Paying to top up NHS treatment

The BBC has this week published a story on co-payment in the UK’s National Health Service. Sue Matthews, a Buckinghamshire woman with terminal bowel cancer, would like to top up her NHS care by paying for a £30,000 course of cetuximab – a drug which could extend her life, but which is not funded by her NHS trust. However, if she does so, she may also have to pick up the tab for her standard NHS treatment. That’s because the NHS guidelines advise against allowing such co-payments: they require that a given instance of treatment be either fully privately funded, or fully publicly funded.

Should co-payments be banned?

One possible problem with allowing co-payments would be that doing so would introduce inequality: the wealthy would end up getting better treatment than the poor. As it’s often put, there would be a ‘two-tier’ health system. But on its own, it’s difficult to see how this could be a decisive objection. If the inequality would arise simply because the well-off would be able to make themselves even better off, then, plausibly, we should allow it. It would seem chirlish to prevent the wealthy from buying better healthcare if this had no negative effect on others (political philosophers call this the ‘levelling down objection’). The obvious conclusion to draw is that inequalities should be fought only when the actually involve someone being made worse-off.

This suggests a second possible problem with allowing co-payments. Doing so might lead the wealthy to be less concerned about the level of care provided in the NHS, since they would always have the option of buying better care outside the Service. As a result, the quality of NHS care might fall (since, for example, wealthy people would be less likely to vote for political parties planning to spend more money on public healthcare). Thus, not only would the wealthy get better care than at present, others would get worse care.

This may be a good argument, though whether it is depends on many empirical and ethical questions which I can’t address here. But its worth noting that the argument seems to count as strongly against allowing private healthcare of any sort as it does against allowing co-payments. In fact, the argument seems to be stronger when directed against the former than the latter. When people opt for fully private care, they really do opt out of the NHS system. And they therefore lose any self-interested reason they may have had in maintaining NHS standards. But if people could instead simply top up their NHS healthcare with additional, privately-purchased treatments, they would retain at least some interest in a high quality NHS. It seems, then, that there is a stronger argument for banning fully private healthcare than there is for banning co-payments.

Indeed, as long as fully private healthcare is permitted, it could be argued that banning co-payment actually worsen the standard of NHS services. This is because banning co-payment may induce the wealthy to opt out of the NHS altogether by purchasing private health insurance, when they might otherwise have settled for co-payment, maintaining an personal stake in the NHS. Certainly, Sue Matthews’ tragic story  might induce some people  to go for fully private care – the Matthews could have afforded private health insurance, but they chose not to buy it because they believed in the NHS. This is why they are now falling afoul of the NHS co-payment rule.   

Perhaps the NHS is right to ban co-payment. But I can’t see any argument for doing so that wouldn’t also suggest that they should ban fully private healthcare.


Nick Triggle, ‘Why can’t we pay for extra drugs?’ BBC News website.

An earlier post by Dominic Wilkinson on the same topic is here.

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