Co-payment for medicines: should the NHS provide what people need not what they want?

1. Co-payment for medicines: should the NHS provide what people need not what they want? 6th October 2010 Co-payment for medicines Roger Walker and Sian Evans Roger Walker and Sian Evans

2. Definition of co-payment Payments made by patients for drugs, devices, procedures and related services that are not approved and funded by the NHS. They are used to supplement or replace other care the patient is receiving from the NHS for their particular condition Adapted from Kings Fund Co-payment for medicines Roger Walker and Sian Evans

3. Ethics We’re monitoring both disease progression and his bank account Co-payment for medicines Roger Walker and Sian Evans

4. Medicine access routes NHS All licensed medicines Positive appraisal by NICE or AWMSG 100% NHS Individual patient funding request Funded by Health Board/WHSSC 100% NHS Co-payment Individual X% NHS Private health care Individual 100% private Co-payment for medicines Roger Walker and Sian Evans

5. Why co-payment? • New treatment not yet appraised and funded by NHS • New treatment appraised but rejected for funding • Unlicensed / off label treatments Co-payment for medicines Roger Walker and Sian Evans

6. Patient perception? • Lack of confidence in NHS appraisal system • Lack of confidence in ability of NHS to purchase necessary high cost medicines • Additional benefit to be gained Co-payment for medicines Roger Walker and Sian Evans

7. Clinician perception? • Lack of confidence in NHS appraisal system • Lack of confidence in ability of NHS to purchase necessary high cost medicines • Additional benefit to be gained Co-payment for medicines Roger Walker and Sian Evans

8. Why co-payment? • New treatment not yet appraised and funded by NHS • New treatment appraised but rejected for funding • Unlicensed / off label treatments (1) (2) & (3) influenced by clinicians, media, big pharma, patient interest groups Co-payment for medicines Roger Walker and Sian Evans

9. Patient A Male Age 57 Lifelong smoker Terminal lung cancer Willing to pay for additional “wonder drug” Consultant does not agree with concept of co-payment The “wonder drug” recently received a –ve NICE appraisal Consultant disagrees with NICE appraisal outcome Patient B Male 57 years Never smoked Terminal lung cancer Unable to pay for additional “wonder drug” Consultant agrees with concept of co-payment The “wonder drug” recently received a –ve NICE appraisal Consultant disagrees with NICE appraisal outcome Case study Co-payment for medicines Roger Walker and Sian Evans

10. Conundrums • Raising the “private” option? • Clinician to discuss all options • Only if patient raises the issue • When? • Safety/risk assessment • Second clinical opinion • Referral to IPF panel • Medicines Committee (MTC, DTC) • Should NHS and “private” care be separated? • What is an “episode of care”? • Practicality • Safety • Indemnity – medical and non-medical staff Co-payment for medicines Roger Walker and Sian Evans

11. Conundrums • Who should be the recipient of payment? • Clinician, Health Board, Trust, Department? • What is included in the co-payment package? • all associated non-emergency care • predicted consequences • medicine, tests, scans, procedures, equipment, facilities, overheads, staff? • How much should the patient be charged? • NHS should not subsidise “private” care. • On cost? • Standard charge across Wales? • BUPA charge> individual charge? Co-payment for medicines Roger Walker and Sian Evans