Top-up payments for private health care: Another step towards two-tier National Health

THE GOVERNMENT recently decided to let patients in England 'top-up' their NHS care with payments for private treatments not available on the NHS. In the past patients who wanted to obtain private treatments did so on the basis that they gave up their right to have NHS treatments alongside this for the same condition.

Jackie Grunsell, Save Huddersfield NHS councillor

Often, the kinds of treatments paid for in this way are expensive or relatively new cancer drugs, which NICE (the national institute for clinical excellence) has decided will not be paid for by the NHS.

Over the years NICE has made some controversial decisions about which drugs will or won't be NHS funded. The decision to give treatments for Alzheimer's dementia to only a select group of sufferers angered patients, carers and support groups who say when treatment is withdrawn they may see a marked deterioration in the person taking it.

They feel NICE puts cost implications before benefits for individuals and does not place enough importance upon someone having a few more months or years of better quality of life.

NICE

In some circumstances drug companies may be trying to market treatments which in reality are not of proven benefit or suitable. However, NICE was recently criticised for refusing to approve a range of new kidney cancer drugs.

Sir Michael Rawlins of NICE was prompted to make a statement saying "We are told we are being mean all the time, but what nobody mentions is why the drugs are so expensive".

This suggests NICE's decisions are made largely on the basis of cost, not just how effective a drug is. He said kidney cancer drugs could be produced at about a tenth of their cost, if it weren't for 'perverse incentives' to hike the prices, such as the linking of pharmaceutical company executives' pay to their firm's share price.

He stated: "The other thing we have to pay for is the cost of marketing. Marketing costs generally are about twice the spend on research and development". Advertising directly to patients is not allowed in Britain but is commonplace in the US and to some extent Europe, implying that the NHS is, in effect, paying marketing costs for elsewhere in the world.

It was not right that working-class or middle-class people who felt forced to top up their NHS treatment with privately bought drugs should have had their NHS treatment withdrawn.

But the main problem with top-up payments is that they will reinforce the two-tiered healthcare system which already exists to some extent. In effect those who can afford to pay for the newer, more expensive treatments, will get them and the poor will go without. In a recent Health Service Journal poll 54% of NHS managers felt the policy would make the NHS 'less equal'.

Already private companies are circling to pick up profits from this policy. WPA Health insurance, Bupa, AXA/PPP and Norwich Union healthcare are all looking at offering insurance cover for treatments requiring top-up payments. The danger is that this policy has opened up the floodgates and top-ups will become more and more the norm for an ever-increasing range of treatments.

NICE may feel more comfortable refusing to allow expensive treatments, safe in the knowledge that patients will be able to buy them. In reality this is one of many steps towards further involvement of private companies in the NHS and a move towards a US-style insurance-based healthcare system.

In fact many of these treatments, where of proven benefit, could be afforded by the NHS and made available to everyone. If the policies of privatisation were reversed, the money spent on expensive PFI projects could be diverted back into the NHS budget.

More importantly, nationalising the drug companies would allow medications to be made more cheaply in generic form rather than under patent. The enormous profits siphoned into the back pockets of drug company shareholders could be spent on research in the genuine interests of the health of the population as a whole.

The matter of 'who decides' what treatments are or aren't made available also needs tackling. NICE is an unelected quango and insufficiently accountable to the public.

Democratically elected representatives of NHS staff, patients and the wider public should be making these vital decisions on the basis of freely open information from those developing new treatments, who should have no interest in making profits, but should put health needs first.