The two-tier NHS

Alan Johnson, the Health Secretary, has announced that patients will now be allowed to buy and be treated with medicines not available on the NHS – but without affecting that person’s entitlement to NHS care. Previously, the rule had been that if a patient was having additional treatment in the private sector, they lost their NHS entitlements. This has become a cause celebre, especially in the case of some recently licensed cancer drugs.

At first glance this strategy might seem fairer – i.e no one should be denied NHS care. That is the heart of the meaning of what the national health service is – free, and available to all in need. Except of course, it’s not completely ‘free’ – many people pay prescription charges, or dental fees.

The reasons why I’m concerned are several. First, this is a green light for even more hype about new cancer drugs. I have not been convinced of either the wider media or even some researchers or doctors to present results of new research findings consisently in an unbiased way. I am afraid of the effects of overselling of benefits and the underselling of harms, or the lack of effect, to this group of patients and their friends and family.

Second, if a treatment is cost-effective, it should be available to all via the NHS. What makes something cost effective depends on how much we are willing to spend, and how much the intervention costs. The intervention may be too expensive for the limited benefit it provides. Or, of course, we could spend more on interventions, even less cost-effective ones, and there are expensive and ineffective white NHS elephants (Connecting for Health, PFI hospitals, Independent Treatment Sectors) which should be got rid of and the funds diverted usefully elsewhere.

But last, the other issue is that of the patient-doctor relationship. Fragmenting care into provision of some treatment in the private sector and the rest in the NHS is far from ideal. How will it be decided which are the ‘top-up’ private treatments and which are not (for example, follow up scans and blood tests which may be required as part of a treatment?) And how are patients going to feel if they are recommended to have a treatment which is too expensive to afford? Will they feel pressed to spend time, emotion and money on something which may not, in the end, be that useful to them?

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