Intended for healthcare professionals

Head To Head

Should patients be able to pay top-up fees to receive the treatment they want? No

BMJ 2008; 336 doi: (Published 15 May 2008) Cite this as: BMJ 2008;336:1105
  1. Karen Bloor, researcher
  1. 1Department of Health Sciences, University of York, York YO10 5DD
  1. keb3{at}

Decisions not to fund some treatments under the NHS have been vigorously contested. James Gubb (doi: 10.1136/bmj.39563.453183.AD) argues that patients should be able to buy such treatments privately, but Karen Bloor believes this will undermine the whole health system

Top-up fees in the National Health Service may sound harmless—surely if patients pay the additional cost of treatments not available on the NHS, they benefit without causing anyone else harm? But explored more carefully this simply is not the case.

Firstly, treatment within a publicly funded NHS should not provide what patients want, but what they need. Need for a treatment implies capacity to benefit from that treatment,1 which means that the treatment must be effective. Within scarce NHS resources, there is also a requirement for treatments to be cost effective and to provide value for money, and it is this requirement that creates the rationing problem in health care. Treatments that offer a relatively small benefit or a low probability of benefit may be worthwhile to an individual, but collectively they have an opportunity cost, in terms of other uses …

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