19 September 2008
While the review on allowing NHS patients to pay 'top-ups' without jeopardising the right to free care gathers data, a debate on this emotive subject showed that opinion in the sector is polarised
As the review into whether NHS patients can top up their treatment without losing the right to free care progresses, the health community has warned of the financial implications of a change in policy.
Political pressure intensified on the issue last week and it seems likely that the current policy, which denies care if drugs are brought privately, will change. Three months into his review, national clinical director for cancer Mike Richards has said views on 'top-ups' remain 'polarised'.
Richards told a debate at the King's Fund think-tank on September 11 that the review team had finished collecting data and was moving towards making decisions, with a 'month or so' to go before it reports.
'A very strong feeling coming through is the distaste people have for people being denied NHS care,' Richards said.
But, he added: 'If you go to opinion polls, you can get any answer you like, depending on how you ask the question.'
Research by the Rarer Cancers Forum shows that primary care trusts receive 3,000 applications a year for 'exceptional funding' for cancer treatment (mainly for drugs), of which only 800 were denied. Richards said there was evidence to suggest that applications were roughly the same for non-cancer treatments.
He stressed that the terms of reference for the review went beyond cancer treatment – the most high-profile cases.
However, there is a growing feeling that the review is a symptom of a much wider debate about how the NHS can finance the increasing cost of treatment free to all at the point of access.
Professor Martin Gore, medical director at the Royal Marsden NHS Foundation Trust, made a passionate defence of the principles of equality in the health service. 'We forget our history at our peril,' he said.
The pre-NHS system, where patients had to be assessed for treatment on an ability to pay rather than on need, could create 'utter humiliation for the patients and their family', he added.
Gore conceded that the issue of 'top-up' payments was symptomatic of a broader issue of how the NHS delivered up-to-date care within a limited budget. He said a major feature of this challenge was the way cancer was now treated. 'Some of the cost of the new cancer drugs is [due to the fact] that we are turning metastatic cancer (where cancer cells spread from a primary tumour) into a chronic disease, where patients receive treatment for many months or many years.'
This presented a major problem for people paying for their treatment. 'People are not going to be able to afford a number of these drugs, and this is very likely to be discriminatory,' he warned.
There is some consensus emerging from the debate on how any policy change could work, including assurances that any additional care should be provided on a non-profit basis, and that the NHS should not incur extra costs – such as treating the side effects of medication.
But complex questions remain, some of them posed at the King's Fund debate by the NHS Confederation, the trade body for NHS organisations. Its director of policy Jo Webber said members found the issue difficult to cope with, not least where the 'practical and emotional collide'.
'Payment is a very emotive, fraught question,' she said. 'What would you do about debt for some of these treatments? The cost is very high. What do you do about debt recovery?'
Other pressing questions yet to be answered include: what happens when a patient is responding to 'top-up' treatment but runs out of money, and at what point does the patient pay – upfront or during treatment?
Another question, one often cited by opponents of top-ups, is the potential creation of a two-tier system.
For practitioners, there are ethical considerations. For example, treating patients next to each other in hospital, one receiving additional treatment, the other not, would create an 'unfairness that would be very clear', said Webber.
'We do have to think about the wider issues and make sure that what we do now doesn't make things worse when these wider issues come up,' she added.
Last week, some clear views began to emerge. The Liberal Democrats backed top-ups in the NHS with provisos. The King's Fund published its response to the Richards review on September 11.
The influential think-tank concluded that the current policy was 'untenable'. It recommended the government specify where 'top-ups' are allowed, calculate associated administration costs that should be covered by the patient, and ensure individuals clearly understand the financial liabilities involved.
The King's Fund also suggested that the NHS should pay for treatment that shows 'sufficient levels of efficacy' based on clinical evidence.
Central to the debate is the role of the National Institute for Health and Clinical Excellence, the body that approves drugs available on the health service. Professor Karol Sikora, clinical director at the cancer treatment organisation Cancer Partners UK, criticised Nice and the time it takes for drugs to receive approval.
There are also increasing calls for Nice's remit to be broadened and changed, to clarify what drugs are available and how primary care trusts decide what they provide.
In response, Andrew Dillon, the institute's chief executive, said he was looking at how decisions could be speeded up. He said there was a 'strong argument for national advice from good quality evaluation and decision-making processes'. Such guidance would attempt to eliminate the so-called 'postcode lottery' on available drugs.
The King's Fund response called for transitional arrangements for new drugs to reduce the risk of quick evaluation, that Nice should approve all new drugs for use, and that risk-sharing schemes should be further explored with the pharmaceutical industry to reduce costs. Such a scheme already exists for the sight-saving drug Lucentis.
But the broader issues remain unresolved. Faced with calls from patients to self-fund cutting-edge drugs and, on the other side of the argument, reminders about the health service's founding principles, ministers face the unwelcome task of making a controversial decision after Richards delivers his report in October.
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