Beyond the matron state (The Guardian)

Two weeks ago the issue of co-payments was sent for review by the health secretary, who has asked "cancer tsar" Mike Richards to assess the state of play. It is time, he said, for an "up to date view". At present, patients who are denied drugs on the health service and are thus forced to pay for them are refused further treatment on the NHS.

...For months, Johnson insisted that it was quite right to refuse to treat these patients - to consider them, in effect, as non-people who had behaved so outrageously in paying for life-saving drugs that subsequently they should be denied health service care. He has based this on the notion that to accept them back would lead to a two-tiered NHS.

If the NHS did its supposed job properly - treating everyone with the most effective drugs - then there might be some medical justification for denying the right to opt back in to those who sought, in effect, worse care elsewhere. But the NHS's record on cancer treatment is lamentable. Only 8% of NHS lung cancer patients are alive after five years; the figures for Belgium and Germany, for instance, are 16% and 15% respectively. Just 17% of British stomach cancer patients survive for five years, as opposed to 33% of Belgians and 31% of Germans. So it is no wonder that many of those patients who can afford to do so pay for drugs that are prescribed by their doctors - Cetuximab and Sutent, for instance - and then denied them by the NHS.

It is little surprise that in a YouGov poll last month 89% of respondents agreed that the ban on co-payment is wrong and only 5% agreed with the health secretary's previous position that the NHS should, in effect, prefer patients to die rather than reach into their own pockets to pay for drugs the health service refuses to finance.

But the irony is that allowing co-payment will, indeed, as Johnson has always said it would, mark a revolutionary break with the health service's history. In recent years governments have started to reform the supply of NHS services through contracting out some provision and reorganising the internal market. Allowing co-payments will address the rest of the picture by opening up reform of demand, since it will introduce, for the first time, non-state funding into the purchase of NHS services.

This, of course, is the real reason why the health secretary and others have resisted co-payment for so long: it changes everything. In any area when consumers - or patients - start to be offered a choice, they soon start to demand an ever greater choice and range of services. The same process will begin once the door has been opened to part-private, part-public funding of healthcare treatment. It might start as co-payment for a small number of drugs, but it will spread, because the hitherto sacred principle of exclusive state funding - other than the basic prescription charge - will have been breached.

Patients are, after all, used to spending their money on healthcare. More than 6.5 million people have private medical insurance; a further six million are covered by private health cash plans. Eight million more pay for alternative therapies not available on the NHS, and many others pay for one-off private treatments. And this is not just the better-off: more than 3.5 million trade unionists have private health cash plans and medical insurance schemes.

The difference is that this money is spent outside the NHS. The introduction of co-payment will lead, inevitably, to a blurring of that divide, as there will be no reason in principle why patients will not be able to "top up" the care they receive from the health service. By the time of its 70th birthday, the NHS will not look remotely as it does as it celebrates its 60th.