Graphic: Not a hard pill to swallow

Fairness has always been at the heart of the National Health Service. That is why the present controversy over cancer drugs is so damaging. Many people believe it very unfair that seriously ill patients are denied all NHS treatment if they choose to buy extra drugs that just might give them a longer life, or even a cure. I agree. It is unfair.

There is a clash of principles here. On the one hand, the NHS must treat all equally and not permit anyone to buy advantages for themselves within the NHS. We can, of course, go outside the NHS and buy anything we want as private patients. On the other hand, the NHS should be able to respond to individual's needs and offer choices.

Alan Johnson, the Health Secretary, The Times said yesterday, is considering allowing NHS patients to pay for extra cancer drugs. Certainly, the Government needs to find a way to deal fairly with these patients. I believe that it can do this if it recognises that they are exceptional cases and treats them as such. It is important that the Government does. This controversy is in danger of undermining the principle of fairness at the heart of the NHS.

Private drug helps cancer man left to die

Cancer patient sent home to die by the NHS sees health improve after cashing in pension and paying privately for drugs

• Banned cancer drugs better than NHS ones

• Doctors back top-up drugs

BACKGROUND

• Ministers rethink ban on private drugs in NHS

• ‘We’ve paid into the system all our lives. Why has the NHS turned on us?’

• Doctors' anger at cruelty to patients

• Cancer patients ‘betrayed’ by NHS

• Voters call for end to ban on private drugs

Dying cancer victim was forced to pay

Linda O’Boyle was denied free treatment in her final months because she had gone private to try to prolong her life

• Cancer victim told to pay for his own drugs by NHS

• Doctors for Reform fight NHS order to halt cancer care

• Fighting cancer and the ‘unjust’ health service

Even more dangerously, some use this example to argue that we must change the whole NHS. They suggest that it can't afford everything; therefore it should provide a core minimum package, with patients free to buy whatever extras they want. This is appealing, but wrong.

First, to take this particular case, these drugs and patients are exceptions. Most drugs and most high-cost treatments are available on the NHS because we know they work. These cancer drugs are controversial precisely because they are, as yet, unproven or because their known effect is limited or uncertain.

The Times reported recently that 1,300 patients faced this dilemma. This is a large number - we need only think of these patients and their families to recognise this - but it is a tiny percentage of the 11 million admissions to NHS hospitals every year or the million people seen in outpatients or GPs' surgeries every 36 hours. They represent less than a quarter of 1 per cent of NHS spending. There is no need to change the NHS on their account.

Secondly, we need only look at other countries to see that “core minimum packages” mean that poorer people get a worse deal. In a recent Commonwealth Fund study, 40 per cent of patients in America - where add-on and co-payments are normal - said that, on some occasions, costs had prevented them getting health care. By comparison, 9per cent said this in the UK. Core packages and add-on payments stop poorer people from seeking care.

Thirdly, we should ask both how we would determine what was in the core package and the effects on costs. I have never heard anyone answer adequately the question of how to specify the package. The answer on costs is clear - they will rise as businesses vie to sell us extra services and overheads will increase through the bureaucracy of determining whether something is covered by the “core package” or not.

Finally, the NHS is relatively low-cost and effective. Germany spends 20 per cent more than we do, France 15 per cent more and the US double. The US has the poorest health and life expectancy of the four. These figures challenge the implicit assumption that higher expenditure is always a good thing.

I can well understand why private businesses favour this argument. Its adoption could lead to the sort of bonanza that we see in the US where patients are bombarded by new health products. I can also understand why doctors faced with desperate patients would grasp at the chance of improvement or cure.

I believe strongly that private enterprise plays an invaluable role in creating new drugs and treatments and that competition creates innovation that benefits us all. I also know that private companies have a responsibility to maximise profits. They will sell their products hard. The NHS needs a means of sorting out what are the best offerings. It doesn't have to buy them all.

We need a mechanism that involves clinicians and patients, such as the National Institute for Health and Clinical Excellence (NICE), to assess the effectiveness and value of products. The NICE won't always get it right, but there is a straightforward choice here. We either stick with a system that aspires to comprehensive coverage and uses Nice to set some limits as to what is available, or we create a new system that specifies every core treatment available and charges for add-ons. The first is, quite simply, cheaper and fairer.

Nothing in healthcare is easy. I hope that this and future governments will study the experience of other countries and our own history if they are seriously tempted by arguments about “core packages” and basic services. Leadership in healthcare requires judgment and an understanding of the balances between clinical effectiveness, the benefit to the population, public opinion, private choices and costs. This balance shifts from time to time. There is no easy way to avoid this.

Returning to the cancer drugs, Professor Mike Richards, the national cancer director, must find a better way to deal with this problem. He should speed up the way of assessing if the drugs are effective and keep pressure on drug companies to reduce prices.

I would also look at whether he could identify specific drugs and make a new policy that, for example, if all other therapies had failed, a terminal patient could pay for these while remaining within the NHS, provided the doctor had explained their chances to them in detail and that the results of their treatment would be available to researchers. He should also make sure that independent information is available to patients. They want to understand risks, side-effects, chances of success and likely consequences as well as costs. Their health is the issue here.

I think that Professor Richards should also discount the dire warnings that allowing any co-payment is the thin end of the wedge. When prescription charges were introduced, soon after the foundation of the NHS, Aneurin Bevan resigned, but the service prospered. The wedge has not got much thicker in more than 50 years. Times change and the Scots and Welsh have abolished prescription charges. So it was interesting that the Government is moving in a similar direction with the Prime Minister's announcement yesterday that prescription charges for cancer patients would be abolished.

The present position is untenable. Whether we see this in terms of fairness and compassion or prefer the language of rights, these desperately ill patients should have a better deal.

Lord Crisp, who sits as a crossbencher, was chief executive of the NHS and Permanent Secretary of the Department of Health, 2000-06

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