This article examines the implications for patient care, and for the future of rationing within the NHS, of the recent decision to permit NHS patients to supplement their care by paying for medicines — mainly expensive new cancer drugs — which are not available within the NHS. The starting point is the recommendations of the Richards' Report and their implementation through new guidance issued by the DoH and NICE. Practical challenges arise from the insistence upon the 'separate' delivery of self-funded medicines, and more flexible cost-effectiveness thresholds for end of life medicines may have repercussions for other patients. While undoubtedly part of the trend towards explicit rationing, top-up fees might also represent a significant step towards regarding the NHS as a core, basic service. Finally, the issue of top-up fees is located within the broader context of current cancer research priorities and persisting health inequalities.