Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Increasing NHS consumerism
- Peter W Ward (15 May 2008)
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Top up fees - Acceptable in education but not in health!
- Nagappan Kumar (18 May 2008)
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Not allowing top up is unethical
- Christoph C Lees (20 May 2008)
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Top-up fairly according to means
- Alfred P J Lake (21 May 2008)
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Top-up Fees, Privatization, and Market Driven Health Care
- Elizabeth McGibbon (5 June 2008)
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Barbed-wire and Watchtowers ?
- L Sam Lewis (10 June 2008)
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Top up fees already exist
- Hendrik J Beerstecher (22 June 2008)
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Peter W Ward, GP Gateshead. NE6 5LD
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I agree with Bloor's statement 'treatment within a publicly funded NHS should not provide what patients want, but what they need'. I am surprised that she feels this is the case as things stand. Many NHS services long ago crossed that boundary. Much money is already spent on satisfying wants rather than needs. The legitimacy of spending taxpayers money on such things as increasing out of hours access to GP's, NHS Direct, Walk in Centres and 'Health Checks' is questionable. If providers of these services were allowed to charge a co-payment for consumer friendly add ons, it would help fund them without reducing resources available for meeting genuine need. I reckon a few of us GP's might open up of an evening happily if we could make a ten pound convenience charge. Competing interests: None declared |
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Nagappan Kumar, Consultant in Transplant and HPB Surgery University Hospital of Wales, Cardiff, CF14 4XW
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Top up fees was introduced in higher education in 2006. The main beneficiaries were the Universities who welcomed the 'additional' funding. However, there was widespread concern that this would deny equity of access to students from the lower socioeconomic status. How can top up fees be right for education but not for health? Health care spending is rising inexorably and has to be funded appropriately to provide high quality care. Weale (1) described the 'inconsistent triad' where it is difficult to provide a comprehensive, high quality care to all in need, in the face of increasing health care costs. The current provision of care in NHS is not comprehensive (e.g. cosmetic surgery is not available in NHS). The provision of high quality care entails the use of all the latest proven treatments, which don’t come cheap. The National Institute of Health and Clinical Excellence (NICE) evaluates the effectiveness of the new treatments and uses Quality of life years (QALY) gained as a measure to approve these treatments for use in NHS. The current threshold is £25000 - £30,000 per QALY (2). However many new treatments (e.g. anti cancer drugs) proven to be effective may be beyond the threshold established by NICE. A system where patients are allowed to pay a top up fee to cover the drug cost alone, for treatments which are effective but beyond the threshold established by NICE should be acceptable. This would allow NHS to buy these drugs at a discounted rate (as a bulk buyer) and recoup the costs from the patient. The right to health care of an individual can be suppressed in a publicly funded system if the opportunity cost is going to be denial of care to some other group. The proposed system will not deny other patient groups of their care. We cannot deny the benefit to a few just because we cannot afford the benefits to all. The circumstances are different in 2008 compared to 1948 and it is better to aim for practical egalitarianism rather than an ideal one which is not achievable in any society. We should move on. 1. Weale A. Rationing Health Care. BMJ 1998:316 (7129):410 (7 Feb). 2. Rawlins M, Culyer A. National Institute of Clinical Excellence and its value judgments. BMJ.2004;329; 224-227. Competing interests: None declared |
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Christoph C Lees, NHS Consultant CB2 2QQ
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Karen Bloor bases the argument against Top Up Payments on fairness, particularly an understandable desire not to allow the wealthiest automatic access to the best drugs while those without the ability to pay for private care are disenfranchised. The flaw in this argument is that the wealthiest already access their own treatment, often exclusively in the private sector. It is patients that are less well off that get caught in the 'trap' of potentially being disallowed NHS care if they pay for so much as one course of treatment with a 'top up' drug. The greatest iniquity and inequity is surely to disallow citizens and taxpayers their NHS entitlement in the name of fairness. These mechanical socialist arguments are propogated through a belief that no man or woman should be in charge of their own destiny but must instead must accept what the state will give them. It is more important to be equal than be allowed to extend the quantity of quality of your life. This is some 70 years behind modern political thinking in a consumerist society-where individuals are and should be in control of their bodies and destinies. Ironically, I can find nothing in NHS legislation that disallows top up payments, nor is allowing topping up against the Founding Principle of the NHS. The Secretary of State for Health would be allowed to enable charges for certain drugs-if he so wished. Competing interests: I am a Founder Member of Doctors for Reform |
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Alfred P J Lake, Consultant in Anaesthesia and Pain Medicine Glan Clwyd Hospital, LL18 5UJ.
