Last weeks ruling about the Alzheimer's drug Aricept, is one of numerous decisions not to fund some treatments under the National Health Service (NHS) that have been vigorously disputed. But should patients be allowed to purchase such treatments privately rather than go without?
Two experts debate the issue on BMJ.com today.
The supplementing of NHS care with private treatment is already widespread and the practice will become more common as the finite budget of the NHS becomes less able to cover all the medical care that people want or require, says James Gubb director of the health unit at Civitas, an independent social policy think tank.
The real issue is that these "top-ups" have been ad hoc, exclusive, unnecessarily expensive, and completely at odds with the purpose of the NHS—that there should be equal access to health care based on equal need—he writes.
The answer, says Gubb, is to create an equitable framework for top-up fees affordable to all, rather than just the wealthy and articulate.
He believes that paying for the cost of a drug as a top-up would allow many more patients to benefit from a drug treatment than if they had to pay for the entire course themselves, and would protect the idea of universal health care for which the NHS stands.
Gubb calls for an insurance type of contract similar to those of many European systems. For example, in the Netherlands, people buy supplementary insurance for health care such as cosmetic surgery and more comprehensive dentistry. This has led to reduced costs, better quality health care, and fees that are affordable to the majority. In fact, 93% of the Dutch population have some form of supplementary insurance, he says.
But Karen Bloor from the University of York, believes that assessing effectiveness against cost is the best way to determine what treatments finite amounts of NHS money should fund. The inevitable rationing of treatments is only acceptable if it is objective, fair, and applies to all, she argues.
Allowing patients to pay top-up fees will greatly reduce the fairness of health care rationing, she writes. NHS patients with exactly the same condition would receive one treatment if they could afford to pay for it, and another if they cannot.
In addition she warns, when the cost of treatment is not paid by the NHS, a strong single purchaser, but by individuals or their insurers, there would be little pressure to keep the prices charged by drug companies down.
So what is the solution?
She believes that if new treatments are judged to have some level of effectiveness, but are not cost effective, drug companies should face incentives to reduce prices so that they become cost effective for use in all NHS patients, rather than just some. "Instead of allowing companies to market limited products to desperate patients, it may be better to link the price of drugs with their value" she says.
"The NHS should be maintained and improved to provide care for all patients, regardless of ability to pay", she concludes.