The key underlying principle of the NHS is to provide medical treatment according to clinical need and not ability to pay" /> The key underlying principle of the NHS is to provide medical treatment according to clinical need and not ability to pay" />

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Is co-pay the answer?

The key underlying principle of the NHS is to provide medical treatment according to clinical need and not ability to pay

The key underlying principle of the NHS is to provide medical treatment according to clinical need and not ability to pay, therefore surely this must be taken as an absolute. That is, NHS care should be given to patients who can afford to pay for medical treatments (and therefore may choose to, given the option), as well as those who cannot.


However, that such a decision - to self-fund what would usually be life-saving or life-extending treatment, otherwise unavailable because the NHS will not pay for it - subsequently disqualifies such patients from receiving further free NHS treatment surely begs a question of equity regarding government policy?


In such a case, it might be argued, current policy already dictates a two-tier system by discriminating against those who can (and do) pay out of their own pocket for clinically effective drugs that the NHS wonít provide on the primary basis of cost-effectiveness.


This is the crux of the debate which has flared up between politicians, doctorsí representative associations, think tanks, NICE and the NHS. The central challenge for all stakeholders seems to be to devise an affordable and equitable means of providing clinical- and cost-effective NHS care to every eligible citizen in England, and possibly the UK, while permitting those with the ability to pay more to access newer, more expensive or specialised medicines on the basis of independent advice.


Then again, this might prompt further questions such as:


  • How would 'paying patients' obtain appropriate information on 'non-NHS-funded' treatments, in order make the decision to co-pay?
  • Would such patients be able to go against their doctor's advice, and either: a) choose to self-fund a more expensive treatment, even given a relatively smaller probability that the ends would justify the means; or b) choose the NHS option, though it may bar access to the very latest, potentially life-extending innovations?
  • Might doctors come under pressure to encourage private payment if it saves the NHS covering the cost of treating cancer, for example, in patients who could (and might be likely to) pay for more innovative treatments?
  • Without DTC information provision, what mechanisms would be in place for pharmaceutical manufacturers to convey the value of their latest innovations to patients able to self-fund?


"This is a complex and sensitive issue," admitted National Clinical Director for Cancer, Professor Mike Richards, charged by Secretary of State for Health Alan Johnson with reviewing current policy on private versus NHS payment for drugs.


In a letter to Strategic Health Authorities, regional directors of public health, Acute and Foundation NHS Trusts and PCTs, he wrote "I am approaching this review with a genuinely open mind, and I am keen to hear view and evidence from all sides of this debate to help inform my final recommendation... I am keen to gather as much evidence as possible."


An NHS insider told PM that NICE would most likely play a central role as an independent intermediary: "the future of co-payments will be left to NICE, which is highly likely to produce a list of drugs considered to have merit but which are outside the NICE QALY limits. It will publish data on the drugs in the normal way as well as recommend they are listed as ëco-payment productsí that the NHS will be able to administer, along with any other treatments and services, but where patient pays the cost of the drug alone."


Andrew Dillon, CEO at NICE, told the Sunday Times in late July that the organisation would be well placed to advise patients wishing to 'top up' their NHS treatment. "One of the contributions that we feel we would be in a very good position to make - and that we would like to make - would be to provide information to patients to enable them to make their own judgements, in an informed way, about whether using their own money was the right thing to do."


At the annual BMA conference in Edinburgh (June 2008), doctors supported the prospect of patients choosing to purchase some treatments (unavailable through the NHS) privately without incurring exclusion from free NHS care covering the rest of their treatment and medication requirements. However, they stopped short of advocating an official co-payment system pending a review and wider debate with the public.


Alan Johnson MP will make public the findings from Professor Richards' review in October this year.

30th July 2008


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