Leading article: A messy medical compromise

In the past few years, the Department of Health has heard a growing clamour from terminally ill patients who have been offered an impossible choice: to take the "cost-effective" medicinesanctioned by the National Institute for Clinical Excellence and Primary Care Trusts, or topurchase privately the more expensive drugsrecommended by their doctors and receive afurther bill for the whole of their NHS treatment. Yesterday, the Health Secretary, Alan Johnson, responded, marking a new era in the history of the Service.

Mr Johnson plans to allow English patients to "top-up" their NHS treatment with additional drugs considered too expensive for the public to fund. His decision will have two immediateeffects. In the first place, it will allow morepeople to receive better treatment – the fundamental objective of a public healthcare system. The second effect is less desirable. By allowing wealthier patients to top-up, the NHS moves away from universal, equitable, health provision and towards a two-tier system whereby two patients might share conditions, even doctors, but enjoy dramatically different qualities of treatment.

This unfairness will cause political problems for the Government. Greater public spendingoffers no quick fix; the willingness of the British public to fund healthcare through taxation isalready at its limit.

Mr Johnson has several responses. He has given an assurance that those patients who top up will not share wards with the patients who cannot. He also proposes to put pressure on the drugcompanies to reimburse the NHS for ineffective treatments, and to find innovative ways ofdriving down the purchasing costs. But neither of these proposals addresses the fundamental issue of equality of care. Perhaps, in the end, we will have to accept a messy compromise.

Care can be free at the point of access, but to require it also to be equally available to all might be asking too much. The founders of the NHS never anticipated the range, cost and complexity of treatments now available. We cannot continue to exalt the principle of equality of care above the question of its quality. And we might just have to live with the inconsistencies that result.