Should patients be able to pay top-up fees to receive the treatment they want? YesBMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39563.453183.AD (Published 15 May 2008) Cite this as: BMJ 2008;336:1104
If the trebling of National Health Service expenditure since 1997 has proved anything, it is that the age old debate over resource allocation and rationing will not go away. Western medicine continues to be a victim of its own success, with each of us likely to consume ever increasing amounts of expensive medical care at the end of our lives whatever our age.1
This trend will increasingly mean that the NHS, which has a finite budget, will not be able to afford all the medical care that people want orindeedneed. Topping up NHS care with private treatment is already widespread in primary, maternity, and cancer care, as well as audiology, where patients often pay privately for new hearing aids to avoid long waits after seeing an NHS consultant.2 As inflationary pressures on medicine increase, such practice will only become more common, but a lack of political honesty about the limits of the NHS budget has meant such top-ups have been ad hoc, exclusive, and unnecessarily expensive—one reason why so many object to them.
The current NHS funding system is far from transparent, meaning many patients are unaware of their entitlement to treatment and there is little appreciation of cost.3 Implicit rationing—clinicians hiding, or placing limits on, the range of choices available to patients under the guise of clinical necessity4—has enabled the more affluent and articulate to gain preferential treatment; they are far more likely, for example, to receive hip replacements or coronary artery bypass grafts than poor people, despite being in less clinical need.5
The same effect has led to massive variation in practice and attitudes towards top-up fees. Patients wanting to use them face excessively high prices—up to £2500 (€3200; $5000) plus installation costs for a hearing aid—or a lottery. For example, after the National Institute for Health and Clinical Excellence (NICE) deemed certain cancer drugs—such as bevacizumab for breast cancer—not cost effective enough for the NHS to fund, some patients were told they must receive the entirecourse of care privately, some received prescriptions to be made up privately while continuing the rest of treatment on the NHS, while the lucky ones forced the NHS to reverse its initial decision.
This is not only perverse but completely at odds with the explicit moral foundations of the organisation: that there should be equal access to health care based on equal need.4 The question is how we address this: do we work to create an equitable framework for top-up fees or do we force individuals to pay for an entire course of treatment privately if they wish to supplement their NHS care with drugs and treatments it will not fund?
The case for top-up fees
The former is the most sensible and desirable course for at least three reasons. Firstly, taking the example of bevacizumab above, requiring people to pay the cost of the drug as a top-up would enable far more patients to benefit from it than if they had to pay for their entire course of cancer treatment.
Secondly, it would serve to protect, rather than threaten, the ideal of universal health care that the NHS rightly upholds. The NHS cannot live in isolation from societal change, where consumerism reigns, where the European Union proposes to open healthcare markets across Europe, and where people are increasingly well informed about health care.6 When there is a clinical benefit, which may be defined in terms of extension of life or pain relief as well as cure, people will naturally want to use the drug or treatment that provides it. For the NHS to uphold the idea that people who have funded the service throughout their life by taxation either don’t get the drug they want or have to pay all costs of treatment privately may undermine commitment to its founding principles.
Instead, top-up fees, if accompanied by an open and honest debate over what is affordable as core NHS care, would help to ensure we retain the most equitable approach possible to allocating limited resources and that we focus on areas of greatest need.7 Rather than the NHS budget being consumed by those who shout the loudest, there could be an insurance type contract as in many European systems.8
Thirdly, such candour is also likely to bring about considerable efficiency gains as dynamic and innovative insurance markets develop to serve the top-up domain and extend access to it from the wealthy to the majority.9
In the Netherlands, for example, people must buy supplementary insurance for health care such as cosmetic surgery, non-rehabilitative physiotherapy, or more comprehensive dentistry. Costs have been cut, quality driven up, and fees are far from prohibitive; in fact 93% of the population have bought some form of supplementary insurance.10 11 A similar example may be found in the UK with optical services, where the introduction of copayment and vouchers in the 1980s moved an expensive and inconvenient service to a fast, high quality one available to all on the high street.2
Unfortunately, the current NHS impasse prevents further developments. Topping up NHS care remains the preserve of the rich and articulate, who can afford to pay for the entire course of treatment themselves or have the knowhow to fight for what they want on the NHS. This has to change.
Competing interests: None declared.