Top up fees- why equality is a cruel doctrine in the NHS

It has taken an inexcusably long time, but last week, the labour Government finally recognised that it was both cruel and unfair to deny NHS patients who decided to buy themselves drugs that the NHS would not purchase for them.

Linda O’Boyle is now dead, but she became the focus of the media campaign that forced the labour Government to change its mind. Her life was prolonged by the use of the anti-cancer drug Cetuximab.

She paid for it because the NHS would not do so. She was denied NHS care as a consequence, and had to pay another £11,000 to private hospitals for chemotherapy and nursing.

Mrs O’Boyle was one of many suffering from terminal illness who have gone through the same ordeal.

Nevertheless, there are plenty of people who continue to insist that, if the NHS cannot afford to pay for a particular drug, it is better that patients who need it die faster without it, and for them to be refused all NHS care should they pay to obtain it for themselves. Why would anyone adopt that cruel and irrational position?

No one is harmed when a patient like Mrs O’Boyle buys a drug which her doctors have recommended but the NHS will not fund. But there is a very obvious benefit to the patient. A policy which generates benefits without causing harm is obviously better than one which just causes harm. The choice between those two is a no-brainer.

Health Direct does not want to accuse those who advocate the policy of denying NHS treatment to patients who buy their drugs of having no brains. It is probably better to call them deluded. The villain is a misunderstanding of the ideal of equality: if everyone cannot have a benefit, it is better that no one should have it.

This implies that there should be no medical care at all if it is impossible to achieve the outcome in which that care is exactly the same for everyone. But that result cannot possibly be achieved, not least because doctors vary in their levels of competence and skill.

Those treated by the better doctors receive a higher standard of medical care than those treated by the less able and experienced. No egalitarian is so deluded as to believe that this means we should dismantle the NHS and make access to any kind of medical care illegal.

But that’s the logical consequence of their doctrine that the most important value is not to provide medical care, but to ensure exact equality of outcomes for everyone.

The “harm” that the egalitarians claim is caused by allowing patients both to purchase drugs and to receive NHS care is, in reality, no harm at all. Someone who does not receive the best care possible from the very best doctors in the world is not harmed by the fact that there are people who do.

Professor Mike Richards, who wrote the report which led to the labour Government changing its policy, ties himself up in knots in an effort to both accept and reject that truth. He ends up recommending a compromise: patients who pay for drugs should not be denied NHS care, but they should not be treated in NHS hospitals. They should pay for any tests, scans and treatments to deal with complications arising from the additional drugs they pay for themselves.

The compromise will soon become untenable: differentiating between the tests and treatments that are made necessary because of the extra drugs, and those that are not, is often impossible. And what will happen if a patient is admitted into intensive care when they are due another dose of the drugs they pay for?

Will those drugs be administered in the NHS ward or not? Assessing such matters on a “case by case basis”, as the Government proposes to do, is a recipe for precisely the outcome the Government says it wishes to avoid: patients being treated in wildly different ways, depending on the whim of the administrator who makes the decision.

The idea that medical care should be distributed according to need, and not on ability to pay for it, has one problem: doctors and nurses do not work for free, and drug companies do not give away drugs for nothing.

In 2003, the Wanless report on the funding of the NHS predicted that total NHS spending would rise from £68 billion to £154 billion in 2022. More recent estimates suggest that spending will increase to £184 billion. Such a huge sum won’t come from general taxation: voters are not willing to pay taxes at the level necessary.

It means that “co-payments” – contributions from individual patients towards the cost of their own care – will inevitably have to increase.

Misguided egalitarians will try to prevent it. But they will only be able to do so by denying people medical care, and by going straight back to the situation in which someone like Linda O’Brien is pushed out of an NHS hospital because she makes a contribution to the cost of the drugs she needs. Is that the outcome they want?


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