Is it morally right to refuse someone a treatment under the NHS because someone else can’t afford it?

The morality of private prescribing in the NHS. #MSBlog #MSResearch

“My post yesterday on private prescribing has raised some interesting philosophical questions. An excellent and very though provoking comment today suggest we need to pay more taxes to support the NHS and also questions the morality of a position of principle. Do you agree?”

Private prescribing in the NHS – Multiple Sclerosis Research – Blogger
27 Jan 2014; The coalition has undermined these principles by allowing private prescriptions in the NHS. In the past private prescribing was the remit of the private sector and you needed to have all your care covered privately. Doctors …

Anonymous Tuesday, January 28, 2014 8:05:00 am

‘ Unless we are willing to pay more in taxes or radically change the way the NHS works eg you pay for your food and laundry in hospitals, we won’t be able to afford it in the future. Most people retired from work and were dead within 10 years. Now we have an aging population who may have 30 years post retirement who will need health care (not taking into account the enormous amount in pensions that will be paid out to NHS workers out of the NHS pot ).

This is such a political issue, but you are dealing with people’s lives. How can you say it is morally right to refuse a patient a drug they are willing to pay for that would improve their health on the basis that you can’t prescribe it for someone else. Therefore, you would be willing to see that patient’s health deteriorate to prove a point. Also if they pay for their drug, surely it is leaving more money in the NHS pot for the other users of the NHS.

We are not talking about the rich here either. A lot of people work very hard for their money, and if they choose to spend it on drugs or healthcare rather than expensive holidays it should be up to them. A dog in the manger attitude helps no one.’

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • Before we talk of raising taxes, we need to look at how what we currently raise is spent.

    Each time I have attended hospital for intravenous steroids and Tysabri infusion, procedures lasting a mere couple of hours, I have been offered food and drink, including hot meals, sandwiches, biscuits and hot drink. Why is this? If the food is left-over from inaccurate ordering, it needs to be addressed. Everything has a cost and if I wasn’t temporarily in hospital, I would still need to eat and drink. On one occasion I did have a cup of tea, as I had a tickly cough and sore throat, but would happily have paid at least a nominal fee to cover the tea bag, milk and boiling of the water.

    I believe that pensioners have a portion of their State pension deducted and claimants also have some benefits adjusted during hospital stays, so why shouldn’t everyone else pay a fee for food and laundry? It is too easy for politicians and administrators to claim that such adjustments would only raise a little money and in the scheme of things the administration would cost more, but as someone who changes processes for a living, I can tell you that this is just bluster. Surely it is better to at least cover the costs by charging fees than artificially inflating the cost of funding the NHS with non-medical / surgical ‘things’. We should also charge people for missed appointments, especially where transport is provided.

    One thing that I feel does need broadcasting is that the NHS is free-at-point-of-delivery BUT it is not a “free” system; it is not magic’d out of no-where or paid for with money that grows on trees, but is a system paid for by taxation. In the same way as people speak about “Government money”, and seem to enjoy getting one over on “the Government” when they can, it needs to be brought home that every penny the Government spends is paid for by current or future tax-payers.

    I shuddered at the 2012 Olympics’ ode to the NHS, because it was yet more proof that people don’t understand what the NHS is. My father, who is old enough to remember the NHS coming into existence, also remembers the days before prescription charges, when people would wait in surgeries for “free” asprin and plasters. Where anything is provided to people without any acknowledgement of the truth about HOW it is provided, people will be inclined to treat it with contempt. If the NHS truly does belong to us all, to patients, doctors, nurses and administrators, and we want it to continue reasonably unchanged, we need to look dispassionately at how it works, acknowledge failings and face the fact that some things are indulgences we can no longer afford.

    One final point is “health tourism”. We MUST implement a policy of those not entitled to NHS care having to take out health insurance and we MUST stop the insanity of said people being issued with NHS numbers! I know that for all kinds of reasons these people will need some type of number applied to them, if they need treatment whilst they are in the country, but it is very simple to provide them with visitor numbers which are distinct from NHS numbers. This sort of administrative thing is easy to do and it shows contempt to tax-payers that politicians and administrators decide to muddy the waters about this by making it a political hot potato through linking it to immigration.

    If the NHS is going to have a hope in Hell of providing 21st century healthcare for those of us who pay into the system and for our valid dependents in society, we cannot afford to support ineligible patients, no matter how heart-rending their stories and circumstances. In the same way that people are slowly coming round to the view that when our military operates in a humanitarian capacity, it should be funded by our aid budget, we should apply the same thinking to the NHS.

    As you can tell, you’ve provoked me with this post and all I know is that there is no easy solution, but there are ways to mitigate the problems and costs.

  • I do think that we need to raise taxes in Britain, especially by taxing the richest who received a 5% tax cut during a period where the poorest are incurring higher living costs and record underinvestment. The "basic rate" of tax in the UK is 20% for incomes of 10,000 to £32,011. For incomes between £32,011 and £150,000, the tax is 40%. Anything over £150,000 is taxed at 45%, though it was 50% prior to George Osborne having his way.

    The taxes for all of us should be 30% of our earnings across the board. All of us should pay it and there can be no get out. If the richest will pay the £77 billion that HM Revenue & Customs is unwilling to demand then that will make a big difference, too.

    There is a lot of money in Britain, yet the gap between rich and poor is increasing exponentially. The idea has now become that if you can pay for your kids to have a good education then that seems fine. Now we are hearing that ill people in Britain wanting breakthrough treatments, and can pay for it, should be prioritised over those that cannot. Do you know that those with private health care in Britain whom develop serious illnesses are still cast off to the NHS when it is deemed by insurance companies that their care is too costly and complex? Should we then deprive them of care because they weren’t receiving their treatments via the NHS from the beginning? What exactly are we fighting for?

