Intended for healthcare professionals


Top-up fees will lead to two tier NHS, doctors tell MPs

BMJ 2009; 338 doi: (Published 02 February 2009) Cite this as: BMJ 2009;338:b417
  1. Adrian O’Dowd
  1. 1London

    Expert clinicians believe that allowing NHS patients to pay top-up fees for expensive drugs as part of their treatment will create a complicated, two tier service.

    The principles of the NHS are being undermined, clinicians told MPs on the parliamentary health select committee on Thursday 28 January during the first evidence session of the committee’s new inquiry into top-up fees, also known as copayments.

    In November last year Mike Richards, England’s national clinical director for cancer, published a report, Improving Access to Medicines for NHS Patients, after reviewing the longstanding rule on copayments that meant that people deciding to buy their own drugs to top up treatment had to pay for the whole of their care directly themselves (BMJ 2008;337:a2418, doi:10.1136/bmj.a2418).

    The health secretary, Alan Johnson, then said that NHS care would not be withdrawn from patients who chose to pay for additional drugs and that, although private care could be carried out alongside NHS care, private treatment should take place in a private facility and not be subsidised by the NHS.

    The witnesses appearing before the health committee last week said that the inquiry headed by Professor Richards had been timely, as a lack of consistency had been shown across the NHS on this issue.

    Jacky Davis, consultant radiologist at the Whittington Hospital NHS Trust in north London, who appeared at the session on behalf of the Keep Our NHS Public campaign group, said that allowing NHS patients to top up their care would “undermine the founding principles of the NHS.”

    “This changes the nature of the NHS,” said Dr Davis. “NHS patients will on occasion end up having different treatments in the same establishment, based on ability (or inability) to pay. This will create second class citizens within the health service.

    “There are also knock-on effects. There will be administrative costs attached to this system, the policing of it, and the time of clinicians.”

    MPs asked the witnesses whether top-up payments meant the establishment of a two tier system. Alison Jones, speaking on behalf of the Royal College of Physicians, said: “The Richards report is useful in that it allows patients to have access to a wider range of drugs. The report has problems in the detail and in its implementation. The concept of separateness is difficult.”

    Dr Jones, a consultant medical oncologist specialising in breast cancer and clinical director for cancer services at University College London Hospitals NHS Foundation Trust, added: “We would wish to maintain holistic care for patients within the team, and if they wish to have the drug as an episode of private care, there needs to be separateness in terms of how we have the discussion and our professional responsibilities.”

    Another witness, Leonard Fenwick, chief executive of the Newcastle upon Tyne Hospitals NHS Foundation Trust, welcomed the Richards report as an attempt to tackle the lack of consistency across the NHS on this issue, but he acknowledged that providing private care alongside NHS care could be problematic: “In cancer it is a little naive to believe there would be complete separation. It is simply not possible.”

    Sophia Christie, chief executive of the Birmingham East and North Primary Care Trust, agreed. She said, “If we don’t clearly separate the private episode of care from the public episode of care we will be cross subsidising private care for some people.”

    The inquiry continues.


    Cite this as: BMJ 2009;338:b417


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