British patients put public health care system to the test

LONDON: Created 60 years ago as a cornerstone of the welfare state, the National Health Service is devoted to the principle of free medical care for everyone in Britain. But recently it has been wrestling with a problem its founders never anticipated: how to handle patients with complex illnesses who want to pay for parts of their treatment while receiving the rest free from the health service.

Although the government is reluctant to discuss it, hopscotching back and forth between private and public care has long been standard here for those who can afford it. But a few recent cases have exposed fundamental contradictions between policy and practice in the system, and tested its founding philosophy to its very limits.

One such case was Debbie Hirst's. Her breast cancer had metastasized, and the health service would not provide her with Avastin, a drug that is widely used in the United States and Europe to keep such cancers at bay. So, with her oncologist's support, she decided last year to try to pay the roughly £60,000, or $116,000, cost herself, while continuing with the rest of her publicly financed treatment.

By December, she had raised £10,000 and was preparing to sell her house to raise more. But then the government, which had tacitly allowed such arrangements before, put its foot down. Hirst heard the news from her doctor.

"He looked at me and said, 'I'm so sorry, Debbie. I've had my wrists slapped from the people upstairs, and I can no longer offer you that service,' " Hirst said.

"I said, 'Where does that leave me?' He said, 'If you pay for Avastin, you'll have to pay for everything' " - in other words, for all her cancer treatment, far more than she could afford.

Officials said that allowing Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.

Patients "cannot, in one episode of treatment, be treated on the NHS and then allowed, as part of the same episode and the same treatment, to pay money for more drugs," Health Secretary Alan Johnson told Parliament. "That way lies the end of the founding principles of the NHS."

But Hirst, who is 57 and was first diagnosed with cancer in 1999, went to the news media, and so did other patients in similar situations. And it became clear that theirs were not isolated cases.

In fact, it is widely acknowledged by patients, doctors and officials across the health care system that patients suffering from every imaginable complaint regularly pay for some parts of their treatment while receiving the rest free.

"Of course it's going on in the NHS all the time, but a lot of it is hidden - it's not explicit," said Dr. Paul Charlson, a general practitioner in Yorkshire and a member of Doctors for Reform, a group that is highly critical of the health service. Last year, he was the co-author of a paper laying out examples of how patients with the initiative and the money dip in and out of the system, in effect buying upgrades to their basic free medical care.

"People swap from public to private sector all the time, and they're topping up for virtually everything," he said.

For instance, he said, a patient put on a five-month waiting list to see an orthopedic surgeon might pay £120 for a private consultation, and then switch back to the health service for the actual surgery from the same doctor.

"Or they'll buy an MRI scan because the wait is so long, and then take the results back to the NHS," Charlson said.

In his paper, he also wrote about a 46-year-old woman with breast cancer who paid £250 for a second opinion when the health service refused to provide her with one; an elderly man who spent thousands of pounds on a new hearing aid instead of enduring a year-long wait on the health service; and a 29-year-old woman who - with her doctor's blessing - bought a three-month supply of Tarceva, a drug to treat pancreatic cancer, for more than £3,150 on the Internet because she could not get it through the NHS.

Asked why these were different from cases like Hirst's, a spokeswoman for the health service said that no officials were available to comment.

In any case, the rules about private co-payments, as they are called, in cancer care are contradictory and hard to understand, said Nigel Edwards, the policy director of the NHS Confederation, which represents hospitals and other health-care providers. "I've had conflicting advice from different lawyers," he said, "but it does seem like a violation of natural justice to say that either you don't get the drug you want, or you have to pay for all your treatment."

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