Is it morally acceptable to allow patients to privately fund part of their treatment and receive the rest of their care from the NHS?

Response from the BGS MEDICAL ETHICS SIG

• Often this refers to drugs used in cancer.  Similar cases occur in other areas, e.g. cognitive enhancing drugs are available on the NHS for moderately severe dementia but are not funded for mild dementia.  Patients who can afford to pay are able to get private prescriptions for these drugs.
• In other areas of life people are free to choose where/how they spend their money e.g. for a holiday, educating children in private schools, buying a bigger house.
• Currently patients can choose to have some care via the NHS e.g. GP services and receive other care privately.  Patients often pay for other health services e.g. podiatry, physiotherapy, and counselling.   Many patients already pay prescription charges and nearly all pay dental fees, so it is already an established principle that some costs of NHS treatment are borne by the patient.
• Some patients will be able to afford private drug treatment and others will not. It is argued that it is not equitable to allow private funded drugs and NHS treatment.  However, there have always been differences in what people can afford.  If parents want to pay for additional private tuition for their children, they are not denied the right to state funded education.  Inequality occurs in all areas of life and the State cannot compensate for all inequalities.
• Access to NHS care is based on need not ability to pay.  Fair access to medical care is a fundamental principle of the NHS.  But fair access does not mean equal access.  Treatment is currently rationed – only given to those where there is a reasonable chance of success.
• The NHS cannot afford treatment at any cost.  Therefore rationing must occur.  However there may be disagreement over the criteria used for rationing.  In the case of dementia drugs – the criteria used by NICE suggest they are not cost effective in mild/moderate dementia.  Yet dementia specialists and patients with dementia argue that the impact on quality of life of medication in mild dementia is significant even if the measurable outcome [change in MMSE] appears small.
•  Physicians have a duty of care to their patients, this means that whether a patient sees them privately or in the NHS the treatment they recommend should be evidence based and appropriate for that patient.  Physicians working within the NHS have an additional duty – to use their resources wisely.  They may therefore, be unable to prescribe a treatment they feel is clinically efficacious.  In this situation if the patient has the money to pay for the drug it is difficult to deny them. 
• If the clinical condition from which the patient suffers is life threatening or causes significant ill health and the new drug has significant clinical benefits then the physician has a duty to advocate NHS funding for the treatment.  However if the drug is very expensive and only has marginal benefits over existing treatments then the physician must think hard about whether it should be recommended at all.
• If people who can afford drugs opt for privately funded drugs there is a risk that those who cannot afford to pay will not have the advocates to make these drugs available free of charge in the future.
• There is already a two tier health service however allowing patients to receive NHS care but privately fund their drugs may accentuate the difference.
• The cost of using new drugs is not only the actual cost of the drugs but also the cost of subsequent monitoring and follow up.  Therefore there may be additional costs to the NHS that need to be taken into account when charging the patient.
• NHS services should be fair to both patients and tax payers.  Patients should be entitled to evidence based NHS care but not automatically be entitled to every possible care irrespective of the cost.
• Vulnerable patients also need protection from pharmaceutical companies or clinicians who exaggerate the marginal benefits of their treatment and encourage desperate patients to go to any lengths to fund it.

Conclusion:

NHS should provide care that is affordable and according to guidelines which consider both clinical and cost effectiveness.  However we should allow patients to choose additional self funded care without being penalised for exercising that choice.