YES

Helen Rainbow
Senior researcher at the independent think-tank Reform

“It is clear that the NHS isn’t going to be able to provide everything for everyone for ever more. Particularly in the current economic climate we have to accept there are not going to be funds available for everything. For this reason we should allow individuals to pay for drugs not available on the NHS – enable them to pay to top up care.

Top-up happens in all sorts of other sectors, for example, people with children in state education are free to buy private tuition. It is also worth highlighting that last week a Scottish government review on the topic decided that they should allow some sort of top-up healthcare payment system – so I think it is fairly inevitable that this is going to happen here at some point.

The core thing we need to do, if we have a top-up payment system, is define people’s entitlements to care. We need to know what people are and are not entitled to on the NHS. We need to do this on a nationwide basis and end the postcode lottery. Once we define what people are not entitled to, it is only fair that we allow them to pay for these things themselves.

The National Institute for Health and Clinical Excellence (NICE) may initially be the body to make those definitions and maybe we could extend its remit slightly wider than new drugs and treatments.

The key thing is that patients receive all of the necessary information when it comes to their treatment options – we will need clinician involvement and patients will need to have information on all the treatments available both on the NHS and privately.

We’ve also got to clarify some implementation issues. For instance, if someone buys a drug privately and suffers side-effects, who should pay for the treatment of those side-effects – the NHS or the private sector? It is important that additional costs are not passed on to the NHS.

Hopefully, if you clarify the legal side of it, it will facilitate the development of a supplementary insurance market that will create a reliable, easy and affordable way for people to access all forms of treatment. This has happened in other countries, such as France, Switzerland, the Netherlands and Israel, where they have quite a big supplementary insurance market.

The key thing is that patients will still be offered the same drugs on the NHS as they are now. We are not talking about denying people any treatment that they are already receiving.

But if people want to use their own resources to top up healthcare then they should be entitled to, as long as it doesn’t take resources away from the NHS or disadvantage NHS patients.”

— Helen Rainbow is co-author of Making the NHS the Best Insurance Policy in the World, reform.co.uk

NO

Karen Jennings
The head of health at Unison

“How the NHS funds treatment is a complex issue, and we welcome the current review, which is much needed.

What is clear is that allowing co-payments is not the answer. As soon as we do this we will create an unfair two-tier system and destroy the NHS’s founding principle of providing a universal service that is free at the point of delivery.

If this happens, two patients with the same condition could find themselves lying next to each other on the same ward, yet receive very different treatments, not because that is what doctors advise, but because one person can afford to pay extra to top up their care while the other cannot.

So far, co-payment has been relatively rare, when seen in the context of the millions of people treated by the NHS every day. At the moment it is being presented as an argument in favour of being a little bit flexible in a few one-off situations. However, if co-payments are allowed, they will fast become the norm. Whenever people seek treatment they will be offered a choice between one ‘basic’ service and a second ‘paid-for’ option, whether they are dealing with cancer, Alzheimer’s disease or mental illness.

In dentistry, where co-payment is standard, in any one visit a patient could choose to have an NHS-funded filling in a hidden cavity and a white, paid-for filling to fix a more visible tooth. NHS dentistry has, effectively, been privatised. Are we prepared to see this for the rest of the NHS?

Currently, people who are desperate for drugs not approved by the National Institute for Health and Clinical Excellence (NICE) are vulnerable to exploitation by huge pharmaceutical companies.

Clearly, the NHS faces challenges around funding of drugs and other treatments to care for patients. However, the response to this is not for individuals to top up, but rather to boost investment in the approval process of NICE and to widen its remit to challenge the pricing of drugs by pharmaceutical companies. What we need to achieve is consistency in the way treatments are allocated and in the way primary care trusts deal with exceptional cases. We also need to make sure patients and taxpayers are getting value for money.

This debate is limited to highlighting co-payments for drugs, but some organisations are pushing the co-payment agenda across all areas of the NHS. Should these small, self-interest groups succeed, we would seriously undermine the principles on which the NHS is founded. Should treatment no longer be paid for by taxation, and based on ability to pay rather than on medical need, major health inequalities would emerge, and a two-tier health service would take hold.”

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