RICHARDS' RECOMMENDATIONS TO ENSURE
THE SEPARATION OF NHS AND PRIVATE CARE
40. Despite the implementation of the measures outlined
above, there will remain instances where patients wish to purchase
drugs not provided by the NHS. Although Professor Richards maintained
that when this circumstance arose the existing rules governing
the separation of NHS and private care had been clear, he also
recognised that some clinicians and PCTs had interpreted them
inconsistently. He also acknowledged that there was some confusion
about how to separate private and NHS care in practice and looked
at how this could be done.
41. Professor Richards considered five options for
enabling patients to purchase additional drugs. He described the
range of options as follows:
One extreme was that you say to patients, "Sorry,
if you have any private care you cannot come to the NHS"
and we got a very, very clear message from the public, from patients,
from a whole lot of people that that was utterly unacceptable.
At the other end of the spectrum we could have gone down a route—we
looked at this and rejected it—of saying that effectively
the NHS can have a set of basic care that you get free and then
on a sort of top-up basis you can pay for extra things on top
of that and then there would be a lengthy menu of things you could
pay for on the NHS. We rejected that as well because that is not
the NHS that I certainly want to see.[45]
The diagram below illustrates the options considered
by Professor Richards.
Source: Department of Health, "Improving
access to medicines for NHS patients"
42. Professor Richards concluded that separation
of NHS and private care (option 3) was the best option because
it enabled people to have that private care while at the same
time preserving the fundamental principles of the NHS that the
NHS should not subsidise private treatment.[46]
Of the options favoured by some witnesses vouchers (option 2)
and co-payments (option 5) were rejected because:
We believed the voucher scheme was the worst of all
options in fact largely because it would take money out of the
NHS and also if people then went to a private hospital their NHS
element would have transferred them into the private sector but
they would be paying more for that same element in the private
sector than they would in the NHS. So it would be bad for the
individual and it would be bad for the NHS. We looked at that
and we set out all the different reasons in the report why we
rejected that. In terms of the option what might be called the
full top-up scenario which is saying that the NHS has a schedule
of things that you can get on the NHS but here are all the other
things which you might want to pay for, I can tell you there was
very little enthusiasm for that amongst the great number of people
that I talked to.[47]
43. Having concluded that separation of NHS and private
treatment was the best option for the NHS, Professor Richards
set out the principles by which it should be implemented. These
were:
- the NHS should make clear that
no patient should lose their entitlement to NHS care they would
have otherwise received, simply because they opt to purchase additional
treatment for their condition.[48]
- the Government should make clear that when additional
private drugs are purchased, the following criteria has been followed:
- clinicians have first exhausted all reasonable
avenues for securing NHS funding; and
- patients should be able to receive additional private
drugs as long as these drugs are delivered separately from the
NHS elements of their care.[49]
44. Professor Richards argued that these principles
(which following our evidence sessions were reaffirmed in the
final guidance issues on 23 March 2009) would end any confusion
about whether patients receiving NHS treatment were entitled to
purchase additional private drugs, whilst ensuring that when drugs
were purchased, the NHS would not subsidise private healthcare.
Moreover, he argued that the Review had brought about greater
clarity to how care should be separated, while at the same time
avoiding the creation of a "two-tier" NHS that other
options would have produced.[50]
The response of the Department
and NICE to the Richards Report
45. On 4 November 2008, the same day that Professor
Richards' report was published, the Secretary of State accepted
all fourteen of Professor Richards' recommendations. In the weeks
following the report's publication, the Department and NICE made
a number of key decisions which were aimed at implementing the
recommendations. These were:
- draft guidance was issued for
consultation on how to separate NHS and private drug treatments;
- revised "end-of-life" guidance to NICE
appraisal committees was issued which encouraged "more flexibility"
in the evaluation of higher-cost drugs which have been shown to
extend the lives of terminally ill patients, and where "the
less common nature of a particular condition may mean that the
more flexible pricing arrangements the Department has negotiated
with industry are not in themselves sufficient".[51]
- the introduction of "new, more flexible
pricing arrangements" between the Government and the pharmaceutical
industry through a revised Pharmaceutical Price Regulation Scheme
(PPRS);
We now look at these decisions in turn.
GUIDANCE ON SEPARATING NHS AND PRIVATE
CARE
- Immediately following Richards'
Report the Department announced that those patients who wished
to buy additional private care would not have their NHS care withdrawn
as long as the private care could be delivered separately.[52]
At the same time, the Department sought to address concerns that
separation might not be possible to implement in all cases by
issuing revised guidance about how the NHS should manage these
situations.
