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Financial pressures continue – Health Policy Today, 13th August 2008

Tom Smith on three health policy stories today, all adding to a sense of increasing financial pressure.

A survey from MacMillan suggests that many cancer patients are struggling to pay for their drugs – not new expensive ones – but NHS prescriptions, which for some can be as high as £44 each month.  The charity is calling for an end to prescription charges, as in Wales and Scotland.  Similar fears about the rising cost of food and fuel are leading to union calls to increase public sector pay in line with inflation, reopening the recently agreed 3-year pay deal. The affordability of drugs has been a huge issue over the last week and, in this context, the new chair of the Care Quality Commission has told the Health Service Journal that NHS organisations will be rated according to their compliance with NICE guidance.

NHS organisations to be measured against their compliance with NICE guidance

In the fierce debate over NICE recommendations and the wide variation between PCTs' approaches to implementation, it may reassure some to hear that Baroness Young (the new chair of the Quality Care Commission) say that the new body will crack down on NHS organisations that fail to adopt NICE guidance.  Doing so, could result in a lower rating.  

She says, “the system has been patchy in implementing NICE standards.  So it’s about saying, “Well, you can only get your good quality rating if you meet NICE standards ... We need to up the ante”.

Baroness Young describes herself as “a great believer in performance related pay”, and there is a hint that as well as a lower ranking, NHS organisations that do not adhere to guidance could face financial penalties.

Peter West of York University says that it may not be easy to find evidence of non-compliance.  “We can find out a drug is being prescribed but not how much of it is being used by patients who, according to NICE, need it”.

Benefiting humanity – helping individuals or populations?

The report in today’s Telegraph will not reassure all.  Picking up on a story in yesterday’s Independent, it outlines some choice passages from a paper on “social values judgement”, published on the NICE website a month ago.  At the time, the paper received little attention, save for the fact that it recommends against limiting treatments to people who are overweight and so on.  But in the light of recent debate, it is being re-read.  The paper aims to set out the basis on which NICE will reach its judgments, recognising that in many cases, it is” judgement” that often comes into play.

The report refers to the “rule of rescue” which is used widely to describe a situation where, despite heavy cost, there is a desire to save ‘an identifiable person whose life is in da nger’.  ‘NICE recognises that when it is making its decisions it should consider the needs of present and future patients of the NHS who are anonymous and who do not necessarily have people to argue their case on their behalf...The institute has not therefore adopted an additional “rule of rescue”.

In other words, NICE has mechanisms for listening to people and will change its rules in response to to individual cases.  But as yesterday’s Independent and today’s Telegraph point out, NICE has not listened to its own Citizens Council, whose earlier report said that where individuals are in “desperate and exceptional circumstances” they should sometimes receive greater help than can be justified by a “purely utilitarian approach”.

Dr Tony Calland, the head of the BMA Ethics Committee agrees with the Citizens Council.  “We would be opposed to ignoring a rule of rescue when it introduces a degree of flexibility around extreme cases.  So what if you waste a few points if you are doing your best for humanity?”

And there is the rub.  On the one hand, NICE are seeking to benefit humanity by not allowing their head to be turned by exceptional circumstances, and ruling for the average citizen.  On the other, some doctors will believe they are helping humanity by intervening in individual cases.  This is a tension present in many areas of the NHS.  In managing an out-patient clinic, for example, is it better to give an individual extra time, should they need it, and lengthen the waiting time of others, or is it better to stick to set consultation times for all patients?

Cancer patients struggling to afford prescription charges

A survey from MacMillan Cancer Support has achieved a lot of coverage today.  The BBC reports that ‘nearly half of cancer patients in England are being forced to cut back on food or heating in order to pay for their prescriptions.’

An online survey of 477 cancer patients found that 44% were struggling to cope with drug costs and MacMillan Cancer Support are using the findings to call for the abolition of prescription charges in England.  They note that 88% of issued prescriptions are dispensed in the community free of charge, therefore, they suggest, there would not be a large financial cost from doing so.

There is evidence to suggest that even a small charge for prescriptions is an important psychological block on too many being issued.  The few years where there was no charge saw a large increase.

The Government does plan a consultation on prescription charges, but is looking at cost-neutral approaches.  

Where there may be scope for change is in reviewing the exemption list.  At present, there are some conditions for which the charge is waived.  More conditions could be added to this list (and others removed).

There is a scheme in England for people who receive prescriptions to spread the cost.  A 3 or 12 month prescription prepayment certificate allows patients to get all prescriptions needed for around £2 per week.  MacMIllan Cancer Support backs the scheme, but says that too few patients are aware of this.

Some of the reports today suggest that some cancer patients are skipping meals to pay for drugs.

Unions  call for wage rises to match inflation

A similar personal appeal is evident in reports that Unison and other unions want to see wage rises to bring members’ earnings in line with inflation.  The general secretary of the Public and Commercial Services union says, “in the face of rising food, fuel and housing costs, the Government cannot continue to penalise the people who deliver vital services with pat cuts and pay freezes and urgently needs to review its pay policy”.

While the Treasury are trying to earn restraint across the board, the unions are asking why the low-paid should see their living standards fall.  The Telegraph today warns of a winter of discontent if the problem is not resolved.