Although the government is reluctant to discuss it, hopscotching back and forth between private and public care has long been standard here for those who can afford it. But a few recent cases have exposed fundamental contradictions between policy and practice in the system, and tested its founding philosophy to its very limits.
One such case was Debbie Hirst's. Her breast cancer had metastasized, and the health service would not provide her with Avastin, a drug that is widely used in the United States and Europe to keep such cancers at bay. So, with her oncologist's support, she decided last year to try to pay the roughly £60,000, or $116,000, cost herself, while continuing with the rest of her publicly financed treatment.
By December, she had raised £10,000 and was preparing to sell her house to raise more. But then the government, which had tacitly allowed such arrangements before, put its foot down. Hirst heard the news from her doctor.
"He looked at me and said, 'I'm so sorry, Debbie. I've had my wrists slapped from the people upstairs, and I can no longer offer you that service,' " Hirst said.
"I said, 'Where does that leave me?' He said, 'If you pay for Avastin, you'll have to pay for everything' " - in other words, for all her cancer treatment, far more than she could afford.
Officials said that allowing Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.
Patients "cannot, in one episode of treatment, be treated on the NHS and then allowed, as part of the same episode and the same treatment, to pay money for more drugs," Health Secretary Alan Johnson told Parliament. "That way lies the end of the founding principles of the NHS."
Maybe that ought to be a consideration. I.e. that the health of the patients be thought more important that of the bureaucracy taking care of them.
In Hirst's case, the confusion was compounded by the fact that three other patients at her hospital were already doing what she had been forbidden to do - buying extra drugs to supplement their cancer care. The arrangements had "evolved without anyone questioning whether it was right or wrong," said Laura Mason, a hospital spokeswoman. Because their treatment began before the Health Department explicitly condemned the practice, they have been allowed to continue.
....One of Hirst's troubles came, it seems, because the Avastin she proposed to pay for would have had to be administered at the same time as the drug Taxol, which she was receiving free on the health service. Because of that, she could not schedule separate appointments.
But in a final irony, Hirst was told early this month that her cancer had spread and her condition had deteriorated so much that she could have the Avastin after all - paid for by the health service. In other words, a system that forbade her to buy the medicine earlier was now saying that she was so sick she could have it at public expense.
Hirst is pleased, but only to a point. Avastin is not a cure, but a way to extend her life, perhaps only by several months, and she has missed valuable time. "It may be too bloody late," she said.