Times: Clegg backs ‘top-up’ payments for cancer drugs by NHS patients

Here’s how The Times is reporting the story:

Nick Clegg, the Liberal Democrat leader, will set out today why he believes patients should be allowed to pay privately for drugs to “top up” NHS care. The Liberal Democrats will seek to outflank both Labour and the Tories after patients who bought life-extending cancer drugs privately were refused further treatment by the NHS.

Under current guidelines, patients risk forfeiting their right to NHS care, such as nursing or chemotherapy, if they pay privately for treatment rejected or not yet approved by the National Institute for Health and Clinical Excellence (NICE).

The Government is expected to publish a much-anticipated review of its policy on so-called co-payments next month. But the Liberal Democrats are the first political party to say that they would give patients the option to pay for drugs without jeopardising the rest of their care. The Conservatives have adopted a markedly more cautious approach to the issue.

[Nick] justifies his belief that patients should be allowed to “pay the difference” as part of a wider liberal philosophy. He will say: “We cannot continue to deny people the right to top up their care, particularly where they are following their clinician’s advice. An extra week of life may not count for much on a bureaucrat’s chart. But if you’re saying goodbye for ever to your children, it couldn’t matter more.”

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  • Clegg's Candid Friend 9th Sep '08 - 11:25am

    There’s a short audio interview with Nick Clegg on the BBC website:

    Three points struck me:

    (1) He does seem to be limiting support for “top-ups” to cases where GPs recommend the treatment in question – “drugs which their doctors are recommending to them even if they’re not paid for by the NHS” (though what he said wasn’t as clear as it could have been, because – unless I missed it – he omitted to mention that the whole point of this is that patients wouldn’t be denied other NHS treatment).

    I must say my immediate reaction is that if drugs are recommended by GPs they should be paid for by the NHS!

    (2) There is a recommendation that people should be given the “flexibility to receive payments themselves which are usually spent on their behalf in the NHS so that people have greater control about how they get their care and how they pay for it themselves”. This sounds rather like some kind of voucher system, doesn’t it?

    (3) Following his previous refusal to rule out cuts in overall health spending, he gives a pretty clear indication that he does envisage such cuts: “the question is how do you make do – or how do you do better – in our NHS with the same amount of money or maybe even in the future we will have to be a little bit more careful with all the money going around the NHS.”

    I suggest that the last item will go down like a lead balloon in Clegg’s target Labour seats.

  • Paul Pettinger 9th Sep '08 - 11:49am

    Are rich people really supposed to lie in the same wards as poorer people and watch them die around them, as they cannot afford the same drugs? This is absolutely horrendous and an attack on the principle of universal health care. A system that allows richer people to op out risks creating a poorer healthcare system for the less well off. You only have to look to the US to see what poor public health care is provided where the rich op out of the public system. I no longer have full confidence in Clegg’s leadership.

  • Hywel Morgan 9th Sep '08 - 12:05pm

    “It is absurd that the NHS should punish people who use what resources they have to compensate for the rationing the NHS imposes upon them.”

    Allowing this will mean there is increased rationing of treatments for people who can’t afford to top up their own treatments though.

    There is therefore a difference with the schools/pensions arguement as neither of those situations require additional state expenditure. It’s more akin to me educating a child at home but wanting him/her to have access CDT education at the school even though that isn’t provided to other pupils.

    That seems to drive a coach and horses through our policy of greater democratic and local accountability for the NHS. What’s the point in having that if the best off people are able to just pay their way around it.

  • David Evans 9th Sep '08 - 12:21pm

    I fail to see how members of a party committed to “build a … society … in which no-one shall be enslaved by … conformity.” can then support refusing treatment on the NHS on the simple basis that they are prepared to pay to enhance what they get from the NHS – not to queue jump, not to get preferential access to other services, nor does it prevent another patient from getting their treatment.

    Perhaps someone would care to enlighten me.

