How patients could benefit from top-up payments
Top-up payments are a clinically and economically viable way of increasing choice and allowing the NHS to reshape services, say Mo Girach and Ryan Irwin.
As inflation and costs rise due to the economic environment and societal challenges around public health, disease chronicity and ageing become greater, an “affordability gap” emerges where the NHS can no longer provide comprehensive services for all, free at the point of delivery.
This adds impetus to the need to examine the concept and application of top-up payments in the NHS, where decisions around decommissioning mean there may be less access and funding for services that had previously been available to patients.
Top-up payments, or voluntary financial contributions from patients for access to drugs, medical devices and health services not funded within the NHS, present an interesting alternative to healthcare funding mechanisms such as private and social insurance, rationing and private care, which all have strong criticism against their adoption on efficiency, equity, quality and safety grounds.
Two clear arguments against top-up payments have emerged. First, that they contradict NHS founding principles, creating a two-tiered system where access to top-up services is limited by financial barrier. Second, their use creates a lack of quality control, where these services may not demonstrate value for money and negate the purpose of organisations such as the National Institute for Health and Clinical Excellence, which makes decisions on cost effectiveness.
These arguments are largely unfounded and subjective. Surely there is greater inequity where services with demonstrated value are not communicated and made available to NHS patients through top-up? Current lack of transparency around available top-up services and their relative cost creates an environment limiting patient access to all treatment alternatives, where clinicians ration available treatment options under other non-clinical operational and financial budgetary pressures.
Restricting choice based on a lack of understanding of top-up services, particularly in an age of consumerism and increased public involvement in healthcare, could have harmful effects in terms of reducing access to potentially life-saving treatment.
Increasing pressure
Top-up payments have clear advantages in improving healthcare quality, safety and cost. Indeed, their use for hearing aids in NHS audiology services and private treatment rooms in maternity care are commonly used by patients to reduce delays due to long waiting lists in the former example, and improving patient comfort in the latter.
The well-publicised use of top-up payments in cancer drug provision is also evidenced, but current guidance dictating top-up service delivery in a private setting does not go far enough in encouraging their use and integration with NHS care, which presents a more clinically effective model of delivery.
Furthermore, if communicated and introduced more widely, top-up payments could actually improve service costs in a competing market environment, creating greater treatment choices for patients at progressively lower cost as more providers compete on provision and efficiency.
More interestingly, the introduction of top-up charges for non-essential clinical services such as extended physical rehabilitation currently provided through the NHS, would enhance the quality and scale of the NHS service, which provides emergency acute care. By reducing provision of some less essential NHS services and transferring them to top-up service categories, greater focus could be placed on budgets and the cost of improving and increasing acute and emergency services, which are facing increasing pressure.
Certainly, evidence from European countries adopting more dynamic insurance models for top-up care have reduced costs and increased access to a paying majority, where an argument also exists that their introduction prompts greater patient responsibility in understanding their personal demand, cost and consumption of healthcare services.
Ultimately, further communicating and integrating top-up charges does not disadvantage those using the current NHS system, it simply increases benefit to those who wish to pay for additional services. Greater use of top-up funding would improve sustainability of the current tax based system without causing risk to users of NHS care. Yet it potentially could provide a more acceptable medium where services can be decommissioned.
Provider organisations should ensure they maintain and communicate a current and relevant top-up policy, in addition to utilising the private patient cap opportunities presented through the new health bill as another mechanism from improving financial performance. Clinicians should not assume knowledge of a patient’s ability to pay and provide all information on services that could be beneficial, even if these occur extra costs, as per General Medical Council guidance. Limiting access to top-up payments is not acceptable.
While the UK tax-based NHS system has not reached its funding peak compared to other countries in the Organisation for Economic Co-operation and Development, based on percentage of GDP invested in health services, the system is clearly under strain. Mixed method healthcare service provision models must be used to improve patient choice, quality, safety and cost effectiveness of service provision. The political arguments relating to top-up payments must be addressed and challenged more aggressively in relation to their clinical benefit, while improving the framework for their use in practice.
Top-up payments represent a clinically and economically viable healthcare provision tool, not least because limiting their use offends against the principle of autonomy and patient choice.
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Readers' comments (5)
Tom Dewar | 13-Jul-2012 5:37 pm
As a general point, I like that articles cite evidence, but they need to do so in a way the reader can check. So for statements like "evidence from European countries adopting more dynamic insurance models for top-up care have reduced costs and increased access" please - Dear HSJ - could you supply a link to the evidence (preferably a hyperlink).
Onto specifics:
"Top-up payments have clear advantages in improving healthcare ... cost."
"Mixed method healthcare service provision models must be used to improve ... cost effectiveness of service provision."
>> No. Top-up's will not reduce costs or increase cost-effectiveness. They will increase the overall cost of healthcare (as %GDP). Unless you believe, as I don't, that every £1 in top ups will displace >£1 of taxpayer funding or that £1 of top up money somehow buys more than £1 from taxpayers.
