Sir, On the face of it and from a moral perspective, a decision to allow “top-up” payments for cancer drugs seems the correct course of action to take (“NHS lifts ban on ‘top-up payments’,” Nov 2). However, this must be seen in the wider context of the future of the NHS and the fundamental principles of “universality” of care. “Top-up” payments will open the door to the insurance industry and private providers to deliver these treatments. This will become the norm for many new treatments, not only cancer drugs, and will lead to a system of “managed care” much like that in the US where it is the insurers and not doctors who decide who gets treated, where they get treated, how they get treated, who gives the treatment and how much it costs.

The universality of care provided by the NHS has already been eroded (eg, loss of the majority of NHS dentistry and eyecare) and this is the last nail in the coffin. The real tragedy lies in the fact that we should not even be having this debate. The total NHS drug spend on cancer drugs in England is approximately £1 billlion per year, but, in the British Medical Journal last week, the chief economist of the King’s Fund, Professor John Appleby, stated that the NHS in England is projecting an underspend of £1.7 billion and foundation trusts are reporting cash balances of £2.5 billion. Furthermore, it is painfully ironic that the huge cost of introducing a market-based system to the NHS has actually helped to spark a debate that will lead to further privatisation and fragmentation.

On a final note, it is no wonder that Professor Karol Sikora welcomes “top-up” payments as he is on the steering committee of Doctors for Reform, who support the notion of mixed funding systems for the NHS.

Dr Clive Peedell

Consultant Clinical Oncologist, James Cook University Hospital, Middlesbrough

Sir, One of the factors behind the current controversy about “top-up” drugs is the absence of any explicit recognition that vital moral issues are involved. If an old person is trapped under a collapsed building late at night, people do not say: “She has not got long to live anyway, let’s leave it till the morning; it will cost a bomb if we get the cranes and crews out at this time of night.” They are more likely to say: “She is pretty frail; we had better pull out all the stops, and get cracking as soon as possible.”

The weakness of the NICE approach is to assume that life and death decisions about whether the NHS should buy new drugs can be based solely on an economic model. Common humanity comes into it too: even if it may involve paying higher taxes.

John Grieve Smith

Shalford, Surrey

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