Health service must evolve at same pace as medical world
THE case of a dying man who had to pay for his own anti-cancer drugs has forced politicians to confront a difficult dilemma which could help determine the future shape of the National Health Service.
Health Secretary Nicola Sturgeon last week announced a review of whether patients should be allowed to pay for top-up private treatment while receiving the rest of their care from the NHS.
From one point of view, any move to deny patients life-prolonging drugs is inhumane and if paying privately is the only option no-one should block it.
But others fear a system which encourages those who can afford it to buy extra treatment for themselves could open the door to a two-tier health service.
And with an increasing number of ever more specialised drugs being developed, some see the possibility of a health service where it is quite common for people to have insurance to cover the eventuality of them needing such treatment.
Ms Sturgeon's review was triggered by the moving story of bowel cancer sufferer Mike Gray, whose consultant wanted to prescribe him the drug Cetuximab to help extend his life, but could not – because his local health board, NHS Grampian refused to fund it.
The health board based its decision on the fact Cetuximab was not recommended by the Scottish Medicine Consortium, which advises on the clinical and cost effectiveness of all newly licensed medicines, even though it is widely available in the rest of the world. And because Mr Gray and his wife Tina McGeever forked out 3400 a fortnight to get the drug privately, he was told he also had to pay the chemotherapy which he would normally have received free on the NHS.
When the couple took the case to the Scottish Parliament's public petitions committee, they said around 400 people a year found themselves in the same position.
Announcing her review last week, just ahead of a parliamentary debate, Ms Sturgeon said the new guidance would seek to combine the rights of the individual with the founding NHS principle that treatment should be based on clinical need, not on the ability to pay.
And she put the emphasis on making sure appropriate treatments were accessible for everyone. "Cases where co-payment is even an issue should be the exception not the norm. Our key focus should be on ensuring equitable and increasing access to new drugs on the NHS," she said.
When the National Health Service was created 60 years ago, it transformed people's lives. Treatment free at the point of use was the watchword of the new service. But there has been a revolution in medicine since then, with a vast range of drugs and treatments available now which were unimaginable when the system was established.
And politicians and medical experts accept that judgements do have to be made on how much can be spent on providing expensive treatments.
But Tory MSP Jackson Carlaw believes it is "unsustainable" to have a position where people who are literally fighting for their lives are denied further treatment on the NHS if they opt to pay for drugs privately. And even if only a narrow dispensation is allowed to start with, he foresees a growing trend towards patients paying to "top up" their NHS treatment.
He told MSPs: "I imagine that co-payment insurance policies will evolve and that premiums for such policies will be minimal by comparison with the comprehensive care model. It would certainly make such an option affordable to millions, rather than a few."
Former Health Minister Malcolm Chisholm, Labour MSP for Edinburgh North & Leith, says such a development would mean a fundamental change in the nature of the NHS.
"There would be a situation that does not exist now in which patients are side-by-side in beds and one is getting one treatment while the other gets a different treatment because he or she can afford it. Not only poor people, but many people on modest incomes will ask, 'Why shouldn't I get the treatment that's available to someone else?'"
And leading cancer charities are opposed to co-payment. In a briefing circulated to MSPs before last week's debate, Macmillan Cancer Support warned there could be an increase in health inequalities in Scotland.
"Macmillan shares the anger and frustration of cancer patients who are denied clinically effective treatment by the NHS. However, they are not telling us that they want to receive private drugs together with NHS care – they want the NHS to pay for the drugs."
And Cancer Research UK said allowing private "top-up" treatment could create more problems than it solves. It called instead for a more sophisticated system of appraisal for drugs, greater consistency in decisions and "value for money" agreements with pharmaceutical companies.
Mr Chisholm backed those suggestions and cited the example of a rebate scheme agreed for the drug Velcade, under which patients who were making progress had the treatment fully funded by the NHS, but when patients showed minimal response, the drug costs were refunded by the manufacturer.
Most people accept funding for the health service will never be limitless, but if ways can be found to make the cash go further and help more people it could preserve the NHS as we know it longer.
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