TOP-UP PAYMENTS                              

GPs say no to offering top-up payments for private primary care (Pulse: 21 May 2015)

GPs gave a resounding ‘no’ to offering NHS patients the option to pay extra ‘top-up’ payments for private services at their annual BMA conference today.

The LMCs conference overwhelmingly voted against a motion put by Gloucestershire LMC, which called for general practice to be allowed to offer both private and NHS treatments - and for the GPC to include this in contract negotiations.

The motion stated: ‘Conference believes patient care would be improved were practices to be allowed to offer ‘top-up’ private services to their NHS patients and requests that the GPC include this in their contract negotiations’.

Putting the motion, Dr Jethro Hubbard argued the move would level the playing field between GPs and other providers like foundation trusts.

Dr Hubbard said: ‘NHS Foundation Trusts and private companies are allowed to provide NHS and private services to the same population.

‘Safeguards and regulations protect patients while allowing them the choice to pay if they wish. Allowing the large providers this flexibility while denying it to small businesses that constitute general practice is an inherent double standard.’

He added: ‘If GPs were able to supplement NHS work with paid-for minor operations then the investment in training and equipment becomes worthwhile and benefits both patients and the NHS profit. If large providers can be trusted to work with the population via both the private and NHS routes, then why are GPs not afforded the same trust?’.... read more


The care bill won't do anything to cap the top-up fees charged by care homes (The Guardian: 17 July 2013)

The practice of care home top-up payments – a "secret subsidy" in the words of the charity Independent Age – is rife. Best estimates suggest that 56,000 families are paying an extra sum to the care home looking after their loved one. Such payments are supposed to be voluntary, typically to enable the resident to have a bigger room or a nice view, but the reality is that many are not. In one case, in which Independent Age advised a man required to pay a top-up fee for his wife's care, the council involved agreed to repay him more than £20,000 after he threatened to seek a judicial review.

This survey exposes a woeful picture of confusion among councils and widespread ignorance of their legal duties. Of 129 authorities that responded to a freedom of information request by Independent Age (86% of all English councils responsible for social care), only 36 said they knew about all top-up payments in their area and so were able to be sure that families were – or at least had been – "able and willing" to pay them, as legislation stipulates. should be monitored by the council, which must anyway contract with the home for the full fee.

There is no prospect of an end to top-up payments under the care bill reforms currently in committee stage in the House of Lords. The bill preserves families' right to make such a payment to supplement "the reasonable cost of securing the provision of the service concerned in the local area" which would be included in an eligible older person's personal budget allocated by the council.

The survey offers a timely reminder that the bill is no at-a-stroke solution to the problems of care funding. The plans it includes for a £72,000 cap on lifetime care costs would not stop families shelling out for top-up fees and/or non-care "hotel" costs. As Labour peer and care costs expert Lord Lipsey warned in a debate last week, that could amount to £37,000 a year even after the cap was reached.... read more


Hospitals accused of creating 'two tier' NHS by charging for some treatments (The Daily Mail: 08 July 2012)

Hospitals are offering patients who aren’t eligible for certain types of care or who don’t want to wait the option of paying for their treatment, according to this article. The hospitals describe the treatment as ‘self-funded’ rather than private and say the payments are significantly lower than those of private clinics. Several hospitals, including Epsom & St Helier Hospital Trust in Surrey and Homerton University Hospital NHS Foundation Trust in London, offer IVF patients the option of NHS, private or ‘self-funded’ treatment.  The practice has raised fears that wealthy patients will be able to jump the queue, while the less well-off suffer. Joyce Robins, of campaign group Patient Concern, said the practice could create a two-tier NHS and she questioned whether ‘normal’ patients would be pushed down the queue in favour of those willing to pay. And critics say it contradicts the founding principle of the health service – that healthcare is free to all at point of delivery.... read more


More GPs discuss treatment outside the NHS with patients (The Guardian: 21 November 2012)

Longer waiting times and restricted procedures mean that more patients are opting to pay for treatment or care themselves. Half the GPs in one survey said patients were asking about self-pay options because of longer waiting times and patients not fitting the eligibility criteria.

In June (2012) it was revealed that limits on cataract surgery were in place at 66% of trusts in England and more than a half were rationing hip and knee and weight loss surgery. Around 70% of GPs in the BMI Healthcare survey said they were unable to refer patients because of PCT criteria issues at least once a month, whilst in some regions this rose as high as 82%. Nearly a quarter said they encountered this on a weekly basis.... read more


NHS could bring in charges for meals and TV to ease cash crisis (Evening Standard: 18 March 2013)

Patients could be charges to call out a GP or eat hospital meals, and could pay more to watch television in NHS wards, according to The NHS Confederation, in what the organisation terms a “frank discussion” document designed to tackle the “unprecedented financial dilemma” facing the health service.  Proposals include charging patients £8.50 to call an out-of-hours doctor to their home. According to the NHS Confederation, the report - ‘Tough times, tough choices: Being open and honest about NHS finance’ - sets out options, not solutions, by being open and honest about the NHS finances and the choices ahead.