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"further communicating and integrating top-up charges does not disadvantage those using the current NHS system, it simply increases benefit to those who wish to pay for additional services"
>>This suggests that the only thing differentiating those who would pay for a top up from those who would not is a *willingness* to pay. This fails to answer the criticism, originally dismissed as "subjective", that a two tier system arises because of a separation on *ability* to pay.
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Roy Lilley | 18-Jul-2012 9:14 pm
This is barmy; taxes out of the left hand pocket, top-ups out of the righthand pocket. Still the same pair of trousers. Very unlike the HSJ to publish drivel.
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Anonymous | 19-Jul-2012 0:12 am
Where does one start? There is so much wrong with this article....
I doubt if the authors have ever worked in healthcare or would recognise a patient if they tripped over one. If I were marking this as an undergraduate essay, I would fail it on grammar, sentence construction, content and lack of references. Tom Dewar 5.37pm makes an important point, if you want to be taken seriously, then back up your claims with peer reviewed evidence.
"top-up payments are clinically and economically viable" How can a payment be 'clinically' viable? A treatment is 'clinically' viable, but a payment? What is the patient to do? Swallow it?
"top-up payments are economically viable"?
Says who? Any payment is economically viable if you can afford it, but if you are a single mother bringing up 3 kids on a part time job, how can a top up payment be 'economically viable' when it means going without something in order to pay for treatment for your sick child?
Top up payments are an 'interesting alternative" ...interesting? Whats interesting about having to pay for services that were once provided free of charge?
The authors say that 'restricting choice based on a lack of understanding of top up services, could have harmful effects in terms of reducing access to potentially life saving treatment'
So in other words ....because no one wants to talk about introducing top up payments so soon after the Health and Social Care Act was passed, (thus proving the critics of the Bill correct), potentially life saving treatments are being restricted/rationed, instead. So in other words, by not charging people, we are killing them.
Dear god.
It gets better.....the authors claim that "top up payments have clear advantages in improving healthcare" because e.g. patients can pay to buy hearing aids and so jump waiting lists ...so in other words they can pay to get in front of people who can't afford to pay.... so thats good then is it?
And then "Further integrating top up charges does not disadvantage those using the current NHS system, it simply increases the benefit to those who wish to pay"
Can the authors be naive enough to believe this? So allowing people to pay to jump ahead doesn't push the NHS people further to the back of the queue? Have the authors never sat in a traffic jam where you only move inches because you obey the rules and stay in line, and others who don't obey the rules speed past you and push in at the top of the queue? Well I have, thats why it took me 2 hours one Saturday night to get through the Blackwall tunnel when one lane was blocked. We would have all got through in time if we had all stayed in line, but those drivers who kept jumping the queue just kept the rest of us waiting longer. its the same with a waiting list. There are only a fixed number of doctors to see the patients so the waiting list for NHS gets longer and longer if private patients take preference. Its not rocket science.
The authors last paragraph has to be the most blatant twisting of the truth to backup a no hope argument that I have ever read in the HSJ......"Limiting the use of top up payments offends against the principle of autonomy and patient choice."
Are the authors seriously saying that a hospital, by not charging me for certain medical procedures is breaching my right as a patient to choice? Breathtaking.
Well, this article offends against my principle of not being driven to extreme irritation by evidence-free neoliberal nonsense. I expect a higher standard of debate from the HSJ.
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Ryan Irwin | 21-Jul-2012 3:32 pm
Dear all,
Thank you for your comments which provide useful stimulus for further debate. Please find a response to some of the key issues raised.
“As a general point, I like that articles cite evidence”
Response: Please find below a few selected key references from the wider list used to inform the above article, not included due to the deliberate utilisation of a narrative style for instigating debate. These present both sides of the debate and I would direct you to the references Hoogervorst (2006) and Gubb (2008) for the specific queries regarding top-up in European countries through health insurance, demonstrating improved quality and cost advantages.
“Top-up’s will not reduce costs or increase cost-effectiveness. They will increase the overall cost of healthcare (as %GDP).”
Response: Top-ups could improve healthcare cost in creating a better communicated, regulated and integrated “top-up” market with providers reducing service cost secondary to competition, thus creating a service cost reduction effect where services without this market outside the NHS, would maintain a higher cost per service in the absence of competition. The access the NHS could provide for top-up suppliers increases this competition effect compared to the current market. Secondly, the statement that top-up’s will increase cost (as % GDP) has too many assumptions attached to it. Cost of healthcare as % GDP is a wider economic indicator linked to societal health, education, taxation, benefits etc., where variation could not be understood by analysing the financial unit cost of top-up payments/services alone. Furthermore, top-up services could definitely reduce cost, where and if, their use improves public health, prevents re-admissions and reduces use of hospital services which demonstrate relative inefficiency compared to the top-up service provider model. Note- where top-up services are provided by third sector and NHS providers, more innovative cost reduction programmes could exist in displacing tax-payer spending.
