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Drug switching - the debate continues

In the second part of our drug switching debate, the panel considers the appropriateness of PCTs pressuring GPs, use of incentives and the legal issues surrounding switching.

In the second part of our drug switching debate, the panel considers the appropriateness of PCTs pressuring GPs, use of incentives and the legal issues surrounding switching.

Pulse: Is it appropriate for PCTs to put pressure on GPs over excessive prescribing?

Dr David Russell (DR): I think if it's a poor prescribing doctor who takes no notice of advice then there should be some pressure put on them. Peer pressure is a good way of dealing with it. There has to be some pressure put on a colleague who inappropriately makes things difficult for the rest of us.

David Fisher (DF): I'm really quite pleased to hear around the table in all of these examples the good practice and principles that should be applied when prescribing. You know, the importance of the doctor-patient relationship, ensuring patients who aren't suitable for a particular medicine are not switched, the following up properly. My key question is how many programmes actually conform to these lofty standards?

With all else being equal doesn't it make sense to use the lowest cost medicine? But only if all else truly is equal. If we've made a decision to move from a low powerful statin to a less powerful statin we need to understand that.

Sue Ashwell (SA): Potent but not more powerful.

DF: Okay, but you take my point that we need to understand the consequences of these programmes. I don't think the industry would have any difficulty with these principles, but I would question how often they are adhered to.

Professor Mike Kirby (MK): There's one example in Stoke certainly.

SA: In Stoke they switched atorvastatin 40 to simvastatin 10 or 20. I don't think there would be many places which would suggest that as an equivalence switch.

Pulse: Do you have any sense of how many PCTs out there might not be using best practice?

MK: I don't think we know.

DF: Do we actually understand what best practice is? I mean is implied consent the right standard. Is it the best standard for our patients?

Dr Peter Fellows (PF): I'm concerned about increasing pressure for generic prescription which is also part of this. Often the drugs we are encouraged to use are generics and the way that drugs are licensed now means that the licence for the branded drug is not necessarily carried over to a generic, and a lot of PCTs don't understand that. A GP who prescribes a generic can be laying themselves open for later problems.

DF: I'm just going to try and re-enforce that point. I think that is particularly true of different medicines within a category. You can have quite different etiquette in safety, different profiles and quite different licensed indications and sometimes the difference can get lost in the switch. ACE inhibitors and ARBs are classic examples.

DR: Give me an example of what you're talking about there please?

PF: Losartan has got a specific license for the prevention of stroke which none of the other ARBs as far as I'm aware of have got.

Dr Neal Maskrey (NM): Peter, are you seriously suggesting that BMA policy is not to prescribe generically?

PF: No, I'm not. I'm saying, and I must make it plain that I'm here on a personal capacity not an official BMA capacity, that I think we need to prescribe generically where possible but we need to be aware of the pitfalls of it. And I think for the Government to push further than we've already achieved, and we do have a very high generic rate, is now causing us problems.

DR: Does Scripswitch software provide any information on licensing?

Martyn Carroll (MC): It can do, yes. The way it works, the knowledge inside it is completely at the control of the customer that purchases, so if it's a PCT for example it could be the Medicine's Management Team who put the information inside.

Pulse: Well we've talked about some of the pressures that may occasionally filter down to switch drugs. What about some of the incentives that may be on offer? Is it appropriate to pay GPs for taking part in these kind of schemes?

MK: There is a cost to the practice, we actually worked out how much it cost to do the exercise. There's time, postage, we tend to do more cholesterol checks, more blood pressure checks. For our two surgeries it costs the practice near £4,000 and the cost of the pharmacist's time as well.

SA: Although we use the word ‘incentive' we know there is a cost, and a big part of incentive payments is acknowledging that GPs are putting in some work to do something for the greater good.

NM: I think the problem with incentive scheme payments is the word ‘incentive', rather than a reimbursement of cost attached to it.

DF: qhy do you have a problem with the term ‘incentive'?

NM: Because I don't think its right that it should be necessarily seen as incentivising somebody to do the wrong thing, you only reimburse reasonable costs.

DF: If you're encouraging somebody to do the wrong thing it doesn't matter what you call it, its bad news. The point is, if you've identified something that's worthwhile doing, why would you have a problem calling it an incentive?

DR: Because the word incentive means you're going to get paid an awful lot of dosh if you do this, and that sounds kind of dark, and its not what we're talking about is it?

PF: The Department of Health guidance to PCTs says prescribing incentive schemes operate alongside and should be compatible with local practice based commissioning incentive schemes. And it says ‘payments or any other inducements to good practice must not reward prescribers or their practices simply for blanket prescribing particular named medicines, i.e., without consideration of the individual circumstances of patients'.

SA: And it's entirely consistent with the jointly agreed guidance on inappropriate or excessive prescribing from both the BMA and the NHS employers on behalf of NHS.

DF: Unfortunately, subject to court judgement, its also illegal.

DR: It's not just the PCTs and the Department of Health that are giving inducements, it's also the pharmaceutical industry. We've had incidents where nurses have been put into practices to do such things as asthma screening of DEXA scans and there may be a spin off in terms of money because of that.

Pulse: What are the precise terms of the legal challenge?

DF: The legal point is, is it legal or not to pay a doctor for prescribing a named medicine? So if I offered one of my medical colleagues £5 to prescribe medicine X, is that legal or not? I think we could probably answer that, that's not legal. But my PCT colleague pays the same £5 to make the same prescribing decision to prescribe Brand X… is that legal or not?

SA: The caricature of the PCT that says ‘this is dirt cheap, I'll pay you to shift', is not what PCTs are about. We are there to improve the health of our population. But I cannot say every one of my PCT colleagues everywhere in the country does it perfectly.

DF: Let's put it in the context of the work that was done on the ARB switch, so the evidence has been looked at, and its been decided that ARB2 is more cost effective than ARB1. And I promote ARB2. This is good news for me because I can now run around to PCT and say ‘guess what, I'll give you a tenner for every prescription that you write for ARB2'. Same scenario, you know, I end up in jail, doctors face a major medical legal issue. Now, a PCT pharmaceutical adviser, based on the same evidence base, offers the same £10 incentive for prescribing ARB2, and that's okay. Please explain the difference to me.

NM: It has been explained to you.

DF: No it hasn't.

NM: The costings for the amount of time and administration and postage.

DF: The point I was making there's a line somewhere between quite appropriate incentivisation and payment of good prescribing, of which there could be many components, versus paying a doctor for prescribing a specific named medicine. Which creates all sorts of issues which I think were very well described by the BMA - the tension between the doctor/patient relationship, versus the financial incentive.

Pulse: What if the incentive is to apply NICE guidance, and NICE has happened to recommend a specific medication, which it does, doesn't it?

Dr Gillian Leng: NICE does but there always has to be decision-making by the prescriber.

MK: I'd like to make clear that our ARB switch was not incentivised in any way. We were incentivised by peer group pressure to try and make a economies of our prescribing.

NM: I'm more interested in perhaps where 350 plus patients are on an ARB who have never had an ACE inhibiter, never been tried, never been thought about.

DR: And the incentive could be for an audit and an action plan, but not necessarily linked to a particular switch.

SA: Yes, the incentive scheme that's about payment on an individual patient basis feels quite uncomfortable, it feels like there should be incentives for the overall proportion of patients you've got on certain type of drug.

Pulse: And where is the ABPI's legal process?

DF: Its in the process is really all I can say.

Pulse: Is there any date set?

DF: No

For a list of the participants, see the first article in this series on the debate.

The debate was organisaed by ScriptSwitch

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