Free at the point of delivery – reality or political mirage


It is commonly said that healthcare in the UK is “free at the point of delivery”. In fact this mantra is now a political mirage rather than a day-to-day reality.

Here we examine a series of twenty case studies which show that patients are beginning to develop sophisticated approaches to purchase upgrades to their basic NHS care. These case studies, drawn from everyday NHS practice, reflect our experience as clinicians within the service. The case studies range from the major killers (cancer and heart disease) to areas of medicine benefiting smaller groups of patients (e.g. maternity services and audiology).

We identify three key reasons for the use of top-up payments:

  • The varying limits of the NHS care package in different localities;
  • and
  • The limits on NHS quality, including waiting times, delays and service access; and
  • The reduction in costs of some private treatments due to advances in technology and the development of a competitive marketplace.

We also draw attention to factors which are hindering patients’ ability to build on their NHS entitlement:

  • The lack of transparency concerning patients’ options and PCT decision-making;
  • The view – wrongly-held – amongst some doctors and managers that it is not possible to “top-up” the NHS package; and
  • The difficulty the NHS system has in coping with requests that are reasonable but disruptive to the existing bureaucracy.

Some may argue that the use of such top-up payments will diminish as public funding for health increases. We would disagree, pointing to several trends, now well-established in the health debate: the upwards pressure on medical costs; the limits to tax-financing; and, most importantly, the increasing importance of consumer choice.

A key factor here is the supply-side reforms that are currently under development in the NHS in England. The progress of the reforms has been uncertain but it remains a possibility that a new NHS “market” could emerge giving some new choices to patients, including voluntary and for-profit providers. If this does happen, a greater variety of supply will hugely increase the likelihood of new kinds of demand.

It is also crucial to understand that top-up payments are entirely legal within current NHS legislation.

The UK healthcare system is therefore closer to Continental systems of mixed funding than many would think. But we are far behind in terms of the coherence of our funding system and in terms of equity. We run the risk of achieving the worst of all worlds: inequitable NHS provision combined with inequitable provision outside of the service. In both worlds the least well-off are disadvantaged.

What is urgently needed is a proper debate on the future of healthcare funding, covering both tax and independent financing, based on the fundamental NHS principle that care should be universally and equitably available. By perpetuating the political mirage of a service completely free at the point of delivery, debate is conveniently stifled.

Health professionals need to be at the heart of this debate. We will make a profound mistake if we leave this debate to politicians.

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