“this suggests the only thing differentiating those who would pay from those who would not is a willingness to pay”
Response: A good point and noted, though to provide a response- the article was not intended to demonstrate that top-up payments would displace NHS services and this is not suggested or promoted in the article, though may be a created effect where decommissioning occurs. Ability to pay is clearly a factor, however, this is not an argument if you believe the NHS delivers comprehensive care and top-up services offer no greater quality. I don’t and would like to see more funding provided for public health promotion and disease prevention, where top-up services could also find a market.
“This is barmy… still the same pair of trousers”
Response: We need new trousers. See second response. An increasingly important debate which comes back to the fundamental question around healthcare funding sustainability. Top-ups, I think, present an opportunity for innovation and greater integration from providers in third sectors such as social enterprises who can create a return on investment which is social, in addition to financial. The current system is not affordable, we are living longer but living longer with increasing chronic disease which needs a new management approach.
“ I doubt if the authors have ever worked in healthcare”
Response: Indeed we both have worked in the NHS for many years. A clinical background and understanding of the clinical perspective has informed our views.
“How can a payment be clinically viable? What is the patient to do? Swallow it?”
Response: Agree that this is the wrong articulation, this should allude to the products and services gained from payment. The insinuation was around the model not the payment mechanism itself.
“How can a top-up payment be economically viable?”
Response: By being an activity that can support itself financially.
“What’s interesting about paying for services that were once free of charge”
Response: The article does not aim to suggest services gained from top-up payments replace NHS services, rather compliment. De-commissioning however, means this issue is becoming increasingly complex.
“…potentially life saving treatments are being rationed”
Response: I direct the reader to the Richard’s review for debate on this.
“so in other words they can pay to get in front of people who can’t afford to pay… the waiting list gets longer if private patient’s take preference”
Response: Why is this true? The article does not indicate this. Top-up payments would not displace current services, but are provided at cost outside this process.
“Are the authors seriously saying, that by not charging me… is breaching my right as patient to choice”
Response: Choice is breached if patient’s are not aware or able to access other services not available through the NHS. There is a duty to inform of these.
Happy to discuss any of these further, in person, or otherwise and thank you all for your comments which have served to inform of differing perspective and to generate a debate which is not going to go away, as part of the new Health and Social Care Reforms,
Kind Regards,
Ryan Irwin.
Selected references
BAILEY, S. AND BRUCE, A. (1994). Funding the National Health Service: the continuing search for alternatives. Journal of Social Policy. 23: 489-516.
BARON, J. (2008) in HC Westminster Hall Debate, Hansard ‘NHS co-payments: Mrs O’Boyle’,10 June 2008 at Column 51. London. Houses of Parliament.
BLOOR, K. (2008). Should patients be able to top up fees to receive the treatment they want? No. British Medical Journal. 336: 1105.
CHARLSON, P., LEES, C., SIKORA, K. (2007). Free at the point of delivery- reality or political mirage. Case studies of top-up payments in UK healthcare. London. Doctors for Reform.
DORAN, E., ROBERTSON, J., ROLFE, I., HENRY, D. (2004). Patient co-payments and use of prescription medicines. Australian and New Zealand Journal of Public Health. 28: 1: 62-67.
DOYAL, L. (1997). The rationing debate: rationing in the NHS should be explicit. British Medical Journal. 314: 1114.
ENTHOVEN, A. and VAN de VEN, W. (2007). Going Dutch: Managed competition health insurance in the Netherlands. New England Journal of Medicine. 357: 2421-23.
FOGARTY, M. (2008). Will top-up payments mean a two-tiered system? Oncology Times. 5: 12: 3.
GUBB, J. (2008). Should patients be able to pay top-up fees to receive the treatment they want? Yes. British Medical Journal. 336: 7653: 1104-1105.
HOOGERVORST, H. (2006). Healthcare reforms in the Netherlands; an example for Germany.
www.minvws.nl/en/speeches/staf/2006/healthcare-reforms-in-the-netherlands-a-model-for-germany.asp
JACKSON, E. (2010). Top-Up payments for expensive cancer drugs: rationing, fairness and the NHS. The Modern Law Review. 73: 3: 399-427.
LEES, C. (2008). Not allowing top-up fees is unethical. British Medical Journal. 336; 7655; 1205.
RARER CANCER'S FOPUNDATION (2011). Funding Cancer Drugs: An evaluation of the impact of policies to improve access to cancer treatments. Kent. Rarer Cancer's Foundation.
RICHARDS, M. (2008) Improving Access to Medicines for NHS Patients: A Report to the Secretary of State for Health.
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_089927
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joe farrington-douglas | 25-Jul-2012 2:25 pm
Here is another reference with a link:
http://www.nhsconfed.org/Publications/Documents/Topping%20up.pdf
I thought this debate had gone to bed since the Govt relaxed rules to allow people to purchase drugs outside the NHS package without being excluded from free treatment. A sensible compromise.
I guess it has come back in the context of tightening clinical criteria - in which context the idea of permitting top-ups to jump queues or to access what was previously free is much more worrying.
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