Co-payments in the NHS - a review at last
The UK Government has at last announced a review of the question surrounding top up fees for patients who wish to receive more expensive care that meets NICE guidance or local spending priorities. This has been discussed on this blog in the context of Donezepil (see link below). However the principle applies as much to drug-eluting stents, ICD's and biventricular pacing devices as to dementia drugs and cancer treatments.
NICE approves treatments on the basis of cost-effectiveness rather than pure efficacy. This leads to 2 broad groups of non-NICE approved drugs:
For these treatments the ethical choice in relation to top-up fees (i.e. co-payments) are clear cut: more lives will be saved for the same amount of taxpayers money expended if the option of top-up fees is accepted. The mechanism for this result is that personal wealth is deployed to access the marginal medical benefit provided by the marginally effective treatments that fall into the affordability gap. Currently these treatments are not available except at full cost to the individual. With a co-payments scheme these marginally effective treatments would be available at marginal cost to the individual.
The counter argument restraining such a use of co-payments is that not all people will have sufficient resource to access these marginally effective drugs. However this evident inequality derives from social inequalities coupled with the NHS rationing that drives the affordability gap . It does not derive from any difference in the rights of individuals to access NHS resources.
This evident inequality is an anathema to the currently prevailing political establishment. This is because the current political establishment is supposed to represent the working class. It is precisely this working class who might not benefit from such an arrangement.
Ironically it was this same political establishment that was responsible for the creation of the transparent and seemingly equitable affordability gap which arose with the creation of NICE (see previous blog post - link below). In essence the creation of NICE crystallised and then brought into stark view the fact of NHS rationing.
Rationing exists. For the present NHS, the creation of NICE coupled with a centrally driven target culture converted rationing within the NHS from rationing by queueing into rationing by limitation of the extent of available treatment. The fact of rationing drives the affordability gap. The degree of rationing drives the size of the affordability gap.
Critically the fact of unequal social access to marginally effective treatments in the affordability gap does not make co-payments unethical. This is because if all patients get equal access to the same NICE approved treatment within the NHS the principle of care free at the point of delivery is uncompromised by top-up fees. All have equal access to NHS resources.
The resulting unequal access to marginally effective treatments that would result from the introduction of co-payments can be countered by the argument that, because these marginally effective treatments are more potent than the corresponding NICE approved treatments, better outcomes will result for patients overall if co-payments are permitted than if they are not.
This population benefit is at no additional cost to the NHS and without compromise to the patients who cannot afford the co-payments who continue to receive NICE approved treatments free at the point of delivery. These patients may receive an indirect benefit from the introduction of top-up fees because their introduction would strongly incentivise the politicians to keep the affordability gap as small as possible. Interestingly it can be seen that if the affordability gap was reduced to zero no co-payments would be required.
Given these arguments why not permit top-up fees and accept the consequent inequality as the price for better overall health care outcomes? The principle of justice, manifested as an equal right to NHS resources is not compromised. The fact that lives will be saved should override any political whimsy.
NICE approves treatments on the basis of cost-effectiveness rather than pure efficacy. This leads to 2 broad groups of non-NICE approved drugs:
- drugs that are more expensive and more potent than their NICE approved counterpart
- drugs that are less potent and, either less expensive or more expensive, than their NICE approved counterpart.
For these treatments the ethical choice in relation to top-up fees (i.e. co-payments) are clear cut: more lives will be saved for the same amount of taxpayers money expended if the option of top-up fees is accepted. The mechanism for this result is that personal wealth is deployed to access the marginal medical benefit provided by the marginally effective treatments that fall into the affordability gap. Currently these treatments are not available except at full cost to the individual. With a co-payments scheme these marginally effective treatments would be available at marginal cost to the individual.
The counter argument restraining such a use of co-payments is that not all people will have sufficient resource to access these marginally effective drugs. However this evident inequality derives from social inequalities coupled with the NHS rationing that drives the affordability gap . It does not derive from any difference in the rights of individuals to access NHS resources.
This evident inequality is an anathema to the currently prevailing political establishment. This is because the current political establishment is supposed to represent the working class. It is precisely this working class who might not benefit from such an arrangement.
Ironically it was this same political establishment that was responsible for the creation of the transparent and seemingly equitable affordability gap which arose with the creation of NICE (see previous blog post - link below). In essence the creation of NICE crystallised and then brought into stark view the fact of NHS rationing.
Rationing exists. For the present NHS, the creation of NICE coupled with a centrally driven target culture converted rationing within the NHS from rationing by queueing into rationing by limitation of the extent of available treatment. The fact of rationing drives the affordability gap. The degree of rationing drives the size of the affordability gap.
Critically the fact of unequal social access to marginally effective treatments in the affordability gap does not make co-payments unethical. This is because if all patients get equal access to the same NICE approved treatment within the NHS the principle of care free at the point of delivery is uncompromised by top-up fees. All have equal access to NHS resources.
The resulting unequal access to marginally effective treatments that would result from the introduction of co-payments can be countered by the argument that, because these marginally effective treatments are more potent than the corresponding NICE approved treatments, better outcomes will result for patients overall if co-payments are permitted than if they are not.
This population benefit is at no additional cost to the NHS and without compromise to the patients who cannot afford the co-payments who continue to receive NICE approved treatments free at the point of delivery. These patients may receive an indirect benefit from the introduction of top-up fees because their introduction would strongly incentivise the politicians to keep the affordability gap as small as possible. Interestingly it can be seen that if the affordability gap was reduced to zero no co-payments would be required.
Given these arguments why not permit top-up fees and accept the consequent inequality as the price for better overall health care outcomes? The principle of justice, manifested as an equal right to NHS resources is not compromised. The fact that lives will be saved should override any political whimsy.
BBC News story link
Blog link to discussion in relation to Donezepil
(c) R Mohindra 2008
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