Why Co-payment is a Cop-out for Us All

Professor Mike Richards, the National Cancer Director, wrote to us in the summer confirming that the Secretary of State had asked him to review policy relating to patients who choose to pay privately for drugs not funded on the National Health Service (NHS). He suggested that his findings would be made public in October 2008. This report is now in the public domain. The acceptance that co-payment is inevitable is disappointing. The use of providers within the community, such as Healthcare at Home, as suggested recently by Professor James, is a short-term stop gap solution. Responsibility for prescribing appropriate medication rests with the doctor who has the expertise and clinical responsibility for a particular aspect of the patient’s care, although the general practitioner often plays a supporting role. The informal practice of co-payment during the same ‘episode of care’ that is being observed in the UK at present, means that two separate consultants cannot in practice be wholly responsible for the patient’s care. Hence, it will be impossible to define and sustain a framework of clinical governance for two separate pathways of care for the same condition. It could well be argued that the moral basis for shunning co-payment as an absolute has been undermined by the unclear and often uneasy relationship that already exists between the NHS and private practice. The current rules allow charging for prescriptions, amenity beds and dental care. In the current NHS, many effective medicines are restricted, because the National Institute for Health and Clinical Excellence (NICE) considers them not cost-effective according to its own strict parameters. We believe NICE’s recent negative decisions on colorectal cancer (TA118) and the appraisal consultation for kidney cancer give insufficient value to patients’ lives. Several opinion leaders supported NICE, suggesting that these drugs would bankrupt the NHS. How have we reached this moral nadir, in facing the cost of cancer drugs, when as a society we did not flinch at the massive human and financial challenges presented by the HIV/AIDS epidemic in the 1980s? The debate highlights the ethical dilemma of ‘copayments’, where patients continue within the NHS framework, but choose to pay separately for a drug. Attitudes, although highly polarised, have certainly shifted