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.