We've got to pay to save the NHS

It is a lamentable fact of human nature that free gifts are not much valued: and the connection between the taxes we pay and the health care we receive is so tenuous and abstract that many people still regard a visit to the doctor or to the hospital as free of charge. The attraction of the free is irresistible: anyone who has seen doctors, none of them on the bread line, flock to free lunches offered by drug companies could possibly doubt it. Moreover, some of those who do remember that the taxes they pay are what fund the NHS react rather like people who patronise the type of restaurant that offers you all you can eat for £4.95: they may not be hungry any more, but they have paid their money and by God they're going to eat their pound of flesh, even if it kills them.

In the circumstances, it is not altogether surprising that quite a number of patients attend the doctor's surgery for the same reason that the climber climbed Mount Everest: because it is there. Neither is it paradoxical that, while many people attend the doctor for no good reason, or for a very trifling one, about a quarter of all NHS out-patient hospital appointments are not kept by the people for whom they are made.

Similarly, it is not surprising that some people use an ambulance as a glorified taxi. The London Ambulance Service estimates that a third of its calls are not for real emergencies, and I know of one man who lives very near my hospital who has called an ambulance as an emergency more than 100 times this year alone, when he desires to return home from an afternoon or evening out.

Mr Duncan Smith's proposal-that we should henceforth-pay to visit the doctor seems eminently sensible, and by no means the hardhearted, Gradgrindian proposal that it will no doubt be depicted as being in some quarters. Indeed, only a deeply infantilised nation, that looks to an omnipotent parent (the state) to take care of it, could find anything remarkable in this mild suggestion.

Of course, a terrible picture will at once be painted, of the prospect of hordes of desperately ill people staggering about the streets or expiring quietly at home for lack of medical attention. This doesn't seem to happen in other countries, including France, where people pay to see the doctor and actually live longer: but perhaps we British are peculiarly susceptible to diseases brought on by the fear of parting with a fiver.

Cases will no doubt be found of old folks who have died because of lack of medical attention through absence of cash. But before we dissolve into the kind of tears that used to be brought on by the description of the death of Little Nell, let us remember that genuinely ill people often have to wait a long time to see their doctor precisely because their doctor is seeing so many cases that do not need his attention.

One of the reasons our casualty departments are so crowded is that many people would rather wait in them for eight or 12 hours to see a doctor than wait two or three weeks to see their own general practitioner, usually with conditions that the general practitioner could perfectly well treat. Unnecessary consultations seize up the whole system: they are not benign.

Given the right incentive, people are perfectly capable of distinguishing between serious and trivial conditions. Shortly after the bombing of Belgrade by Nato, I spoke to the doctor in charge of the emergency medical services there. When an ambulance is called out to an emergency in Belgrade, a doctor goes with it: and the doctors sent out in such ambulances estimate that, before the bombing, about 50 per cent of calls were genuine medical emergencies. During the bombing, however, the number of calls halved, and of those that were received, fully 98 per cent were for real emergencies.

Thus people are able to make proper distinctions (I see no reason to suppose the British any less capable in this regard than the Serbs), if they believe it to be in their interest to do so. Far be it from me to suggest the general bombing of Britain as the solution to the ambulance service's problems with frivolous or unnecessary emergency calls. It would be a little drastic. However, a small payment to the doctor for a consultation would almost certainly reduce the number of unnecessary consultations, and therefore, the congestion in the service. As for the more outrageous abuses of the ambulance service, I suspect they could be deterred if the abusers were charged with obtaining goods and services by deception.

A payment for visiting the doctor is not the sovereign solution to our health-care problems. Underinvestment in new infrastructure started from the very inception of the health service - which, incidentally, was never able to offer universal health care absolutely free at point of service, since prescription and other charges were introduced almost at once. And there are not enough doctors to man the kind of service we would like. For example, in Germany there are some 5,000 consultant dermatologists and in Britain 300: and no amount of fee-paying alone will alter the obvious consequences of that fact. If you have a skin condition, you would be well advised to go to Germany (it will cost you a fraction of what you would pay here for a private consultation, and the difference in the fee would nearly pay your fare).

But improvement has to start somewhere: every journey begins with the first step. Let us reduce waste by raising revenue.