Doctors think the NHS will have to start charging in the future.
By Nick Triggle
Health reporter, BBC News
The issue of paying for healthcare keeps cropping up, but will the idea ever be introduced?
NHS charging remains controversial
Like a nagging sore, charging patients for NHS treatment just will not go away.
All three main political parties have ruled it out, but doctors, academics and MPs keep putting various proposals forward.
The thrust of the argument is that the NHS cannot continue as it is.
The number of over 65s in the UK is expected to rise by 53% to over 14m by 2031, putting already stretched NHS resources under further strain.
The coming years are also likely to see a host of so-called wonder-drugs come on the market.
The recent controversy over breast cancer drug Herceptin, which ended up with the NHS being taken to court for refusing to pay for it, illustrates the difficulties the health service faces.
The drug costs over £20,000 per patient, but with taxpayers contributing just £750 a year towards the health service, the maths are obvious.
Interestingly, it seems to be doctors who are most vociferous in encouraging a debate.
Earlier this year, public health chiefs suggested patients could be asked to contribute to some minor treatments, such as tonsillectomies and varicose veins.
They even went as far as to say there was an argument for asking for contributions towards hip and knee replacements.
Co-payments - Ask patients to contribute towards the cost of non-emergency surgery, such as hernias and varicose veins. Key question is how far you go. Some have suggested contributions could be made for hip and eye ops
Ration care - To some extent, this is already done by the NICE watchdog, but some have argued the NHS could stop doing a host of minor treatments to save money
NHS tax - A specific tax could be levied to help pay for treatment, but could be unpopular as national insurance has already been increased to pay for health
Social insurance - Public could be asked to pay into an insurance scheme, critics point out that the rich will buy better cover
And a poll of young doctors this weekend by the British Medical Association showed that nearly two thirds thought patients would be charged for some treatment in the future.
Dr Andrew Thomson, of the BMA, said: "The pressures the NHS is facing means we need to have this debate.
"We can no longer ignore it. Care or the way the systems works will have to change. That could mean charging, doing less or paying more in taxes."
Others argue that a system of top-up fees is already emerging.
A report by Doctors for Reform, a centre-right group of 950 doctors, said patients are finding ways of getting quicker and better treatment by exploiting loopholes in the system.
The group said patients have been known to pay to have diagnostic tests, such as MRI scans, done privately so they could jump the NHS queue and then return to the NHS for treatment.
They also pointed out that the health service is already rationing care with some primary care trusts, which hold the purse strings locally, refusing to fund treatments such as IVF and podiatry.
Karol Sikora, a member of the group and leading cancer specialist, said: "The current debate on healthcare is strikingly inadequate.
"Having to pay to access much-needed care is a reality for many patients.
"Politicians refuse to accept this basic truth and continue to perpetuate the political mirage of a service completely free at the point of delivery.
"We must have a full and frank debate about the future of healthcare funding."
Patients though seem suspicious about the prospect of charging.
Katherine Murphy, of the Patients Association, said they were against any idea of charging for care that was needed.
"We need to look at what we can do and we would not be opposed to patients being charged for food they are given in hospital. After all, they would be paying for food if they were at home.
"But I think we would draw the line elsewhere."
And this seems to be the key behind the political parties reluctance to discuss the issue.
Patients are already charged for some services, such as dentistry
Professor Alan Maynard, a health economist at York University, said the NHS - and the idea of it being free at the point of need - is close to voters' hearts and would be political suicide for any party that wanted to change it.
"The truth is that this issue crops up all the time, but it is not going to happen. The political parties just do not have an appetite for it.
"It would be unpopular with voters and debating it like we are is as far as it goes."
John Appleby, chief economist at the King's Fund health think-tank, agreed to some extent.
He said he believed the only way charges could be introduced would be to target areas where patients already contribute to.
While the NHS is referred to as free at the point of need, prescriptions and dentistry in England both carry charges.
He said: "I suppose we could have a situation where patients are asked to pay more towards less effective drugs they get on prescription.
"But to introduce charges elsewhere is a very tricky thing for politicians.
"However, it is not even a given that we will need to do this. We already ration what care is available and if we continue to do that effectively the NHS could carry on as it is."