    Don Giovannoni , I really don’t think it is ethical to suggest that “[average MSers] work very hard for their money, and if they choose to spend it on drugs or healthcare rather than expensive holidays [then] it should be up to them” . There are many Msers and ill people not in that situation and rely on the state for all their health needs. After all, 50% of all disabled people in Britain are currently living in poverty and many of them may be MS sufferers. Where is your sense of fairness and compassion, man?

    Oh, and Posy, who are you to suggest that the NHS should withhold from offering food to all outpatients? The greatest thing about universal services is its egalitarian principals. While I am heartened to hear that you decline food on the basis of not abusing the system, there will be Msers in attendance of intravenous steroids and Tysabri infusions that may be on disability benefits and may not have eaten because they can’t afford it. Rather than stigmatising such people the NHS is designed to offer blanket care and courtesy, not a two-tier system.

    This blog, including its contributors and readers, are nothing short of Thatcher’s children. Mark my words, if this ‘I’m alright, Jack’ attitude continues then I’m telling you there will be mass riots in Britain. There is a growing young population that are being done over and poor families at breaking point. Everyone has a threshold, Don Giovannoni .

    • Please note that I am discussing the issue of private prescribing in the NHS as it creates a real dilemma for me and other MSologists and clinicians. On the one hand I have to look after MSers and do my best for them and this includes prescribing therapies that are licensed in the EU, but not approved by NICE. All that NICE is saying that these treatments are not cost-effective and too expensive for the NHS. On the other hand we who work in the NHS are proud of what NHS stands for and writing out private prescriptions undermines everything the NHS is about; free-at-source and equitable. Do you see the dilemma? Damned if we do damned of we don't.

      Please vote; we live in a democracy and everyone's vote counts.

    • This blog is an open forum and not a place for abusive personal comments. We should respect each others views. We have been asked by our Institution to not let abusive comments through. What one considers abusive can be difficult and is often a judgement call. Dr Dre can be very abrasive; I hope not abusive.

  • My apologies, Don Giovannoni. Just realised you were quoting an anonymous comment which I accidently took too be you. Sorry, bro, my bad.

  • The NHS should focus its efforts on patients who though sheer bad luck get grim diseases eg MND, cancers, MS etc. etc. No more funding illnesses which are self-inflicted e.g. Gastric bands, tattoo removal. Go the A&E on a Friday and Saturday evening and see the consequences of binge drinking. Such cases should be charged £100. My MS wasn't my choice. However, the NHS spend billions on those who take drugs or abuse alcohol. Perhaps the NHS needs to redefine the diseases and illnesses which it treats.

    • I am not sure Dr Dre has it right when he tars Prof G and Mouse Doctor with the Thatcherite brush. The fact that we are having this conversation on this blog tells me that Prof G is in a real predicament. He needs help or advice and not a neo-liberal lecture from Dr Dre. This issue is not black or white.

  • Dr. Dre, I will come out from behind anon. I was worried that I would receive abuse for my comments on the NHS so stuck with anon, but put your money where your mouth is, as is said. I agree with Posy- there is a tremendous amount of waste in the NHS, and maybe sorting this out is one way in which to get the money in the NHS to those who need it. It is not a limitless pot. I never said the average MSer works hard and can pay. If you read my comment, I said a lot of people. This may be friends or relatives of the MSer who would be willing to forgo their expensive holiday to pay for treatment that might prevent the MSer from becoming unable to work. Unfortunately those who were diagnosed 20 years ago or have very active disease may not have had the chance to try and prevent disability, but with the newer DMDs those recently diagnosed do have a chance, even if they have to pay. Where is your sense of fairness and compassion that you would be willing to condemn them to a future of possible disability because the state can't help everyone so no one should be able to get a useful drug. Don't say the state should be able to help everyone- please live in the real world. Are you suggesting that everyone pay 30% taxes across the board, that is the rich and those on £8,000 a year? I don't see how that would help.

    • I don't think it's fair to claim that the NHS is wasteful as it has been shown to be very efficient when compared with other systems. To claim that it isn't plays into the Cameron/Hunt view that it would all improve if it was privatised (I know that in the UK at least current private medicine is in no way cheaper than the NHS – everything is more expensive). There may be an argument to be had that a fixed fee should be chargeable for every GP or A+E visit (as in Ireland), but this would be no deterrent for those who wouldn't have to pay due to financial circumstances which would presumably include many chronic alcoholics.

      I agree that there may be questions about NHS funding for weight loss surgery, but looking at its website, NICE does recommend it for very obese patients. It's probably reasonable to assume that this would help these patients' health. It would be interesting to compare NICE's recommendations for this and other problems with those for MS. I note that NICE seem happy enough to try to justify their stance on obesity with long term computer models ( I'm not even sure they know how durable the procedures would be in 20 years time, yet they seem to support it anyway. I know for certain that there are expensive interventions supported by NICE that have nowhere near the evidence to back them up that they require for MS drugs.

      The cost of MS drugs will always be an issue and if they continue to be a high fraction (or a multiple) of average earnings paying for them will continue to be a massive issue.

  • I'm not sure a debate on the taxation rate in the UK is going to get us very far. The question is simple – should neuros be able to precsribe drugs outside of the NHS? The answer, in my view, is equally simple – of course they should. It would be scandalous if someone who could afford to pay for a drug that would help his condition was prevented from doing so because NICE won't pay for it for everyone. It applies equally for any condition – just because NICE's analysis is against funding it, it shouldn't stop people accessing it if they can afford it. Whether NICE's decision in any particular case is fair or not or whether the NHS should be paying for more than they do is another matter entirely but if someone is lucky enough to be able to afford a drug – let them have it or we're living in the most warped world imaginable.

By Prof G



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