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 of NHS resources, that is too high.

Fair care

Although individually our treatment decisions are guided by medical professionals, collectively we rely on organisations like the National Institute for Health and Clinical Excellence (NICE) to make difficult judgments about what treatments should be reimbursed by the NHS, by balancing evidence of effectiveness and opportunity costs of treatment. The inevitable rationing of treatments is acceptable only if it is objective, fair, and applies to all those treated within the NHS.2

Allowing patients to pay top-up fees vastly reduces the fairness of healthcare rationing. In practice it would mean that NHSpatients with exactly the same condition could receive one treatment if they can afford to pay for it and another if they cannot. This contradicts the founding principles of the NHS, which stated that patients’ access to treatments and services “shall not depend on whether they can pay for them or on any other factor irrelevant to real need.”3 The potential destabilising effect of seeing rich patients receive different care from otherwise identical poor patients could undermine public support for our health service in ways that would be difficult or perhaps impossible to reverse.

If patients wish to pay for treatments not available on the NHS they should pay the full cost of their course of treatment in the private sector, not just the additional top-up. Although it could be argued that patients already switch between public and private health care, for an individual course of treatment they must currently be either NHS or private patients, and the use of private consultations to queue jump NHS care is, in my view, also unfair and inappropriate.

Control on costs

The second reason that patients should not be allowed to pay top-up fees is longer term. Patients with life threatening diseases are likely to be desperate for treatment, and therefore they and their nearest and dearest are least responsive to price. Over time, an insurance market may emerge to cover top-up payments, but this market would be sustainable only if customers fear that they could in future need unaffordable treatments. Either way, drug companies have little or no real incentive to compete on the basis of price. Patents granted to drug companies effectively give them a monopoly position. When the cost of treatments would be paid not by the NHS, a strong single purchaser, but by individual patients or their insurers, there is minimal downward pressure on the prices charged by companies. Although present regulations prevent companies advertising directly to patients, this may be reversed by European law, and internet advertising is already difficult or impossible to restrict. Overall, this situation could create a vicious circle of increasing prices for products of marginal benefit.

If new products are effective and cost effective they will be recommended by NICE for reimbursement on the NHS. If they have some marginal level of effectiveness but are not cost effective, companies should face incentives to reduce prices so that they become sufficiently cost effective for use in all NHS patients, not just some. Instead of allowing companies to market limited products to desperate patients, it may be better to link the price of drugs to their value.4

There are of course counter-arguments to this view. NICE decision making could be faster,5 although it is difficult to rush decisions of this complexity and importance. And patients with life threatening diseases might reasonably view esoteric arguments about cost effectiveness as irrelevant to their situation. Thinking back to when my mother died of cancer 10 years ago, I wonder how I would have felt if she were refused a treatment that could perhaps have helped, however little and however low the probability of success, and how much I would have been willing to pay for a little extra hope. But this perhaps makes my argument stronger rather than weaker.

The fact that treatments sometimes have to be rationed is the price paid for the comprehensiveness and humanity of the NHS. Permitting top-up fees, by enabling some patients to buy their way out of rationing processes, conflicts with the founding principles of the NHS. The NHS should be maintained and improved to provide care for all patients, regardless of ability to pay, and should not be undermined by an understandable but misplaced desire to provide patients with all the treatments that they want.


  • Competing interests: None declared.


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