Mike Richards’ review of what to do about top-ups seems to reaffirm the line that the NHS should not subsidise private consumption of healthcare.



Responding to one of his recommendations, which would limit demand for topping up, NICE has suggested that it might approve some treatments costing more than£30,000 per quality adjusted life year (QALY) - its upper threshold - by considering other factors. In effect, NICE is proposing to give a higher weight to the QALYs, or health benefits, enjoyed by some patients over others. Can this be fair?

The new guidelines for NICE appraisal committees would only apply to drugs for rare conditions and for terminally ill patients expected to live no longer than two years. Also the evidence of effectiveness should be robust and no alternative NHS treatment available.

But why should such medicines for some people be singled out in this way? NICE says the values that underpin its appraisal criteria should reflect those held by the public, who it says, “place considerable value on treatments which offer the possibility of extending life when we are close to death”.

Of course there is rarely benefit without cost. While some will benefit from access to drugs NICE might have rejected as lacking cost-effectiveness, others will inevitably lose.

What is fair?

The question NICE is confronting has a long philosophical history: what is a fair allocation of resources in society? The Rawlsian answer, which underpins the principles of the NHS, is not equal shares but unequal shares - justified on the basis that such inequalities benefit the least well-off; in the case of healthcare, the least healthy.

It is worth bearing in mind that this debate is in the context of a system that allocates twice as much health spending per head to Manchester as to Oxford, and that NICE’s plans affect only a small number of people. Moreover, NICE’s suggestions in effect clarify existing guidance to its appraisal committees which have always been able to consider factors other than cost-effectiveness in reaching their decisions.

Nevertheless, while we may agree about the basis for allocating primary care trust budgets - that inequality is more equitable than equality - as with the weighted capitation system there will be arguments about the weights. What is a year at the end of life worth?£35,000?£100,000? And do other patients merit special treatment? Is there a case for, say, funding treatments which cost more than the threshold that save the lives of babies and let them live a full life?