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Beyond the matron state (The Guardian)

Thursday, 3rd July 2008

I have a piece in today's Guardian on the NHS. Here's an extract:

One might have thought that a self-proclaimed plan for the NHS's next 60 years would deal with one of the most iniquitous of its many problems. But when health secretary Alan Johnson introduced Lord Darzi's report on Monday, mention was there none.

Two weeks ago the issue of co-payments was sent for review by the health secretary, who has asked "cancer tsar" Mike Richards to assess the state of play. It is time, he said, for an "up to date view". At present, patients who are denied drugs on the health service and are thus forced to pay for them are refused further treatment on the NHS.

...For months, Johnson insisted that it was quite right to refuse to treat these patients - to consider them, in effect, as non-people who had behaved so outrageously in paying for life-saving drugs that subsequently they should be denied health service care. He has based this on the notion that to accept them back would lead to a two-tiered NHS.

If the NHS did its supposed job properly - treating everyone with the most effective drugs - then there might be some medical justification for denying the right to opt back in to those who sought, in effect, worse care elsewhere. But the NHS's record on cancer treatment is lamentable. Only 8% of NHS lung cancer patients are alive after five years; the figures for Belgium and Germany, for instance, are 16% and 15% respectively. Just 17% of British stomach cancer patients survive for five years, as opposed to 33% of Belgians and 31% of Germans. So it is no wonder that many of those patients who can afford to do so pay for drugs that are prescribed by their doctors - Cetuximab and Sutent, for instance - and then denied them by the NHS.

It is little surprise that in a YouGov poll last month 89% of respondents agreed that the ban on co-payment is wrong and only 5% agreed with the health secretary's previous position that the NHS should, in effect, prefer patients to die rather than reach into their own pockets to pay for drugs the health service refuses to finance.

But the irony is that allowing co-payment will, indeed, as Johnson has always said it would, mark a revolutionary break with the health service's history. In recent years governments have started to reform the supply of NHS services through contracting out some provision and reorganising the internal market. Allowing co-payments will address the rest of the picture by opening up reform of demand, since it will introduce, for the first time, non-state funding into the purchase of NHS services.

This, of course, is the real reason why the health secretary and others have resisted co-payment for so long: it changes everything. In any area when consumers - or patients - start to be offered a choice, they soon start to demand an ever greater choice and range of services. The same process will begin once the door has been opened to part-private, part-public funding of healthcare treatment. It might start as co-payment for a small number of drugs, but it will spread, because the hitherto sacred principle of exclusive state funding - other than the basic prescription charge - will have been breached.

Patients are, after all, used to spending their money on healthcare. More than 6.5 million people have private medical insurance; a further six million are covered by private health cash plans. Eight million more pay for alternative therapies not available on the NHS, and many others pay for one-off private treatments. And this is not just the better-off: more than 3.5 million trade unionists have private health cash plans and medical insurance schemes.

The difference is that this money is spent outside the NHS. The introduction of co-payment will lead, inevitably, to a blurring of that divide, as there will be no reason in principle why patients will not be able to "top up" the care they receive from the health service. By the time of its 70th birthday, the NHS will not look remotely as it does as it celebrates its 60th.

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David Lucas

July 3rd, 2008 1:53pm

It matters a lot (in law) exactly how the co-treatment is organised. The NHS and Alan Johnson seem happy to dwell on the scenario where their current policy is strongest - but there is no real block on a hospital that wants to organising it within the rules (except for Alan Johnson's policy guidelines which appear to contradict the law in certain important areas - for example in withdrawing access to NHS care on non-clinical grounds.)

It is illegal for the NHS to charge for NHS care except where it has been specifically authorised in legislation - dentistry, prescriptions, road traffic accidents but only from motor insurance companies, etc.

A patient has to be either NHS or private for an episode of care, and to be private has to agree to accept charges.

So the NHS charging a hospital patient for a specific drug as part of their NHS treatment - without legislative authorisation is clearly wrong.

On the other hand if the patient purchases the drug privately under a private prescription (even if it is purchased from the NHS hospital itself) and then brings it into hospital as a "patient-owned drug" then there is no barrier to the NHS administering it during their hospital episode, whether NHS or private.

These rules are more often used for patients with on-going prescriptions staying in hospital for other treatment - but the rules are clear.

It is also I understand illegal for the NHS to refuse care on non-clinical grounds to patients returning to NHS status - they have no greater priority than anyone else, but, to take an essentially theoretical, if they turn up with an a bleeding surgical incision, there is clearly enormous clinical priority to closing it whatever circumstances lead it it.

Dramatically, this is the first major case where ideological platitudes about the NHS are being confronted by public outrage at the perceived spitefulness and injustice of the NHS's position.