Tom Smith writes from the BMA conference in Edinburgh.

At its Annual Representatives Meeting today, the BMA debated copayments in a fiery, passionate and characteristically chaotic thirty minute session.

Representatives debated a six-part motion. After a vote, they supported the principle that patients who buy their own treatments should not be denied NHS care; called for a Royal Commission to explore the implications; and came within a hair’s breadth of voting to ‘demand’ the introduction of copayments in the NHS.

In five years of attending the BMA’s annual conference, it was the closest vote I have witnessed: so close it was decided electronically. The result was 49.8% in favour of the introduction of copayments with 50.2% against and in an audience of around 400 people, it means the vote was decided by a single vote.

Health Policy Today explores the debate.

The BMA has members with a range of views, including, for example, David Wrede, who works with Doctors for Reform – a man who believes that the NHS is unsustainable and that insurance is the only way to finance health. It also has a range of doctors to the left, for example, Jacky Davis, a member of Keep Our NHS Public.

The exceptionally close vote on co-payments reflects the wide-range of views on the issue within the BMA as well as its inherent complexity. In Friday’s BMJ, Rudolf Klein wrote that the co-payment debate is a classic example of the trade-offs inherent within the NHS. ‘While co-payments clearly offend against the equity principle... to prohibit it would offend against the autonomy principle – that the decision and preferences of patients should be respected.’

It is important to understand the context for the BMA debate. Back in June, the consultant conference passed a motion ‘that the government must permit co-payment for treatment in the UK health service’. The audience was swayed by an intervention from orthopaedic surgeon, Gordon Matthews. His wife Sue is suffering from colon cancer, and therefore he is personally affected by the debate. His view is that allowing payments will boost the NHS by stopping people from leaving it.

Co-payment is a highly politicised issue. In an interview with the Sunday Telegraph, comments by Hamish Meldrum implied that he was personally opposed. He was keen to correct that today: “whatever has been reported in the press, I have not expressed a personal view for or against copayments”.

He said he wanted to see a debate and that’s what he got.

To aid discussion, the BMA’s Health Policy & Economic Research unit issued a briefing note. It makes the point that though the debate seems to have come from nowhere, it is a subject that is ‘regularly revisited in the media when particular cases occur’. ‘The issues at hand are usually brought into sharp focus by their typically very emotive context and the considerable consequences for those at the centre of the particular case’.

Today’s debate was no different. It was brought into sharp focus by the contribution of Gordon Matthews. “I speak to you as a doctor and as a husband of a most cherished wife who has end-stage colon cancer”. He understood the concerns about equity that are expressed in this debate and feels there is a need for debate about where the limits of private and public funding lie - and where they should lie. “What is not fair is to exclude someone from NHS care just because they have made a personal decision to pay for a drug when they are clinging for their lives” – shouts of “hear, hear” rang out at this point.
“All patients must have a right to treatment offered by the NHS. This is not a slippery slope for the NHS to be eroded to a basic core service”. His comments were applauded loudly.

Speaking against, Jacky Davis argued that the right were using stories of individual patients, which were heart-wrenching, in order to support their critique of the NHS and the introduction of insurance. She said it wasn’t often she agreed with Doctors For Reform, but their view that co-payments would mean the end of the NHS is one with which she absolutely agrees. “If we vote to support co-payments we will be voting for NHS charges. You will hear arguments that we have copayments already – yet they are minimal at 1%. ... If we vote yes to this, we will place co-payments at the heart of the NHS and we will allow pharmaceutical companies to put pressure on vulnerable patients. There are no easy answers but let us think of alternatives to deal - let cool heads prevail.” Again, her comments were loudly applauded.

The mover of the motion, Steve Austin from Northern Ireland, believes that a bar to co-payments “is rationing in its most cruel and brutal form”. The former head of GPC, John Chisholm also argued for the motion and said that it was common to have a public-private mix in the NHS – patients using the private sector for diagnosis, for example.

Kevin O’Kane spoke passionately against the motion. “This is the most difficult and the most emotive issue we are going to debate all week. Please think with your heads and not your hearts.” He argued that changing the way that NICE worked could make this whole debate redundant. He worries about the implications of the co-payment debate. “I worry that individual budgets will lead in the same direction – no money when the budget runs out, so people will have to pay”. “This is not the NHS; this is not what we stand for.”

