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Co-payment for health care is a feature of many insurance and tax based systems of health care. It can range from bribes that have to be paid in some state funded systems to get access to care priority to organised systems of co-payment such as the insurance organisation or state only reimbursing a proportion of a health providers fee with top-up fees such as prescription charges. It is important to note that terms such as top-ups, co-payments, user charges and patient contributions can have different definitions and implementations in different (social/cultural) circumstances.

Co-payment has the potential to create disincentives and incentives which may distort healthcare delivery and access[1]. It can change both supply and demand of health services[2].

The evidence-based co-payment with the most overall positive benefit to patients and health economies is reference pricing where fees are used to encourage patients to use the most cost-effective drug available for their condition.[3][4]. There is some evidence for reverse co-payments where cash transfers occurred conditional on certain behaviors[5].

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The situation in the NHS is that co-payments can be legal, but co-payments that might be seen to allow differential access to care, such as patients topping-up to obtain different care are discouraged or effectively banned. Any co-payment that might effectively result in a fee for service situation or a general practitioner providing private care for a patient entitled to NHS care would create conflicts of interest that for doctors might result in severe contractual and professional difficulties. The situation can vary, with for example Scotland presently having a more generous interpretation for mixing elements of private and NHS care than England. The general rule is that all elements of a single episode of health care must be delivered and paid for in one setting either private or NHS funded and patients can not pick and choose the individual elements. In practice there is differential interpretation of the term episode. However healthcare providers need to be very careful, particularly where their personal interpretation of this rule might conflict with other's interpretation. Conflicts of interest with contractual and political dimensions can arise. The UK government has consulted on[6] and effectively implemented[7] the following policy: "The NHS will provide a universal and comprehensive service with equal access for all, free at the point of use, based on clinical need, not ability to pay.

Healthcare is a basic human right. Unlike private systems, the NHS will not exclude anyone because of their health status or ability to pay. Access to the NHS will continue to depend upon clinical need, not ability to pay. Unless a charge has been specifically sanctioned by the NHS (e.g. for prescriptions or dental treatment), we will not charge a fee or require a co-payment from any NHS patient. We will provide appropriate care for all those referred to us, within our clinical competence."

It is probable that indirect guidance such as in the 2008/9 contact that "A tenet of ensuring a 'fair playing field' for all providers is that payment regimes must be transparent and fair." [8] will restrict the possibility for co-payments not agreed centrally.

In 2008 clarification of the issue as to whether patients purchasing drugs which the NHS does not provide for whatever reason may also be treated for their condition - usually cancers - within the NHS commenced.

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A report by Prof Richards on Improving access to medicines for NHS patients is accepted in November 2008 with some recommendations immediately implemented and others out to consultation or with implimentation timescales such as the methodology of NICE



  1. Austvoll-Dahlgren A, Aaserud M, Vist G, Ramsay C, Oxman AD, Sturm H, Kösters JP, Vernby A. Pharmaceutical policies: effects of cap and co-payment on rational drug use. Cochrane database of systematic reviews (Online). 2008; (1):CD007017.(Epub) (Link to article – subscription may be required.)
  2. Rosen B, Brammli-Greenberg S, Gross R, Feldman R. When co-payments for physician visits can affect supply as well as demand: findings from a natural experiment in Israel's national health insurance system. The International journal of health planning and management. 2011 Apr-Jun; 26(2):e68-84.(Link to article – subscription may be required.)
  3. Canadian Health Services Research Foundation. Reference-based drug insurance policies can cut costs without harming patients. Evidence Boost. Ottawa, Ontario: Canadian Health Services Research Foundation, 2005 (June):1-2
  4. Ess SM, Schneeweiss S, Szucs TD. European healthcare policies for controlling drug expenditure. PharmacoEconomics. 2003; 21(2):89-103.
  5. Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review. JAMA : the journal of the American Medical Association. 2007 Oct 24; 298(16):1900-10.(Link to article – subscription may be required.)
  6. Consultation on core principles for everyone providing care to NHS patients Dec 2006
  7. The NHS in England: The operating framework for 2007/8 Annex C
  8. The NHS in England: The operating framework for 2008/9 Annex D