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Are drug switching incentives a necessary evil?

Fast forward to 2012. The London Olympics is billions over-budget, Northern Rock makes its first down-payment to the Bank of England and Prime Minister Cameron agrees to send troops to Iran.

By Nigel Praities

Fast forward to 2012. The London Olympics is billions over-budget, Northern Rock makes its first down-payment to the Bank of England and Prime Minister Cameron agrees to send troops to Iran.

GPs are anxious. PCTs are enforcing a wholesale switch of patients to atorvastatin as it approaches the end of its patent. There are serious reservations, but most practices are too reliant on the associated financial incentives to argue, after seven consecutive cuts in GP pay.

A doom-laden scenario, but not out of the realms of possibility. A Pulse investigation this week shows an explosion in switching schemes across the UK, with nearly 90% of PCTs now having switching schemes in place and 40% planning to introduce new schemes this year.

The information released by 92 PCTs under the Freedom of Information Act shows trusts are moving well beyond the initial targets for generic statins, with 46% now having schemes for proton-pump inhibitors, 38% for ACE inhibitors or angiotensin-receptor antagonists and 23% for bisphosphonates.

Legal challenge

But it is the increasing levels of financial support GPs are offered to switch patients which are proving most controversial. Our investigation reveals 60% provide some financial incentives to prescribe cheaper drugs, but are these inducements for best practice or merely a bribe?

The Association of the British Pharmaceutical Industry will attempt to outlaw all such schemes this year as it challenges the use of incentives in the UK European Court. A spokesperson from the ABPI said the Pulse survey confirmed the ABPI's opinion that many PCT schemes were likely to be illegal.

‘The ABPI remains convinced that paying doctors to prescribe specific, named medicines is illegal - a question that will be clarified by the judical review that is being sought by the ABPI,' he said.

These payments will be even more difficult to defend if they look like they allow clinical care to suffer. A number of PCTs reimburse practice costs or lost QOF points and allow exception reporting to entice GPs to support switching schemes – a practice the GPC had ‘great misgivings' about last December. And a new report from the Centre for Health Economics - published in the Journal of Clinical Pharmacy and Therapeutics - warns that prescribing incentive schemes influence GP prescribing in ways that may have ‘unintended consequences' for patient care.

Quite what those unintended consequences might be the report doesn't specify, but the drug companies are convinced they can make a case that incentivised drug switching is damaging patient care. A recent study from Pfizer claimed switching patients from atorvastatin to simvastatin in general practice increased their risk of all-cause death or major cardiovascular events by 30%. The study, published in the British Journal of Cardiology, appeared the start of a fight back by Pfizer against the Government drive to squeeze out use of its drug.

But far from backing down in the face of an industry backlash, politicians and NHS managers seem determined to increase the pressure on GPs over cost-effective prescribing. Last year, Pulse revealed that the NHS was bringing in tougher targets for use of generic statins and a host of new prescribing targets for other drugs this year. And only last month, a parliamentary report called for greater controls on GP prescribing. Despite record levels of generic prescribing in primary care, the report recommended additional controls on GPs could save the NHS more than £200m a year.

Dr Jim Kennedy, RCGP prescribing spokesperson, says that while GPs recognise the importance of keeping prescribing costs down, there is a worrying trend of GPs in some areas being pressurised to switch large numbers of patients. ‘We have reports of wholesale switching schemes in some parts of the country and they are not ideal as they don't adequately respond to the individual needs of patients,' he warns.

Professor Martin Cowie, head of the Health Services Research Group at the National Heart and Lung Institute, says PCTs advocating blanket drug switching schemes is ‘meddlesome' as they force a switch in patients who are stably controlled. ‘It focuses a lot of the effort and administration in a direction that is not hugely beneficial in terms of outcome for patients. One has to weigh up the benefits of switching and how long-standing that benefit will be. There are very few classes of drugs where switching is worth it,' he says.

He warns manufacturers often react to switching schemes by changing their prices, so savings from switching schemes are sometimes unpredictable.

Professor Mike Kirby, head of health and human sciences at the University of Hertfordshire and a GP in Radlett, agrees, warning that switching schemes have to be carefully executed.

As lead investigator for an influential switching trial at a practice in Hertfordshire, he showed switching patients to cheaper therapies can work.

His trial showed most patients switched to cheaper statins or angiotensin receptor blockers for up to two years remained successfully on the cheaper therapy and blood pressure control and cholesterol levels were not adversely affected by the switch.

Professor Kirby said his secret was making sure cases were assessed individually and that patients were well-informed, but this came at considerable cost to the practice. ‘There is a cost to the practice both in terms of time and postage, telling people about a switch and then following that patient up to make sure they understand why there has been a switch, to make sure they are being concordant and are in control of their risk factors,' he said.

Pulse's investigation shows that many PCTs are recognising the cost of switching patients and are providing support for GPs to carry out switching programmes.

Nearly 80% said they provided teams of pharmacists to identify candidates to switch from GP lists and 87% had access to prescribing advisers. The majority were also providing written protocols to identify patients and communication materials for patients.

A model scheme?

Devon PCT may provide a model that other PCTs can follow. With some of the most wide-ranging switch targets in the country, their schemes are voluntary and provide a lot of support for GPs.

Dr Peter Jolliffe, chief officer of Devon LMC, said GPs in his area were content with the PCT's approach. ‘The schemes are very much based on good clinical practice and pharmaceutical advisers are very helpful around here,' he said.

But not all GPs are as fortunate. Dr Kennedy said PCT support can be coercive. ‘Support for GPs which is well-informed, and evidence-based is very helpful, but not if it is used as a restraint or as an inappropriate pressure on prescriptions,' he said.

A Pulse survey in 2007 showed that many GPs felt undue pressure from PCTs to switch patients to cheaper drugs, with 38% saying it compromised their own ability to take clinical decisions and 42% saying the drug switching scheme was not consistent with maintaining patient safety.

There are some worrying trends that the Government will hope the European Court will not pick up on. In an ironic twist, a victory for the pharmaceutical industry would also benefit pressurised GPs in many areas. But if the legal challenge fails, then blanket switching schemes in the UK may become much more common, and then we may not have to wait until 2012 to see the effect of that.

Support provided to GPs to support switching schemes Support provided to GPs to support switching schemes

79% - teams of pharmacists to identify candidates to switch from GP lists

77% - written protocols to identify patients

87% - access to prescribing advisers

83% - communication materials for patients

47% - training

Most popular PCT switch schemes Most popular PCT switch schemes

Statins 84%
PPIs 46%
ACE/ARBs 38%
Bisphosphonates 23%
Antihistamines 11%
Aspirin 10%
SSRIs 6%

Simvastatin Should GPs be offered financial incentives to switch patients? Should GPs be offered financial incentives to switch patients?

YES - Dr George Rae, a GP in Whitley Bay, Tyneside

‘There are times when cost-effectiveness will be to the overall benefit of all your patients. I am quite relaxed about incentives and as long there is no coercion and there is no detriment to the patient, then I have no great qualms about them. Certainly the way it is working here, it is all done with a sort of collegiate educational way of doing things and that is the way to do it. As long as they are ethical, they are fine.'

NO - Dr Andrew Sykes, chair of Wakefield LMC

‘I would feel very uncomfortable if I knew there was a financial link with my practice in any sort of funding stream that would bring drug budget in. For the simple reason that we ought to be doing what is best for the patient, whilst still accepting that you have to balance what is going on in the wider budget. I need proof that a more expensive medication is better, but where they are, I would not want my judgement to be clouded by financial concerns.'

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