Intended for healthcare professionals

Rapid response to:

Head To Head

Should patients be able to pay top-up fees to receive the treatment they want? Yes

BMJ 2008; 336 doi: (Published 15 May 2008) Cite this as: BMJ 2008;336:1104

Rapid Response:

Copayments and the affordability gap - it is ethical

There are a series of co-payments that could be considered including transport, parking, prescription fees and fees for dental care. Here focus on the co-payment model whereby the patient can choose to pay extra to top up NHS care thereby permitting that patient access to treatments that lack NICE approval but do have an evidence base to support their use.

These treatments, including some treatments for cancer, lie in an affordability gap for the NHS. I have argued elsewhere1 that it is ethical to permit such access despite the apparent inequity. The core argument is that it can potentially deliver better patient outcomes where the more expensive treatment has been shown to have a more powerful effect, albeit less cost effectively, than standard treatment (e.g. drug-eluting stents1).

The cost to the NHS would not be greater. No NHS patient would suffer any lesser treatment than they would otherwise have had. Indeed the existence of such a system would incentivise politicians to ensure that the affordability gap is kept as small as possible.

If the NHS, through NICE, can make a moral judgement from the perspective of the tax payer2 that a treatment can not be afforded by the NHS for a particular patient because it is not cost effective; then why can that patient, from their own perspective, not make the moral judgement that the personal financial cost of the treatment is justified. The patient can already make this choice by paying for the full cost of the treatment. Extending the power of this choice by permitting the patient to top-up the NHS care would increase public access to the more powerful treatment by lowering the cost barrier of the treatment faced by the patient.

Can the principle that no one should be treated differently by the NHS3 prevent a potential harnessing of personal resources to improve health care outcomes? In fact the NHS would not be treating any patient differently. Each patient would still receive all care deemed to be cost effective by NICE free at the point of delivery. Any difference would arise from individual choices made by patients within the affordability gap. This approach would increase patient autonomy. The justification for the existence of this patient choice is the fact that an affordability gap exists at all. In the absence of an affordability gap there would be no choice to be made.

This option was recommended by the Commons Health Select Committee in their Inquiry into NHS Charges4 as a recommendation for the introduction of a system of reference pricing. The Government rejected this because: “a variable co-payment that is related to the difference between the price of a medicine and the reimbursement price that the NHS was prepared to pay would not be consistent with the Government’s values for the health services”5

The legal thread holding back the introduction of such copayments3 is easily reversible if, and only if, the Government can be persuaded by the arguments. A legal action for judicial review6 would be an uphill struggle.7 Better to recognise the strength of the case and use the ethical arguments to push aside the political veil holding back change.

1 Mohindra RK, Hall JA. Desmond’s non-NICE choice: dilemma from drug- eluting stents in the affordability gap. Clin Ethics 2006;1:105

2 House of Commons Health Committee. National Institute for Health and Clinical Excellence. London: Stationery Office, 2008.

3 Para 2 and 4 Directions to Primary Care Trusts and NHS Trusts in England (2003)

4 House of Commons Health Committee. Inquiry into NHS Charges. London: Stationery Office, 2006. -i.pdf

5 Government response to Health Select Committee Inquiry into NHS Charges. (2006) Cm 6922

6 Dyer C. NHS faces legal action over copayment for private drugs while receiving NHS care. BMJ 2008;336:1265

7 R v N and E Devon Health Authority ex Coughlan [1999] Lloyds Rep Med 306

Competing interests: None declared

Competing interests: No competing interests

09 June 2008
Raj Mohindra
Consultant Cardiologist
North East