Expert blog: The hidden cost of GP letters - why medical evidence fees deepen justice inequality

The National Health Service (NHS) was founded on the principle of care being free at the point of access. Yet, for many patients who are very poor and struggling to survive, this is no longer true.

The practice of GPs charging for medical evidence letters seems to be a recent phenomenon, but reports from charities across the country show this practice is becoming more widespread.

This disproportionately affects the poorest individuals, who rely on critical medical evidence to prevent their conditions from worsening and to avoid social isolation.

Whilst GPs might feel they cannot afford not to charge, we argue that the knock-on effect of charging to people’s health greater widens health inequalities by limiting access to justice which exacerbates poor health – increasing costs to the NHS.

Recently, a Central England Law Centre (CELC) client had been newly diagnosed with dementia, along with deteriorating eyesight. CELC successfully supported the client to claim a Personal Independence Payment however the client did not qualify for the mobility element. He was advised he would need a disabled person’s bus pass. As part of the support process, Transport for West Midlands wanted evidence of his medical condition from a qualified medical expert. The client’s GP required the client to pay £60 for the letter.

This is just one example of many hurdles people experiencing poverty face in accessing justice.

CELC supports many people who are living on at most £400 a month and so £60 represents a significant portion (15% of their income) of what they need for rent, medications, transport to medical appointments, food and energy. Even with careful budgeting, £400 does not go far and stark choices to go without essentials are their only option.

These medical evidence letters can be pivotal in establishing their case and are a legal requirement to access wider support for their problem. Patients cannot afford to have the letters, but they cannot afford not to have them.

The Central England Law Centre’s (CELC) health justice partnership sees firsthand the struggles people face in obtaining medical evidence to prove their right to support.

For example, clients approaching homelessness services are being advised that GP medical notes are too brief, and to substantiate a claim they need a GP letter to confirm medical issues are severe enough to warrant priority need. These are people living with mental health issues, disabilities, significant health conditions (e.g. asthma) and often have complex trauma.

Some CELC clients are living in properties where damp and mould is affecting their health. We saw the dangers of this in Awab’s case, which highlighted the tragic consequences of mould in homes. Clients now need to pay to get GP evidence to raise a full complaint with a landlord. They too struggle to pay this GP impost.

Some GPs have also started charging for expert reports. These are required by authorities to substantiate a patient’s claim. In certain circumstances GPs can charge up to £175. If you are lucky enough to have legal aid, the Legal Aid Agency will not pay more than a maximum fee of £50.40.

Whilst we understand how poorly resourced some GP clinics might be, we argue that charging the poorest people for critical evidence is misconceived, unhelpful and further entrenches inequality. Perhaps GPs have not considered fully the effects of this on wider determinants of health.

There are solutions to this problem and there is a precedent. GPs used to charge victims for letters confirming their abuse. Women were left with no choice than to pay this charge or risk remaining unsafe. This GP evidence is a critical document needed to access legal aid for protective orders. Now the law has safeguarded this. Victims of abuse are not to be charged for medical evidence letters.

Why is it that the poorest people end up having the biggest obstacles in front of them just because they lack money? Whilst some GPs may argue these letters fall outside NHS-funded services and require time and administrative effort, the knock-on effect of charging will deprive people of letters evidencing severe conditions.

The impact on GPs will never be as significant as this charge is for the people in dire need.   Without this evidence and the support it enables, patient health will deteriorate and their circumstances will worsen.

GPs will then see patients in a worsened state thus costing more downstream for the health system. This all drives further inequality.

What is occurring is a two –tiered justice system where those most in need cannot afford evidence of their conditions.

We call for this practice to be stopped and suggest that people experiencing poverty, who rely on GP letters for evidence to access vital services, should be protected by the law and be exempt from this charge.

Associate Professor Liz Curran has recently been appointed as academic health justice partnership advisor (pro bono) for Central England Law Centre.