International experience of paying for expensive medicines

BMJ 2009; 338 doi: (Published 29 May 2009) Cite this as: BMJ 2009;338:b1993
  1. Monica Desai, academic clinical fellow public health,
  2. Ellen Nolte, senior lecturer,
  3. Nicholas Mays, professor of health policy,
  4. Athanasios Nikolentzos, research fellow
  1. 1Health Services Research Unit, London School of Hygiene, London WC1E 7HT
  1. Correspondence to: E Nolte enolte{at}
  • Accepted 6 May 2009

NHS patients in England are now allowed to pay for private treatment with drugs that are not funded by the NHS. But as Monica Desai and colleagues describe, it may not be easy to maintain a distinction between public and private care

The use of so called top-up payments for drugs that are not available on the National Health Service has caused controversy. Some people believe that it will result in increased access to medications1 while others warn that such payments contradict the founding principles of the NHS and may lead to greater inequalities.2 Mike Richards’s review Improving access to medicines for NHS patients and the government’s response to the review have acknowledged that additional payments, which are already used in a non-uniform manner, must be accepted into practice.3 4 The review does, however, recognise that the right to pay for additional specialist care that is not funded by the NHS should be invoked rarely so as to minimise compromising the founding principle of the NHS—namely, to provide a comprehensive service to all on the basis of need, not ability to pay.4

The Department of Health has set out a series of safeguards to ensure that patients opting to pay for additional private care do not lose their entitlement to NHS care while minimising the risk of public funds being used to subsidise private care.3 We discuss some of the challenges posed by these new proposals and their implications for the NHS against the background of international experience.


The Richards review attempts to conclude a longstanding controversy surrounding payment for high cost medicines in the NHS. In England, funding decisions for drugs are informed by the National Institute for Health and Clinical Excellence (NICE). Medicines recommended by NICE must be funded by primary care trusts …

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