Consultant negotiator, Mark Porter also spoke against the motion and worries about who benefits if co-payments are introduced. He recalled working in a private termination clinic where he heard screams from women who could not afford general anaesthetic. “Ask yourself, who benefits if this is passed? Ask yourself, why are some companies not submitting their evidence to NICE – is it because they want to market direct to patients?

The final speech for the motion came from David Wrede. “I have spent 25 years working in the NHS, I do no private practice.” He rejected the accusation that he was levering personal cases to advance his argument. “The emotional debate here has come from those who want to deal with the NHS by asking people to pay a bit more tax and improve NICE”, which will not resolve the problems. Even a huge increase in budgets for the NHS, he said, would not pay for all the drugs that are being developed. Therefore we have to set limits. “It is patients like Gordon Matthews' wife who will suffer if this is not allowed”. Wrede spoke against the suggestion of a Royal Commission to tackle the issue, which he believes will kick the issue into the long grass.

The final speech against the motion came from Director of Public Health, Steve Watkins. He fears a scenario where patients in adjacent beds will receive different chemotherapy regimes. There are other solutions to this problem, such as reforming relationships with pharmaceutical companies and improving the way that NICE works. “If you vote for this you will be going down the road of progressively introducing co-payments in to the NHS”. He worries that the government will use this to move costs onto the NHS. “Oppose this motion and defend the NHS”.

At this point things got a little bit confusing. Jonathan Fielden, the head of the BMA consultants committee, came to the stand to address the argument for a Royal Commission, a move that he and the Juniors’ leader, Ram Moorthy, feel would allow proper attention to the debate. “Yes, the Consultant’s conference adopted co-payments as policy, but have we reviewed this issue fully? I believe not. This is why we need a Royal Commission to ensure this is done properly so we can look at the implications of this beyond cancer drugs”. “I urge you to support the idea of a Royal Commission looking across the countries of the United Kingdom”.

As Jonathan had been interpreted as supporting the motion, in the interests of balance, a further opposing speaker was called. Lancashire’s Kailash Chand said allowing copayments would put doctors “in an impossible position”. “How could we tell patients that if they had money, they could buy a few extra months of life?” “Private spending is not desirable in healthcare and this is why the NHS was founded. Please reject this motion.”

It is never an easy job to try and summarise a divisive debate, but Hamish Meldrum had a go. The chairman of BMA council said a 30-minute debate is not really able to resolve these difficult issues. “In that sense, I do have some sympathies with the view about the Royal Commission, though I do not want to see this debate this kicked into the long grass. My personal view would be to call for a Commission with very tight timescales. Nevertheless, you’ve heard the debate, and it is up to you.”

At this point the conference chairman, Glaswegian psychiatrist Peter Bennie, called an electronic vote. The results follow each of the six parts which were voted on separately.

1. Recognising that not all treatments are available equitably to NHS patients - For 82%, Against 18%

2. Patients should have the choice to purchase non-NHS treatments if they wish and still receive NHS care – For 62.8%, Against 37.2%

3. Health departments should recognise that banning co-payments denies treatments that could be to their benefit and forces patients to accept rationing. For 59.7%, Against 40.3%

4. A co-payment system does not imply a two-tier NHS but rather recognises the reality of healthcare rationing in the UK. For 47.1. Against 52.9

5. Demands that government must permit co-payments for treatment in the UK health service - For 49.8%, Against 50.2%

6. Set up a Royal Commission to review all the evidence and implications for the NHS and patients and report with recommendations by summer 2009 - For 70.9%, Against 29.1%

Conference chairman described the debate as “stormy and procedurally difficult”, and there was a lot of confusion about what had been agreed. Chaand Nagpaul asked if parts 2 and 5 of the vote were contradictory – part 2 against the denial of NHS treatments for those who co-pay and part 5 against the introduction of co-payments. A junior doctor complained about the confusion - “we are making policy up on the hoof.”

So what did the BMA decide? It voted against the denial of NHS treatment for those who buy drugs, but has not called for the introduction of co-payments before the implications have been properly examined. The ARM would like that done through a Royal Commission.

Speaking to me after the debate, Gordon Matthews said he was extremely disappointed that the ARM has not demanded the introduction of copayments. Although the BMA will encourage an exploration of the associated issues, he feels that any change will probably come too late to help his wife.

Jacky Davis was not fully satisfied with the outcome either. She remains worried that Pandora’s box is going to be opened and that the NHS will never be the same again.
So a fraught and passionate discussion with no overall conclusion – this debate will run and run.