how can you ever define abusing the service? I accept that the two stories quoted were blatant abuse of the services provided, but there may be borderline cases or people who are just scared and call an ambulance as an overreaction. Some cases need further NHS help, not bills.

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  15. Loth says:

    A stupidity tax. That’s a BIG can of worms you are opening there!

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  16. Angie says:

    Your readers took this pretty seriously. We have a similar trouble in Canada. Last week a doctor discharged one of my patents because she said he could refuse medical treatment at home as easily as in hospital. Unfortunately he went home in an ambulance paid by the system.
    Oh, and did I mention the ambulance service is “on strike”?

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  17. Win-Stone says:

    I think I probably come fairly and squarely down in the ‘splinters in arse from sitting on fence’ camp: I would love to see the arseholes who call out a doctor in the middle of the night being charged when it is founf that it is because they have run out of tampax; I would love the tosser who bimbles serenely up Ben Nevis in flip flops and a tee shirt (‘yes, I saw the snow on the top, but I didn’t think it would be cold’) charged by the mountain rescue. Better yet take a straw out of Traumaqueens book and issue persons with nailguns so that doctors/mountina rescue types can remove arses like that from the gene pool with a swift and certain finality. BUT………… it’s the start of a loooooong and slippery slope. Do you charge/despatch someone who genuinely FELT that they needed help? Is the underlying problem psychological rather than physical (a call for help?) and where does it stop? Do you then automaticaly charge all Daily Mail readers/Sun Readers/Concervatives? Now THERE’S an idea :-)

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  18. Win-Stone says:

    PS. Note to self……… check the spilling BEFORE hitting the SEND button. Grrr

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  19. Sharon King says:

    It is not fair to sick people to have to sit with a bunch of drunks. Drunks should go to a drunk tank, not to the hospital. Hospitals are for medical problems. I would say “inless they are injured” but they seem to bounce. They only hurt other people.

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  20. Lauren says:

    I love the drunk tank we have up here – if you’re clearly incapable of looking after yourself but haven’t committed a crime it’s where you end up. Apparently they do have a wee chat with you the next day about whether you have a drink problem however they are attached to a rehab facility and are pretty well placed to help you out if you do.

    I don’t agree with charging those who abuse the NHS, not least because of the “where do you draw the line” argument and also the fact that those who do it probably can’t afford it. However I do think some sort of a reality check is in order (kind of like the scare em straight programme in place for some young offenders)!

    That said, I, and a lot of people I work with, would like to see the people who insist on having an out of hours gp visit their house rather than go to the pcec a 2 minute walk down the road when they don’t have good reasonn for needing it (I’m mainly talking fairly young, normally hale and hearty people with ailments that really should be seen before the end of the weekend but aren’t all that serious) be told exactly what we think of them. Not least in light of the fact that it delays the dr visiting people who (to pluck a recent example out of the air) have just found their elderly relative dead.

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  21. Aaron RN says:

    Not wanting to sound ignorant I had to look up paracetamol.
    It wasn’t in any of my drug books but a quick google search later and I was amazed that it was (what americans call) acetaminophen.
    Who in their right mind demands a script for tylenol?

    A doctor once tried to prescribe me a huge bottle of ibuprofin in addition to antibiotics when I came in with an ear ache. It seemed like an awful waste and I told him not to bother.

    I guess I just always took it for granted that most everyone has at least a tiny bottle of analgesics at home next to their box of band-aids and antiseptic.

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  22. cindy says:

    I would be very grateful have this problem. Come see what it’s like in the ‘States for a while & I refer you to your own post called “Language Barriers,” 01/09/09. I wish I lived in a civilized country.

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  23. Aoife says:

    I’m another one wavering in the middle.

    Essentially I believe wholeheartedly in free healthcare for all. Even fuckwits. Nobody should have to worry about the cost of being ill.

    But then I know the drain on resources and frustrations of those on the front line. People need to know that they can’t use the system in the ways they seem to want to. Education, I suspect, is key here, but I fear the generally selfish post-Thatcherite attitude that permiates society nowadays might stand in the way of enlightenment.

    It’s hard. And for me, it only gets harder when talk of who deserves free healthcare, and NI contributions crop up. As somebody who got very sick when I was 19 and have been trying my damndest to get back into work, but struggling to manage the 6 hour a week voluntary scheme the jobcentre found for me without severely comprimising my ability to care for myself… I have somewhat of a sensitive spot when it comes to attacks on those sponging off the state.

    That and I wouldn’t call an ambulance in most circumstances. Include many that probably deserve it. I’ve had to force NHS direct to not call ambulances for me when I’ve only called for home-care advice and they go all blues-alert because of my symptoms.

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