James Raftery: The NHS top-up policy for drugs not recommended by NICE – challenging the limits?

A recent breakfast meeting at the Kings Fund discussed the issue of an NHS top-up policy in relation to multifocal lenses in cataract surgery. My contribution from the commissioner perspective involved six points:

i) the lenses were dear, adding several hundred pounds to the around £800 NHS cost of a cataract procedure,
ii) that they were highly unlikely to be cost effective as the main gains appeared to have to do with some patients not requiring glasses,
iii) that within NHS budgets, the bigger issue had to do with lucentis versus avastin,
iv) that commissioners would consequently and rightly say no to funding multifocal lenses,
v) that top-ups for such lenses were worth considering, and
vi) that were I faced with the choice of top-up I would want more information to do with longer term follow up.

An ophthalmologist presented the case for the more expensive lens. The RNIB made the case against limiting access to cataract surgery, in particular to the second eye.

In relation to top-ups,  multifocal lenses in cataract surgery are not allowed. Indeed, the Department of  Health guidance gave lenses in cataracts surgery as an example of what was not allowed. It provided four case studies, two were to do with unfunded cancer drugs, one of which was provided in a private wing of an NHS Trust, the other in a room designated for private care. Both were allowed because “the NHS element of care can be delivered separately.” Similarly, privately funded physiotherapy after hip replacement was allowable in a separable private clinic. However a patient wanting a multifocal lens in place of a single focus lens could not be funded privately because “the NHS element of care and the private element of care cannot be delivered separately(p.10).”

The emphasis on separate care came from the Richards Report which considered five options:

i) Either NHS or private.
ii) A voucher scheme from the NHS to patients who want unfunded drugs
iii) Separate care (different locations, different times)
iv) Simultaneous care (same location, same time)
v) NHS delivery of unfunded drugs at NHS prices, and charging patients the excess cost

The Richard’s report rejected options one and two but found options three, four and five “finely balanced.” It came down in favour of option three on the basis that it had the fewest downsides. Option four- simultaneous care – had the additional downside of “patients on NHS wards regularly receiving different care based on the their ability to pay.” What has come to be known as NHS top-ups is option three, which in turn ruled out choice of lens in cataract surgery.

Multifocal lenses necessarily imply simultaneous care. However the reasons given against option four in the Richard’s report seem to depend on the difference between drugs (readily separable) and surgical devices such as lenses in cataract surgery. But separability  in the sense of avoiding patients in the same ward receiving different treatment could be achieved by patients attending different clinics, or attending on different days given this is normally a day case procedure. Since a sizeable proportion of cataract surgery is done in private treatment centres, ruling that the lens cannot be privately funded seems perverse. 

Although I can usually find a rational argument in favour of specific health policies, this time I failed. Any suggestions?