Are top-up payments a good idea?

GPs are broadly behind top-ups, but want NHS funds for those who cannot pay. Tom Moberly reports.

Allowing NHS patients to 'top up' treatment with drugs they paid for privately fails to resolve the fundamental issue of access to expensive medicines in the NHS, GPs have warned.

Health secretary Alan Johnson announced last week that NHS patients will no longer have treatment withheld if they have paid privately for drugs.

The decision follows a recommendation in a report on access to medicines by national cancer director Professor Mike Richards, published last week.

Professor Richards said the report was 'the most challenging task' of his career.

Under the new system, the DoH has said that each episode of care must be clearly distinguished as being provided by the NHS or privately, and a 'pick and mix' approach where patients can pay to upgrade individual elements will not be allowed.

Possible confusion
But GPs fear this will be almost impossible to implement. Trying to separate private and NHS care for the same patient for the same condition will cause confusion and create problems the NHS will have to sort out, according to Dr Ron Singer, president of the Medical Practitioners' Union.

'I think GPs will be hearing all sorts of stories from patients that show the difficulty of implementing this policy,' he said.

Dr Singer said the decision increased inequality. 'What the DoH could and should have done was to announce at the same time that it was setting up a fund so that people who could not afford to pay for these drugs could be given them on the NHS.'

Dr James Kingsland, president of the National Association of Primary Care, argued that top-ups were unnecessary. 'There is so much waste and inefficiency in the NHS. If you stripped away even a small part of that, you could afford to pay for expensive cancer drugs.'

The public needs to understand that the NHS is a cash-limited system and hard decisions have to be made about how resources are allocated, he said.

He said decisions on which patients should receive which drugs should be made by clinicians, not politicians or PCTs. Clinicians should be handed budgets and be left to manage them, he said.

Dr Kingsland added that there have long been payments made for NHS care, such as for prescriptions and dental care. GPs have to make difficult decisions daily about discussing treatments not available on the NHS.

'There is a perception of change within the NHS,' he said. 'But it is happening anyway.'

The BMA has welcomed the decision to allow top-ups, but called for a wider public debate about the scope of a publicly funded healthcare system.

GPC deputy chairman Dr Richard Vautrey said top-ups could be the start of a slippery slope to a two-tier health system. But he said: 'It is only when these things are introduced that you can see how they work.'

It will be important to monitor how it is used, he pointed out, to ensure it does not compromise equity of access to NHS care.

Existing guidance
GMC guidance will not need to change to reflect the policy - doctors already have a duty to tell patients about any bills they face and 'treatments that you believe have greater potential benefit for the patient than those you or your organisation can offer'.

Mr Johnson's announcement will only affect patients in England. However, BMA Northern Ireland plans to lobby for the same policy. The Scottish Government is reviewing its guidance on NHS care for patients who buy drugs privately and the Welsh Assembly Government is considering the issue.

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