Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Please don't kill Zombie
- Christoph C Lees (4 July 2008)
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Undead or Alive ?
- L Sam Lewis (5 July 2008)
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Inequality - the boot is on the other foot
- Gwendoline M Harlow (6 July 2008)
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Re: Inequality - the boot is on the other foot
- Alan Rodger (7 July 2008)
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This zombie won't die
- Karol Sikora (7 July 2008)
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These arguments are never-ending
- Neville W Goodman (8 July 2008)
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The Zombie returns
- Cam Donaldson (14 July 2008)
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All men are not equal
- Anne Savage (14 July 2008)
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Christoph C Lees, Consultant Obstetrician Cambridge CB2 2QQ
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Cam Donaldson's argues emotionally but erratically against copayments. What he fails to acknowledge is that many other European countries, spending a similar proportion of GDP on health to the UK, do allow automatic and 'free' access to expensive drugs and procedures frequently not available here. Is the solution that he proposes-namely raising more revenue by increasing taxation-really the answer? Do we need to spend even more of taxpayers' money in order to fail to afford what other health systems offer while spending less? But there is another important principle too. Those of us that support co-payments do so with the realization that they represent an imperfect solution to an imperfect health funding system. Though we cannot pretend it represents equity, should individuals not be free to choose to spend their own money in a way that might improve their lifespan or quality of life, without being financially penalised? To argue the converse is to argue against the right of an individual to determine their own destiny in an unequal world. To suggest that the solution is "called taxation", as does Cam Donaldson, is surely the ultimate, original, 100% pure organic zombie. Competing interests: Founder Member, Doctors for Reform |
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L Sam Lewis, GP Surgery, Newport, Pembrokeshire, SA42 oTJ
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I agree with Christoph Lees, that Cam Donaldson argues erratically. Certainly Cam is right to argue that the problem of listing what 'beneficence' will be funded by the NHS is not 'solved' by copayment, and nor will total health-spending be more efficient. The NHS also aims to offer equity. But the point of "copayment" is to pay some respect to the autonomy of the individual .. Unless Cam intends to take ALL our money, and ALL our freedom, his cause must be one of compromise between effectiveness, efficiency, equity and 'patient-centredness'.
But Christoph is mistaken to argue that we can match those other countries spending the same share of GDP, in having many more drugs available. The "percentage GDP" fallacy is neatly revealed by Delamothe's graph of per capita health spending. Norway seems the place to go !
Delamothe T. A centrally funded health service, free at the
point of delivery. BMJ 2008;336:1410-2.[Free Full Text]
Tony Delamothe How the NHS measures up Competing interests: my health or yours ? |
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Gwendoline M Harlow, retired My home. DN20 9HR
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In all the arguments I have read about this issue, I see that no-one seems to have considered that if co-payments are not allowed, there is likely be a situation whereby patients will die because they are unable to afford NHS care. Surely this is an even worse breach of the basic tenets of the NHS than allowing people to try and save their lives by selling everything they have, friends doing fund raising and so on, to buy an extra drug? Not allowing co-payments seems to me to be completely unethical. Do no harm? Competing interests: None declared |
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Alan Rodger, Medical Director Beatson West of Scotland Cancer Centre, Glasgow, G12 0YN
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Baroness Finlay and Lord Crisp in their editorial,"Drugs for cancer and copayments" support copayments with four essential criteria. The first legislates to restrict to a list of approved drugs, the second is a given that "the patient should want the treatment", the third about reasonable belief by and peer support for the treating clinician is wide open to abuse and misinterpretation and legal challenge and the fourth insists on data collection in order to aid research.This latter criterion will fail as the demoninator is described as a small group in the scale of the NHS's customer base. There is also the assurance that this is "mostly" for those drugs yet to be reviewed by NICE. That is not the experience revealed by recent high-profile cases in the media where cetuximab for colorectal cancer has featured prominently and it has been rejected by both NICE and the Scottish Medicines Consortium (SMC). Finlay and Crisp state