It is instructive that Alan Johnson’s common sense decision to allow cancer patients and others with serious conditions to privately purchase drugs not currently provided by the NHS has led to Tory claims that this creates a ‘two-tier’ NHS. It is true that the rule change may disadvantage those patients unable to pay for private treatment because at least in the previous system all patients were in the same ship. Seizing on this, shadow health secretary Andrew Lansley has argued that unless the government makes all cancer drugs available in the private sector free of charge on the NHS, it is creating a new system of haves and have-nots.
Lansley ignores two fundamental points. The first is that the NHS is already two-tiered – in fact more like a multi-tiered system – which perpetuates numerous inequalities, not least on the basis of geography. The step which the health secretary has taken, following the conclusions of a commissioned report from the cancer tsar Mike Richards, is designed to alleviate an obvious unfairness in the current system which condemned some patients to make a choice between not having a potentially effective treatment privately or having to pay for all of their treatment currently covered by the NHS if they did go private. While this step does technically create a new inequity in the NHS, the inequity it replaces is surely more pernicious?
The reason for this is because of a second key point – free treatment on the NHS is, and always has been, necessarily rationed. There is a potentially infinite demand for healthcare but not the requisite pot of taxpayers’ money to cover it. This has led successive governments to prioritise those treatments and drugs proven to be the most cost-effective on the basis of quality of life given. Labour’s answer to this conundrum was to largely take decisions about cost-effectiveness of treatments out of the hands of politicians and place it with the National Institute for Health and Clinical Excellence. NICE has come in for a lot of flak, and the good thing about the Richards review is that it makes some necessary changes to the process by which it gives new drugs the green light. But it is irresponsible of Lansley to imply that because patients still won’t have access to all of the drugs which they could purchase in the private sector, the NHS is creating inequalities.
If anything this would be a licence for pharmaceutical companies to pioneer drugs which were only effective in a tiny number of patient circumstances rather than investing in R&D for treatments which satisfied the huge amounts of public money being spent on them. The government should ensure that the NHS provides as many clinically effective drugs free of charge as possible – but the crucial phrase here is ‘clinically effective’. Lansley’s prescription would be to allow drugs companies to determine whether their treatments are effective, by shifting the burden of proof at assessment stage from NICE (who currently have to prove if drugs are not effective), to expecting pharma companies to prove instead they are. Once again this does not seem to act either in the interests of clinical or cost effectiveness.
This issue is indicative of the haphazard stances the Tories take on tricky issues of public policy. From one perspective it looks like Lansley is the champion of the NHS’s founding principles, demanding equality for all. But it is not clear how he would prevent public money from being poured into the coffers of drugs companies without the requisite proof of effectiveness. Instead the government has taken the most sensible option of only paying for new drugs after it has been proven they have worked with a particular patient, or buying in the drug at an initially lower price and raising it if it is subsequently proven to be effective. Those defenders of the NHS should resist the Tories’ siren calls of greater equality since they may mask more old-fashioned instincts of courting the corporate dollar.