Michael White on private vs public

Wow! What a shocker! Yet when I mentioned it in passing to a minister he said that, no, the Treasury doesn't resist measures to curb smoking or drink any more. But yes, it uses similar arguments against efforts to curb sugar, fat and salt in food.

Elsewhere we learned that Fujitsu's major contract to provide the southern chunk of the national IT programme is at risk after negotiations broke down.

Don't worry, insist ministers, it shows we are defending the taxpayer's interests from big suppliers. Do worry, says Tory health spokesman, Andrew Lansley, it shows the NHS is not going to get the IT functions it needs at the price it set.

We'll know in due course. What intrigued me this week was The Sunday Times' decision to return to the thorny question of co-payments. By that I mean those awkward situations where a patient buys a drug therapy not on the NHS approved list - though on medical advice - and thereby forfeits his/her right to NHS treatment.

The newspaper highlighted the case of Linda O'Boyle, who died at 64 after she bought cetuximab to help fight bowel cancer and Southend University Hospital foundation trust withdrew her NHS treatment, including chemo. Mrs O'Boyle and her husband were both career NHS staff.

Bad stuff, and the paper dug up more cases, plus health secretary Alan Johnson's recent Commons statement - minister Ben Bradshaw has also made the point - that the NHS cannot allow a two-tier system to develop, nor subsidise the private sector. A founding principle of the NHS is that "one is either a private patient or an NHS patient".

I remember registering puzzlement in this column at the time, so I made enquiries. Clearly ministers are aware of the problem - the pressure too - and may well have examined it in the context of Lord Darzi's review and even the promised NHS constitution.

Their conclusion? That it would be very difficult indeed, though not impossible, to devise a system that would prevent a cross-subsidy to the private sector one way or the other.

The Liberal Democrats and Conservatives know the problems it would create and shy away from such a change too, ministers murmur. I thought it best to check and rang both Mr Lansley and Norman Lamb, the Lib Dem spokesman.

Both MPs turn out to have had direct constituency experience of people undergoing cancer treatment being denied services, scans for instance, because they bought an extra drug not approved by the National Institute for Health and Clinical Excellence, but one they had been told would raise their chances.

The NHS must treat people fairly, but why should primary care trust managers feel able to overrule medical opinion, he asks? Well, we all know the answer: cost and proven effectiveness of drugs. But Lib Dem leader Nick Clegg is looking at it and may propose a review shortly.

Mr Lansley's position is more nuanced. He understands the need for NHS patients to be just that and that we do not want the NHS to offer a minimum service which citizens have to top up.

But he also says the distinction has always been blurred in places. NHS patients can still get (private) amenity beds in hospitals, consultants sometimes provide extra (private) services.

Patients should be able to buy their own drugs, but proven effective drugs should also be introduced into the NHS faster than is now the case: that should help solve this dilemma.

If I understand him, he means talking to the pharmaceutical industry so that value-based pricing deals with the NHS can be reached over new drugs more quickly.

Mr Lansley cites the case of the "Velcade Three", a trio of Yorkshirewomen suffering from the myeloma bone marrow cancer, who fought to get Velcade NICE approval. The manufacturer agreed that if it didn't work it would refund the NHS.

I'm still puzzled, but sense that things are on the move.