that "it is a fundimental and essential principle that all drugs and devices fully proved through appraisal should be available freely". Good, but do they support the corollary that those rejected by appraisal are excluded from their approved copayment list? The authors also compare favourably the use by patients of self-funded complementary "therapies" nearly all of which have no evidence base and have never undergone the rigours of the appraisal by NICE or SMC. Such self-medication cannot be used as an argument to assist one apparently small group of patients to copay what others will be denied. The critical issue to address is the rapidity of NICE and SMC review, a process that is often lengthened not by those bodies but by the time it takes industry to submit to them after license; to ensure that which is approved is made available at no cost to the patient as soon as possible; and to manage a fair and open system of assessing nonformulary applications. The next by-election to the UK parliament is in a constituency where cancer mortality statistics are poor. Allowing those on disability benefit or the old-age pension to copay for new cancer drugs will make no impact on that - because they could not. This debate is emotional because it affects lives and, I suspect like 60 years ago, relates not a little to fears over clinical freedom. It needs also to focus on equity and fairness. Competing interests: I am required to assess all nonformulary medicines requests for our cancer centre. |
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Karol Sikora, medical director 21 Barrett St, London W1U 1BD
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Why is it that all the arguments against top-up payments seem to come from well meaning public health doctors? Do they know what it's like to be in a cancer clinic these days? Patients and their families know the score. The internet tells it as it is. Platitudes from the government about world class services - mentioned 40 times in the recent DH Cancer Reform Strategy cut no ice. It's great to intellectualise about the problem from a cosy isolation of a health policy group. Those of us out there are struggling. Increasing taxation is not the answer. We now spend similar amounts per capita on cancer than the rest of Europe where there are no problems with these drugs. Monolithic monopolies such as the NHS are riddled with inefficiency. And why can patients living in Fulham get drugs that patients in Oxford can't even though they come to the same West London Cancer Centre? Top-iup payments should not be necessary if the system worked well. Competing interests: Medical Director, CancerPartnersUK |
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Neville W Goodman, Retired Anaesthetist BS9 3LW, UK
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These arguments get nowhere. Similarly, the debate that appeared in the same print issue got nowhere. (1) People have entrenched views, pick the evidence to fit, and distort whatever evidence there is to suit those views. Karel Sikora says the NHS is an inefficient monopoly, but the USA spends lots, allows all sorts of payments, is riddled with inefficiency and people taking money from the system, and has worse healthcare than we do. Polly Toynbee and others say that the NHS, despite its faults, is the most efficient system there is. That is what I believe, but I, too, pick my evidence to fit. Tony Delamothe (2) mentioned the paradox that it is in everyone's interests to carry on complaining about the NHS so that notice is taken. The downside is the effect on staff of constantly being told they are rubbish. Rudolf Klein, also in this same print issue (3), highlights the inevitable and uncorrectable strains between competing demands in any healthcare system. To add to the strains, we know, as John Snow tells us (4), that "NHS is fantastic" does not sell newspapers. About the only certainty is that these same arguments will continue for the next 60 years of our system, whether it is the NHS or not. 1 Coombes R. The NHS debate. BMJ 2008;337:a628. 2 Delamothe T. How the NHS measures up. BMJ 2008;336:1469-71. 3 Klein R. What does the future hold for the NHS at 60? BMJ 2008;337:a549. 4 Snow J. How the media are failing the health service. BMJ 2008;337;a572 Competing interests: None declared |
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Cam Donaldson, Director and Health Foundation Chair in Health Economics Institute of Health & Society, Newcastle University
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Despite naively thinking we might kill the zombie of user charges for good, I feel compelled to reply to the interesting set of responses my article received. Christoph Lees raises a whole set of issues in his short response. It is not clear to me, however, whether he views the more mixed public- private funding arrangements of continental Europe to be better or worse than ours, although I suspect it is the former. However, despite many recent references to such countries as success stories, they tend to have more problems with cost control than we have in the UK precisely because of these mixed funding regimes. Given the recent states of their economies, they are also struggled to maintain these systems. Drs Lees and Lewis also point out