article
Keep the cash flowing
08 January 2009
The “end of the NHS as we know it” (according to some) might
have attracted greater public attention if it had not been
announced on 4 November 2008, the same day as the US presidential
election.
The problem was obvious: a free NHS can’t
provide everything for everyone, but it was Department of Health
policy that you could not be a private and an NHS patient in the
same episode of care, so if you pay privately for something that
the NHS will not fund – the latest expensive cancer drug, for
example – you risk losing entitlement to all NHS care for that
condition. It is easy to see why this caused great media
interest and public outrage in high profile cases, not soothed by
the fact that some Trusts softened the effect with a more generous
interpretation of the policy, adding another layer to the perceived
“postcode lottery”. Professor Mike Richards (“the Cancer Tsar”) was
asked to review the issue and quickly concluded that the strength
of feeling made the status quo untenable.
The solution, however, is less obvious,
especially with the spectre of patients in neighbouring NHS beds
receiving different treatment for the same condition according to
the depth of their pockets, rather than clinical need.
To avoid this, Professor Richards recommends
an approach, already accepted by the Government with immediate
effect, which is built on the principle of “separateness”: a
patient will not lose entitlement to NHS care if they privately top
up their treatment as long as the extra treatment is administered
separately from the NHS care – quite literally, in another part of
the NHS hospital set aside for private patients, or in a private
clinic. You will also have to pay for any associated costs of that
extra treatment, ie tests, follow up and management of any
complications.
A few issues are immediately obvious:
- Is it practically possible to separate costs associated with an
extra private treatment in this way? How can unpredictable
consequences, like (private) drug side effects, be distinguished
from effects of other (NHS) drugs?
- Given that uncertainty, will greater involvement of private
providers at the same time as NHS care lead to more litigation over
where liability lies, or the effect of any indemnity, when things
go wrong?
- Powerful as the image is of different treatment in neighbouring
beds, does it really make any ethical difference to wheel one
patient down a corridor to have their extra treatment out of
sight?
- Will the insistence on separation of care, to protect these
sensibilities on (perceived) inequality lead to discontinuity of
care, in a way that is avoided at all costs in every other clinical
context, given the obvious problems for communication, clinical
governance and patient safety?
- Will separation of follow ups / test etc to ensure payment is
made for those associated with the private treatment mean
duplication of time and resources, as often the same NHS staff will
be delivering both parts of the care, not to mention the challenges
of assessing and enforcing these charges?
- The definition of the key concept of separateness is unclear,
making the scope of the new policy uncertain. The example
given in the report says that a privately purchased additional drug
(and all associated treatment) can be permitted as separate, but an
upgraded cataract implant cannot be bought as it is inseparable
from the NHS operation. This seems counter intuitive.
To be fair to Professor Richards, the central
thrust of his report (significantly titled “Improving Access to
Medicines for NHS Patients”) is that fewer people should find
themselves wanting to pay for a private top up, though this relies
on a fairly wishful combination of pharmaceutical companies
dropping their prices, and quicker and “better” decision making by
NICE and funding PCTs. The implication is that saying “yes”
to funding a drug is a “better” decision than saying “no”, but of
course the NHS will still have to balance the books.
Doctors should explore all NHS funding options
before advising on a private top up, but this has real practical
problems. Any clinician must advise of all appropriate
treatment options at the outset, and a patient in extremis may not
want to wait while a PCT reviews exceptional funding. Will
the PCT’s decision be affected by private payment already being in
place? Will patients seek reimbursement? How will
vulnerable patients be protected from “snake oil” sales or the
temptations and financial pressure of treatment they can’t
afford? How ruthless will the NHS debt collection be where
top up treatment is started and then funds run out (or the patient
dies before payment)? How can NHS doctors advise on the costs
/ benefits of private top up drugs without becoming surrogate
marketing for those drugs companies, and will this tempt more staff
away from the NHS and into private practice?
Just like the Darzi review, this adds to the
pressure on PCTs to review and reform their commissioning and
exceptional funding policies, collaborating where possible, and
they will need to be careful about taking advice on getting this
right.
But clearly the implications of the new policy
will reach far into every organisation that provides NHS care as
well, raising issues of efficiency, clinical and financial
governance and patient safety, as well as redrawing the doctor /
patient relationship to some extent, making healthcare more
explicitly a commodity.
Although draft guidance has been published and
is out for consultation until 27 January 2009, the questions are
only about the implementation of the principle of separate care,
and the policy change is a done deal. We will have to see how the
far reaching implications unfold across the whole NHS, private
medicine, pharmaceuticals and insurance industries.
save to PDF