Mike Farrar, chief executive of the NHS Confederation, said: “We need to talk openly and honestly about why our health service needs to change. We cannot risk the wheels coming off and patient care suffering.” Campaigners said the proposals undermine the founding principle of the NHS that care must be free at the point of delivery and warned that seriously ill patients could be discouraged from seeking treatment if they thought they were unable to afford the fees.... read more


NHS chief says patients face more charges (The Telegraph: 15 April 2013)

The NHS will have to charge patients for more of its services unless the economy recovers strongly, according to Professor Malcolm Grant, the chairman of NHS England, the new body responsible for the day-to-day running of the service. He notes that demand for the services of the NHS is likely to rise rapidly in the years ahead, and that it would rise faster than the health budget itself, which could force the NHS to start charging for more of its services. The article is based on a report published by the NHS Confederation, in which NHS managers have suggested charging patients for certain services, such as hospital meals and home visits by GPs.... read more

Why top-up fees are not the answer (Health Services Journal: 23 July 2012)

In an article triggered by the article - How patients could benefit from top-up payments (Health Services Journal: 12 July 2012) - the author argues that top up charges would mean that a patient’s access to services would be decided on their ability to pay rather than on clinical need, and that a two-tiered health service would be created.... read more


How patients could benefit from top-up payments (Health Services Journal: 12 July 2012)

The authors of the article argue that top-up payments (voluntary financial contributions from patients for access to drugs, medical devices or health services not funded by the NHS) are an alternative to other healthcare funding mechanisms (e.g., private insurance, rationing, private care). They suggest that top-up payments are a clinically and economically viable healthcare provision tool.... read more


Two issues with competition in healthcare (BMJ: 2011)

Research fellow Lucy Reynolds presents two issues with competition in healthcare. Firstly, she argues that fees for services result in overtreatment of some patients and undertreatment of other patients: those who can pay end up getting treatment that they do not necessarily need, whilst those who cannot pay may lack much needed treatment. Secondly, according to Reynolds, fees for services combined with patients’ trust in doctors leads to ‘supplier induced demand’; healthcare in which the demand is not determined by the patients.... read more


Response to the consultation on the draft guidance on NHS patients who wish to pay for additional private care (KONP consultation response January 2009)

Dr Jacky Davis argues that extending Top-ups will lead to great inquity and push the NHS towards an insurance based system. 


NHS chief warns of potential for user fees (PharmaTimes: 16 April 2013) 

NHS chief warns of prospect of charges (Financial Times: 14 April 2013) 

NHS boss warns charges will have to be considered (The Telegraph: 15 April 2013)

Public in favour of charging for 'some' NHS services (Health Insurance Magazine: 17 April 2013)













more on charges: 




Key facts:

14% increase in self pay in the last 3 years

70% of GPs blame restrictions in NHS treatments

NHS rationing is rising

Hospitals encouraged to offer more private care

Two in five fear NHS will soon cease to be free 

57% of survey respondents ‘unprepared for personal health budgets'

Key trends:

Stricter rules for GPs on rationing (gp examples)

Hospitals offering more private care

More people forced to pay for care


More patients are already being forced to pay?

Related content:

More articles on rationing

Background on rationing

Background on personal health budgets

Background on top-up payments

Ways people could be forced to fund their own health care



Policy controversy:

The current market-led NHS changes are restricting care and driving hospitals, GPs and patients towards private care.

Few politcians openly support fees for care, but policy and funding pressure could mean patients have to pay to top up their care beyond basic levels, and a two-tier NHS could result.

Colin Leys explains "Shrinking of NHS hospitals means free provision will be reduced to being good enough for the poor, and a safety net for the rest"

The costs of healthcare are rising worldwideTax rises could be needed and cost savings are being made. What's next, more of the market, more personal responsibilty and new user charges?

The NHS confederation has proposed increasing NHS user charges for GP and hospital visits, which according to Allyson Pollock quite ignores "decades of research evidence about the catastrophic effect that this would have on access and the poor."



Who thinks there should be more charges?

MPs committee says "we are concerned that other savings are being achieved by rationing patients’ access to certain treatments. These include cataract surgery and hip and knee replacements.

The NHS managers organisation says "we identify four tough choices: do nothing; spend more; do more for less; ordo things differently", which could include more user charges.

The government say NHS care will remain free at the point of use, Jeremy Hunt, health secretary, said he would “oppose” the introduction of new user charges into the NHS.


Recent reports:
A report by the NHS Confederation March 2013

Forder, J., Jones, K.,  Glendinning, C., et al. PSSRU Discussion Paper. November 2012.

A report by the King’s Fund and Ipsos MORI based on two deliberative events in London and Leeds in April 2013 

This report for the Nuffield Institute 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.
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