Tom Smith on today’s health policy debate.

Health policy is so widely debated that today saw two themes arise. In the morning, discussion was about the capacity of maternity services to cope as well as questions about why given much higher funding in recent years. The announcement late this afternoon, however, that the government will look again at co-payments in cancer care is likely to capture the evening headlines.

Government to review the ban on patients ‘topping up’ their NHS care with privately purchased medicines

At a quarter to three the BBC website reported that ‘the policy of penalising patients who top up their NHS care with private treatment is to be reviewed’. Having previously argued that co-payments would create a two-tier service, Alan Johnson has asked ‘cancer tsar’ Mike Richards to look at this issue and report back to him in October.

“This is a very complex issue so it needs to be reviewed. We want to be fair to everyone...while protecting the principles of the NHS” – Alan Johnson.

The government has been forced to explore the issue after many people pointed out that the rules are inconsistently applied, almost exclusively to cancer, whereas they are hardly every applied in dentistry.

Shadow health secretary Andrew Lansley said it was right to review co-payments, but his concern continues to be the availability of drugs and the speed with which they are assessed. “We should be looking at why these drugs are available in other countries and not here”, he told the BBC.

NHS Confederation join the ‘top-up’ debate

The NHS Confederation this afternoon published ‘Paper 4’ in its ‘Futures Debate’ series: ‘Topping up: should it be allowed in the NHS?’

Although published by the NHS Confed it is the work of Joe Farrington-Douglas and James Crabtree at the IPPR (Institute for Public Policy Research). The Confed asked IPPR to ‘share some of its thinking...as a starting point for a discussion with NHS organisations and other stakeholders’. The report trails a forthcoming IPPR report, Private spending on healthcare.

The authors say that a number of factors have combined to increase the prominence of top-ups as an issue for the NHS:
• New drugs and treatments
• More information available
• Patients have greater access to assets
• There is more explicit rationing by the NHS

The authors note that ‘interpreted strictly’ (only in cancer it seems) ‘the guidance allows NHS providers to deny the NHS patients the NHS package of care they need because they have purchased an additional treatment’. In doing so, it could be argued this is ‘undermining the universalist principle that everyone should have equal access to NHS services according to need’. They note that current policy is being applied inconsistently.

Also, patients commonly ‘top up’, for example, if they pay for private tests before NHS surgery or purchase private prescriptions from NHS GPs for Viagra. Moreover, there is a strain of economic theory that supports the idea of allowing patients to top up publicly–funded care.

‘Publicly funded healthcare inevitably sets a limit on the package based on the average value placed on healthcare spending. If individuals value a particular treatment more highly than the median value reflected by the NHS, then allowing them to purchase would improve efficiency’ – NHS Confederation report, Topping up.

That said, there are also ‘risks associated with allowing top-ups’.
• Top ups could threaten NHS equity principles
• Top ups could lead to a ‘two-tier NHS’
• Allowing top ups could create false hope
• Top ups could encourage the promotion of special interests

With regard to the last point, the authors are worried that drug companies or consultants could promote the take-up of treatments that are not necessarily best for patients, something that should be guarded against. But in relation to the idea of top-ups being inequitable, after rehearsing the arguments the authors conclude that some people will always pay more and allowing a top-up solution would enable all patients to access the same NHS package of care equitably.

‘NHS patients who top up their treatment would not be choosing to exit the NHS risk pool into a supplementary system’.

‘The IPPR believe that the current political impasse is not helpful and ignores long-term trends’. Even before the review was announced, the paper calls for a review ‘to look at the possibility of relaxing NHS rules for patients who wish to top up their NHS care with specific treatments’.

They say the review should consider the following:

• Information for patients to make top-up decisions
• Whether charges could be introduced for older treatments that are not cost-effective
• How to mitigate equity concerns
• Improve public confidence in NICE processes and PCT decision making.

At the end of the document, some questions are posed for Confed members to consider. If topping up is to be allowed:

• To which areas should it be applied – just treatments waiting for NICE approval, those sees as not cost effective by NICE or to other treatments not covered by PCTs?
• How could any potential adverse effects be mitigated?
• Would it be helpful for all PCTs to have a common approach to what is not funded – i.e. a negative list?

And there are other questions. Read them at: http://www.debatepapers.org/papers.aspx

Bad news about NHS neonatal care

While the day may have ended with talk of fundamental financial challenges, in a way it started in the same fashion. A report from the Commons Public Accounts Committee found that neonatal units face staffing pressures and cannot cope with demand. The Telegraph said there are particular delays in transferring babies to appropriate hospitals.

Responding to the report, Dr Sheila Shribman, the DH tsar for maternity services, said that spending on neonatal services increased from £655m (2003-4) to £802m (2006-7). The extra money does not appear to have improved services, however.

Five years ago, the DH led a reorganisation that involved 189 neonatal units being placed within 23 regional networks, to provide a range of services in each area, the idea being that rapid emergency transport would ensure each baby could reach intensive care should they need it.

Today’s reports suggest the centralisation of services and reorganisation into networks has not been successful.

Amongst the most shocking statistics indicate that there are 4.8 neonatal deaths per 100 live births in 2005 compared with 1.8 in Surrey and Sussex. In the Guardian today, John Carvel noted that the DH is unable to explain ‘whether the difference is caused by social and economic characteristics of the population or the quality of the neonatal service’.

More GPs offering extended hours

The bad news about neonatal services and the row about co-payments overshadowed the one bit of good news that came out today. Statistics released by the DH showed that more patients are able to see their GP in the evening and at weekends. ‘The figures for May 2008 show that 20 percent of practices are already offering extended opening in 21 PCTs’.