People in England remain firmly wedded to the fundamental principles underpinning the NHS, but could support the introduction of charges for some treatments and services, researchers have discovered.

There is strong support for the principle that access to health care should continue to be based on need rather than ability to pay, while means testing is rejected as a way of controlling future spending and people are adamant that the quality of clinical care should not be compromised to reduce costs, according to a report published by The King's Fund and Ipsos MORI, based on public events which they held recently in London and Leeds.

The events followed recent research from The King's Fund into the funding challenge faced by the NHS, which showed that, on current trends, health and social care could consume half of all government spending in 50 years' time.

Participants at the events were found to be reluctant to consider fundamental changes to the current NHS funding model, even when confronted with the scale of challenge which it faces, the researchers report. However, discussions revealed some support for introducing payments for some NHS services and for charging patients in certain circumstances, including:
- treatments that are not perceived as clinically necessary, eg, cosmetic surgery and elective caesarean sections;
- people who are thought to misuse services, for example by missing appointments or arriving drunk at A&E;
- patients requiring treatment as a result of lifestyle choices considered inappropriate, such as smoking or obesity; and
- "top ups" to non-clinical aspects of care, eg, private rooms and other "hotel" services.

While means-testing was unpopular with the groups both in principle and for practical reasons, there was some support for requiring the very rich to pay for some services and for voluntary insurance. Allowing people to pay to secure preferential treatment was strongly resisted.

Participants in the London and Leeds events indicated that they want more information about how the NHS is currently funded and would like to engage in a debate about how it should be paid for in future, say the researchers. Overall, while many understood that the NHS is under pressure, few accepted that this is on a scale to justify changing the fundamental principles on which the NHS is based, they found.

Also, people were clear that the current system must be shown to be working as efficiently as possible before they would consider changes to funding, and that the government should tackle tax avoidance before asking people to pay more towards the cost of care.

"Although difficult choices lie ahead, politicians have been reluctant to discuss the future funding challenge facing the NHS - this research shows that people want to engage with these issues," commented Anna Dixon, director of policy at The King's Fund.

"With pressures to spend more on health care 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," she added.

Moreover, people's attachment to the founding principles of the NHS and reluctance to amend the current funding model indicate that an incremental change is likely to be more acceptable to the public, the researchers suggest.