Guest blog by Sihaam Dhiblawe, Politics student at LSE who has joined CPP for a week-long placement led by the Social Mobility Foundation.

The NHS is in crisis. The number of people waiting to start treatment has reached a record-breaking 6.6 million – just as the health service attempts to recovers from the calamity of the pandemic. The state of our increasingly fragile and creaking health service has led to Rishi Sunak expressing his desire to make dealing with the NHS backlog his “number one public service priority”. Focussing on the health service in a hustings event with Conservative party members in Grantham, Sunak’s principle of “paying what you owe” was outlined – a position he sees as applicable to most areas of governance. To deal with this crisis of waiting times, Sunak’s ‘common-sense’ Conservative approach is to introduce £10 fines for those who miss their GP or hospital appointment.

The proposition of fines for missed appointment is not a novel one. Echoing a traditional Conservative zeal for financial deterrents, it has been parroted as a solution by many financially prudent critics of the NHS. Yet Sunak’s adoption of the proposal as a means of managing demand on the health service carries serious risks. It could exacerbate our already entrenched health inequalities, and undermine the Government’s commitment to reduce disparities in healthy life expectancy among people and places as set out in the Levelling Up White Paper earlier this year. Indeed, the Government’s efforts to improve the primary care of underfunded and marginalised communities is undermined by the introduction of penalising measures that are likely to target these vulnerable groups.

Sunak’s ‘all-in-one’ solution to introduce a financial deterrent in a bid to cut waiting times is deceptively short-sighted, ignoring the reasons why appointments are missed in the first place. Various studies have demonstrated that missed healthcare appointments are a result of last-minute changes or barriers faced by minority groups or those most vulnerable in society such as caring commitments or difficulties accessing transport. The British Journal of General Practitioners found that 58% of patients who had missed GP appointments had done so as a consequence of a work or family related issue. Moreover, it found that those with pre-existing mental and/or physical health conditions were disproportionately more likely to miss an appointment than those who had not. Placing a financial punishment on these groups does not aid the cause of the NHS – it makes the challenges it faces even greater.

The British Medical Association has vehemently opposed Sunak’s pledge, warning of the detrimental effect such fines would have towards doctor-patient relations. Deteriorating patient conditions is a very real concern for the sustainability of the health service and although it is estimated that missed appointments cost the UK approximately £216 million per year, the total cost of illness to the NHS is estimated to be around £31-33 billion. The financial and social impacts of a healthcare system which potentially disincentivises the patients most likely to need access to healthcare from making appointments in the first place could see access to the NHS for some groups collapse.

Increasing barriers to access to the health service will disproportionately impact those vulnerable communities who shouldered the most devastating consequences of the pandemic. The London Borough of Brent – one of the worst hit areas concerning Covid transmission – already suffered from financial disparities when the pandemic took hold. Local Government Inquiries now detail of a link between the poor housing within the borough and poor rates of healthcare access and high rates of covid-related mortality. Applying fines to these communities will not cut waiting lists as deliberate absences are not the primary issue. It simply reinforces the narrative that these communities already feel - that free hospital treatments are not something that they have access to.

What then is the solution to missed appointments and long waiting lists? Recent Government measures have already attempted to find zero-cost measures to reduce missed appointments with some success – pointing to providing more transparency for patients in order for them to feel confident about resourcing. Ultimately, however, as we recover from the effects of the Covid-19 pandemic, instead of illusionary deterrence programmes we need progressive moves towards digitalisation and prioritisation. Policy options could include giving more attention and funding to local public health teams, and providing them with the space to prioritise and concentrate on the conditions most affecting their unique local health challenges. Additional work on the NHS app could also facilitate this transition towards digital efficiency, with the foundations for this already being set via the conversion to remote working during the Covid lockdowns. In the long run, it is inclusionary measures that will make the most difference in addressing the problems the NHS faces – not divisive, discouragement projects.