The government has deemed that NHS cancer patients cannot pay for an additional anticancer drug without losing their entitlement to state-funded care at that time. It says a patient cannot be a private and an NHS patient in the same “episode of care”.

But we already have a mixed economy in healthcare with private contractors providing NHS-funded care and with those patients who run into problems in the private sector ending up in the NHS at varying stages of their treatment.

The past decade has seen a seismic shift in the NHS, as private contractors provide services, which they do for profit. We use NHS funds to pay agencies for temporary staff, despite the exorbitant cost. Why not allow NHS and personal funding to be integrated if that is what the doctor thinks best for the patient?

The National Institute for Health and Clinical Excellence (Nice) provides important boundaries to what treatment is paid for and what is not by the NHS, but individuals sometimes fall outside the norm. They deserve to be allowed to help fund their care.

When the consultant assesses that a patient is likely to benefit from a drug, yet the drug is not funded by the NHS, what do they do? Do they tell the patient, knowing that the patient has a right to know about their condition and its treatment, or do they keep silent to avoid distress?

Professional codes of conduct demand disclosure. Without that honesty, the patient and their family are left unsupported to surf the net in the vain hope of finding something to help.

The government also objects to allowing NHS cancer patients to pay for additional medicines on the grounds that this would create a two-tier NHS with patients on the same ward being administered different drugs based on their ability to pay.

We already have multi-tiered healthcare in this country, however. Those who can afford to pay for their care privately do so.

The government is adamant that an “episode of care” is either in the NHS or funded privately by the patient. Yet there is no clear and consistent definition of “an episode of care”. Is it just the standard course of a drug, including or excluding background investigations and potential but not expected complications? Or is it everything associated with a treatment, even if life-threatening complications occur? We have different definitions of an “episode of care” around the country.

If, for example, a patient has a hernia operation, then suddenly has a massive heart attack immediately after the operation and is shipped into the local NHS coronary care unit, the patient’s dressings relating to the surgery have to be attended to – the NHS does not wash its hands of the patient just because the surgery was done sooner but privately. When some complication arises following private surgery, many patients land in an accident and emergency department and are treated, not sent away. The episode of care is deemed to be over in the private sector and the patient reverts to the NHS.

There is a provision for the NHS to charge the patients or insurer but this happens rarely, even when the complications arise directly from the privately funded intervention. We have patients in nursing homes paying for their social care, having been means-tested. This includes care from trained nurses although the rest of their care is rightly provided on the NHS. Yet the boundary between some aspects of health and social care is very blurred.

At present, different NHS trusts take individual decisions in conjunction with their local commissioners over individual high-cost drugs. Often the difficulties arise when high-cost drugs are licensed for one indication but the clinician wants to prescribe it for an individual with another condition. This can either be because the patient wants to buy the drug but have NHS care, or it may be that the patient wants to top up their care, or wants to self-administer the drug (perhaps purchased via the internet) but remain treated by the NHS. The danger is that if the NHS does not know what the patient is taking, the consultant is unable to advise if the drug is likely to do more harm than good. And the NHS still has to treat the patient when problems arise.

No patient can expect a clinical team to administer a treatment that is unlikely to be of benefit – on balance the benefits must outweigh the risks and burdens.

There will always be patients getting funded drugs but not responding as hoped for. Similarly for unfunded treatments, there will be a small number of patients who might have benefited if they had had the treatment; predicting that can be hard.

But why should we pretend that the lines around NHS episodes of care are clear? They are not. Without clear national definitions of what the NHS does and does not do, can we justify spending billions of pounds on the relief of relatively minor conditions and deny patients with life-threatening disease the support of the NHS when they want to bridge the costs themselves?

Interestingly, the opinion of Nigel Griffin QC is that there is no bar in law, and no reason in principle, for NHS and privately paid-for care to become more integrated so that treatment runs concurrently, providing that nobody else is excluded from treatment in the process.

It cannot be beyond the wit of managers to ensure that those who fund their own treatments integrated with the NHS do so in a way that allows a small fund to be generated to subsidise the odd patient who cannot pay but really would benefit from that rare off-licence treatment.

Surely this would be more equitable than restricting access to potentially life-prolonging treatment to those able to pay for everything included in the “whole episode of care” – whatever that means.

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