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While Karen Bloor is right that treatments should be cost effective and provide value for money she fails to recognise that any need for them will always be a value judgement and individual patients as well as the state will differ in their assessment. The cornerstone of the NHS is equity of provision but the existing service fails to deliver this because the inevitable and necessary rationing is not applied in an objective and fair way across the board. As James Gubb says, we need to have an open and honest debate about what is affordable within the NHS, the opportunity cost needs to be appropriate and reflect the benefit derived by both the individual and wider society. Properly organised and arranged ‘top-up’ and other fees would increase the fairness of any health service rationing allowing an equivalent range of treatment to all users. It could be argued that, in some respects, the NHS, as such a powerful national institution, is itself part of the problem preventing the necessary closer examination of these issues. Already many users of NHS services quite effectively ‘top up’ by paying for private care which not only effectively discriminates against those who cannot, for whatever reason, pay but also serves to alleviate much pressure to reform as such users are the ones who could exert the most influence. So, how to square the circle? Services could today be considered in three groupings which would need to be properly defined. First, core services of high quality free at the point of use to be provided as part of the tax-funded NHS. Second, cost effective services outside core should still be open equally to all by being paid for in proportion to disposable/taxable income (1). Third, services at the margins, perhaps wanted but not needed, would be down to the individual to fund in full. Identifying core services and setting a relative value to the others would be the task of a body (such as exist elsewhere) set up for the purpose. 1. Lake APJ. Patients should pay a percentage of income. BMA News Review 2000; January: 30. Competing interests: None declared |
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Elizabeth McGibbon, Associate Professor St. Francis Xavier University, Antogonosh, Nova Scotia, CANADA, B2G 2W9
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Top-up Fees, Privatization, and Market Driven Health Care Top-up fees provide a seemingly effective solution to increasing access to treatments and services. If a patient has the means to pay for better care and services, then why should the state deny this possibility? However, this argument becomes much less sound when top-up fees are considered in the context of the social fabric of a nation. As is the case in the argument for privatization of health services, there are clear winners and losers in the global movement towards increasingly market driven health care provision. This is because the goals of commodifed health services are efficient service production, satisfied health care consumers, and corporate profit. These goals are fundamentally inconsistent with fairness and equity in access to services and treatments. Principles of fairness and universal access are violated when money becomes a prerequisite for timely and effective treatment. For example, the case for top-up fees as an equitable solution for health care shortcomings increasingly disintegrates as one moves down the socioeconomic gradient: top-up fees only work for people with sufficient financial resources. The equations are reasonably simple: money leads to increased access; poverty leads to compromised access (Raphael, & Bryant, 2006). There are many questions to be explored as Western countries inch towards fully market driven health care. Three core questions remain: 1) What are the legal and ethical implications for countries who have legislated that access to health care shall not depend upon a patient’s ability to pay for services?; 2) How does the opportunity to pay for services affect the provision of ‘free’ services in countries who choose to ‘consumerize’ health care? ; and 3) How are decisions about resource allocation linked to a country’s political ideology or political compass? These kinds of questions urgently point the analytic lens towards social scientific exploration of how a country’s policy decision making can increase morbidity and suffering among the most vulnerable of its citizens. Proponents of social gradient dependent solutions, such as top- up fees in the UK, and privatization of services in the United States and Canada, most often fail to offer a clear analysis of how these initiatives will affect the publicly funded system. When market forces enter the health care equation, or any economic equation, a new layer of complex political and social variables must be considered with a longitudinal focus (Navarro, 2004). In the haste to allow family financial status to dictate access to health care, this larger picture has often been obscured - which leads to my third point. In keeping with any governmental decision making over time, these ostensibly practical policy decisions are rooted in the political ideology of the state. An open debate about the political economy implications of health system decision making is urgently needed. The reigning governmental philosophy very much influences whether grandma will have her cardiac medication when and if she needs it- or even if she is financially able to navigate the urban or rural pathways to her health clinician’s office. Navarro, V. (2004). The political and social contexts of health. New York: Baywood Publishing Company Inc. Raphael, D & Bryant, T. (2006). Staying alive: Critical perspectives on health and health care in Canada. Toronto: Canadian Scholars Press International. Competing interests: None declared |
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L Sam Lewis, GP Surgery, Newport, pembrokeshire, SA42 0TJ
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I have had children brought to me with meningitis whose parents had been giving Paracetamol syrup for the temperature, bought over the counter. Did I say " Sorry, its all NHS or no NHS " ? Of course not. Plainly ridiculous. "Permitting top-up fees, by enabling some patients to buy their way out of rationing processes, conflicts with the founding principles of the NHS", says Karen Bloor. So the plan seems to be to reconstruct an Iron Curtain or Berlin Wall around the NHS ?? Socialist NHS values do include equity, but if they do not also accept "Respect for Autonomy" then we have a totalitarian regime. That is simply not acceptable in Britain. There will shortly be a court case regarding the (illegal and unethical) attempt by misguided NHS management to deny treatment to somebody who had the temerity to pay some of their costs. Competing interests: I am an NHS GP in Wales, and a 'free man'. |
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Hendrik J Beerstecher, GP principal 111 Canterbury Road, Sittingbourne, Kent, ME10 4JA
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I protested about the bodge of top-up fees relating to treatments for erectile dysfunction in 1997. The majority of the patients with this condition does not qualify for NHS treatment, yet a special clause was introduced in the NHS act (section 28U) to allow patients to have an NHS consultation, an NHS prescription in all but name and then have to buy the drugs privately. It is time the dishonesty and hypocrisy surrounding rationing in the NHS is put to rest. Competing interests: None declared |
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