  • Clegg's Candid Friend 9th Sep '08 - 12:30pm

    There’s more on this in the Guardian, based on an early release of Clegg’s speech:

    However, Clegg did say that he was only in favour of top-up payments provided that three conditions were met.

    First, there should be no hidden costs to the NHS. Second, top-up payments should be limited to drugs and procedures that were clinically approved. And, third, the NHS should not use top-up payments as an excuse for cutting services.

    I think that little phrase “clinically approved” involves a host of difficulties.

  • Paul Pettinger 9th Sep '08 - 12:34pm

    Tom, this would be the start of a two-tier health system. If people can top up their treatment for cancer drugs where does it end? The proposal does let richer people top up and opt out of a basic provision of health care. I do not pretend for a moment that this is an easy topic. Having thought about this and the merits of cons of voucher systems for some time I do however know where I stand.

  • Hywel Morgan 9th Sep '08 - 12:51pm

    Where did I suggest any sort of opting out. I’m quite clear that this is about well off* people making extra payments.

    You haven’t addressed my point about this affecting other patients who can’t afford to do this. For a patient to be treated in the way you describe there will be someone else who isn’t getting the treatment they need. Should we be treating on the basis of clinical need or who can contribute most towards their treatment?

    * I agree this isn’t actually about the well-off as they will be paying to go exclusively private. However “people who whilst they have assets they can borrow against don’t have the resources to go exclusively private” is a bit unwieldy 🙂

  • Hywel Morgan 9th Sep '08 - 1:07pm

    Because they use NHS resources to administer the drugs, check for side effects, monitor their effectiveness etc. That all uses up NHS resources which do have a finite limit.

  • I think the major problem is the cost of drugs from commercial drugs companies. Why is it generic drugs are dirt cheap, yet branded drugs cost thousands.

    I was told by an ex drug rep, that at one time the price the NHS paid was used to set the price for the rest of the world. THis may still be the case as we are probably the largest single customer.
    So we suffer for their profit margins.

    So should we give into drug companies emotional black-mail so they can keep the price up, my answer is no.

  • Paul,

    Are you advocating the restraint of people based on the lowest common denominator? Not a very liberal attitude. Do you feel the same about private education, or pensions?

    In addition, it is not the start of a two tier system. This already exists. Have you heard of BUPA? Google it.

    This is an intelligent proposal, it is needed, and I fully support it. No doubt some people, yes that means you Paul, will pull the covers back over their eyes and hope the whole problem of funding modern health practices goes away.

  • Paul Pettinger 9th Sep '08 - 2:09pm

    That’s pretty facile reply Schneider. If you want people to be able to top up their NHS treatment are you therefore proposing a full-blown voucher system for state healthcare and education??

    Whelan, Clegg’s views are Liberal, but they are very classically so and too far for this social-Liberal. Call me old fashioned, but I think the NHS should be funded by general taxation and that people should receive treatment based on their need. I don’t claim for moment that this is the most efficient model to pursue.

  • Clegg's Candid Friend 9th Sep '08 - 2:19pm

    Hywel Morgan:
    “Because they use NHS resources to administer the drugs, check for side effects, monitor their effectiveness etc. That all uses up NHS resources which do have a finite limit.”

    The Guardian report I quoted above said that one of Clegg’s conditions was that “there should be no hidden costs to the NHS”. Also that “the NHS should not use top-up payments as an excuse for cutting services”.

    I think there are a lot of complications and difficulties lurking in the details, but I don’t see the same kind of fundamental objection to this that you seem to, though obviously it has cost implications.

    But I think the real problem is one of resources. If Clegg is saying that we do not propose any further increase in the NHS budget, and that it may even be necessary to cut it, then I think that’s quite wrong.

  • Paul Pettinger 9th Sep '08 - 2:34pm

    With the greatest respect there will be hidden costs and I believe in the long term top up payments will lead to a decline in services for those who can not afford to top up. That’s realpolitique.

