The response to Mike Richards’ review of co-payments has been largely positive. The cancer czar had a tricky job to do, forced to navigate choppy ideological waters and land at a practical resolution.

Most managers think he did the best he could under the circumstances, accepting that the existing rules, removing the right to NHS treatment from those who “topped up” their care, were inconsistently applied and out of step with public opinion.

But while patients welcomed the review, it is managers and clinicians who now have to apply the new rules. And that is not going to be easy.

Insisting that private top-up treatment should be carried out “at a different time and place” from NHS care makes ideological sense, but managers will have to make it work in practice.

Clear guidance

The Department of Health will need to make sure its guidance is clear and practicable; strategic health authorities, charged with policing the arrangements, must support trusts and help spread best practice.

Primary care trusts are entitled to ask what modelling has been done on how much the additional drugs they will be funding will cost.

Having gratefully adopted Professor Richards’ recommendations, ministers will need to ensure they follow through by working with the royal colleges to provide training for clinicians in how to “talk top-ups” to patients. Communicating the complexities of top-up treatments - and their often distressing side-effects - requires pragmatism and delicacy.

Next must come an overhaul of end of life care. Above all else, people want to die with dignity. Being allowed to buy expensive drugs that will extend lives but not save them is not a panacea.

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