The proposed introduction of top-up fees for certain medical treatments in Southland and Otago may be well intentioned. But it may also act as a Trojan Horse for creating a widely separated two-tier health system unless the idea is rapidly and vigorously resisted.

The proposal sets out rather starkly that certain "effective treatments are not currently funded by the Government", and that the solution is to allow patients to pay for them as "top-ups". However, once it is explicitly accepted that it is okay to withhold "effective treatments" in the public system, it will not just remain at expensive cancer treatments - all sorts of other costly treatment options become fair game in common diseases such as heart attack and stroke.

The scenario is thereby foreseeable where two young patients arrive in the emergency department with heart attacks in side-by-side cubicles. One gets the "budget" clot buster treatment option which is probably okay, but the guy next to him opens his wallet and gets the "elite" option of emergency angioplasty with direct opening of the blocked coronaries. Both of these treatments have been shown to work, but angioplasty is slightly better and is very much more expensive.

Over time, the difference in survival would add up and eventually, more wealthy patients would survive heart attacks than less well off patients. The cumulative effect of a range of survival differentials in many diseases and injuries would eventually exaggerate the already marked differences in mortality rates between races and social classes.

Furthermore, those patients paying in public hospitals simply to get the best treatment option will become more and more resistant to funding anything other than pure "safety net" bargain basement treatment for the non-paying patients out of their taxes. Over time, therefore, no health dollars are saved by some people topping up their treatment options. The free public health system just slowly collapses into an under-funded first aid station, while those with means pay large insurance premiums (if of course they are accepted as a "reasonable risk") to cover the multiple "top-ups" needed for adequate medical care.

Paying directly for health care is not divisive or destructive when this involves securing convenience, privacy and certain creature comforts in a private hospital for example.

Once it is explicit that dollars buy better clinical outcomes through initiatives such as the proposed Otago / Southland top-up scheme, then the notion of equality of healthcare as a universal right is gone, probably not to return.

Dr Tim Parke is clinical director of the adult emergency department at Auckland City Hospital.