Intended for healthcare professionals

Head To Head

Could private top-up insurance help fund the NHS?

BMJ 2016; 355 doi: (Published 12 October 2016) Cite this as: BMJ 2016;355:i5424
  1. Christopher Smallwood, former chair1,
  2. David Wrigley, general practitioner2
  1. 1Kingston Hospital NHS Foundation Trust and St George’s University Hospitals NHS Foundation Trust, London, UK
  2. 2Carnforth, Lancashire, UK
  1. Correspondence to: Christopher Smallwood csmallwood{at}, David Wrigley dgwrigley{at}

Current tax revenues cannot maintain healthcare standards, writes Christopher Smallwood, but David Wrigley worries that introducing inequity sounds the death knell of a service free for all who need it

Yes—Christopher Smallwood

It is hardly controversial to suggest that standards of healthcare in the NHS are declining. A stream of recent reports has shown the strain the NHS is under, drawing attention to a near universal failure to meet the target of four hours’ waiting time in emergency departments,1 the longest waiting times for operations since 2007, and unprecedented staff shortages.

The principal cause of this lamentable state of affairs is unquestionably underfinancing of the system. In 2012-13, few trusts were in deficit but by 2015-16 the proportion had reached 85%.2 As the King’s Fund has said, we are “facing a health system buckling under the strain of huge financial pressures.”2

Current problems are set to intensify at an alarming rate. The budget for NHS England is planned to rise by 1.4% next year, then by 0.4% and 0.7% in the following two years, compared with an expected rise in demand and cost pressures of between 4% and 5% a year.3

Muddling through

If we try to go on “muddling through,” a steady erosion of standards is inescapable. Trusts under ferocious pressure to balance the books leave vacancies unfilled, cut the ratio of staff to patients, slash capital spending, defer operations, increase waiting times, cut training, and restrict the treatments they are prepared to offer.

The only hope of reversing this process is properly to debate how to bring …

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