Topping up dilemma

Patients topping up NHS treatment may lose their right to the NHS completely. Sam Barrett examines the rights and wrongs of the current rules

Topping up NHS care by paying for drugs or treatment that it can’t provide is a controversial issue. On one side the government argues that allowing this would create a two-tier healthcare system, while on the other opponents say that denying NHS patients the right to fund part of their healthcare is unfair.

Under the current rules, if a patient decides to top-up their NHS treatment by paying for drugs themselves, they can find themselves unable to get any NHS treatment at all. This leaves them either having to fund the entire course of treatment themselves or forego the drug.

Among the opponents of the status quo is independent, non-party group Doctors for Reform. The group, which counts among the members of its steering committee Professor Karol Sikora and Dr Christoph Lees, is calling on the government to allow top-ups. It says that although the Department of Health has said patients shouldn’t be able to top-up, legal opinion indicates that this is unlawful. Further, some NHS patients have been allowed to top-up their treatment, while others have not.

As part of its campaign Doctors for Reform has set up a fighting fund of £35,000 to enable a patient who is denied the right to top-up their NHS treatment to undertake a judicial review of the current legislation.

WPA is also supporting its policyholders in cases where they have been denied treatment. Charlie MacEwan, head of communications at WPA, explains: “If one of our customers is challenged by the NHS regarding a top-up then we may fund a judicial review on their behalf. Much depends on the primary care trust but generally, if you challenge their decision and go public, you’re unlikely to fail.”

This isn’t always the case though. Among the high profile cases that are still being fought is that of Linda O’Boyle, a 64 year old NHS patient who was diagnosed with bowel cancer in 2006. After a course of NHS treatment, she paid £11,000 for an eight week course of Cetuximab to prolong her life and was then denied further treatment on the NHS. O’Boyle died in March 2008 but her husband and MP are still fighting for the government to amend the rules on top-ups.

Given this level of pressure, the government announced it would reconsider the issue in June, appointing cancer tsar Professor Mike Richards to head up the review. He is expected to report back in October.

What Professor Richards will report is still uncertain but many feel that it will be necessary to allow top-ups at some point. “We published a report, Mind The Gap, in 2007, which recognised that there’s likely to be a gap in NHS healthcare funding of some £11 billion by 2015. This has been corroborated by other organisations, for instance the King’s Fund, and indicates that there will be a need to consider some sort of mixed funding for healthcare at some point,” says Fiona Harris, head of personal markets at Bupa.

She adds that for any form of co-payment or top-up to work it would need to satisfy a number of criteria. “Whatever you do it needs to be integrated,” she explains. “It has to be a simple care journey, both for the patient and their consultant and it also needs to be clear what the patient is paying for and what their liability will be.”

The requirement to shift to mixed funding at some point means other commentators feel Professor Richards may come down in favour of top-ups too. “It’s impossible to predict what he will say but it would be a sensible move to allow top-ups,” says Julian Ross, head of marketing and communications at Standard Life Healthcare. “It doesn’t have to undermine equal access or affect the quality of NHS service but it does seem unfair to deny people NHS treatment simply because they want to fund a drug that isn’t available because NICE has said it’s not cost-effective. If a patient and their consultant finds a drug works then this decision is really up to them.”

It must also be remembered that allowing top-ups for medical treatment and drugs wouldn’t be the first instance of this practice within the NHS. It has been possible to access a mix of NHS and private dentistry for some years, for example having a six monthly check-up on the NHS but paying privately for a scale and polish. Shifting this approach into the medical arena could be regarded as a natural progression of this.

Although there is huge support for top-ups, Professor Richards may find in favour of maintaining the current situation with another recent review perhaps making this position more feasible. “In his review of the NHS, health minister Lord Darzi has recommended more funding for the National Institute for Health and Clinical Excellence to speed up the treatment appraisals process. This may see it reviewing drugs at the same point that the drug goes to the European Medical Agency (EMEA) for licensing,” says John Dubois, a spokesman for Axa PPP healthcare. “It can take a long time for a drug to be assessed so this should mean that the number of drugs awaiting approval will fall.”

Further, with Lord Darzi recommending that all patients will be guaranteed access to drugs and treatments approved by NICE, this should remove issues around the postcode lottery.

It may not even be so black and white. “All the discussions suggest he is looking for a middle way – an option to top-up but with a number of conditions in place,” says MacEwan.

He believes these conditions could be along the following lines. Firstly that a patient could top-up, providing no NHS patient suffers as a result of their doing so. Secondly, taking the drug must be clinically driven, and finally, the NHS suite of benefits mustn’t decrease as a result of patients being able to top-up. “This would complement what the NHS does,” MacEwan adds.

Although members of the medical insurance industry aren’t prepared to put money on the outcome of the review, they’re all eagerly awaiting the findings. “We’re certainly an interested stakeholder,” says Dubois. “We already offer a wide range of options for cancer cover and we would design something to fit in with this.”

Some insurers have decided not to wait for the results of Professor Richards’ report. For instance, the first of WPA’s top up plans, mycancerdrugs, gives access to certain cancer drugs that are licensed but not available on the NHS. Although an individual product, MacEwan says it has received interest from companies too.

With this, in return for an annual premium equivalent to your age in pounds plus insurance premium tax, you receive access to a £50,000 life benefit pot that can be spent on any of the listed cancer drugs. These include Avastin, Tarceva and Vectibix.

If top-ups do get the green light then innovative product development will be possible. “It would be an opportunity to restructure how medical insurance sits alongside NHS provision,” says Dave Priestley, director of sales at PruHealth. “At the moment there is some duplication but we could design a product that is truly complementary to the NHS.”

Cash plan style products could also fit well into the top-up arena, allowing employees to access a pot of benefit to cover the cost of any treatment they decide to fund themselves.

Again, this is an area WPA has already explored. “Earlier this year we launched Health Top-Up,” says MacEwan. “This is a modular plan that has traditional cash plan benefits such as optical and dental cover plus other modules that cover areas such as cancer drugs and cosmetic surgery after an accident.”

Again it’s primarily an individual product although MacEwan says it could be packaged for a corporate market. As far as the cancer drugs module goes, in return for an additional monthly premium of £4.20, or £10 for smokers, policyholders would receive a lifetime benefit of £50,000 to spend on drugs that are licensed by the EMEA but not available through the NHS as they have not been approved by NICE.

Although pricing is keen, there are restrictions on the cancer cover available on this plan. Policyholders must be under 60 at the time of treatment and there mustn’t be any family history of cancer. Given that the risk of cancer is low in this age group, with 64 per cent of cases occurring in people aged 65 and over, according to statistics complied by Cancer Research UK, this will keep claims low.

Having an age 60 upper limit will also struggle in the corporate arena where age discrimination legislation could see claims brought against employers. Removing this to increase appeal would be sensible and, according to Bupa’s Harris, become more pressing in the future. “The workforce is ageing and employers will start to see a very different set of health issues among their employees. Cancer will become more of a problem,” she says.

Whatever the design of the product, with top-ups permitted, there’s a real opportunity for a much wider take-up of medical insurance, both in the individual and corporate market. “If we could achieve stakeholder pension style momentum then this could be a very low-cost product that doesn’t require underwriting,” says Ross. “It will definitely be interesting to see what arises in October.” n

Cancer tsar Professor Mike Richards: Due to report in October