Intended for healthcare professionals

Head To Head

Should patients be able to pay top-up fees to receive the treatment they want? Yes

BMJ 2008; 336 doi: (Published 15 May 2008) Cite this as: BMJ 2008;336:1104

Acknowledgement of implicit rationalisation

Implicit rationing is already a reality in the NHS, particularly in the realm of elderly care. How often have we heard that patients might not benefit from level 3 medical care, might not benefit from newer statins, might not benefit from both emergency and non-emergency operations. And how often has that view been challenged subjectively. The American Geriatrics Society published a positional paper in 2002. This identified how the manner in which rationalization occured might make it more acceptable for the society, for example a system wide based allocation rather than a bedside based allocation for resources. (1) The National Service Framework for older people's services highlighted where we could perform better in this respect.(2) Articles like this should be encouraged to bring about a more frank discussion between the medical profession and the society at large. This will hopefully lead to a discussion on what "core treatments" should be provided by the finite NHS resources and what should be paid for as a top up fee.


1. American geriatrics society (AGS) position statement rational allocation of medical care: A position statement from the AGS ethics commitee. 2002. 2.Older people National Service Framework (NSF). 2001.

Competing interests: None declared

Competing interests: No competing interests

08 May 2008
Zhan Yun Lim
The Royal London Hospital