The “self funding” NHS patient: thin end of the wedge?BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5128 (Published 01 August 2012) Cite this as: BMJ 2012;345:e5128
It’s simple—the NHS is free at the point of delivery. Or is it? Prescriptions, eye tests, and dental treatments have long been removed from the guarantee of NHS funding, but it is now becoming apparent that other areas of healthcare are being added with the advent of the “self funding” NHS patient.
A recent investigation found that several trusts are offering patients the choice of paying for treatment or services themselves if these are either not approved for NHS funding by primary care trusts (PCTs) or have long waiting times.1
In vitro fertilisation (IVF), bone scans, cancer surgery, and screening for hereditary diseases are all areas where patients may be given the opportunity to self fund. How patients are classified varies between trusts, with some describing them as NHS patients merely taking the opportunity to pay for something themselves and others as private patients being seen on NHS premises.
The main concern is what effect this has on the founding principle of the NHS. Shadow health minister Jamie Reed wrote in a recent letter to health minister Simon Burns: “The Health and Social Care Act established an unprecedented change within NHS hospitals, with an increased private patient cap now allowing hospitals to devote 49% of their beds, procedures and services to private patients.
“The government’s PPI [private patient income] cap and successive NHS budget cuts have simultaneously given hospitals the freedom and incentive to open up a private market within the NHS.”
The BMJ spoke to some of the trusts identified in the investigation and found a range of attitudes and approaches to this practice, but all believe they are not doing anything inappropriate.
In vitro fertilisation
The fertility centre at Homerton University Hospital NHS Foundation Trust in London offers IVF for people described on its website as “self funding NHS patients.”2
Its website says: “Self funding NHS patients are those patients who have to pay us for their treatment costs by cash or credit card prior to starting the treatment. The price list is attached on the following pages and is very competitive in comparison to the private treatment option.
“This option allows you to have your treatment when you are not eligible for the NHS funded treatment. You will still remain as an NHS patient and will be seen by the fertility team members just as any other NHS patients.” (The National Institute for Health and Clinical Excellence (NICE) currently recommends that three free courses of IVF be offered to women aged 23 to 39 who have an identified cause for their fertility problems or who have had infertility problems for at least three years.)
John Coakley, trust medical director, says: “These patients are seen in NHS time. They are NHS patients entitled to NHS care. They are seen in NHS premises. They are not private patients. The nurses and staff who deal with them are NHS staff.
“I see no grey area at all. Many aspects of fertility treatment are provided free by the NHS, but IVF has some restrictions. We use solely clinical criteria—can this couple benefit? We don’t impose arbitrary rules. That some commissioning bits of the NHS won’t pay shouldn’t disadvantage patients who can benefit.”
It is highly unlikely, he believes, that a private insurance company would pay for infertility treatment, and when asked to comment on this, BUPA declined to comment.
Asked whether trusts are, in effect, introducing a cut price private health system within NHS hospitals, Coakley rejects this, saying: “Our self funding patients are diminishing as a proportion of the total. It’s a shrinking market at present, but who knows what might happen in the future?”
Around five years ago, about half of the patients at the trust’s fertility unit were self funded, but currently around 80% of the work is NHS paid, with only 20% self funded.
“This is entirely done to help patients who some other body has decided don’t fit the bill,” says Coakley.
A similar approach is taken at Epsom and St Helier University Hospitals NHS Trust in Surrey. Its website says: “You may wish to fund your own treatment if your PCT does not fund IVF, or you do not wish to wait for funding, or you are not eligible for NHS funding.”3
Carolyn Croucher, a consultant obstetrician and gynaecologist at the trust, says: “The care patients receive from our hospitals is paid for by PCTs. For certain types of treatment, PCTs will only fund the care if the patient meets specific criteria. For IVF, this may include the woman’s age or the number of children she has had previously.
“If a woman (who is referred to our trust) is not eligible to receive IVF under the PCT’s criteria, they will be offered the opportunity to self fund the treatment—ie, pay for it themselves. It is important to note that this is not a new service and that it is offered by many other hospitals.
“Our trust only offers self funding for IVF, and the amount paid by the patient covers only the cost of providing the service. We do not make a profit (as a private hospital might). In addition, the money they pay is channelled back directly into our service.”
Croucher stresses that women who self fund are not seen any quicker than other women (who are funded for IVF by their PCT) and they receive exactly the same care.
“Self funding patients are not private patients. As such, they are seen on NHS premises and charged by the NHS.”
These self funding patients would pay around half the amount they would pay if they received this treatment from a private provider, she says, adding: “I think the trust is being very altruistic and providing a cost effective, high quality service for patients who would otherwise not be able to have children.”
At University Hospitals Bristol NHS Foundation Trust, oncology patients are offered dual energy x ray absorptiometry (DEXA) bone scanning at a cost of £72 per scan.4
The trust says that the majority of its scans are carried out in line with NICE guidelines and in accordance with the policy of its local commissioners—that is, postmenopausal women or men aged 50 or over who have a raised clinical risk of fracture or have had a low impact fracture.
