Top-up Fees – The Future of the NHS?


The National Health Service is an organisation envied across the world for its ability to provide treatment free at the point of contact. For over the last 60 years the NHS has provided the British people with this right to free healthcare. However, is this right under threat, and what would the introduction of so called top-up fees mean for the future of the NHS? Dan Paddock investigates.

When the National Health Service was launched in 1948 it was with the ideal that good healthcare should be available to all, regardless of wealth. Three core principles have guided the NHS since that day. Those are; that it should meet the needs of everyone, that it be free at the point of delivery and that it be based on clinical need, not ability to pay.

Despite this, last week leading doctors and medical experts at the British Medical Association (BMA) stated that the NHS had to face the truth that ‘free at the point of contact can no longer be sustained.’ The group has called for plans to charge patients for services which the NHS can no longer sustain. A list would be created outlining to patients which services would count as ‘care’ services and remain free and those services that would be deemed as ‘extras’ which would require a fee.

This call for top-up fees has split opinion across the country, and has raised questions about the future of the NHS and the implications that their introduction would have for the general public.

A number of health experts and professionals have expressed their fears that the possible introduction of top-up fees for NHS services will see the country move towards an insurance based model of healthcare, in a similar vein to the United States.

Christina McAnea, Unison’s National Secretary for Health believes that the introduction of top-up fees would ultimately spell the end of the NHS as we know it. She said: “The founding principle of the NHS is that it is free at the point of need. Can the new system in England sustain this? The danger of this would push people into an insurance model of healthcare, with the public encouraged to take out health insurance to pay for “top-up” services. This would be the beginning of the end for the NHS.”

Dr Kailash Chand OBE, Deputy Chair of the British Medical Association fears that the introduction of top-up fees to the NHS would leave insurers ultimately in control of patients care. He said: “Insurance companies believe there is a lucrative market opening up to sell policies to NHS patients. Leading firms are looking into the implications of top-up policy. This will become the norm for many new treatments, and will lead to a system of “managed care” much like that in the US where it is the insurers and not doctors who decide who gets treated, where they get treated, how they get treated, who gives the treatment and how much it costs. The potential for this market is phenomenal and could dwarf private medical insurance. We could sleep-walk in to insurance-based health care.”

A number of medical experts believe that the introduction of top-up fees to the NHS would ultimately affect the people which rely on it the most the hardest.

Dr Chand explained that: “A system that allowed top-up payments would be regressive, in that it would penalise the poor, the sick and the old – the most frequent users of the NHS. We believe that over time a system of co-payments could reduce the NHS to providing basic services only, with the more elaborate or expensive treatments requiring top-ups and, therefore, only available to the wealthy. It could turn the clock back to the days before the NHS when your life chances were decided by your ability to pay. Unfortunately, the poorest sections of society are the unhealthiest and will have to pay the most.”

Dr Clive Peedell, the co-leader of the NHA Party, and a member of the BMA Council agreed with Dr Chand. He said: “The introduction of NHS top-up fees would be irresponsible, dangerous and an administrative nightmare. This fundamentally undermines the founding principles of the NHS. We do not want to go down that road. Charges and fees will put patients off from seeing their doctors when they have genuine needs. This will increase health risks and potentially increase costs as patients may present later with more advanced healthcare problems, which can increase complexity and cost of treatment. Once again, the poorest and most vulnerable in society will be affected the most.”

Kristian Niemietz, Senior Research Fellow at the Institute of Economic Affairs, London stands in direct contrast to many others health experts. He believes that a move towards top-up fees is inevitable, and if approached correctly would actually be beneficiary to people’s health, with patients having greater control over the care that they receive.

He said: “The question should really be phrased as: Would you prefer to have some say over which healthcare services you use, even if it means accepting some of the financial responsibility for it? Or would you prefer to fully delegate these choices to healthcare administrators, and put yourself entirely at their mercy?”

“A properly devised system of co-payments would make you think twice, or thrice, before using a medical service.”

“Issue of equitable access to healthcare can be dealt with quite easily. The poorest could be exempted from co-payments altogether, just as they are currently exempted from prescription charges. To avoid penalising the long-term sick, co-payments could be capped, for example through an annual ceiling. For those with cash flow problems, an instalment plan could be worked out. In short, these are merely technical issues, which are clearly resolvable.

“Perhaps the most beneficial effect of a co-payment system would be in its impact on our attitudes as medical consumers. Whenever we pay for something ourselves, we are much less willing to put up with shoddy services. Co-payments would make us much less tolerant of the medical establishment’s capriciousness. We would start to hold providers to account, and demand value for money, rather than bow our head and be content with what we are given.”

While it remains to be seen if the BMA’s calls for the introduction of top-up fees will actually be heeded by the government, it is impossible to deny the importance of the discussion. The choice to support the introduction of top-up fees would alter the very fabric of the NHS as we know it and change the way people in this country receive healthcare for the foreseeable future.