Top-up payments—a reasonable response to rationing?

In May 2007, the British Medical Association published A rational way forward for the NHS in England a discussion paper outlining an alternative approach to health reform in the NHS.1 The BMA has been critical for many years of the Government’s piecemeal approach to NHS reform, and the discussion paper made a series of recommendations for an alternative, more coherent way forward. Among the recommendations was a call for a “national and explicit” approach to priority setting in the NHS (p45).1 Following this recommendation, the BMA’s Medical Ethics Committee put together a small working group to take forward the work on rationing. The underlying approach of the working group was to try and develop guidance that would provide practical assistance to health professionals who may be engaged in some aspect of rationing.

One of the issues that the working group touched upon was top-up payments. Should patients be permitted to augment a single episode of NHS care with their own money? Should, for example, a patient be able to pay a percentage of the cost of a drug NICE had said should not be routinely available on the NHS as it was not sufficiently cost-effective? Discussion of this issue coincided with enquiries to the BMA from doctor members who were concerned that, because of cost constraints, patients were being denied optimal treatments. Some of these doctors were suggesting that those patients who could afford to should be able to pay an additional sum to ensure optimum treatment.

The BMA has not yet considered this issue in detail. BMA guidance on the interface between NHS and private treatment states:

Dilemmas can arise if patients choose to seek part of their treatment privately and part on the NHS. A common scenario is where a patient seeks private investigations in order …