A trust spokeswoman says: “There is a demand for DEXA scans from a very small proportion (3%) of patients who do not qualify for the scan under the NICE criteria and the trust provides this service as required.”
However, these patients are considered to be private and not NHS, as the spokeswoman adds: “Care that is funded directly by the patient or their healthcare insurance provider is considered private healthcare and is delivered in line with the trust’s policies and procedures for private practice which are compliant with NHS guidance and legislation.”
Stereotactic radiotherapy, often know as CyberKnife after the brand name of one of the machines, is offered by East and North Hertfordshire NHS Trust to cancer patients whose primary care trust is not willing to fund it.5
A trust spokesman says: “At our hospitals, we have two types of patients—the vast majority get their care on the NHS, with a very small minority being treated on a private basis.
“We do not have a separate classification of self funders as we do not promote NHS services for payment.”
Patients choosing to be treated privately, either by paying themselves or through a health insurer, is nothing new, argues the trust. “Many NHS hospitals have offered some element of private work for a very long time. The vast majority of our work is on the NHS, with a tiny percentage being for those who choose to become private patients. The latter is a decision taken by the patient, uninfluenced by the trust,” says a spokesman.
Questions have arisen over situations when a trust seems to be offering a service or treatment that is not recommended by national bodies such as NICE or the UK National Screening Committee.
Since May of this year, University College London Hospitals NHS Foundation Trust has been offering a self funded interim ovarian cancer screening service,6 which offers ultrasound scans and serum CA125 tests for £330 a year to women who are considered to be at high risk of developing this form of cancer.
Until June 2011 patients could opt to join the UK Familial Ovarian Cancer Study, which has now closed. The self funded screening service since then, says a trust spokesman, is an “interim” arrangement until the situation is reassessed after the study reports back, possibly next year.
The trust says the UK National Screening Committee will not support ovarian cancer screening being carried out on the NHS until the study results are available.
A spokeswoman for the screening committee says it “is responsible for systematic population level screening and does not make recommendations for screening of individuals already identified as high risk. As such, the service offered by UCLH to identify ovarian cancer in high risk groups is outside our remit.
“We review the evidence for screening for conditions against strict criteria on a regular basis. Population screening for ovarian cancer is due to be considered again in 2015-16.”
A spokeswoman for NICE says: “NICE is asked by the Department of Health to develop guidance on specific topics. It is inevitable that there are some aspects of healthcare that are not covered by NICE guidance. In these situations, local providers are expected to make their own decisions as to what treatments and services they will provide.”
Definitions and approaches to the reality of self funding, therefore, exist in the NHS, but despite trusts’ upfront defence of this practice, which they are adamant is appropriate, not everyone agrees.
Observers from the United States say there is a legitimate concern here. Lisa Schwartz, professor of medicine at The Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire, says self funding patients are, in her opinion, private patients.
“It seems to contradict a basic tenet of [the] NHS—that care is free at the point of service,” says Schwartz.
“If self funding is to be allowed, it should be carefully regulated to ensure that it is not abused (that is, promoting useless or harmful services). Self funding seems like it would open the door to the worst of the for-profit side of American healthcare.
“This should be an explicit national policy—not one developed on an individual basis driven by the financial needs of individual trusts or hospitals.” She adds: “I worry that this will lead to more marketing of potentially unnecessary services to patients.
“Unfortunately, financial incentives all too often encourage doing more to patients— regardless of whether it is in their best interest. The NHS should do what it can to prevent increased marketing of medicine to drive patient demand—not encourage it.”
The government does not believe there is a problem here, but says it will take action against any trusts that are shown to be refusing to treat patients on the basis of cost alone.
Health minister Simon Burns says: “NHS care is and will remain free at the point of delivery. If NHS treatment is available, patients must not be charged.
“However, NHS hospitals can provide services to private patients—income from this goes back into the NHS and supports the services that NHS patients receive free of charge.”
A clear distinction on the nature and future of self funders remains elusive.
Trusts offering some form of self funding treatment
Homerton University Hospital NHS Foundation Trust—offers IVF to “self funding NHS patients”
Epsom and St Helier University Hospitals NHS Trust—offers self funded treatment for IVF
Kingston Hospital NHS Trust Assisted Conception Unit—offers IVF services for NHS funded treatment, a “NHS eligible self-funded package,” and self funded treatment7
University Hospitals Bristol NHS Foundation Trust—offers a specialist “self funding” DEXA scanning
East and North Hertfordshire NHS Trust—offers CyberKnife radiotherapy to patients funded by the NHS, themselves, or a private insurance provider
University College London Hospitals NHS Foundation Trust—offers a “self funded interim ovarian cancer screening service”
Cite this as: BMJ 2012;345:e5128
Competing interests: All authors have completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.