This autumn, debate about patients paying to 'top-up' NHS care has dominated the media. In West Sussex, Carole Simmons' family paid privately for the drug Avastin, not available on the NHS. They believed it would prolong her life. However, their NHS treatment was withdrawn as a consequence, leaving them with a £20,000 bill for her routine care. [1]

This story is not unique. Although the issue is not confined to cancer treatments, the government asked the National Clinical Director for Cancer to review this policy. He concluded 2 patients could continue with 'top-up' treatments administered in non-NHS settings, but this is unlikely to signal the end of the debate. Deeper issues still need to be explored:

• The 'fiction of the wonder drug': the media frequently describe drugs as 'lifesaving' when they may only prolong survival for a few weeks. Some argue this detracts from open and constructive discussion about end of life care. [3]
• The increasing tension between the autonomy and demands of patient-consumers, and the role of the doctor as a service provider.
• The relationship between senior clinicians - focused on their patient - and the local PCT, making individual funding decisions, but responsible for the population's health. [4]
• The place of evidence in clinical judgment, and particularly the role of the National Institute of Health and Clinical Excellence, considered by some to be 'denying care to those who need it most'. [5]
• Whether we should be striving to provide NHS care free at the point of need to everyone, regardless of the cost or evidence, or looking at other ways to deploy finite resources wisely.The debate raises questions about ethical principles such as fairness and equity. [6]

We should be cautious about measures that would further marginalise those already disadvantaged, and must think about how Christians should make use of the resources God has entrusted to us, [7], as well as about our relationship to authority structures such as NICE. There may be no clear answers, but it is time we engaged in this debate logically, carefully and sensitvely, avoiding the knee-jerk reactions that dog the media.