4 min read

We’ve only just begun: the debate about the impact of ‘top ups’ in the NHS – Health Policy Today, 10 November 2008

Last week the Government said it could no longer defend a ban on patients receiving NHS care if they paid privately for cancer drugs.  Making the announcement quietly on the day of the US election sought to avoid fuss and attention, but has only postponed the inevitable debate, which began to take off again over the weekend.  The charge is that the government has pulled the plug on the NHS.  


In the Guardian on Friday, the broadcaster and cultural commentator Mark Lawson shared his view  that the announcement represented ‘fundamental change in the nature of the NHS’.  He worried that future films might record the story of English patients dying for lack of treatments that others could afford – an English version of the Michael Moore film Sicko.  His final paragraph began, ‘how paradoxical would it be the election of a president who aims to make US healthcare fairer was used to cover up British provision becoming more unfair’.

The article has attracted a number of responses as highlighted by
a series of letters published in The Guardian yesterday .

Dr Wendy Savage is a leading light in Keep Our NHS Public.  Her letter to The Guardian says it is a myth to say the NHS cannot afford cancer drugs, which is a fraction of the surpluses held across the NHS. She says her organisation will be launching a campaign to fight proposals they believe will destroy the NHS.

In a   letter published by the Independent today, Kailish Chand agrees.  He says the change in policy will end up, over time, ‘reducing NHS care to basic services only’.

Reinforcing the theme, a director of community services from Preston notes a tendency towards top-ups in social care, influencing access to quality care homes for example.  ‘This approach to health and social care funding may help the government meet rising costs, but where does it leave those customers who can’t pay the top-up?’

This debate is not what the Government want to hear.  Their intention was to focus the debate on how to increase access to medicines.  That this hasn’t happened may be the Government’s own fault.

Although the Government intended to keep the cancer drug announcement quiet, by making it on the day of the US Presidential election , a piece in Saturday’s Times by Simon Crompton says the government has done itself a disservice by not explaining the crux of its plan.

The fact is that, with the announcement of top-up law relaxation (and, of course, the election of Barack Obama), the week's real story about cancer drugs got lost. The Government accepted a report by Mike Richards, the Department of Health's national cancer director, calling for a raft of measures to allow patients greater access to life-extending drugs, so that “top-ups” would never have to paid. In particular, it called for NICE to speed up its approval process and be more open to approving cancer drugs, even if they extend life by a short period.’

In his letter to The Guardian, John Murray, the director of the Specialised Healthcare Alliance, also took the government’s side.

‘The whole thrust of the report is to improve access to medicines and minimise the need for patients to purchase additional drugs. There will be debate about whether these arrangements should be restricted to end-of-life medicines or encompass conditions which make life not worth living. The success of the policy will be judged by the extent to which it sustains treatment on the basis of clinical need, not ability to pay. Meanwhile, the government deserves credit for seeking ways to sustain the NHS's founding principles.’


Stories that private insurance firms are preparing to launch products aimed at patients who worry they will not have adequate cover will worry the left, concerned about further advances on the NHS by the private sector.  It should also worry the Government as, in order to sell these products, the industry will have to play on public fears that the NHS is not able to provide all the healthcare people might want.

The BBC on Friday, followed by the FT on Saturday reported that a range of private health insurers are considering launching products to cover "top-up" payments for drugs that are not provided on the National Health Service.  

The FT noted that only WPA Health Insurance offers such a product at the moment, and for cancer only.  The BBC said the product had existed for about eighteen months.
In the FT, Nicholas Timmins notes that ‘WPA's current product has tight exclusions. It debars anyone aged over 65 - the age beyond which cancer is most common - along with those who have had a close relative die of cancer before the age of 60.’  These restrictions might be loosened by competitors.

A spokesperson for Axa/PPP told the FT, "I don't think there is any reason why there has to be that age limit, but above that it is going to be reasonably expensive." He told the paper that Axa/PPP hoped to launch a new product "in the first half of next year".

The article says that Bupa and Norwich Union Healthcare have also ‘confirmed that they were looking at the issue’. The market is, however, very uncertain – difficult to guess the demand or the cost at which it can be sold profitably.

On the BBC website, Nick Triggle cites some optimism amongst insurers that the market will grow. Triggle quotes Paul Lynes of Standard Life who said, “the products that could be developed will be a lot cheaper than comprehensive medical insurance so we are likely to see many more people take them up”.  Other analysts agree that this area could be bigger than the private medical market.

What we have seen this weekend is a new stage of the top up debate: how far will they go?  Will we see an insurance market flourish?  Or will the Government successfully expand access to new medicines, meaning there is little public demand?

The ‘top up’ debate was never going to be closed down by a quiet announcement on a good day to set out controversial plans.  The extent to which the NHS is eroded by the move, or the private sector strengthened for that matter, depends on a number of factors.  

Will NICE be able to adapt and speed up its appraisal process? Will the NHS be able to bear the cost of a plan to to award greater weight to additional years that might be gained at the end of life, and thus issue more drugs to those at the end of their life?

The future depends upon the success or otherwise of new rules that will aim to make the system for dealing with exceptional cases more uniform across the country.  It also depends on the detail of the Government’s response, which is not expected until next year.