Intended for healthcare professionals


BMA meeting: Doctors call for Royal Commission on copayments

BMJ 2008; 337 doi: (Published 10 July 2008) Cite this as: BMJ 2008;337:a765
  1. Zosia Kmietowicz
  1. 1Edinburgh

    Doctors at the BMA’s annual representatives’ meeting expressed their support for allowing patients to pay for treatments that the NHS does not provide without losing their right to further NHS care.

    However, they stopped short of recommending a swift introduction of the system of copayments to run alongside NHS provided care, calling first for a Royal Commission to review the implications and possible alternatives.

    The question of whether to permit copayments produced the most stormy debate and procedurally difficult motion of the meeting.

    Those speaking against allowing copayments saw giving permission to fund non-NHS treatments as a “slippery slope” towards privatisation and exploitation of the public by the drug industry. And both sides cited the founding principles of the NHS as a reason to allow and reject payments for extra treatments.

    The Department of Health in England has already asked Mike Richards, the cancer tsar, to review the situation, but his remit is restricted to payments for extra drug treatments.

    The BMA says that a wider review, in the form of a Royal Commission, is needed to look independently at what is happening throughout the United Kingdom, how allowing copayments would affect the NHS, what safeguards would need to be put in place, and whether there are any alternatives.

    Jacky Davis, a member of the BMA Council, pleaded against the introduction of top-up payments.

    “Don’t let this genie out of the bottle,” she said. “Copayments are an import from the American health industry. They overturn a basic principle of the NHS—that of equitable treatment independent of ability to pay. If you vote to support copayments we will vote for NHS charges because since we have conceded the principle we cannot dictate where it will stop.”

    Last month the consultants’ committee voted to allow copayments. Stephen Austin proposed the motion in Edinburgh to allow copayments and argued that forcing patients to go private for all their care would discriminate against poorer patients, who could somehow find the money to pay for one extra treatment, but not all the tests and other care that they would need.

    “This is grossly unfair to these patients at the most vulnerable time of their life. This is not what the NHS stands for, and goes against the founding principles of the NHS,” Dr Austin told the meeting. “The patient is hit with the double whammy of not only paying for the additional therapy but also for all of their healthcare costs.

    “I believe that the government should admit publicly that health care is rationed and not hide behind public bodies set up to ensure cost effectiveness. I believe that with the reality of healthcare rationing in the real world a form of copayment needs to be allowed in the NHS to assist patients if they do require rationed therapies.”

    Dr Davis called for alternatives to “deal with this complex and emotional issue.”

    “Plans are already under way to streamline NICE [National Institute for Health and Clinical Excellence] decisions. Solutions will emerge if cool heads prevail,” she said. “Thanks to Bevan’s vision of a fair and equitable health service we are a privileged generation of doctors. We have never had patients in adjoining beds receiving different care because of their ability to pay. Don’t let’s abandon that dignity.”

    Mark Porter, a member of the consultants’ committee, said that research had shown that patients who were excluded from treatment by charges would be adversely affected.

    However, Gordon Matthews, an orthopaedic surgeon whose wife had end stage colon cancer, said that a tax funded health system could not provide unlimited funds for treatment. Copayments were not a “threat to the NHS,” he said.

    “What is not ethical is to exclude a person from care because they choose to pay for a drug or treatment to cling to their life,” he said.

    David Wrede, a member of the centre-right group Doctors for Reform, which is campaigning for copayments to be allowed, accused doctors arguing against copayments as having “emotional attachment to some kind of fantasy of what the NHS should be.”

    Representatives voted by 82% to 18% in support of the principle of copayments, but the motion to demand that the government act to allow copayments was narrowly lost by 50.2% to 49.8%. More than three quarters of doctors (70.9%) voted for a Royal Commission.


    Cite this as: BMJ 2008;337:a765


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