Editor's blog 17 June 2008: The line, and how to toe it

Andy Cowper, editor, Health Policy Insight

Welcome to Health Policy Insight, a new online health policy information and analysis service.

New on the site today is Nick Timmins’ first HPI column, which considers the impact of ‘top-ups’ to NHS care. The Government is due to announce today or tomorrow that it will change policy. The level of detail to be announced, however, is uncertain.

The abstract principle of payment for healthcare was breached with prescription charges in the NHS’s earliest days. In the English NHS today, dentistry and audiology show us a residualist NHS service for much of the country, while access to physiotherapy and various mental health services in psychotherapy can be deeply patchy. And then there’s car parking charges …


Timmins poses the salient question: should there be any cut-off point? Do we draw a new line in the sand? So if a patient wants the new Nike TM Sports Knee, is that OK now? Apparently it will be. But the Sports Knee takes a surgeon 35 minutes more to fit than the standard NHS knee. So what’s a national standard NHS knee fitting time, and how do we charge for the supplementary time of the operating theatre running costs, anaesthetist, theatre nurses etc?

Handling these sorts of issues is going to require an improved understanding of baseline activity and outcomes, which is good; and may require management to spend a lot on calculating the right top-ups, which ain’t so good.

And if your customer - as the topping-up patient will have become - thinks that your surgeons take too long for a standard knee fitting, they may issue you with a legal challenge on your bill.

This is going to get interesting. It is complex territory in which to draw lines.

While the state is involved in healthcare funding and regulation, it’s a political issue. The origin of the phrase ‘toeing the party line’ dates back to when MPs carried swords in the Commons chamber, and were instructed to remain behind lines more than the sword’s length from their opponents.

If drawing lines is hard, toeing them can be harder.