Tom Smith on where the top up debate could go next go next.

At the end of a recent HSJ piece, on the political history of the NHS, Julian Le Grand said the remarkable thing is that consensus has held, surviving even three Thatcher reviews. Reading some commentary over the last week would suggest we are seeing the beginning of its end, following the announcement that ‘top ups’ will be reviewed. It is important, however, that this debate does not become overblown. Although all the ingredients exist for a huge political fight so does the potential to renew the political consensus, allowing top-ups and keeping patients within the NHS. An opportunity to do this has this weekend come from an unusual source - the Conservative Party, which has launched its own consultation on the issue.

The focus of the Richards’ review

This week’s HSJ leader says the NHS is being ‘forced to re-evaluate its founding principle’. But is it? A lot of the commentary on this issue is focused on the horizon and the theoretical implications of a new policy for the NHS model. Yet the focus of the three month review, which will start next month and finish in October, is narrowly defined ‘on drugs rather than operations’ and even then fairly limited to cancer drugs. Also, it may not be fully accurate to talk of this ‘founding principle’ as if it had never been contravened and always ruled.

As the Economist this week notes, the strict application of the rule is a recent thing.

‘Last year an old rule forbidding the combination of private and NHS treatments – originally framed to stop consultants raiding their NHS waiting lists to pad their lucrative private practices – was dusted off and cited to justify refusing NHS care to those who paid for treatment privately’

This pragmatism is evident in the words used by Alan Johnson to outline the focus of the review – that it will describe current practice rather than prescribe the right public-private mix in the NHS. The NHS needs “guidance”, he said, “that is actually up to date with what’s happing now in the NHS, that is fair to everyone and that actually resolves some of the problems raised”.

The politics of the review

The HSJ say of the review, ‘the change in tone is understood to have been directed by Number 10’. The Times on Saturday said the NHS is seen as critical to re-establishing the credibility of the Prime Minister. The two things together suggest Number 10 did not want images of people dying for lack of funds clouding the 60th anniversary, an opportunity for Labour to trumpet its achievements. If the debate had not been announced, the campaign against the government’s position would have dominated the celebrations on July 5.

The politics of the review are important. They note that the government would have realised that health debates are the quickest to flare up: ‘a single tale...can convince people that the NHS is unfit for purpose’. For this reason they knew they must respond quickly, but The Economist notes speculation that they deliberately waited a bit.They were hoping to draw the Conservatives ‘would be lured into saying something it could spin as proof that the Tories deal with problems in public services by facilitating escape from them.'

Labour’s challenge is to keep the debate focused on the pragmatic application of a principle important to all, but one that most of us accept has some limits. In this it will be aided by a cautious Conservative opposition, that does not want to put its feet down in the wrong place.

The Conservatives launch a consultation

Despite accusations of silence on the issue, from the Economist and others, this the Conservatives launched a consultation ‘on the best approach to the circumstances where an NHS patient wishes to ‘top-up’ their NHS care by purchasing, privately, additional drugs or services’. It can be read Here

Contributions are requested by the 4th September, in time to respond to the government’s review, due in October.

The Conservative’s say they want their approach to this issue to be ‘determined in accordance with our continuing commitment to NHS principles, including that NHS resources should be devoted to NHS patients(a reversal of the “Patient Passport” idea) and that NHS patients should have equitable access to NHS care with services ‘free of charge except in so far as the making and recovery of charges is expressly provided’ (a quote from the NHSAct 2006).

The Conservatives believe that ‘if patients access private treatment this should not affect their NHS entitlements, either positively or negatively’.

Can consensus be achieved on topups?

The Conservatives and Labour have oddly moved closer to one another on health policy since 1997 with Labour supporting tariff payments and private sector provision and the Conservatives flirting with and then rejecting the idea of helping individuals to leave the NHS. Both agree that the NHS should be the bed-rock of care and there is an opportunity for political consensus on this issue..

Although some Labour activists want ‘clear red water’ between government and opposition policies, it would be a mistake to force people out of the NHS, into a separate private system, and an end to the idea of a service for all. Though there are some who will tempt the Conservatives to ‘be bold’, the opposition would be daft to enter an election with a consensus breaking stance.

Focusing on the way drugs are introduced to and withdrawn from the NHS

The main idea in the Conservative’s consultation is to improve the way by which the availability of drugs is determined.

Alongside the issue of ‘top-ups’, recent cases have highlighted that the NHS system used by the NHS to determine which drugs are available may need to be improved. At present, the NHS may be paying too much for some older drugs that were introduced before the current NICE evaluations were introduced. At the same time, the NHS may be denying patients new drugs, which could in practice meet the criteria for value set by NICE, but which have not yet been evaluated

One idea, is a ‘value-based pricing’ scheme which would mean the price paid by a drug would be proportionate to its assessed effectiveness.

A ‘value-based pricing’ scheme would mean that the NHS would bring medicines into use as soon as they are licensed and clinicians would be able to do so on the basis of their relative clinical effectiveness. As soon as the evidence is available to do so, the NICE appraisal would form a part of the pricing scheme, and the price of a drug would be required to reflect its therapeutic benefit. Where the cost-effectiveness data is insufficient, this would not lead to a drug being refused, but could be subject to a ‘risksharing’scheme, the one we suggested which was piloted by Johnson and Johnson in relation to Velcade, a drug for the treatment of multiple myeloma.

The Conservative consultation is a welcome new angle on the funding debate and in conjunction with the government’s review of the top-up scheme could be the basis of a consensus for how the NHS handles this challenge – the prospect that people may want treatments that the NHS has not licensed.

A positive opportunity for consensus?

It is inevitable that a wider debate about whether the NHS model and its predominatly tax-based funding can cope. It is happening everywhere in the world. In today’s Observer, for example, is a report from Spain where the regional government in Valencia has announced that it will no longer provide for the British ex-patriot population, mostly based in the Casta Blanca region. ‘The Spanish authorities say that providing for 500,000 Britons – most of them over 50 – as well as caring for other Europeans, ‘is placing an impossible burden on the health service’. It is costing £790m per annum.

The challenge is to find a pragmatic solution to accommodate something that already happens in the NHS with a founding principle that has not been removed. Though the issues are complex, the debate is necessary in order to achieve consensus on the future role of the NHS in our society.