Top-up fees - Health Committee Contents

Examination of Witnesses(Questions 220-239)


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 I would really like to emphasise that both within the draft guidance and in the chief executive's letter to the NHS we are very, very clear that this was about minimising the circumstances in which people would ever have a need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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