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What will changes to top-up fees mean for nurses?

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The government has announced a range of measures that aim to increase access to expensive drug treatments. Helen Mooney outlines the new system and its implications for nursing

Patiets in England are now able to top up NHS care by paying for drugs privately, health secretary Alan Johnson announced last week.

The move comes as part of a package of measures designed to widen access to drug treatments within the NHS, especially for the terminally ill.

The issue of top-up fees has been attracting increasing amounts of media attention. Previous health service rules stated that: ‘a patient cannot be both a private and an NHS patient for the treatment of one condition during a single visit to an NHS organisation’.

However, the term ‘single visit’ has been open to interpretation and almost impossible to apply to modern drug treatment.

In practice some trusts have already been allowing a version of top-ups while others have withdrawn the right to NHS care if patients have opted to purchase extra drugs privately.

In total, 15,000 patients appealed to their local NHS trust last year after being denied treatment. According to national clinical director for cancer Mike Richards, almost 75% of patients who appealed were successful.

Although small in scale, the problem is a highly emotive one, with the public placing great importance on prolonging life.

The decision to review current guidance has been welcomed by both NHS staff and patients. However, the government has been keen to stress that the new policy will not lead to a two-tier system split between those who can afford to pay for additional drugs and those who cannot.

The Department of Health has also said that any private treatment should take place in a private facility and must not be subsidised by the NHS.

‘A small number of patients may still choose to pay for additional drugs not available on the NHS. But I have agreed that, from today, NHS care must never be withdrawn in these cases – as long as private treatment takes place in a private facility,’ said
Mr Johnson.

Patients will have to cover all costs associated with privately bought drugs. This will include the cost of staff time in administering the drugs and that of scans and blood tests.

While the government has stated that patients must receive their top-up medication away from NHS wards – in a private ward of an NHS hospital, in a private hospital or at home – it may not be that simple.

It could be difficult for the NHS to deduce which side-effects are related to a the top-up drug and which result from the NHS care.

Many drugs – especially those subject to top-ups – come with side-effects ranging from diarrhoea and nausea to heart problems. These can be exacerbated when combined with other drugs and treatments, such as chemotherapy, that are part of the package of care.

It is also possible that a patient may be admitted to ICU or a high-dependency unit at the same time as they are due more top-up drugs. It is unclear whether they would be able to take these drugs in an NHS facility. The government says that in such circumstances, decisions on the administration of top-up drugs will be made on a case-by-case basis.

It is also unclear whether drug treatments would be stopped where patients could no longer afford to pay.

The top-up ban is set to remain for implants used during hip, knee or cataract surgery. For example, patients would not
be able to have privately purchased devices implanted in an NHS procedure.

The decision to allow patients to buy drugs without losing NHS care came after a four-month review conducted by Professor Richards. It was prompted by an outcry from patients over what was considered a hard-line stance and increasing evidence of an inconsistent approach by individual NHS trusts.

The move will be subject to a three-month consultation on how the recommendations will be implemented. Howard Catton, head of policy at the RCN, said it was crucial that frontline nurses became involved in the consultation on how to turn the ‘principle into practice’.

‘It is really important to recognise that this is a package of recommendations and, if they are effective, then the hope is people will only top up in a small number of cases, perhaps 2,000–3,000 people,’ he said.

Mr Catton added that the issue of separate care for patients who chose to pay for top-ups would have ‘very significant relevance’ to nursing staff.

‘It is unlikely that there will be separate nursing, technician or allied health professionals teams administering patients their
top-up drugs so we need clarification on how this will work in practice,’ he said.

‘Nursing staff will be smack bang at the interface of these issues,’ he added.

Molly Courtney, nurse prescribing adviser to the Association for Nurse Prescribing, warned that separating care might jeopardise patients’ continuity of care.

She also called for more guidance on training.

‘As more and more patients start to be treated in the community, it may be that nurses and nurse prescribers will need more training on administering these drugs and giving patients information about the top-up drugs available,’ she said.

As part of the wider package of measures, NICE is holding a five-week consultation on proposals to significantly raise the cost ceiling when deciding if a new drug for treating people who are terminally ill with rare cancers is worth the NHS’ money.

The institute has also said that it will speed up its appraisal system so that new drugs are appraised within six months of their coming on the market.

Mr Johnson said that these measures would ensure that only a ‘small number’ of patients would be in a position where they would need or want to pay for drugs themselves.

‘This issue was causing distress to patients and their relatives, and none of us wanted the uncertainty and inconsistency to continue,’ he said.

However, Karen Jennings, Unison’s head of health, warned that the introduction of top-ups would ‘shake the very foundations of the NHS’.

‘There is a very real danger that introducing top-ups for drugs will open the floodgates in other areas. There is a whole raft of policies waiting in the wings that will further encroach on the principle of healthcare based on need not ability to pay,’ she said.
‘It’s time drug companies faced up to their social responsibilities and cut the cost of their outrageously expensive drugs.

‘These multinational companies spend more on marketing than they do on research and development. They could play a major role in ensuring patients get the drugs they need without having to resort to top-ups,’ she added.

However, Mr Johnson also stated that he would be ‘working closely’ with drug companies to ‘agree new and more flexible pricing arrangements’, that should see new drugs coming on the market at lower initial prices than is currently usual for novel treatments.

In an effort to standardise local decision-making, Mr Johnson also pledged to ‘set core principles to guide PCTs on funding drugs where there is no NICE guidance in place’.

Despite some concerns about implementation, the package is being viewed as progress.

Harpal Kumar, Cancer Research UK chief executive, said the measures struck the ‘right balance between significantly improving access to effective medicines for cancer patients and not giving a blank cheque to pharmaceutical companies’.

He said: ‘If all of the measures announced today are taken forward, tens of thousands of cancer patients will benefit.’

The Government's package of measures:

  • Patients will have the right to pay for top-ups without losing their basic NHS package of care

  • Those paying for extra drugs will have to cover the cost of any staff time, tests and scans associated with the extra drugs, as well as for the medication itself

  • Top-up care has to be carried out inside a private facility or in the patient’s home

  • The arrangements do not extend to implants used during hip, knee or cataract surgery because NHS treatment cannot be separated from privately paid for treatment in such cases

  • NICE will raise the threshold to allow more expensive drugs to be prescribed on the NHS. The NICE appraisal process will also be speeded up to make new drugs available more quickly

  • The Department of Health intends to ‘work closely’ with the pharmaceutical industry to agree new and more flexible pricing arrangements to increase access to new drugs – these will include lower initial prices, with the option of higher prices if value is proven at a later date, and patient access schemes

  • The DH will set out core principles to guide PCTs in their decisions on paying for drugs to improve consistency

Click here to see the Nursing Times team discuss NHS top-up fees

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