that individuals should have right to spend their money as they see fit. To me, patient-centredness, as Dr Lewis puts it, is not about saying to some that they can have the drug because they can afford to pay for it out-of-pocket whilst saying to others who cannot afford it that they are excluded. Surely, such an objective can be achieved in ways other ways. On Gwen Harlow’s points about patients dying because they are not allowed to spend the money they have raised on a drug, I agree, but only to an extent. Likewise with her point about 'do no harm'. Harm will be done through top-ups, in that doctors' and facilities' time spent on those who can get access through paying the charge could have gone to someone else. It is these trade offs we need to face up to. If the drugs are indeed effective to some degree, my point is that Gwen’s scheme may be OK if people can self-prescribe, stump up the cash for the drugs and get them off the Net, self-administer and self-monitor as to how the drug has worked. All these things take publicly-funded resources (mainly carers' time, space in hospitals etc.) which may be diverted from someone else because a person was able to come up with the cash. So, it still has to be an issue with which the public system engages, unless one wishes to go private for one’s whole package of care. Therefore, in response to all of these proposals, the keys are (1) to sort out inefficiencies in the NHS, which allow for more (useful) care to be provided and (2) to recognise, as a society, that the quid pro quo for having a publicly-funded system is that we cannot provide everything (which politicians do not seem able to admit publicly) and so we need an open and honest debate, as a society, about what the criteria for provision should be. This still keeps things within public funding without (initial) resort to higher taxation. However, if we decide more funding is indeed required, I disagree with the anti-extra-taxation arguments of Drs Lees, Lewis and Sikora. We currently pay less tax than many of our European neighbours, including Norway, where Dr Lewis eloquently intimates we should go! I am not entirely clear what other arguments Dr Sikora is making. It seems, in part, to be based on saying that because (as a health economist, not a public health doctor, by the way) I am not on the front-line of care, I cannot have an opinion. It can just as easily be argued that physicians on the front-line do not have a balanced perspective, often dressed up under the smokescreen of ‘Me and my patients…’. These dichotomies get us nowhere. As a mere economist, I can only point out the consequences of different funding regimes. Despite my personal opinions, as an economist, I am comfortable with individuals having the right to spend their own money on top-ups as long as the proponents of such policies come clean and admit that we are now changing the resource allocation system within the NHS towards one based, at least in part, on willingness and ability to pay, and that the politicians who introduce any such scheme seek societal approval for it at the ballot box. Competing interests: None declared |
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Anne Savage, retired NW3 5RA
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There has been much criticism of Dr Meldrum in the national press recently but no one seems to have pointed out that the NHS is not, and cannot be, equal for all. During the last century, when not working in Africa, I did locums in all parts of the country from St Austell to the Orkneys. In Cornwall I treated patients in the local hospital with help from visiting specialists, in Surrey I did surgeries in the Church Hall, in rural Somerset in cottage parlours, perfectly adequate for checking blood pressures or looking into ears. On a small Orkney island I delivered the drugs by hand and arranged air ambulances when necessary. Patients that needed Out Patient appointments in Aberdeen were given Rail Vouchers for themselves and a companion and free accommodation for the night. On the service side most of the rural GPs I worked for did their own ECGs and minor surgery and the surgeon in Kirkwall was happy to do a Caesarean Section or SMR. When I was there he was off learning to do TURs. I suspect that many of these informal arrangements still exist. I hope so. Those who press for equality intend either that they should either be scrapped or the citizens of Hampstead be asked to open up their sitting room for the doctor to do a surgery once a week and accommodation for out patients at UCLH arranged at the local Hilton. I fear we are returning to the state the nation was in sixty years ago. The middle class doing all right, their minor ailments, neuroses and life style ailments catered for. The poor finding, not paying for medical treatment but accessing it, increasingly difficult. I am now 81 and crippled with arthritis and rarely visit the doctor, it is too difficult. Referral to our local hospital is a nightmare. My blood pressure hasn't been taken for a couple of years and I have never had my cholesterol measured. But, thanks to voluntary organisations I am escorted to the theatre and Art Galleries and enjoy life. Anne Savage Competing interests: None declared |
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