Policy responses and statements

Name of organisation:

Department of Health

Name of policy document:

Draft guidance on NHS patients who wish to pay for additional private care

Deadline for response:

27 January 2009

Background: This document provides new guidance on how to proceed in situations where NHS patients want to buy additional secondary care services that the NHS does not fund. It has been published in response to a review commissioned by the Secretary of State for Health and conducted by Professor Mike Richards, the National Clinical Director for Cancer. Professor Richards’ report, published on 4 November, showed that there was a great deal of confusion about the rules in this area. Existing guidance was being interpreted differently in different places, and many patients were not clear whether they would still be entitled to NHS care if they purchased additional private drugs.

Professor Richards recommended that:

• The Department of Health should make clear that no patients should lose their entitlement to NHS care they would have otherwise received, simply because they opt to purchase additional care for their condition;

• Revised guidance should be issued as soon as possible to make this clear and to promote greater consistency across the NHS in England; and

• The guidance should set out mechanisms to ensure that these cases are handled in a way that supports good clinical practice and is fully consistent with the fundamental principles of the NHS.

This document responds to those recommendations, outlining guidance on NHS patients who receive private care and setting out a series of important safeguards.

COMMENTS ON
DEPARTMENT OF HEALTH
DRAFT GUIDANCE ON NHS PATIENTS WHO WISH TO PAY FOR ADDITIONAL PRIVATE CARE

The Royal College of Physicians of Edinburgh is pleased to respond to the Department of Health on its Draft guidance on NHS patients who wish to pay for additional private care.

The College believes this is a timely consultation in view of recent publicity about the distressing consequences when patients who have opted to finance private cancer therapy have subsequently had to pay for their usual NHS care.  However, this is a complex issue, and we have concerns over the departure from the NHS principles of effective healthcare free for all at the point of delivery.

The College wishes to make the following points:

1. The document makes it clear that there is a need to separate the private element of care from the normal NHS care, and deliver the private care at a different time and place.  This would avoid the potential problem of patients in the same NHS unit receiving two different levels of care and treatment but, in practice, such separation will be complex and difficult to achieve in many hospitals.  It will also result in unnecessary, counterproductive and costly duplication, e.g. two venepunctures and two ward admissions on the same day in the example given in Case Study a.

2. The document concentrates on cancer chemotherapy and the example of additional, rather than alternative, treatment.  No guidance is given for the situation when two alternative treatments are available and the advising specialist favours the option not supported by NICE or the local PCT (perhaps because of delays in the publication of guidelines etc).  Such alternative equivalent treatments, or the equally problematical situation of available additional procedures and treatments of unproven clinical benefit, will present a clear conflict of interest to the advising clinician if they were to benefit personally from a treatment option that is only available in the private sector.

3. The issue of treatment “upgrades” is controversial.  In Case Study b, it seems illogical not to allow the more expensive lens to be inserted during a routine NHS procedure, rather than making the whole procedure private.  The College can foresee further difficulties where a patient demands a “private upgrade” in the mistaken belief that more expensive treatment must be better than standard NHS treatment.  For example, a patient might request a more sophisticated pacemaker although their clinician considers that a simpler model is indicated.  We feel the document should include some statement to the effect that clinicians should always present their views on optimal management to the patient, irrespective of funding issues.

4. In section 4.4, the document proposes that “clinicians should exhaust all reasonable avenues for securing NHS funding before suggesting a patient’s only option is to pay for care privately”.  This raises several issues: 

   1. Exploring these avenues for funding will take time and give rise to increasing anxiety for all concerned; there must be provision for rapid review of funding decisions.

   2. When a patient opts to pay for additional treatment while a decision is awaited, is there a process for retrospective reimbursement if the PCT later decides to fund the treatment?

   3. More paperwork will be generated and considerable consultant time will be expended in making applications under exceptional circumstances to PCTs before “top up” treatments can be instituted; will this time and effort be monitored and funded?

5. Additional follow up investigations and monitoring (eg by CT or MRI) that are not routine practice may be required after the use of unfunded drugs.  It is not clear whether the cost of these extra procedures and monitoring would have to be paid for privately or would be accommodated within the NHS budget.

6. Similarly, it is not clear how complications of privately funded treatment will be managed. Additional chemotherapy may result in pancytopenia and sepsis; although the document mentions that patients should not be denied emergency treatment, there may be disagreement between clinicians and managers about what constitutes an emergency.

7. We feel it is important that the additional private care scheme is carefully monitored to allow meaningful review of rates of uptake, implementation and costs.  Point 9.6 says “it is important that the NHS should not be seen to be profiting unreasonably from patients in these circumstances”. In our view, we believe the NHS should not be profiting at all, but neither should it be subsidising the private sector.  Ideally, the scheme should be cost neutral.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[26 January 2009]