Who should pay for cancer drugs?

Co-payments exist in many aspects of health care already. The Department of Health's own website states that

‘Entitlement to help with health costs (NHS prescription and dental charges, optical and hospital travel costs) is based on the principle that those who can afford to contribute should do so, while those who are likely to have difficulty in paying should be protected.’¹

Prescription charges in England are the clearest example of co-payments, where occasionally the prescription charge is greater than the cost of the drug, although usually the converse is true. Dental charges are in three bands for patients seeing an NHS dentist, but of course it is often difficult to find an NHS dentist and many have left the NHS to practice only privately. But co-payments are also required for eye tests, spectacles and contact lenses, for wigs and fabric supports. Each has a series of potential exemptions but the underlying principle behind the exemptions is ability to pay.

Unlike the issue around cancer drugs, however, none of these is particularly contentious, for several reasons. First, there is an option available that is means-tested; second, the very nature of the condition is not life-threatening, even though it may be debilitating. Life-saving dental treatment may be required but is covered by the NHS. Similarly, the choice of spectacles is an open one, but those with severe or potentially severe eye disease are not required to pay the charges, so the ability of the partially sighted to have life-protecting vision correction is not subject to means testing. Thus if someone cannot pay at all, they will still be able to have spectacles that enable them to move around more safely.

But for cancer drugs the ability to obtain the drug is perceived as the key to life itself. The likelihood of response to one drug might outweigh the likelihood of response to the drug available through the NHS – and it is well known that patients will opt for trying even a tiny chance of response if possible in an attempt to prolong life.²

The other difficulty is that the episode of care is not clearly defined, so it is open to widely varying interpretations around the country. Is it just the drug itself or is it the associated services such as the equipment and nursing and medical staff time for it to be administered? Does it include ambulance transport to and from the hospital for the drug to be given? Does it include any adjuvant drugs, anti-emetics, etc.? And what if the patient becomes neutropaenic – is the management of life-threatening complications included or excluded from the episode of care?

A third problem is that these are very high-cost drugs and therefore much more expensive than items currently subject to co-payments.

The fear of many who resist allowing patients to copay for high-cost cancer drugs is that there will be two patients on the ward with the same condition, one of whom has the drug because they can pay, but another who does not because the NHS is not funding the drug and there is no means to finance its administration. Although unlikely to arise often, this scenario concerns those who fear a dangerous precedent will be set.

As new technologies allow minimally invasive treatments in a few specialist centres, and as new technology provides expensive alternatives to current devices such as cardiac pacemakers, demands will increase for an ability to purchase superior treatments that may improve the chance of survival.

So how can this be managed? One way to handle the funding itself would be to sell the drug or device at retail cost to the patient and to run a fund into which is paid the difference of the price to the NHS (cost price) and the price charged to the patient (retail price). This fund would then be available to be tapped for co-payment for those truly unable to pay. Fundraising events would encourage top-ups; it would be open to those who wished to donate into it when they had been successfully treated or if their fundraising efforts had delivered a surplus over and above the cost of the drug to be purchased.

For now, seriously ill patients anguish while those with minor self-limiting conditions access primary care relatively easily and complain if they have to wait; accident and emergency departments groan under the strain of four-hour waiting targets; the NHS struggles to meet its costs; and inefficiencies in the system are juggled. We need to decide clearly what the NHS does and what it does not do – where its responsibilities begin and end. Calls for unproven alternative and complementary treatments to be funded by the NHS must not be allowed to drown out the calls from the very ill for access to treatment when the evidence is there that it may meaningfully prolong life. If the evidence is uncertain, why not let them buy the drug through the NHS system?

Footnotes

DECLARATIONS —

Competing interests None declared

Funding None

Ethical approval Not applicable

Guarantor IF

Contributorship IF is the sole contributor