In 1948 the National Health Service brought to an end a system where those who could pay necessarily got better treatment. Except in so far as prescription charges applied, care was to be provided on the basis of clinical need, not the ability to pay. However, Health Secretary Alan Johnson, anticipating the results of an independent review scheduled for October, has indicated that it is very likely that the rules about top-up will be overturned and the ban on people topping up their care by paying privately for medicine while being treated on the NHS will be lifted. Yet another step is being taken towards turning the NHS into a two-tier system.
The National Institute for Clinical Excellence (NICE) was set up to stop the postcode lottery by ensuring that all drugs approved by NICE have to be funded by every Primary Care Trust (PCT) in England and Wales with a similar set up in Scotland. Until then, PCTs were under no obligation to agree the prescription of new drugs, particularly new and expensive ones required for cancer treatment. Hence the postcode lottery: whether or not a patient could get such drugs depended on where he or she lived and whether the PCT was prepared to approve.
Before approving drugs, NICE reviews the evidence for both their claimed effectiveness and, inevitably, their cost. However, as this process can take months, patients can appeal to their PCT to be treated as an exceptional case, and so have access to drugs which have yet to be approved. If the appeal fails, those who can afford them can buy such drugs, but they lose the right to free NHS treatment.
Now there is a head of steam behind moves to overturn this arrangement, with many leading figures in the world of health care arguing that top-up must be allowed. They are supported by an extensive media campaign around people dying from cancer who have been denied NHS care after privately buying unapproved life-prolonging drugs. These figures include the NHS Confederation and the chief executive of the King’s Fund who feels that the current arrangements are now ‘untenable’. Cancer Partners UK, a private provider of cancer services, says that if top-ups are not allowed, people will buy drugs on the underground market. The Liberal Democrats have also jumped on the bandwagon saying that they would give patients the option of paying for drugs without affecting their care.
With all the media hype it is not surprising a recent survey of over 800 people in Cambridge found that 82% of NHS patients back top-up payments and 90% of doctors and nurses support the payment of supplements for cancer medicines not funded by the NHS. The government’s ‘cancer tsar’ is also investigating the withdrawal of NHS treatment from those who have paid privately for treatment and some Tories are advocating that co-payment should be allowed to access treatment for any condition.
Socialists should be quite clear about the implications of changing the top-up arrangements. It will drive a coach and horses through the principle that NHS treatment should not depend on the ability to pay.
As if by magical coincidence, the EU will unveil plans in October to let drug firms use the media to give information about prescription-only medicines. If this is allowed, patients will start demanding specific drugs they have seen promoted as part of ‘patient choice’ and reduce doctors’ ability to prescribe cheaper and equally effective alternatives. The result? Either a huge increase in the NHS drug bill which is already £11bn, or yet more pressure to extend any proposed relaxation of the ban on top-up payments. Whatever the outcome, it will be the poor who lose out.
Hannah Caller
FRFI 205 October / November 2008
