Examination of Witnesses(Questions 220-239)
PROFESSOR MIKE
RICHARDS CBE, DR
FELICITY HARVEY,
MS UNA
O'BRIEN AND
PROFESSOR SIR
MICHAEL RAWLINS
12 FEBRUARY 2009
Q220 Dr Taylor: If they have gone
to the separate unit or separate facility for this bit of their
treatment, how and when do they come back to the NHS?
Professor Richards: They can come
back at any time and that has always been the rule. The old wording
was "as long as it is not in a single visit". You can
always come back. That may have been misunderstood but that is
what has been there since 1986.
Q221 Dr Taylor: I quite understand
your aim for improving access and speed and battling with the
pricing and the drug firms. Was there widespread acceptability
among all the people you talked to that this was not causing a
two tier system?
Professor Richards: I think there
was a very widespread view that we should avoid creating a two
tier system. We heard that loud and clear from a lot of different
places and when we talked through these options with people they
felt that this was the best approach that combined, as I said,
the ability for people still to get private drugs if that is what
they want and, at the same time, not to change the fundamental
principles of the NHS.
Q222 Dr Taylor: The best approach
but a compromise and not avoiding the two tier system entirely.
Professor Richards: I believe
it has avoided a two tier system because the two are kept separate
and people have always had that right to have private care. I
think it does avoid that.
Ms O'Brien: The whole thrust of
the Government's response to Professor Richard's report is a pro-NHS
response. The NHS, as we all know, is a comprehensive and universal
service free at the point of use based on clinical need. What
Mike's report showed us was that on the outer fringes—a
very, very important area of care—there were some issues
that had to be addressed about access to medicines. That was one
of the most powerful set of recommendations that he brought. I
would really like to emphasise that both within the draft guidance
and in the chief executive's letter to the NHS we are very, very
clear that this was about minimising the circumstances in which
people would ever have a need to seek to have drugs provided privately.
However, in those circumstances which might remain it is very
important for care to be delivered separately. So I think it is
about the proportionality of this and also about the thrust of
the Government's response. It is not about setting up a parallel
private system but actually driven towards reducing the circumstances
in which this would be necessary.
Q223 Dr Taylor: Do you think it is
actually only the tip of the iceberg? Do you think there are a
large number of people who would never consider because they do
not have the money at all—the silent voices who would never
consider top-ups or increasing their healthcare spending—that
we have not even touched?
Ms O'Brien: I am sure that Professor
Richards would comment on that, but in general terms what I would
say is that the NHS works at the boundaries of science. I think
this is very clearly stated in the NHS Constitution. There are
always going to be new forms of treatment, new medicines that
are becoming available and the pace of the system to keep up with
that will always be a challenge on the fringes as that happens
in terms of time. The fundamental point connecting back with a
question the Chairman asked at the beginning is, are these the
same principles applied? In fact they are and it is about adapting
the guidance to different and more modern circumstances. However,
there is a real continuity about the comprehensive nature of the
NHS and about the NHS itself in not charging except where there
is parliamentary agreement for doing that.
Q224 Dr Taylor: I think you said
you had adapted the principles.
Ms O'Brien: No, I think the principles
are true and we have to adapt the guidance as circumstances change
and also as pathways of delivering care change over time.
Professor Richards: The fundamental
element of the new guidance is that patients should not have their
NHS care withdrawn if they choose to pay privately for other treatments.
That is something that is very important that is stated. It was
one of my key recommendations and one which I was extremely pleased
that the secretary of state readily adopted.
Q225 Dr Taylor: One of the witnesses
we had at our last session has since sent in an entirely different
proposed solution, a central funding mechanism for additional
cancer drugs. Money for this could come from top-slicing PCT budgets
to the tune of the amount that is spent now by exceptional funding
reviews. Is there a real alternative?
Professor Richards: Personally
I do not see what the advantage is in that as long as we get clear
guidance from NICE as quickly as possible on these drugs so that
the NHS will then adopt standardised responses to it. That is
what we need to get to and, after all, it is NHS policy to devolve
as much responsibility to the front line and therefore not to
have large central pots of money.
Q226 Dr Taylor: The advantage of
it would be that there would be absolutely equal access for all
patients to all the drugs. That is the theoretical advantage.
