nhs health care, nhs top up, nhs cancer patients
Jason DeCrow/AP
British Prime Minister Gordon Brown

Policy Changes Imperil Mission of Britain’s National Health Service

November 19, 2008 08:57 AM
by Denis Cummings
Britain’s universal health care system now allows patients to pay for drugs and treatment, prompting a debate about whether it still provides equal treatment to all.

NHS Approves Top-Up Care

The National Health Service has faced heavy criticism over the past year for enforcing a policy that prohibited patients from “topping up” their NHS care with privately funded cancer drugs. On Nov. 4, Health Secretary Alan Johnson announced a reversal of the NHS top-up policy, declaring that “NHS care must never be withdrawn” to patients who pay for private treatment.

“With those six words,” wrote The Times of London, “the era of truly universal NHS care came to an end in principle as well as in practice.”

The NHS was founded in 1948 to provide equal care to all British citizens regardless of their wealth or power. By allowing top-ups, patients who can afford expensive drugs and treatments will now be able to receive superior care than those who cannot.

Many in the country have said that equality is worth sacrificing to provide thousands of patients access to life-extending treatment. “We cannot continue to exalt the principle of equality of care above the question of its quality,” writes The Independent.

The future of NHS care will depend heavily on the National Institute for Health and Clinical Excellence (NICE), an independent health organization that determines which drugs and treatments should be covered by the NHS. It has been criticized for its approval process, in which cost-effectiveness is a significant factor.

Several days before the top-up announcement, NICE announced that it would delay a decision on the approval of four kidney drugs until 2009. It has been under intense pressure in the media to approve the drugs, which have been shown to extend lives, but have not been deemed cost-effective.

NICE’s decision on the kidney drugs may indicate how it will approach drug approval in the future. Health Secretary Johnson pushed for NICE to “give more weight to the value of the last months of life when assessing how much the NHS should pay for the treatment of terminal conditions such as cancer and motor neurone disease,” according to the Financial Times.

However, this would require an increase of funding and, as the Independent writes, “the willingness of the British public to fund health care through taxation is already at its limit.” And some health care experts, including Geoff Martin of the advocacy group London Health Emergency, fear that the new top-up policy will allow NHS and NICE to cover less treatment.

“It could turn the clock back to the days before the NHS when your life chances were decided by your ability to pay,” he said. “There is a very real danger that NICE will slow down drug approvals as a cash-saving measure, knowing that desperate patients and their families will plunge deep into debt to get the best medicines.”

Opinion & Analysis: Top-ups and equality in the NHS

The majority of Britons has supported the NHS’ decision to allow top-ups. While most writers and health experts acknowledge that it is a threat to the NHS’ commitment to equality, they feel that benefits for cancer victims outweigh the possible violation of the NHS’ founding principle.

“In one sense this decision does indeed encroach on the fundamental principle that NHS care should be free at the point of use, based on need not ability to pay,” writes Niall Dickson, chief executive of health charity The King’s Fund. “But it also protects the principle that those who have paid their taxes, and who expect the health service to be there for them, will not be deserted in their greatest hour of need.”

There are, however, concerns about how top-up care will be administered. The BBC warns that it may be difficult to distinguish between care that is provided by the NHS and care that is part of a top-up, especially regarding routine tests and scans, and treatment of side effects or complications stemming from top-up treatment. Furthermore, there is a question whether NHS hospitals will be allowed to administer top-up drugs in the case of emergency.

“We need greater clarity on what will happen—and who will pay—when things go wrong,” said Nigel Edwards, director of policy at the NHS Confederation. “It is critical that patients are made fully aware of what they are paying for with clear and explicit advice from clinicians about drugs that have not been approved as both clinically and cost effective.”

There is also worry about how the NHS and NICE will proceed with the top-up plan in place. Ian Beaumont, campaigns director at Bowel Cancer UK, expressed a common fear about the top-up policy in an editorial.

“We have real concerns that the NHS will be less likely to fund new drugs if there is a system in place to allow patients to pay for them themselves,” he wrote in The Scotsman. “Despite the review’s no doubt good intentions, top-up payments will result in a two-tier system based on ability to pay, not on clinical need, which will further undermine the NHS and its underlying principles.”

Many health advocates have said that the NHS should eliminate the need for top-up treatment by increasing the number of drugs and treatment plans available. “But the real tragedy is the inefficiency of the NHS which has led to many cancer drugs routinely available in European countries simply not being used here, writes Karol Sikora, medical director of Cancer Partners UK. “Continuing the reform of the service is more important than ever. There should be no need to top-ups for cancer care.”

Reference: NHS and NICE


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