On 21 feb, 14:39, john_k...@hotmail.com (John Kulp) wrote:
> In the NY Times:
>
> LONDON -- Created 60 years ago as a cornerstone of the British welfare
> state, the National Health Service is devoted to the principle of free
> medical care for everyone. 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.
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> Enlarge This Image
> Jonathan Player for The New York Times
>
> Debbie Hirst with her husband, Ian, on the beach at Carbis Bay in
> Cornwall, England.
>
> Although the government is reluctant to discuss the issue,
> 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 $120,000 cost herself, while continuing with the rest of
> her publicly financed treatment.
>
> By December, she had raised $20,000 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. Mrs. 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,' " Mrs. Hirst said in an interview.
>
> "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 Mrs. 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
> N.H.S. and then allowed, as part of the same episode and the same
> treatment, to pay money for more drugs," the health secretary, Alan
> Johnson, told Parliament.
>
> "That way lies the end of the founding principles of the N.H.S.," Mr.
> Johnson said.
>
> But Mrs. Hirst, 57, whose cancer was diagnosed 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, patients, doctors and officials across the health care system
> widely acknowledge 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 N.H.S. 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 a
> 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," Dr. Charlson said in an
> interview. For instance, he said, a patient put on a five-month
> waiting list to see an orthopedic surgeon may pay $250 for a private
> consultation, and then switch back to the health service for the
> actual operation from the same doctor.
>
> "Or they'll buy an M.R.I. scan because the wait is so long, and then
> take the results back to the N.H.S.," Dr. 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
> dollars on a new hearing aid instead of enduring a yearlong 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 $6,000 on the Internet because she
> could not get it through the N.H.S.
>
> Asked why these were different from cases like Mrs. Hirst's, a
> spokeswoman for the health service said 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 director of policy for the N.H.S. 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."
>
> Karol Sikora, a professor of cancer medicine at the Imperial College
> School of Medicine and one of Dr. Charlson's co-authors, said that
> co-payments were particularly prevalent in cancer care. Armed with
> information from the Internet and patients' networks, cancer patients
> are increasingly likely to demand, and pay for, cutting-edge drugs
> that the health service considers too expensive to be cost-effective.
>
> "You have a population that is informed and consumerist about how it
> behaves about health care information, and an N.H.S. that can no
> longer afford to pay for everything for everybody," he said.
>
> Professor Sikora said oncologists were adept at circumventing the
> system by, for example, referring patients to other doctors who can
> provide the private medication separately. As wrenching as it can be
> to administer more sophisticated drugs to some patients than to
> others, he said, "if you're a doctor working in the system, you should
> let your patients have the treatment they want, if they can afford to
> pay for it."
>
> In any case, he said, the health service is riddled with inequities.
> Some drugs are available in some parts of the country but not in
> others. Waiting lists for treatment vary wildly from place to place.
> Some regions spend $280 per capita on cancer care, Professor Sikora
> said, while others spend just $90.
>
> In Mrs. Hirst's case, the confusion was compounded by the fact that
> three other patients at her hospital were already doing what she had
> been forbidden to do -- buying extra drugs to supplement their cancer
> care. The arrangements had "evolved without anyone questioning whether
> it was right or wrong," said Laura Mason, a hospital spokeswoman.
> Because their treatment began before the Health Department explicitly
> condemned the practice, they have been allowed to continue.
>
> The rules are confusing. "It's quite a fine line," Ms. Mason said.
> "You can't have a course of N.H.S. and private treatment at the same
> time on the same appointment -- for instance, if a particular drug has
> to be administered alongside another drug which is N.H.S.-funded."
> But, she said, the health service rules seem to allow patients to
> receive the drugs during separate hospital visits -- the N.H.S. drugs
> during an N.H.S. appointment, the extra drugs during a private
> appointment.
>
> One of Mrs. Hirst's troubles came, it seems, because the Avastin she
> proposed to pay for would have had to be administered at the same time
> as the drug Taxol, which she was receiving free on the health service.
> Because of that, she could not schedule separate appointments.
>
> But in a final irony, Mrs. Hirst was told early this month that her
> cancer had spread and that her condition had deteriorated so much that
> she could have the Avastin after all -- paid for by the health service.
> In other words, a system that forbade her to buy the medicine earlier
> was now saying that she was so sick she could have it at public
> So, is this an argument for American style healthe "care"? The Market will look after you?
> Mrs. Hirst is pleased, but up to a point. Avastin is not a cure, but a
> way to extend her life, perhaps only by several months, and she has
> missed valuable time. "It may be too bloody late," she said.
>
> "I'm a person who left school at 15 and I've worked all my life and
> I've paid into the system, and I'm not going to live long enough to
> get my old-age pension from this government," she added.
>
> She also knows that the drug can have grave side effects. "I have
> campaigned for this drug, and if it goes wrong and kills me, c'est la
> vie," she said. But, she said, speaking of the government, "If the
> drug doesn't have a fair chance because the cancer has advanced so
> much, then they should be raked over the coals for it."
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