To pay or not to pay

There are lots of decisions that we make as a society that enrage the few. Hospitals must either be completely cost free environments or we must accept charging for non-core services. In principle, it appears that as a society we have decided to accept charging in certain areas. We cannot now complain as the charging frontier moves from the tea rooms and car parks towards the core operations, say Michael Pitt and Rebecca Pitt

Analysing the problem

What people often don’t understand about facilities management is that it is essentially the provision of non-core activities that support the core function of a business or organisation.

Hence the place to start in understanding hospitals is in clearly defining the core business. In most organisations it is fairly easy to do. Toyota manufacture cars, Barclays sell financial products and GSK manufacture drugs.

But hospitals are more problematic. It will seem odd to some people that this is important and it will seem strange to others that we should be unable to define it easily.

Take the example of Ryanair. The core business is to move people from one place to another. It is not to operate planes or to provide customer satisfaction.

The Ryanair business model takes all non core activities and charges for as much of it as possible on the basis that the core business operation (the transit) can be provided at as low a cost as possible. Hence you will now pay to physically check in at an airport or to put a bag in the hold.

Ryanair are supposedly even considering charging for the use of toilets on board aircraft. The charging for non-core services makes you think about whether you really need them. It is human nature to take what is provided free of charge.

Most travellers have never turned down a “free” meal on an aircraft but have often chosen not to buy one on an airline like Ryanair. And that is the point, they are not really free at all as we have already paid for them in the fare.

Hospital car parks

Running car parks is clearly not the core business of a hospital. It is a peripheral support service that may be essential for the hospital to operate efficiently but it would and could not operate in isolation.

What we are looking for is an interface between the core and non-core functions, a point at which the support services end and the core business begins. Hopefully by now you will be able to see where this is going.

Once you leave the car park and walk into the building you will be met by a whole host of other services. In the Edinburgh Royal Infirmary, for example, you will find shops that sell, amongst other things, food and drink. This is a support service. It is not core and it is not free.

The floor upon which you walk has been cleaned. This is a support service but you are not charged. The lights in the corridor are a support service but you are not charged. The use of TV and telephone services in wards is not core and often charged to patients.

As we move closer to the core service it becomes harder to be certain. In Cuba, people are expected to bring their own bed linen. This strongly suggests that it is a clear non-core activity and yet in the UK generally it is not charged.

If we jump over the interface between core and non-core activities to look at it from the other side, it is clear that a surgeon operating or consultant diagnostic meetings are core business. It is arguable that there are other services that are less clear. Certain aspects of nursing care for example might be viewed as non-core whilst others are clearly core.

Any service that can be defined as non-core can be outsourced and any service that can be outsourced can be separately charged.

The question becomes do we want the NHS to provide a basic state treatment service or do we want it to provide all the support services as well? We could examine all the current legislation that governs hospital administration and argue that charging is necessary or we could take the view that there is an overriding principle of free provision of care.

Categories of building users

Another possible approach is to look at the building users. Should we be treating staff, visitors and patients in a different way?

In universities, many staff pay charges for car parking. Nobody likes it and people respond to it in different ways. Some will reluctantly pay and others will use public transport.

Where public transport is a viable option, the opposition will not be as fierce. However, in hospitals, where shifts finish late at night, there are clearly security issues which may be more important for the trust to address than the cost.

The fact remains, however, that there are precedents in other businesses for staff being charged for car parking.

Visitor charging may be annoying but it cannot be seen as a core part of the NHS treatment service. The problem is defining what is meant by a visitor. If a friend brings a sick friend to hospital are they a visitor? If you cannot differentiate in reality, you cannot differentiate in charges.

There are numerous sub-categories of visitor, all of whom it may be argued might be treated differently. We already discriminate in favour of disabled visitors. Should we then not differentiate in favour of the parents of a terminally ill child? If not, who makes that decision?

Patient charging is a different matter. The patient is the intended beneficiary of the NHS system. Here it is as simple as this: we must decide on the principle of whether NHS care begins at the gate or the operating theatre.

Conclusion

Hospital managers can argue that budget cuts and certain legislation make charging for non-core services in hospitals unavoidable. It cannot be argued that funding should be spent on peripherals rather than key services. Therefore, if we want a wider free NHS service we have to oppose the wider national funding issue as well as the local allocation of resources.

What is interesting is that in researching this article we have failed to find anyone strongly in favour of charging for car parking at hospitals per se. What is worrying is that the argument that spending on car parks reduces the number of possible operations is never ending. But it has to end somewhere because we have already made a decision as a society to fund the arts, necessarily not spending the money on healthcare or education.

Michael Pitt is professor of facilities management, Liverpool John Moores University

Rebecca Pitt is a student