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Change My Mind: Should The NHS Consider 'Top-Up Fees' For Non-Essential Services?

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On Monday, the British Medical Association consultant warned that the NHS needed to "face the unpalatable truth that free at the point of contact can no longer be sustained”, at the BMA's annual meeting in Edinburgh.

Gordon Matthews' claims were met with outcry by unions and patients' groups, who claimed that the addition of new fees would put patients off treatment and ultimately affect the health of the nation, particularly the poorer population.

However, Matthews' argued that politicians and the health industry needed to "engage with the public, to explain the issues and seek consensus as to what priorities are for health and social care, and making explicit what can be funded from central taxation and what cannot."

“A publicly funded and free-at-the-point-of- delivery NHS cannot afford all available diagnostics and treatments,” he added.

So, would top-up fees for certain services be a net gain or a net loss for our nation's health? Unison's national secretary for health, Christina McAnea, writes that more fees "would push people into an insurance model of healthcare" and "would be the beginning of the end for the NHS."

However, the Institute of Economic Affairs' senior research fellow Kristian Niemietz argues that a co-payment system would drive up our expectations of the services we receive, in turn improving the NHS. "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," he writes.

What do you think? Can either of our bloggers change your mind? Read their blogs below and cast your vote.


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Should the NHS consider 'top-up fees' for non-essential services?

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Who makes the better argument?

Kristian Niemietz Senior Research Fellow at the Institute of Economic Affairs (IEA), London

Would you like to receive something for free? Or would you prefer to pay for it, out of your own pocket? Phrased in those terms, the issue of top-up payments for medical treatments appear to be a no-brainer. But these are not the alternatives we are faced with in healthcare, and it is a serious misunderstanding to think of the issue in this way.

The NHS is under severe financial pressure. Demand for healthcare services is growing, and this trend is expected to continue, which means that maintaining a given standard of healthcare - never mind improvements - will get more and more expensive. The Nuffield Trust forecasts an annual funding gap of at least £12billion (in today's prices) by 2021, even under the assumption that public healthcare spending continues to increase in line with economic growth.

For the time being, a major surge in public health expenditure is not a realistic option, and it is not even clear whether it would be desirable. Contrary to popular belief, in terms of public healthcare spending, the UK is already in the top group internationally. The UK government already spends 8% of GDP on healthcare, a higher share than in Sweden and Finland, in Switzerland and Luxembourg, in Spain and Italy, or in Iceland and Ireland.

Unless we get a productivity revolution, this means that demand for healthcare services will have to be limited, and there are, in principle, only two ways how this can be done: rationing and financial incentives. Top-up fees and co-payments fall into the latter category. So 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? After all, just because something is notionally offered 'for free' does not mean you can easily obtain it. Think of 'free beer' promotions: These occasions rarely entail unlimited drinking, because the owner of the venue will find non-monetary ways to limit consumption. They will understaff the bar to produce long queues, store the best beers away, instruct their staff to leave a large head, etc.

Healthcare rationing is not that different. You may never have to reach for your wallet, you may never have to fork out money. But you will find your choices limited in more subtle ways, such as a denied referral, an outdated treatment, or a withheld new drug. Monetary payments are far from the only mechanism to limit demand. But they are the most explicit, the most visible mechanism to do so. This is precisely why many are so emotionally uncomfortable with the idea: It replaces covert, hidden ways of rationing with a brutally honest one.

In the absence of financial incentives, demand has to be limited in more roundabout ways - but this relationship also holds in reverse. If we introduced smart financial incentives to encourage a more economical use of medical resources, crude rationing tools would become much less necessary. A properly devised system of co-payments would make you think twice, or thrice, before using a medical service, but unlike in a system of pure top-down rationing, you would still be the judge.

Issues 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. There is no need to compromise the objective of universal healthcare.

But the devil will be in the detail. A co-payment system will achieve little if the funds raised just disappeared into the black hole of the public finances. But if healthcare providers were given the right to keep and re-invest the co-payment revenue they raise, co-payments could be turned into catalysts of competition. Good healthcare providers would be able to expand, and poor providers would be forced to shape up.

But 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.

The NHS is the country's most overrated institution. Anything which undermines the undeserved reverence it commands is a good thing, and co-payments might do just that.

Christina McAnea Unison’s National Secretary for Health

The BMA have rightly highlighted the danger to the UK's NHS at their conference this week. The future of the NHS was also hotly debated at Unison's conference in Liverpool last week. And as the largest healthcare union in the UK representing over 450,000 workers we agreed on the need to keep on campaigning to protect the NHS.

We will be leading a national lobby at the Tory Party conference in September this year to keep up the pressure. There is unanimous agreement among all the health unions that this government is setting up the NHS in England for privatisation, or to be run on a health insurance model or a combination of both.

It is clear from information from our members that certain services are being at best rationed and at worse stopped. Whilst recognising the pressure that doctors and other healthcare providers are under moving to a "top up" situation, as some BMA doctors have called for, would be disastrous. This would mean identifying "core" services that would be free and patients paying for additional services. It would be easy to see more and more services being seen as "extra".

The founding principle of the NHS is that it is free at the point of need. Can the new system in England sustain this?

Will healthcare be free for long-term conditions such as cancer, diabetes, arthritis etc probably yes - even this right wing market driven government may not go so far as to change that.

What about needing care in an emergency - the answer might be probably yes - but what if the accident was a result of being drunk or on drugs? Or because of high risk activity - maybe even a spots injury. Will decisions be made about blame and culpability and who will take these decisions?

But what if it's not about saving your life but about improving the quality of your life - hip or knee replacements, infertility treatments, physiotherapy, counselling? Will these be the kind of treatments that aren't seen as "core" but somehow choice driven extras?

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.

What we need is more investment in ill-health prevention, early intervention where this is proven to be effective and better controls on the costs of drugs. Above all we need a government committed to the NHS funded by taxation - and a government committed to making big businesses pay their taxes and not be able to make a virtue out of tax avoidance.

Instead we have a government hell-bent on the "marketisation" of healthcare, a system which would allow private companies to make profits for shareholders rather than investing in better healthcare for all. A system where there is no evidence base for supporting this approach. That is why we are calling on local communities to join with the unions and other protestors at the Tory party conference in Manchester in September.



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