The pursuit of equity of access to health care is a central objective of many health care systems. Yet, financial incentives can influence patients because, although the UK system is essentially ‘free at the point of use’, there are charges for specific services including eye tests, dental check-ups, and dispensing of prescription medicines. Charges can act as a deterrent to patients and as a barrier to access. The impact of user charges affects different socio-economic groups in different ways. For some groups, access may not be compromised by a co-payment, while for others the charge may represent a significant deterrent.
The impact depends on the size of the co-payment and crucially depends on the patient’s ability to pay (and therefore directly links with equity considerations). The insurance market (and social insurance-based schemes such as the UK) essentially removes most of the financial barriers to access so that patients do not face the full cost of care. This in itself, of course, creates an incentive, where patients may over-consume services. Where this occurs, other patients with more pressing needs may have problems accessing services (waiting times will become longer and patients who require urgent care may be displaced).
Furthermore, it is argued that insurance-based systems create a further problem, which is known as ‘moral hazard’, whereby individuals fail to take full responsibility for their own health because they do not face the full costs of any ill health associated with their behaviour (for example, smokers might not smoke if they had to pay the full costs of cancer treatment). Thus, insurance systems take away barriers to access and this may lead to inappropriate utilisation of services, or may lead to excess demand for services and the subsequent problems this causes with respect to prioritising care.
The theoretical impact of user charges, or fees, levied on services is straightforward. It is hypothesised that if people have to pay for a service they will use less of it. The main impact of user charges is, therefore, on utilisation. The rationale behind user charges is that they can be used to deter frivolous utilisation of services, raise revenue for the health service, and act as a reminder to individuals of the value of the services they consume.
There are, however, clear disadvantages in that user charges can have the negative impact of potentially excluding low-income individuals from consuming beneficial health care services. The National Health Services (NHS) since its inception has aimed to make health care available to all regardless of income, at the same time assuring equitable distribution of resources regionally. Until the reforms introduced by the 1989 White Paper, the NHS was characterised by centralised financing and regulation. There are, however, two main areas where user charges are imposed: dental services and prescription charges.
The impact of user charges in these two health care sectors has been examined in the UK. Recent changes in the NHS General Dental Service have arguably led to a reduction in the availability of NHS dental care and increased charges. A study by Stoelwinder (1994) explored public and user views and experiences of NHS and private dental care in the light of these changes. The study employed a combination of quantitative and qualitative methods. The first phase involved a postal survey of a random sample of adults on the electoral registers in a county in Southern England.
Follow-up face-to face interviews were carried out with sub-samples selected from survey respondents. The evidence shows greater satisfaction with certain aspects of private dental care than with NHS care and suggests that the decline in perceived quality of NHS care is less to do with the quality of dental technical skills and more to do with access and availability. However, there was general support for the egalitarian principles associated with NHS dentistry, although payment for dental care by users was acceptable even though dentistry on the NHS was preferred.
The shift in the balance of NHS and private dental care reflects the interests and preferences of dentists rather than of the public. It suggests, however, that a continued shift towards private practice is a trend that the public will not find acceptable, which might limit the extent of expansion of private practice. Hughes and McGuire (1995) estimated the impact of charges for drug prescriptions in the NHS and found evidence to suggest that user charges reduced the number of prescriptions cashed in the UK.
However, the impact of user charges is likely to affect different socioeconomic groups differently. Lundberg et al. (1998) found that price sensitivity decreased with age, income, education and self-rated health status. Furthermore, they found that sensitivity to user charges for drugs varied greatly between different types of drugs; for example, they found that if user charges doubled 40% of antitussive users would reduce their consumption, whereas only 11% of users of drugs for menopausal problems would reduce their consumption.
It should be recognised that in the UK user charges are means-tested; low-income families and people over 65 years are exempt, as are individuals with certain chronic conditions, such as diabetes. Some commentators suggested that user charges could (and should) be extended in the UK. Mufti (2000) suggested that user charges would be an important source of revenue in the UK where services cannot be cut and taxes are not imposed. He argued that user charges in public facilities would curtail over utilisation and reduce inefficient use of resources by providing a link between financial responsibility and the provision of services.
The financial implication facing patients would encourage them to be more cost-conscious, and their physicians would be encouraged to limit over-prescribing of drugs and the use of highly specialised diagnostic procedures for routine investigations or minor illnesses. Mufti suggests that the lack of economic incentives has led to a lack of concern for the cost of medical care. User charges would not only encourage both consumers and providers to be cost-conscious, but would raise revenue to ease pressure on the health budget, combat moral hazards and assert priorities.
In order to be effective and make a serious impact on the health system, Mufti argues that user charges must be extended to all government sectors and specialist hospitals, and charges must be high enough to discourage inappropriate use of services. Explain the actions to be taken in the event of suspected fraud. (AC 3. 2) No precise legal definition of fraud exists; many of the offences referred to as fraud are covered by the Theft Acts of 1968 and 1978.
The term is used to describe such acts as deception, bribery, forgery, extortion, corruption, theft, conspiracy, embezzlement, misappropriation, false representation, concealment of material facts and collusion. For practical purposes fraud may be defined as the use of deception with the intention of obtaining an advantage, avoiding an obligation or causing loss to another party. The Auditing Practices Board’s Statement of Auditing Standards (SAS) 110 “Fraud and Error” gives more background information on the meaning of fraud and distinguishes between fraud (deliberate falsification) and errors (unintentional mistakes).
The criminal act is the attempt to deceive and attempted fraud is therefore treated as seriously as accomplished fraud. Computer fraud is where information technology equipment has been used to manipulate programs or data dishonestly (for example, by altering, substituting or destroying records, or creating spurious records), or where the use of an IT system was a material factor in the perpetration of fraud. Theft or fraudulent use of computer time and resources, including unauthorised personal browsing on the Internet, is included in this definition.