Unfortunately the NHS becomes more messy by the day with increasing variability of service and whereas the cornerstone of the NHS is equity of provision, the existing service fails to deliver this because the inevitable and necessary rationing is not applied in an objective and fair way across the board.
The NHS will not be what might be considered adequately financed because it is a political football (albeit a very large one) with players trying to keep the ball on the ‘free at the point of use’ pitch of fixed size but it spends more and more time off. In reality the service has probably not been so since soon after its inception.
Already many users of NHS services quite effectively ‘top up’ by paying for private care which provides an imbalance and not only effectively discriminates against those who cannot, for whatever reason, pay but also serves to alleviate much pressure to reform as such users are the ones who could exert the most influence.
Properly organised and arranged ‘top-up’ and other fees would increase the fairness of any health service rationing allowing an equivalent range of treatment to all users.
So, how to square the circle? Services can still be considered in three groupings which would need to be properly defined (1). First, core services of high quality free at the point of use to be provided as part of the tax-funded NHS. Second, cost effective services outside core should still be open equally to all by being paid for in proportion to disposable/taxable income (2). Third, services at the margins, perhaps wanted but not needed, would be down to the individual to fund in full. Identifying core services and setting a relative value to the others would be the task of a body (such as exist elsewhere) set up for the purpose.
Beyond the core service everyone would be expected to make some contribution, even those ‘on benefits’ as this ensures community cohesion.
Money must not be wasted in administration, the cost of collecting any top-up fees must be strictly controlled.
The level of top-up for high earners will approach that of private care presently so they will most probably continue to opt out.
1. Top-up fairly according to means. 21 May 2008.
2. Lake APJ. Patients should pay a percentage of income. BMA News Review 2000; January: 30.
Competing interests: No competing interests