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 But you will find your choices limited in more subtle ways, such as a denied referral, an outdated treatment, or a withheld new drug.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.