Tom Smith on today’s health policy debate.

Today’s press (and reports from the weekend) carry three key themes: speculation about the implications of top-ups, questions about the long-term viability of collective finance, and the attitudeof GPs to NHS reform. My personal favourite, however, and not completely divorced from the third topic, wasy esterday’s Desert Island Discs when Lord Ara Darzi told Kirsty Young his top eight tunes.

Ahead of the Richards review, NHS trusts are already beginning to allow top-ups

The Sunday Times yesterday included severalexamples of people who are already beginning to pay for Avastin and receive NHS care. This move is partly a result of two woman successfully challenging the ban. ‘Melissa Worth, a solicitor at the law firm Halliwells, who is representing eight patients fighting for the right to co-pay, said: “Many more NHS trusts are finding different ways of allowing patients to pay for cancer drugs”. The Sunday Times points to three or four examples: one woman, for example, ‘has been told she can pay for Avastin, the bowel and breast cancer drug, in the hospital’s private wind while receiving the remainder of her care on an NHS ward’. The Trust explained, ‘This patient is having complete treatment on the NHS and has chosen to purchase separate treatment as well. Because the hospital has a unit for private patients on site, it has been agreed that the patient can receive Avastin on that unit’. Another patient’s husband explains a different variation, in place at the Royal Marsden. The Trust does not object to the purchase of Avastin “provided we were not getting treatment in the private (wing) and onthe NHS in the same episode of care, on the same visit. Effectively, we have won the right to pay”. These cases reinforce a view (expressed by me on HPI yesterday) that the Richard’s review will gather evidence of what is happening already and look to clarify the rules across the NHS. This is what one breast cancer patient would like to see. Sue Matthews, who has breast cancer and is a former physio from Bucks as well as the wife of an NHS surgeon feels the change“could all be too late for me”. She told the Sunday Times, “if the government turned round now and said, ‘We realise it has been happening in other areas of the NHS and we are prepared to accept it now’, that might be of some use to me. But he [Alan Johnson] is just trying to placate people and for those in my position it doesn’t help at all”. She worried that reviews “go on for years” and she “will be dead by then”. The government could helpfully clarify the application of current rules in October and introduce immediate change. A pragmatic acceptance of a private-publicmix, at the margins, could see the debate settle. Yet despite this evolutionary view, there is no shortage of commentary and groups who believe the change could be revolutionary,or perhaps hope it will be.

Is the beginning of the end for collectively funded services ?

The FT today report new work from the management consultants AT Kearney who argue that whatever we wish for, the days of collective funding of universal services is coming to an end. According to the FT, the report is not only talking about the UK. ‘All developed countries will be forced to define core health services and allow more expensive and marginal treatments to be covered by out-of-pocket payments or private health insurance’. Global pressures ‘will test the limits of collective funding mechanisms’, which ‘will have to concentrate on “core” services. The head of health at IT Kearney, Jonathan Anscombe says that while countries may not want this change, it will be forced upon them. “It is hard to see how this can be achieved without making care more unequal”, he told the FT.

Is the NHS consensus ending?

A few Sunday newspapers provided leaders on the state of the NHS. The Times and theTelegraph were critical, talking of wasted money and flawed models. The Observer finds itself in a difficult position as it can see where some of this criticism is coming from, but fears that it is wrongly being used to pour scorn on the idea of the NHS. In a leader, ‘how to preserve our national asset, the paper says, “It will require political courage – from Labour in admitting where its reforms have failed to deliver value for money, and from the Tories in avoiding the temptation to denounce everything the government does for the sake of it when they do not seem to have radical alternatives in mind. Striking a realistic tone, ‘it is perhaps expecting too much that negotiating the future of the NHS be conducted without resort to Punch-and-Judy politics. But...the NHS performs best as a collective enterprise. It does not belong to any party; it belongs to everybody”’

Darzi is critical of doctors’defending professional boundaries

There is a gloomy atmosphere around policy debate today. The Times (and Telegraph) report comments from Lord Darzi suggesting some doctors are “laggards”obstructing the introduction of new initiatives. He singles out doctors and “senior medical staff” in particular who ‘’are so determined to protect “professional boundaries” that 14 years after his unit began allowing nurses to perform minor surgery, others have yet to follow. CMO Liam Donaldson who sets Darzi’s comments in a wider context. He tells the Times, “The culture of medicine has been one of clinical autonomy. Doctors are trained to take decisions, to feel they are in charge, to lead teams. They want to do what they feel is best and anything that suggests that they should standardise their practice in any way is sometimes seen as degrading of their professional ethos”.

Lord Darzi’s Desert Island Discs

Leaving the gloominess aside (until tomorrow perhaps), Healthcare Republic reports that Ara Darzi yesterday ‘took a break from his review of the NHS’ to tell Kirsty Young about his favourite tunes (listed below).

1. Yekeghetsin Haikakan. Performer Haissmavourk Choir cond. Mihran Ghazelian. Composer Vahan Petelian
2. Tubular Bells. Mike Oldfield
3. Finnegan's Wake. The Dubliners
4. Don't Give Up. Peter Gabriel and Kate Bush
5. Another Brick in the Wall. PinkFloyd
6. Seven Seconds. Performer Youssou N'Dour and Neneh Cherry
7. Jerusalem from the Soundtrack to Chariots of Fire. The Ambrosian Singers
8. The Logical Song. Supertramp

This is, of course, a serious review of the day’s debate so cheap jokes about some of the titles will be avoided. That said, the temptation to link choices 4 and 5 to his plans to reform primary care is almost irresistible.