On 4 November the Government announced that patients can retain their entitlement to NHS treatment as well as paying for private care. The Confederation sees this as a necessary and welcome move towards addressing an issue that threatened to seriously undermine confidence in the NHS.

New treatments, greater availability of information, greater personal wealth and rationing had created a pressure for the top-up issue to be addressed. The Government asked Professor Mike Richards, national clinical director for cancer, to review the policy on whether patients should be allowed to buy additional treatments not offered by the NHS.

Top-ups announcement

The Government's announcement on 4 November came at the end of Professor Richards' review. The package of measures announced included:

• Supporting NICE's proposal for greater flexibility in appraising more expensive drugs for terminally ill patients
• Working closely with the pharmaceutical industry to agree new and more flexible pricing arrangements to increase access to new drugs - these will include lower initial prices, with the option of higher prices if value is proven at a later date, and patient access schemes
• Speeding up the NICE appraisal process for new drugs so that they become available to patients more quickly
• Improving quality and consistency of local decisions by setting out core principles to guide primary care trusts on the funding of new drugs, where there is no NICE guidance in place
• A consultation on revised guidance for trusts for those rare cases where patients purchase additional private care.

Read our briefing for members.

Confederation viewpoint

The NHS Confederation called for the following policy changes on behalf of members and was pleased to see them included in the final review:

• speeding up NICE decisions
• clarifying guidance to help PCTs make better, more transparent decisions on exceptional case drug funding
• working with drug companies to share the risk of new treatments.

It is now time to iron out the details of this policy change so that patients get the best deal.

NHS Confederation policy director Nigel Edwards said the change in policy is welcome and helps deal with a situation that had become unsustainable. He said: "Patients must be reassured that this is not the thin end of the wedge - no one wants a two-speed NHS. It is encouraging that Professor Richards has acknowledged that we still need to sort out what this policy will mean for patients on the ground.

'We need greater clarity on what will happen - and who will pay - when things go wrong. It is critical that patients are made fully aware of what they are paying for with clear and explicit advice from clinicians about drugs that have not been approved as both clinically and cost effective."

He added that practical difficulties remain, for example how patients who choose to pay privately can be moved into private facilities, how these drugs should be priced and what form new guidance on exceptional funding panels will take.

Involving members

In August 2008 we asked NHS Confederation members for their views on this difficult issue, asking them to comment on our paper with suggested options for solution. Members were very concerned that top-ups undermine the NHS by creating a strong impression of unfairness. Others expressed concern that the practical difficulties associated with creating a new system would outweigh any benefits.

Feedback from members suggested a need for the approach to be harmonised, if not nationally then certainly regionally, or across and between cancer networks. We were clear that this should be discussed as part of the debate about a new constitution for the NHS, rather than as part of discussing top-ups.

Read our letter to Professor Mike Richards, national clinical director for cancer.

We will continue to involve members in our work on the top-ups issue, particularly our work with NICE.