An equitable solution for “top-up” fees

James Gubb, 8 May 2008

In a head-to-head debate in the British Medical Journal, we argue that instead of backing away from the reality that supplementing of NHS care with private treatment is already widespread – and will become even more so as the finite budget of the NHS becomes less able to cover the medical care that people want or require – the government should instead work towards creating an equitable framework for top-up fees. This would allow access to new drugs and treatments to all, rather than just the wealthy as is the case currently.

The real issue is that privately paid “top-ups” have been ad hoc, exclusive, unnecessarily expensive and completely at odds with the purpose of the NHS — that there should be equal access to healthcare based on equal need. Following the NICE decision that Avastin was not cost effective to be provided on the NHS, some patients have been told they must receive the entire course of care privately; some have received prescriptions to be made up privately while continuing the rest of treatment on the NHS; while the lucky ones have forced the NHS to reverse its initial decision.
This situation is perverse. Rather than the current Department of Health line, which is to force all those who wish to use new drugs and treatments not available on the NHS to buy their whole course of care privately, it should be drawing up an insurance-type contract with clear entitlements similar to those of many European systems.
For treatments not available, markets should be allowed to develop to provide equitable solutions. For example, in the Netherlands, people buy supplementary insurance for healthcare such as cosmetic surgery and more comprehensive dentistry, which has been shown by experts to have reduced costs, led to better quality healthcare, and has been affordable for the vast majority. In fact, 93% of the Dutch population have some form of supplementary insurance.
Another option would be for the government to match top-ups from private contributions until a maximum benchmark is reached, as was suggested by Sir Derek Wanless for the provision of social care. This could provide an even more equitable solution, akin to optical services where the introduction of co-payment and vouchers for those less well-off in the 1980s moved a high-cost and inconvenient service to a fast, high quality one available to all on the high street.
At present, however, there is a complete impasse. While this lasts it is only the poor and less educated that will suffer; private treatment for cancer care runs into hundreds of thousands of pounds.