Should patients be allowed to pay top-up fees to acquire certain treatments?

Should patients be allowed to pay top-up fees to acquire certain treatments?

Should patients be allowed to purchase the treatment they want? UK

In the UK, some believe that patients should be allowed to purchase any treatments that they want. This policy shift is debated between two experts in an article published on

The motivation for debate comes from a recent ruling regarding the Alzheimer's drug Aricept. It is one of several decisions made by the National Health Service (NHS) to not fund certain treatments, and it is a decision that has been passionately disputed. Many argue that patients should in fact be allowed to purchase treatments privately instead of being without them.

James Gubb, director of the health unit at Civitas (an independent social policy think tank), says that the practice of supplementing NHS treatment with private care is already widespread. As the NHS budget tightens and it cannot cover the medical needs and wants of the people, he believes, the practice will become even more common.

Gubb finds issue in the fact that these so-called "top-ups" have been ad hoc, exclusive, more expensive than necessary. They are also not in line with the purpose of the NHS: equal-access health care based on equal need. He suggests the creation of an equitable framework that mandates affordable fees for these top-ups. This will help provide access to those who may not be wealthy and articulate.

Gubb says, "Requiring people to pay the cost of the drug as a top-up would enable far more patients to benefit from it than if they had to pay for their entire course of cancer treatment." He also believes it would better uphold the ideal of universal health care.

One recommendation given by Gubb is the implementation of a type of insurance contract similar to that of many existing European systems. The Netherlands, for examples, allows people to purchase supplementary insurance for items like cosmetic surgery and comprehensive dentistry. The result of this system is overall reduced costs, better quality health care, and affordable fees. Some 93% of Dutch people have participated in this supplementary insurance system, says Gubb.

On the other side of the debate sits Karen Bloor (University of York). She argues that the optimal way to decide what treatments the limited NHS budget should fund requires an assessment of the tradeoffs between effectiveness and cost. "The inevitable rationing of treatments is acceptable only if it is objective, fair, and applies to all those treated within the NHS," says Bloor.

According to Bloor, if patients are allowed to pay top-up fees, there will be a clear reduction in the equality of health care rationing. Essentially, NHS patients who could afford to pay for an additional treatment would benefit over a citizen who has the exact same condition but more scarce resources. She cautions that a system that has individuals and insurers paying health care costs instead of the NHS (a strong single purchaser) provides little incentive for drug companies to keep drug prices down.

The solution, says Bloor, is for effective new treatments to be available for all NHS patients and the drug companies should be pressured to keep prices down so that these treatments are cost-effective for the NHS. "Instead of allowing companies to market limited products to desperate patients, it may be better to link the price of drugs with their value," she says.

Bloor concludes that, "The NHS should be maintained and improved to provide care for all patients, regardless of ability to pay."

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


doi: 10.1136/bmj.39563.493218.AD

doi: 10.1136/bmj.39563.453183.AD

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