Sir, Patient top-up payments run the risk of depriving many of benefits from medical research (“Top-up fees for drugs herald two-tier NHS”, Sept 23). We stand at the beginning of a period in which exciting new drugs are in trials. Many of these drugs are biotherapeutics offering real benefits in chronic inflammatory conditions and cancers. They are expensive drugs with high costs for research, development and manufacture.

Under the proposed scheme, doctors will need to take difficult decisions not just about the diagnosis and treatment, but also about social factors — does the patient have savings or assets? Doctors must be able to prescribe freely the most effective treatment for a patient’s needs. How much harder will this decision be in those cases where a treatment may not offer a cure, but might slow disease, offering improved quality of life. The resulting division between those who can pay and those who cannot would leave healthcare in Britain lagging far behind other developed countries, particularly in cancer survival rates.

Professor D. Altmann

London N3

Sir, Anti-cancer drug treatments require staff, buildings, beds, equipment and other drugs for their administration, and medical consultations, blood tests and scans to monitor their efficacy and toxicity. All of these may be required to deal with side effects. These resources are finite. Increasing their use within the NHS for those patients able to pay for relatively cost-ineffective drugs could divert resources away from other patients for whom they might have been used more effectively.

If co-payments are to be allowed it would seem only fair to require that patients buying drugs meet the associated costs of care. Some hard-pressed cancer units have no or very limited scope for increasing their service in the short term, even if the required funding is available.

Dr Gareth Rees

Clifton, Bristol

Sir, Fears centring on the creation of a two-tier health service can be countered by pointing out those areas where, currently, NHS patients mix their treatment with private care. Two other reforms will be crucial. First is the speeding up of NICE decisions. Second is to encourage other forms of collective health provision which were part of everyday life before the Health Service was nationalised in 1948.

One very enterprising mutual society already offers individuals insurance coverage should they need to pay for cancer drugs on top of their own NHS treatment. This initiative needs to be made universal but not just for individuals. The task is to seek ways in which communities can extend collective insurance coverage for top-up fees.

In this way we begin rebuilding the sense of a collective identity outside the State. This will strengthen the NHS by giving it an active base that will arise from these new forms of collective insurance. NHS partnerships can go beyond the ones that the Government has forged in the private sector.

Frank Field, MP

House of Commons, SW1

Sir, Is it not cruel for a doctor to tell a patient that he will soon die without an expensive drug? In gentler times, a doctor would murmur that it was cancer, the patient would ask “How long?” and would then set about putting affairs in order. Now terminal patients have to meet their inexorable end full of resentment and surrounded by frantic fundraising efforts.

Nigel Macnicol

Oakham, Rutland

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