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Acknowledgement of implicit rationalisation
- Zhan Yun Lim (8 May 2008)
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Yes. Top-up any fees
- GEORGE Y CALDWELL, SINGAPORE 259858 (14 May 2008)
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Copayments and the affordability gap - it is ethical
- Raj Mohindra (9 June 2008)
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Zhan Yun Lim, ST1 The Royal London Hospital
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Implicit rationing is already a reality in the NHS, particularly in the realm of elderly care. How often have we heard that patients might not benefit from level 3 medical care, might not benefit from newer statins, might not benefit from both emergency and non-emergency operations. And how often has that view been challenged subjectively. The American Geriatrics Society published a positional paper in 2002. This identified how the manner in which rationalization occured might make it more acceptable for the society, for example a system wide based allocation rather than a bedside based allocation for resources. (1) The National Service Framework for older people's services highlighted where we could perform better in this respect.(2) Articles like this should be encouraged to bring about a more frank discussion between the medical profession and the society at large. This will hopefully lead to a discussion on what "core treatments" should be provided by the finite NHS resources and what should be paid for as a top up fee. References 1. American geriatrics society (AGS) position statement rational allocation of medical care: A position statement from the AGS ethics commitee. 2002. http://www.americangeriatrics.org/products/positionpapers/agsratio.shtml 2.Older people National Service Framework (NSF). 2001. http://www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Olderpeople/OlderpeoplesNSFstandards/index.htm Competing interests: None declared |
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GEORGE Y CALDWELL, GENERAL PRACTITIONER 31 BALMORAL PARK, #18-33,, SINGAPORE 259858
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It would not be a bad idea at all if the whole of the NHS system was undermined. The General Practitioners again would be working all the hours they wished if they were paid on the nail (use a plastic Medical Card) for whatever work they did and they would again be happy bunnies, earning their keep. Each should have access to a fully-fitted Town Clinic with X-ray Unit, competent laboratory, Physiotherapy, Pharmacy making up those simple medicines the industry has now managed to forbid being made, Minor Surgical Theatre and ambulance station attached in places to a Cottage Hospital. The General Practitioner should then have quick access to whichever Hospital he chooses and whichever Consultant he wants for his particular patient. The present system is run rather like a Supermarket and there is no choice. Which is bad for the patient. The appointment system at Primary Care level with rude Receptionists is "un-feeling" and should be a matter for the G.P.'s choice. Better by far to open the Surgery (or Town Clinic's) doors early each morning and get on with the work, first come first served. Yes, top-up wherever extra expense is required. Remember always, it is the patient's best interest that is most important. NOT the blooming System! Competing interests: None declared |
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Raj Mohindra, Consultant Cardiologist North East
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There are a series of co-payments that could be considered including transport, parking, prescription fees and fees for dental care. Here focus on the co-payment model whereby the patient can choose to pay extra to top up NHS care thereby permitting that patient access to treatments that lack NICE approval but do have an evidence base to support their use. These treatments, including some treatments for cancer, lie in an affordability gap for the NHS. I have argued elsewhere1 that it is ethical to permit such access despite the apparent inequity. The core argument is that it can potentially deliver better patient outcomes where the more expensive treatment has been shown to have a more powerful effect, albeit less cost effectively, than standard treatment (e.g. drug-eluting stents1). The cost to the NHS would not be greater. No NHS patient would suffer any lesser treatment than they would otherwise have had. Indeed the existence of such a system would incentivise politicians to ensure that the affordability gap is kept as small as possible. If the NHS, through NICE, can make a moral judgement from the perspective of the tax payer2 that a treatment can not be afforded by the NHS for a particular patient because it is not cost effective; then why can that patient, from their own perspective, not make the moral judgement that the personal financial cost of the treatment is justified. The patient can already make this choice by paying for the full cost of the treatment. Extending the power of this choice by permitting the patient to top-up the NHS care would increase public access to the more powerful treatment by lowering the cost barrier of the treatment faced by the patient. Can the principle that no one should be treated differently by the NHS3 prevent a potential harnessing of personal resources to improve health care outcomes? In fact the NHS would not be treating any patient differently. Each patient would still receive all care deemed to be cost effective by NICE free at the point of delivery. Any difference would arise from individual choices made by patients within the affordability gap. This approach would increase patient autonomy. The justification for the existence of this patient choice is the fact that an affordability gap exists at all. In the absence of an affordability gap there would be no choice to be made. This option was recommended by the Commons Health Select Committee in their Inquiry into NHS Charges4 as a recommendation for the introduction of a system of reference pricing. The Government rejected this because: “a variable co-payment that is related to the difference between the price of a medicine and the reimbursement price that the NHS was prepared to pay would not be consistent with the Government’s values for the health services”5 The legal thread holding back the introduction of such copayments3 is easily reversible if, and only if, the Government can be persuaded by the arguments. A legal action for judicial review6 would be an uphill struggle.7 Better to recognise the strength of the case and use the ethical arguments to push aside the political veil holding back change. 1 Mohindra RK, Hall JA. Desmond’s non-NICE choice: dilemma from drug- eluting stents in the affordability gap. Clin Ethics 2006;1:105 2 House of Commons Health Committee. National Institute for Health and Clinical Excellence. London: Stationery Office, 2008. www.publications.parliament.uk/pa/cm200708/cmselect/cmhealth/27/27.pdf. 3 Para 2 and 4 Directions to Primary Care Trusts and NHS Trusts in England (2003) 4 House of Commons Health Committee. Inquiry into NHS Charges. London: Stationery Office, 2006. http://www.publications.parliament.uk/pa/cm200506/cmselect/cmhealth/815/815 -i.pdf 5 Government response to Health Select Committee Inquiry into NHS Charges. (2006) Cm 6922 6 Dyer C. NHS faces legal action over copayment for private drugs while receiving NHS care. BMJ 2008;336:1265 7 R v N and E Devon Health Authority ex Coughlan [1999] Lloyds Rep Med 306 Competing interests: None declared |
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