Will the NHS top-up plans unravel?

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ANALYSIS By Nick Triggle Health reporter, BBC News The top-up plans will make life more complicated on the wards, some sayOn paper it sounds so simple - top-ups are only to be allowed under strictly regulated conditions.

The extra drugs are to be administered away from NHS wards, while patients will be expected to pay for any tests and scans associated with that treatment.

But in the hustle and bustle of the daily life of a hospital, it may not be so clear cut.

For example, while ministers want those topping up their care to pay for all the related-elements of treatment, it is not always so easy when it comes to side-effects.

Many drugs - especially those likely to be subject to top-ups - come with side-effects ranging from diarrhoea and nausea to heart problems.

NHS package

These can be worsened when combined with the other drugs and treatments, such as chemotherapy, that are part of the rest of the package of care.

"It is sometimes hard to distinguish exactly what causes what," says leading cancer specialist Professor Karol Sikora, a member of the centre-right Doctors for Reform group.

"Of course, you can perhaps levy a surcharge, but in the end it is not as simple as the government is suggesting."

We need greater clarity on what will happen - and who will pay - when things go wrong Nigel Edwards, of the NHS Confederation <a class="" href="/1/hi/health/7458908.stm">Q&A: NHS top-ups</a><a class="" href="/1/hi/health/7706964.stm">A doctor's story</a><a class="" href="/1/hi/health/7706921.stm">Top-ups ban lifted</a>

The government's desire to keep the top-up aspects of care out of NHS wards could also unravel.

For example, what would happen if a patient is admitted into a high dependency ward or intensive care unit when they are due for another course of top-up drugs?

Would the NHS deny them the extra drugs or would they let the medical teams administer them while other patients who were not paying for the drugs looked on?

The government's answer - it would have to be assessed on a case-by-case basis.

Merits

Or what about if a patient had been paying for a drug which was prolonging his or her life, but that meant they ran out of money to fund it? Would the NHS the step in?

Again, the government says this would have to be judged on the merits of the individual case.

Unsurprisingly, Nigel Edwards, director of policy at the NHS Confederation, which represents managers, believes those working on the front-line will need more guidance for this plan to work.

"We need greater clarity on what will happen - and who will pay - when things go wrong.

"It is critical that patients are made fully aware of what they are paying for with clear and explicit advice from clinicians about drugs that have not been approved as both clinically and cost effective.

PROPOSALS: AT A GLANCE Patients get right to pay for top-ups without losing their basic NHS package of careBut those paying for extra drugs will also have to cover the cost of any staff time, tests and scans associated with that treatmentTop-up care must be carried out away from NHS ward to avoid patients in beds next to each other getting different quality careArrangements do not apply to implants used during operations such as cataract, knee and hip surgeryNHS aiming to ensure more drugs available on NHS by raising the threshold it is willing to pay for treatments for rare terminal illnessesMinisters seeking to get better deal from drug firms through the use of risk-sharing pricing such as refunds when the drug does not work <hr> <a class="" href="http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/04_11_08_nhs_topups.pdf">Improving access to medicines for NHS patients [410KB]</a> Most computers will open this document automatically, but you may need Adobe Reader <a href="http://www.adobe.com/products/acrobat/readstep2.html">Download the reader here</a>

"At the same time, practical difficulties remain on how patients who choose to pay privately can be moved into private facilities and how these drugs should be priced."

But, for some, the proposals spell outright disaster.

Unison, which represents a range of health workers, has been one of the most vociferous opponents of top-ups.

Karen Jennings, the public sector union's head of health, said the plan could open the "floodgates".

She says she is concerned the NHS package on offer could actually shrink as a result, making it more and more difficult to get comprehensive health treatment without paying for it as has happened with dentistry over the years.

With this in mind, it is perhaps telling that insurance firms have already started thinking about a range of packages to help patients top-up their care.

But of course not everybody shares this doomsday vision - and certainly not the government which is quick to reject any suggestions a two-tier health service is imminent.

However, what does seem certain, is that life on the wards of the NHS is about to become more complicated than ever.