NHS might have to attract more private money if it is to improve standards

Public and professional concern regarding ‘top up payments’ is of particular concern in cancer medicine. The JCCO (Joint Collegiate Council for Oncology sent a postal questionnaire to all non- surgical oncologists (consultant and trainee), excluding hematology, in the UK identified through the data bases of the Royal College of Radiologists (RCR) and the Association of Cancer Physicians (ACP) to inform the debate and provide professional input into the review being undertaken by the National Cancer Director, Professor Mike Richards 1481 oncologists were contacted by e-mail in July 2008. 289 oncologists (20%) responded in the 4 week time frame with responses from 144 (15%) clinical oncologists and 145 (29%) medical, oncologists. Seventy four (26%) of responses were from trainees. Responses were received from clinicians in 58 hospitals or cancer centres across the UKwith higher response rates from larger cancer centres [e.g. Christie 22, Royal Marsden 19, Edinburgh 16, Leeds 14, Clatterbridge 12]. The results are shown in the table; Overall 61% of oncologists thought that top ups payments should be allowed; 30% were opposed to them and 9% responded “don’t know”. Only 7% of oncologists reported no problems with drugs not funded by the NHS. Where funding issues had arisen two thirds stated that they discussed the unfunded drugs with their patients while one third had not. Most oncologists (95%) recognized that they could apply to the patient’s PCT for unfunded drugs. Nearly two thirds of oncologists 181/2899 (63%) had made applications for funding and amongst those who had applied the median number of applications in the last six months was 3 (range 1-5). A higher proportion of medical oncologists made funding applications (70%) than that clinical oncologist (55%). Medical oncologists were also more likely to make 10 or more applications (20% vs. 8% of those making applications). Over half of the trainees had made at least one application. Assuming respondents are representative of all oncologists in their geographical areas, application rates appear to be high in London and the East of England and markedly low in the North East The total number of applications to PCTs by the 289 responders over the 6 months leading up to July 2008 was 1009. Funding for these applications was granted in 527 (52%) of applications. A further 252, patients (25%) chose to pay privately for the drug concerned. For these patients the question did not distinguish whether any of these patients has private medical insurance. Opinion was divided as to where unfunded drugs should be delivered, with 52% favoring the NHS chemotherapy unit, 29% favoring a separate facility and 19% uncertain. Of the respondents 61% oncologists worked in Trusts which do not have private chemotherapy facilities on site. Given the short time frame the response rate of 20% was satisfactory. This survey highlights the problem of currently unfunded drugs for patients with cancer in England and demonstrates that although the majority of oncologists replying favored allowing ‘top up’ payments, a significant minority were opposed. The so called post code lottery for funding has been highlighted before in relation to PCT funding. What is striking here is the number of patients prepared to self fund. This raises important ethical and research questions for us in terms of the information given to patients and their perception of the benefit of treatment which applies irrespective of the source of funding. We await the outcome of the review by the National Cancer director with interest, however whatever the outcome, it is clear that the oncology community need to engage with patients and providers to provide transparent and equitable treatment for patients Dr Jane Barrett Dean Faculty Clinical Oncology Royal College Radiologists and Consultant Clinical Oncologist Dr Alison Jones Chair Joint Specialty Committee Medical Oncology Royal College of Physicians and Consultant Medical Oncologist

References 1. Coombes R. NHS might have to attract more private money if it is to improve standards.BMJ 2008; 336:1457 2. Audrey S, Abel J, Blazeby JMK, Falk S, Campbell R. What oncologists tell patients about survival benefits of palliative chemotherapy and implications for consent: qualitative study. BMJ 2008;337:

Competing interests: None declared