Professor Richards: Yes, I believe
we can achieve the same objectives through the combination of
measures that we have set out. One of those is about getting more
timely advice from NICE, which is happening anyway. A second is
about improving the processes at the PCT level, and that is being
taken forward as part of the NHS constitution. There is a firm
recommendation from me that PCTs should work together on this.
The reason for that is that a PCT may only have to deal with a
particular drug once or less often a year; to do a full health
technology assessment at an individual PCT level is crazy and
therefore it makes very good sense for PCTs to collaborate on
this, which they are doing in certain parts of the country. The
north east has been leading on this, as has London. There are
a whole number of processes that we put in place that will mean
that we have far more standardised approaches and far quicker
advice on which drugs are good value for money and should therefore
be made available on the NHS.
Q227 Chairman: Could I ask you whether
you could see a situation where you would have two patients presenting
with the same problem in an NHS hospital and one of them goes
for chemotherapy which is different to what the other one gets
on the basis that they can afford it and that would be acceptable?
Professor Richards: I think that
is an absolutely logical conclusion from this report, that there
may be people who decide on the basis that they can pay that they
will pay, but they will be paying for that element of care privately.
Q228 Chairman: It could be on the
same ward in the same hospital.
Professor Richards: With the arrangements
we have said it will not be on the same ward, it will be, as I
said, either in private facilities or through home help care or
through specially designated areas. That is what we have set out,
the principle of separation.
Q229 Chairman: Do you agree with
that?
Ms O'Brien: I think it is theoretically
possible but I would stress again that the thrust and intention
of the policy overall is to reduce the circumstances in which
that is ever likely to arise. The key thing would be that the
circumstances in which someone was choosing to have additional
medicine privately ought to be those circumstances where the choice
of medicines is for something where it has been decided that it
is not cost effective for the NHS to fund. We ought to be in a
situation with the new arrangements as they come on board where
those circumstances are more and more rare. I think that is the
important thing to get the perspective around; it is not about
arranging a completely new set of possibilities to open up private
provision in the NHS but it is about being clear about people's
rights to maintain their access to NHS care and also about implementing
the principle of separateness in practice.
Dr Harvey: From our perspective
it is also very important that we get NICE appraisals to the NHS
in as timely a fashion as possible. As you will be aware there
are various things we are doing with NICE to actually ensure that
that happens. We will be aiming to get all new drugs with better
horizon scanning into the NICE work programme at least 15 months
prior to market authorisation. That means that as we go forward
we should have the technology appraisals out to the NHS either
in draft or final guidance within six months of market authorisation.
That does actually start making the problem less of a problem
where those drugs are deemed to be clinically and cost effective
by NICE looking at the value of drugs to patients.
Q230 Chairman: The issue of the speed
of NICE is something that this Committee has called for on more
than one occasion.
Professor Richards: It is happening
in practice already. Cancer has been the area where we have been
piloting the new approaches and I chair the panel for NICE that
looks at what cancer drugs will be considered by NICE and already
we are seeing a marked shift, so we are beginning that process
early.
Q231 Dr Naysmith: Dr Harvey mentioned
just now the recommendations of this Committee on previous occasions
when we have been looking at NICE; it is good to hear that we
are having some influence.
Professor Richards: You always
do.
Q232 Dr Naysmith: Thank you. Professor
McCabe who was here in the previous session argued in his written
submission to us that allowing private top-ups within the NHS
would have number of undesirable effects including a substantial
increase in the administration cost of the healthcare system.
Has anybody made an estimate of the administrative and other costs
to the NHS associated with separating care and the recommendations
made by Mike?
Ms O'Brien: Can I just be clear
on the use of the words "top-up"? In the way that we
use the term that is something we are not allowing, ie topping
up NHS care or the NHS itself charging. Just to be clear, when
we are talking about charging mechanisms what we are actually
talking about are those circumstances in which the NHS would charge
for privately provided care. So it is either one or the other;
there is no middle position.
Q233 Dr Naysmith: You may find that
from the top you are not allowed to use that phrase but I bet
you find on the ground many people will be using it.