  • David Evans 9th Sep '08 - 3:23pm

    I’m sad to say that I can’t see how anyone claiming the title liberal, even in part, could propose withholding NHS treatment from someone who used their own money to save their life. In essence it would totally destroy the middle ground between the very rich who have so much they don’t need NHS treatment and the rest of us. What is being promoted by some here is not “social liberalism”; it is “absolute authoritarianism” of the worst kind. Old style liberals know that every liberty for one has a cost for others (my car stereo may be your noise pollution). This applies throughout life and judgements have to be made as to the compromise to be made.

    For Hywel’s argument to ban it “because they use NHS resources to administer the drugs, check for side effects, monitor their effectiveness etc. That all uses up NHS resources which do have a finite limit.” is to be considered valid, I would have to be convinced that this was a sizeable use of NHS resources, enough to preclude it as a greater denial of the liberty of life to others. After all the NHS supports the monitoring and treatment of people who administer their own drugs and treats the side effects when they are drug or alcohol addicts. Or do we think we should become a party which refuses to support NHS treatment for those who have taken care of themselves for years, are now getting old and treatment is getting expensive but we will give treatment to those who have chosen not to.

  • Clegg's Candid Friend 9th Sep '08 - 3:28pm

    I said above I thought that Clegg’s suggestion – that people should have “flexibility to receive payments themselves which are usually spent on their behalf in the NHS so that people have greater control about how they get their care and how they pay for it themselves” – sounded rather like a voucher system.

    I’m a bit surprised that no one has picked up on the fact that Clegg’s speech is being given at the launch of a report by the think tank Reform, which is proposing the introduction of a voucher scheme in which the NHS would be replaced by state funding for private medical insurance.

    The Telegraph reports that Clegg “is said to be broadly in favour of its proposals”. The BBC says he “welcomes” the report but disagrees with what it says. If so, it seems strange that he is attending – and speaking at – the launch.

  • Some drugs naturally will not be cost effective for the NHS. This is awesome well done Nick.

  • Hywel Morgan 9th Sep '08 - 8:08pm

    “For Hywel’s argument to ban it “because they use NHS resources to administer the drugs, check for side effects, monitor their effectiveness etc. That all uses up NHS resources which do have a finite limit.” is to be considered valid, I would have to be convinced that this was a sizeable use of NHS resources,”

    I don’t have the figures – but I doubt anyone does. However at the moment there aren’t a huge number of people doing this.

    A calculation of what treatments produce hidden costs and lead to excuses for cutting services will be vastly opaque and really pretty subjective.

    If it were allowed however it would grow in popularity and it is highly probable that companies would start to offer insurance to cover the costs.

    The next logical step would then be why not allow people to have an operation if they pay for say the costs of their nursing care. That isn’t in principle any different to what is being suggested here which is a part payment of the costs of treatment.

  • David Evans 9th Sep '08 - 9:06pm

    Hywel, you are right, it is all subjective and based on judgement. What I don’t see is why someone paying for better drugs (possibly more effective, possibly with less side effects) is any more than a minor element in a situation where you seem to be proposing the totally extreme and illiberal banning their access to the NHS. The next logical step to counter your view is that if the parents of a child bleeding from a knife wound used their own bandage, you would ban him as you couldn’t be sure that it was sterile and so could require extra nursing.

    I really must ask you if you believe in liberty, or only when it can be shown not to affect anyone else? Personally, I can only see authoritarianism in this area at present.

  • Hywel Morgan 9th Sep '08 - 9:32pm

    “where you seem to be proposing the totally extreme and illiberal banning their access to the NHS.”

    Where did I say that? The only thing I said they shouldn’t be entitled to is the cost of administering/monitoring etc the treatment that they have purchased privately.

