Q&A: NHS top-ups

The co-payments debate has been gathering pace

The issue of so-called top-up fees has hardly been out of the headlines in recent months.

It has polarised opinion among patients and the medical community alike and now the government is set to announce what it is going to do about it. But why has the topic proved so controversial?

What are top-ups?

Payments made by patients who chose to pay privately for extra treatment in addition to the care provided to them free at the point of delivery by the NHS. They are also known as co-payments.

Patients who have attempted to purchase cancer drugs not available on the NHS have attracted most media attention.

But the concept of paying for extra care alongside the standard NHS package can be seen in other areas of the health service.

Patients have been known to pay for diagnostic tests to speed their way through the waiting list system.

And in regards to dentistry, it is common for patients to pay privately their teeth to be cleaned, while benefitting from NHS subsidies for fillings.

Why are they proving controversial?

This year cases have come to light of patients being denied NHS care because they pay for drugs not available on the health service.

NHS rules state that a patient cannot be both a private and NHS patient for the treatment of one condition during a "single visit".

The government initially backed this hard-line stance, saying it did not want to create a two-tier system.

But in June ministers announced there was to be a review into the issue amid mounting anger and the realisation that not all trusts were interpreting the guidelines in the same way.

Some trusts allow top-ups with at least 30 known to be allowing patients to use the services of a firm called Healthcare at Home which get round the rules by administering the drug in the patient's home.

How has the government carried out its review?

Ministers appointed the cancer tsar Professor Mike Richards to look into the issue.

He has headed-up a four-month review carrying out surveys of NHS trusts, one-on-one interviews and focus group exercises.

His remit has been to look at all types of drugs, not just those for cancer.

But Professor Richards has also looked at how the NHS can ensure more treatments are available on the health service.

This is something the Tories have made a particular point of raising, claiming fewer drugs are available on the NHS than in other western countries.

Announcing the review, Health Secretary Alan Johnson said it was a "complex issue" that needed to be examined carefully.

He said the government wanted to be fair to patients, while safeguarding the principles of the NHS.

The devolved administrations are all closely following the English review and are expected to clarify their positions in the near future.

What sort of patients have been affected?

While the review has covered all drugs, the focus of media attention has been on cancer patients.

One of the most high profile cases has featured Linda O'Boyle.

The 64-year-old, from Essex, was diagnosed with bowel cancer in 2006 and received NHS treatment, including chemotherapy, until September last year.

She then paid �11,000 for an eight-week course of a drug called Cetuximab, which is not available on the NHS, to prolong her life.

But she was subsequently denied the basic package of NHS care she had been receiving, before dying in March.

Since her case attracted national attention, a number of other cancer patients, particularly those with kidney cancer, have also had their plights highlighted.

But getting a clear idea of how many people have been affected is tricky.

Perhaps the best indication is the number of exceptional cases brought to the attention of local health bosses.

All primary care trusts have a system to allow patients to put forward cases for funding where it would normally be denied.

There have been 26,000 of these in the last year covering everything from lupus to Crohn's disease.

However, what must be remembered is that when talking about top-ups the treatments in question are not cures but life-prolonging drugs instead.

These are treatments that generally work by slowing the progression of the disease and relieving some of the symptoms.

Such drugs can add anything from a month or two to over a year to a person's life.

What has the government proposed and will it work?

In a nutshell, the Department of Health has suggested the ban should be lifted on top-ups.

But the move comes with strings attached. Patients paying for drugs privately will also have to cover the cost of the staff time to administer the drugs as well as covering any extra scans and blood tests needed.

Ministers are also insisting that patients be treated for top-ups away from NHS wards.

This they say will avoid the two-tier situation whereby patients lying in adjacent beds are getting very different treatments.

Not everyone agrees it is as simple as that. For example, how can the NHS define which side effects are related to the top-up drug and which are due to the NHS care?

Such grey areas have left the government open to accusations that a two-tier system is being created.

The plan also rests on ensuring more drugs are available on the NHS.

The threshold is set to be raised for what the NHS is prepared to pay for life-prolonging treatments for rare illnesses.

At the same time they are hopeful the drug firms will meet them half-way by agreeing to more risk-sharing arrangements over the pricing of drugs.

These could include refunds when drugs are not effective on certain individuals or a sliding-scale of pricing for the longer the drug works.

Ministers are already in talks over this, but the agreement of industry is far from certain.