Ms O'Brien: I appreciate that
and I think that is why it has actually caused some degree of
confusion, and I think Mike's report has really helped to bring
that out. The key thing to say is that there are no detailed estimates
of the administrative overheads, if you like, involved in charging
but a number of hospitals do this anyway because they have to,
for example, charge for overseas patients; it is not at all uncommon
in NHS hospitals. So there are methods for doing this; it is not
something that has been brought to our attention as a major overhead
or a significant cost that would be brought to bear on the NHS
as a result of Mike's report. I am confident that we will be going
in the direction of reducing the circumstances in which this is
necessary; I would not see it as a major problem.
Professor Richards: The principle
is there that the NHS should not subsidise the private element
of care so yes, we would expect the NHS to charge for the drug,
we would expect the NHS to charge for the time of the pharmacist
preparing the drug, the time of nurse delivering the drug. If
there are costs of administration and billing that should be built
in as well so I think we can say those are all elements that we
would expect the NHS to take in order to fulfil that principle
of not subsidising.
Q234 Dr Naysmith: The point is that
no estimate has been made of how extensive this is likely to be.
Professor Richards: As Una has
already said, this is already happening. A lot of hospitals have
private facilities and hospitals have overseas visitors so I do
not think this is something that is beyond the wit of man.
Q235 Dr Naysmith: The other aspect
of this which is perhaps a bit worrying is that if the private
care treatment was wrong in any way then presumably it will revert
back to the National Health Service. Does this pose any kind of
problem?
Professor Richards: That has always
been the case. Patients who have chosen to go privately for any
care, if they then have a problem and present as an emergency
to the NHS, the NHS has always taken that on and that has been
going for the 60 years of the NHS.
Q236 Dr Naysmith: Is that going to
become any more difficult or any more of a problem in the future?
Professor Richards: It is no more
or no less of a problem than it has been in the past. It is something
we expect to do.
Q237 Dr Naysmith: If some of these
patients are being treated in a facility that currently does not
exist—which is happening in some places—you are saying
that people will not be treated in the same ward as another patient,
which means providing in some cases which may not have a private
wing or facility at the moment for administering a drug privately.
Does that not follow from what you have said?
Professor Richards: What I was
equally saying is that we believe that the other measures in my
report will reduce the total number of people who are currently
choosing to pay privately for their care. There are patients who
are paying privately for their care and if we reduce that need
because we make more drugs available at an affordable cost to
the NHS, then this will not arise.
Q238 Dr Naysmith: There will be a
pressure to try to keep the patient in the same institution I
am sure. In fact we had the chairman of a trust here a couple
of weeks ago saying that he felt it was impossible to separate
in practice and where it does occur that will incur expense that
was not there before.
Professor Richards: Not to the
extent that some of these patients are having these drugs anyway
and funding them and when they get complications they can come
into the NHS. That is already happening within the NHS and we
believe the extra burden of this will be minimal because we believe
that the number of patients who are choosing to buy drugs will
be a very small number.
Q239 Dr Naysmith: I think Professor
Richards has already answered this question but I will ask it
anyway and probe it a bit further. Having accepted the principle
that there will be this element of separation of care, no matter
how it is done, would it not have been simpler to allow the alternative
option for purchasing additional treatment such as top-ups in
the NHS or voucher schemes? You said this had been considered;
could you tell us how seriously it had been considered. You also
said there were many noises against it or words to that effect.
How thoroughly was it considered and what was the evidence that
made you reject it?
Professor Richards: It was considered
and in fact the option appraisal is set out in my report. We believed
the voucher scheme was the worst of all options in fact largely
because it would take money out of the NHS and also if people
then went to a private hospital their NHS element would have transferred
them into the private sector but they would be paying more for
that same element in the private sector than they would in the
NHS. So it would be bad for the individual and it would be bad
for the NHS. We looked at that and we set out all the different
reasons in the report why we rejected that. In terms of the option
what might be called the full top-up scenario which is saying
that the NHS has a schedule of things that you can get on the
NHS but here are all the other things which you might want to
pay for, I can tell you there was very little enthusiasm for that
amongst the great number of people that I talked to. Again it
would be an administrative nightmare. If somebody said, "I
want to have a slightly different sort of artificial hip joint"
we would look at the scale of charges and we would be billing
every patient. Compared with your previous question about billing
which I think will be a very, very minor impact on the NHS, if
we had gone down that route of saying that there are full scale
top-ups for everything it would have been a billing nightmare.
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