  • David Evans 9th Sep '08 - 10:15pm

    Hywel, The previous stages in our discussion were all within the context of a single though possibly extensive course of treatment. The same applies to my last comment and so I consider that it still stands. I still really don’t see how your views stack up in a liberal context.


  • Hywel Morgan 9th Sep '08 - 10:51pm

    “I still really don’t see how your views stack up in a liberal context.”

    Fundamentally they don’t – no system of rationing health care (which is what is at the core of this issue) really does.

    There is little logic to the Linda O’Boyle case – AIUI the whole of the non-NHS sanctioned treatement was paid for privately so there was no additional cost to the NHS. However if it wasn’t NICE approved then it doesn’t seem it would fall under our proposals.

    The idea that if a Dr recommends the treatment the NHS should pay for it sounds attractive but I think a Dr would be under an ethical duty to recommend any appropriate treatment regardless of NHS policy.

  • Thanks for that Hywel, I think I can see where the root of our divergent opinions lies. When faced with a policy decision, I always ask the question “What do liberal democrat principles bring to this policy decision that needs to be made?” However, I often find once we are in power we often revert to simplistic policy rather than principle to make decisions. Thus the NHS has a policy that people who pay for their own treatment have to pay for the full amount, – you appear to agree with this, presumably due to the fact that, the NHS, subject to Doctors getting their prioritisation right, delivers equality. However, society as a whole doesn’t come close because the mega-rich can afford to pay for the entire thing, while the moderately well off can’t or if they can only do so by beggaring themselves to pay for it. Thus we end up forcing conformity or poverty on the moderately well off in order to make then equal with the poor, while ignoring the rich. This I believe is actually creating an unfair, unfree and divided society, rather than the fair, free and open one we aspire to.

    To take an example which I consider ridiculous, the NHS in our area, when it wanted to save patients travelling large distances couldn’t find premises in our area which met the full disability friendly criteria. Consequently, it expanded one miles away to take extra patients. As a result all patients have to travel significant distances by a slow minibus to be equal (i.e. identical). At lower cost, the NHS could have provided a local service for all but the most severely disabled, and a personal taxi service to the most severely disabled to travel to the disabled friendly premises much further away. End result, perfectly identical equality, with everyone travelling for much longer than if a less authoritarian approach had been adopted.

  • Clegg's Candid Friend 10th Sep '08 - 1:15pm

    “Allowing people to top-up their own healthcare might just give the poorer people in society the chance the NHS alone isn’t providing.”


  • Clegg's Candid Friend 11th Sep '08 - 1:53pm

    Here’s a little snippet from Matthew Parris on this:

    “The merit yesterday of Nick Clegg’s online Guardian endorsement of “co-payment” in the NHS (letting us buy for ourselves drugs that the NHS won’t) is that the Liberal Democrat leader almost acknowledged the logical conclusion: a health service dismantled into core provision plus bolt-ons provided from patients’ own pockets. It is an idea we should debate. What journalists and MPs should not do is rant and emote about the individual cases of dying cancer patients, as if no general principles were involved, or general principles didn’t matter. In the end, they always do. Next will come insurance for co-payment drugs. Wedges have thin ends. Would we let children be removed from school for particular lessons that their parents wanted to buy elsewhere?”

    Much as I like opportunities to be candid with Clegg, I think Parris’s analogy here is obviously flawed. We aren’t talking about people wanting to get treatment elsewhere, but about treatment the NHS is refusing to provide.

    We aren’t talking about people who want to go private, but people who are being driven to it. They will have recourse to “bolt-ons” only to the extent that the NHS is unable to pay for them. Surely the real issue is overall funding.

    And I do think Clegg was quite wrong to talk about the NHS looking for excuses to cut services. It’s politicans who do that – and, ultimately, the people who vote for them.

  • Paul Pettinger 11th Sep '08 - 6:28pm

    I think Matthew Parris clearly understands the logical consequences of supporting top up payments, which I’m not sure is immediately apparent to most.

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