The next government could find itself in the difficult position of having to introduce certain user fees for the National Health Service unless there is a turnaround in economic fortunes, Malcolm Grant, chair of NHS England, has forecast.

Demand for NHS services is expected to rise by 4%-5% a year, at a time when it has been issued with the unprecedented task of making efficiency saving of some £20 billion over the next three years.

"It’s not my responsibility to introduce new charging systems but it’s something which a future government will wish to reflect [on], unless the economy has picked up sufficiently," Grant told the Financial Times, but also indicated he would not support such a move.

He warned that merely increasing productivity would not be enough to address the shortfall, and stressed that “a complete rethinking of some of the fundamental tenets of the way in which care is provided” is necessary.

A key strand of this will be to "shrink" hospital services but increase those provided in the community, the FT reports.

Grant's comments fit with the conclusions of a report by the Institute of Fiscal Studies, published last year, that the tightening the screws on NHS budgets will mean that future governments will be forced to reconsider the health services that can be provided free of charge.

'Controversial' move

Ana Nicholls, Healthcare Analyst at The Economist Intelligence Unit, said that if they are introduced user charges could take several forms, "though all would be controversial".

Patients may have to start paying for services or treatments that are currently free, as some people have started to do for drugs not considered cost-effective enough for NHS fundings. 

The NHS may also introduce small payments towards treatment to stop overuse, such as is already the case with prescription drugs and dental care, though this may also be extended to doctor's visits like in many European countries . 

"That helps to cut costs, but the price is sometimes that people with chronic illnesses are put off getting treatment," she said, and noted that "Germany recently had to backtrack on charges for hospital visits, after an outcry".

People are, on the whole, very protective of the NHS' core value of being 'free at the point of delivery', so moves to introduce user fees will likely meet much opposition.

Public 'wedded' to NHS principles

However, a survey by think tank The King's Fund has revealed that while the public "remain firmly wedded' to the fundamental principles of the NHS, in certain circumstances they could support the introduction of charges for some treatments and services.

Recent research from The King's Fund showed that, based on current trends, health and social care could account for half of all government spending in 50 years’ time, highlighting the fundings challenges that need to be addressed.

According to a new report, How should we pay for health care in future?, by the think tank and Ipsos MORI, participants surveyed "strongly supported" the principle that access to healthcare should continue to be based on need rather than ability to pay, and means testing to help control future spending was rejected.

The survey found that people are reluctant to consider fundamental changes to the current funding model despite the current challenges. 

However, there was some support for the introduction of payments for some NHS services and for charging patients in certain circumstances, including: for treatments that are not perceived as clinically necessary, such as cosmetic surgery and elective caesareans; for those misusing services, for example by missing appointments or arriving drunk at A&E; and to treat conditions resulting from lifestyle choices such as smoking or obesity.

"With pressures to spend more on healthcare growing and the public finances likely to be under considerable strain for the foreseeable future, it is time for an informed public debate about how much we should spend on the NHS and how this should be funded," said Anna Dixon, Director of Policy at The King's Fund.