Rules on top-up payments risk creating two tier system in NHS, MPs warn

BMJ 2009; 338 doi: (Published 13 May 2009) Cite this as: BMJ 2009;338:b1973
  1. Rebecca Coombes
  1. 1BMJ

    Seriously ill patients who choose to top up their NHS care by buying additional drugs for treatment at the end of life are likely to be treated on the same ward as patients who can’t afford the extra drugs, MPs warned this week.

    Since November 2008 a change of rules has allowed patients to buy additional drugs without losing their right to NHS care—as long as these drugs are administered separately from NHS treatment. The change came after an increasing number of challenges to the NHS by patients to provide new unapproved drugs to treat cancer and other life threatening conditions.

    But in its report on top-up payments this week, MPs from the health select committee said that the government had fudged the issue. “We are very concerned that separation will be hard to achieve in practice,” they said.

    “We believe it would be wrong for very seriously ill patients to be moved from an NHS ward to a different location so as to administer a privately paid for drug separately.”

    In such cases patients must remain on the ward, but this creates new problems, MPs concluded. “It creates a two tier system, where two patients with the same condition on the same ward receive different treatments because one can afford it and the other can’t.”

    The committee stopped short of saying that the changes of rules was wrong. One member, Richard Taylor, the independent MP for Wyre Forest and consultant physician, said it was the “least worst solution” to the problem of improving access to drugs for NHS patients. But the government must monitor how separation is achieved in practice.

    Under Department of Health guidance, issued to managers in March, patients who opt to buy, for example, an unfunded anticancer drug in addition to chemotherapy they are receiving on the NHS must be removed to a private healthcare facility, the private wing of an NHS hospital, an amenity bed, or private room to receive the additional treatment. However, doctors could insist on patients staying in NHS facilities if they feared that moving them would endanger their safety.

    MPs were also sceptical of health department claims that the costs associated with separating NHS and private care were “not a major problem.” It cited witnesses who argued that costs may be substantial.

    As part of the government’s action to increase NHS patients’ access to new drugs, the National Institute for Health and Clinical Excellence (NICE) was instructed to increase the availability on the NHS of expensive end of life drugs. But this was “inefficient” and “inequitable,” said MPs. “By spending more on treatments for limited health gain the NHS will spend less on other treatments which give greater benefits to more patients,” said their report.

    Giving evidence to the committee in February, Michael Rawlins, chairman of NICE, denied that the organisation’s quality of life year (QALY) threshold has risen to £70 000 (€78 000; $110 000).

    Sir Michael told the committee: “We have always stated that we have a threshold range of somewhere between £20 000 and £30 000 per QALY, but we have always given our advisory committees latitude to go above it. There has been an incident going up as far as £60 000, a particular treatment for children undergoing renal transplantation. We have not got to £70 000.”

    The health department has advised doctors, working with NHS managers, to exhaust all reasonable avenues for securing NHS funding before suggesting that a patient’s only option is to pay for care privately. Primary care trusts can make exceptional funding available for drugs that aren’t approved by NICE. It is estimated that about three quarters of the 3000 requests that primary care trusts receive each year for cancer treatments are approved, although this figure varies greatly from trust to trust. Before the change of rules only 18 patients had ever lost their right to NHS care because they had paid for top-up treatments.

    A health department spokesperson, referring to the package of changes it has made since November, said, “Patients and the public can be confident that there will [now] be greater clarity, greater fairness, and, most importantly, greater access to a wider range of drugs.”


    Cite this as: BMJ 2009;338:b1973


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