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.
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.