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

Abstract

Disorganised fundingThe current NHS funding system is far from transparent, meaning many patients are unaware of their entitlement to treatment and there is little appreciation of cost.3 Implicit rationing—clinicians hiding, or placing limits on, the range of choices available to patients under the guise of clinical necessity4—has enabled the more affluent and articulate to gain preferential treatment; they are far more likely, for example, to receive hip replacements or coronary artery bypass grafts than poor people, despite being in less clinical need.5The same effect has led to massive variation in practice and attitudes towards top-up fees. Patients wanting to use them face excessively high prices—up to £2500 (€3200; $5000) plus installation costs for a hearing aid—or a lottery. For example, after the National Institute for Health and Clinical Excellence (NICE) deemed certain cancer drugs—such as bevacizumab for breast cancer—not cost effective enough for the NHS to fund, some patients were told they must receive the entirecourse of care privately, some received prescriptions to be made up privately while continuing the rest of treatment on the NHS, while the lucky ones forced the NHS to reverse its initial decision.This is not only perverse but completely at odds with the explicit moral foundations of the organisation: that there should be equal access to health care based on equal need.4 The question is how we address this: do we work to create an equitable framework for top-up fees or do we force individuals to pay for an entire course of treatment privately if they wish to supplement their NHS care with drugs and treatments it will not fund?