We know that the health insurers are rubbing their hands in glee at the prospects opened up by Andrew Lansley’s Act and the £20bn cuts in the NHS, declaring that there has “never been a better time to be in private health insurance”.

But it’s still surprising to see people other than the usual suspects from “Doctors for Reform” openly proposing to abandon the two fundamental NHS principles of delivering treatment free at point of use, and sharing the risk of ill-health among the whole population by funding it through general taxation.

Nonetheless now we have a debate in the HSJ on top-up fees.

The warning signs have been there for a while. In 2009 the now notorious and in many ways impractical McKinsey Powerpoint suggestions for £20bn “efficiency savings” included a list of “procedures with limited clinical benefit”, which have since become a crib sheet for PCTs excluding treatments from the NHS, leaving  patients with a stark “choice”: go without, or go private.

Last year the first findings were published from work on “person based resource accounting”, in which the basic health costs of individuals are calculated as a way to decide budget allocations to GP practices and CCGs: this would break down the national risk-pooling of the NHS.

But the same calculations could also form the basis of a cash limited allocation of health services per person, leaving the individual to “top up” from their own pocket or health insurance if they need additional treatment.

Personal budgets are being rolled out for more and more mental health patients and frail elderly people – posing the issue of top-up payments where the budgets are too small to meet needs.

Now the Nuffield Trust has published a report by the Institute of Fiscal Studies which predicts the NHS will be charging for treatment within ten years. It suggested a “review” of the range of services that the NHS should offer free at point of use.

This dovetails into the discussion on top-up fees (headlined in HSJ as “A small change to how we pay”. The headline is misleading: indeed the very phrase “top-up” is a coy euphemism.

“Top-up charges” are simply charging for health treatment, with each patient’s access to services decided not on clinical need, but on their ability to pay. It would be a massive change, create a 2-tier health service, fly in the face of equity, and undermine the NHS as a universal service. It would limit or reduce demand while making no impact on health needs.

The authors say top-ups are a “viable way of increasing choice”: neither of these is true. They are neither viable, nor a means to increase choice for most people.

The most widespread charges already levied in the NHS are the £7.65 per item prescription charge: the only reason these regressive charges have survived in England is because of truly massive exemptions, with something in excess of 85 per cent of prescriptions issued free. The charges raise hardly any money, but deter low-paid workers from accessing proper treatment.

So if (top-up) fees are to be introduced without widepread protests, how many people would need to be exempted? And how high would the fees have to be for the minority who have to pay? Would they generate any serious level of income above the cost of administering the charges?  

Of course high fees would be an advantage in enticing some people into private health insurance to avoid them.

If there are no exemptions, only those with the money to pay are offered any “choice”: the clock is wound back to 1947, the hospitals reopen the old cash windows, and open up a back entrance for the NHS-funded patients, to ensure they do not offend the sensibilities of the paying customers.

And of course top-ups can only apply to elective care, and to acute services: few mental health clients or the frail older and disabled people using community health services have any money to pay top-up fees.

The authors studiously ignore the demographic profile of NHS caseload – with the bulk of care required by the very young, very old and the poor, none of whom will feel in any way empowered as consumers by top-up fees.

They also ignore the grim experience of low-waged patients in the areas of care where “top-up” fees and private provision have been established since Thatcher’s heyday: dental services, opticians and of course the dysfunctional basket case that is laughingly called “social care,” where services have been dismantled, quality largely abandoned and charges run rampant under the guise of ‘choice’ and consumerism.

Charges for health care have been unthinkable up to now for good reason: they are wrong in every way. They should be unthinkable again.