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Top hats and top-ups: better health for the better off

The health secretary announced today that patients in the UK who choose to buy medicines not funded by the national health service, will no longer be excluded from receiving public health care. This announcement follows controversy about expensive cancer drugs that are available in other countries, but may not be available under the NHS.

Given that private healthcare is available in the UK (and overseas) for those who are able to pay for it, it seems unreasonable to punish patients who choose to spend their money on cancer drugs by denying them access to the public health system for part of their care. (See here, and here for previous blogs on this topic).

But, although this announcement might be welcome, it is inevitable that this will widen health inequalities between the rich and the poor in the UK. The Conservatives have claimed that this will lead to a two-tier healthcare system.(*)

Future developments in healthcare, for example medicines or technologies that lead to enhanced health and wellbeing – not merely the elimination or alleviation of disease may well also come with hefty price tags. One concern about enhancement is that, like the new cancer drugs, they will be available only to the well-off. Our society will diverge even further between the haves and the have-nots.

So this debate may be useful, to prompt us to consider what significance we should give to the distribution of wellbeing in our community and the gap between the rich and the poor. Should we focus, as the national health care does, on maximising the wellbeing of the worst off? Should we try to raise the well being of all? How much of a problem is it if the wealthy are able to live longer, healthier lives than the economically disadvantaged, and how much are we all willing to pay (and what liberties forego) to minimise this?

(*) This seems a slightly odd ‘criticism’. There is already a two-tier healthcare system in the UK (it is just that one tier is much smaller than the other). It also seems disingenuous, since conservative politicians are usually supportive of the wealthy being free to spend money on private education or health care if they so choose 


Johnson lifts NHS ban on top up treatment Guardian 4/11/08

Paying to top up Practical Ethics Tom Douglas 07/08

Paying for better healthcare Practical Ethics Dom Wilkinson 01/08

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2 Comment on this post

  1. It should also be remembered that the actual health impact of many health technologies (and enhancements) is smaller than most people think. While a new wonder drug may be more effective than the old one, lifestyle interventions that reduce the risk of getting the condition in the first place often tend to have a bigger effect (in terms of healthy lives). Maybe the real risk for a two-tier system comes from different levels of preventative medicine and proactive health behaviours rather than topping up?

  2. The criticism that this will widen the gap between the health and well being of the rich and poor is either a tautological argument or seems to miss the point. If what critics of this policy really mean is that people with money will have better health care then this doesn’t seem to be much of a revelation: as Dominic points out, it is already possible for those who can afford it to get private care both in England or abroad. Moreover the real gap in health between the wealthy and poor seems to have much more to do with factors such as proper nutrition, quality of work environment, etc. If this is a question of distributive justice, then surely the more appropriate and ‘cost effective’ approach would be to improve these more fundamental conditions rather than worry about the odd case in which an advanced treatment is provided to one patient rather than another. Moreover perhaps improving the quality of care at all levels is where the NHS ought to focus its efforts; allowing people to ‘top up’ their care with new technologies does not seem to meaningfully affect the fundamental problem of outmoded practices, but rather seems to present an opportunity for NHS apologists to shift the discussion onto more comfortable ground. Critics of the new announcement need to decide what the NHS’ primary function is: to create a sense of social solidarity, or to provide the best possible health care. If the aim is the latter, there surely is no way to see this development as being anything other than a step in the right direction.

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