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Drug switching: unacceptable pressure or essential cost control?

The eight panellists drawn from general practice, the pharmaceutical industry, NICE and ScriptSwitch, which supplies software to facilitate drug switching, consider the effect that the increasing focus on switching has on GPs'' practice and the doctor patient relationship.

The eight panellists drawn from general practice, the pharmaceutical industry, NICE and ScriptSwitch, which supplies software to facilitate drug switching, consider the effect that the increasing focus on switching has on GPs'' practice and the doctor patient relationship.

Pulse: Where does the balance lies between a doctor's responsibility for the patient in front of them and their duty to prescribe cost effectively?

Professor Mike Kirby (MK): It's a matter of giving the right drug to the right patient at the right time. Most of us would do our very best with a patient sitting in front of us. But we also live in a community that isn't able to fund what we are doing, so I think it means reasonableness and may need negotiation. But if treatment is being withheld from patients on the basis of cost they should be involved in the debate and know about it.

Dr Neal Maskrey (NM): Effectiveness and cost is entirely legitimate to be considered because that equates to justice and equality. But the patient's autonomy clearly comes into it as well.

Dr Peter Fellows (PF): The patient is paramount as far as I'm concerned. We all have a responsibility to try and be as cost effective as we can with our prescribing, and we must never lose sight of the fact that we are already the most cost effective prescribers in Europe and yet the Government is still demanding more.

Dr David Russell (DR): I would suggest GPs are much better at prescribing cost effectively than our secondary care colleagues. Anecdotally they have no idea of the cost of medicines. I think a lot of my consultant colleagues are not aware and don't really care what it costs.

PF: The Office of Fair Trading report was critical of doctors' awareness of drug costs and inferred that GPs are not particularly aware.

DR: I think we are more aware now, don't you think?

Sue Ashwell (SA): Experience tells me there are people that are aware but that do not always necessarily work it through to the implications. I think one of the useful things when looking at that balance is the way the GMC puts it - that is that we have a duty to our patients but you must also think about the implications of your choices for other patients. I think that's what we are asking GPs to do. As a PCT advisor I would strongly support that GPs remain as an advocate for their individual patients, but I would also ask them to join with me in thinking about the implications for the wider group of patients to help us make the money we have go further. I do think though that because hospital doctors often don't know or see medicines prices, they are less able to make informed choices about medicines use.

NM: I'm a bit uncomfortable about this stereotyping of one group against another. I think one thing seven years prescribing has taught me is that most people are trying their level best everyday and, okay, occasionally decisions might not be always be optimal. But then how many of us make 100% perfect decisions every day?

MK: I think knowledge is really important - there is a lot of new knowledge all the time as to whether we really know that drug A is that much better than drug B, and if it is that much better is it worth the extra cost? When we're deciding one thing that might be very important is that what sort of side effects is the patient going to suffer, what is the impact on their quality of life? That often doesn't get costed in.

Dr Gillian Leng (GL): There are choices that the prescriber makes when the patient is in front of them and that is really mostly about cost. You're looking at what's the cheapest with the fewest side effects that we think is the most appropriate fit for the patient. That's because we have a system at the moment that is saying that the cost effectiveness of a particular drug is so poor that we don't think it should be available.

Martyn Carroll (MC): Through the course of our business we undertook some research of a GP panel - 200 GPs - and 86% said making prescribing decisions was becoming increasingly complex. Over three quarters felt they needed some support at the point of making the prescribing decision. In terms of the ScriptSwitch software what it does is to enable the GP to have information on drugs, and they're empowered with the patient in front of them to make a call on whether it is clinically appropriate for that individual.

Pulse: Has the pressure on GPs to switch drugs from one drug to another increased the difficulty of these kinds of describing decisions?

MK: I think there has been quite a lot of financial pressure to switch to cheaper drugs and we've actually looked at this very carefully because we've been asked to switch statins. I was quite worried about this as, if you look at the literature, there is very little written about what happens when you switch drugs.

We dug quite deep. We followed patients for over two years because I was worried that there would be safety issues. You only need one patient to lose heart and to be told ‘oh sorry we've taken you off this drug because it's cheaper' and not to take it and have one event, and all your savings are out of the window.

I think it's really important that if switchings are made then they're made with good judgements about equivalents and safety, and the patients are carefully followed up and they need to be part of the decision making.

DR: And they have to be told the truth as well as to why you're doing it - because you can do this many more hip replacements or whatever. You have to be truthful to patients.

NM: Nobody's going to say this is going to be done in an unethical way are they? We're all going to say it's got to be done safely. Patients have got to be identified for where a switch would be inappropriate.

Pulse: Do we think that PCTs are taking that message on board? Have PCTs been following switching protocols to the letter?

MK: I don't believe they have, no, because nobody reads a published paper carefully. They just read the headlines and I think it does need to be done very carefully and patients do need to be followed up very carefully. Probably a hand full of patients came in quite angry, more so with the ARB switch than the statin switch, and I suspect the reason is that by the time you've got onto giving the ARB you've probably tried everything else and they know it doesn't give you side effects and they didn't want to switch, which is fine. You don't have to switch.

PF: We had a lot of patients switched between ARBs and most of those have gone back to their original ARB because they felt they were getting side effects. We also found that they weren't getting the blood pressure control that they had before.

SA: That's not consistent with the experience we have. I think it is difficult to say PCTs are all doing the same because there are a 100 or so and they work in very different ways. But our particular PCT engages individual patients by writing to them and going round to patients' groups to get feedback. And there's been a shift - over the last 3 or 4 years they are now finding me in these sort of meetings and saying ‘why isn't my GP doing this because I know that there are other things that are not being provided'.

Pulse: Is it partly down to the procedures that are used to select patients to switch, because presumably not all patients are suitable?

MK: Certainly with the statin switch only 54% were suitable, while with the ARB switch more patients were suitable. In fact, during 2 years over 90% of switched patients are still taking the drugs they were switched to and their blood pressure is lower than it was before they were switched.

PF: There are some things that are just nonsense. The classic one is the 40mg tablet which is cheaper. We had patients who were perfectly stable on 80mg once a day who were switched to two 40s and that affects concordance for a lot of elderly patients who are confused. I mean, it is absolute nonsense.

DR: But you wouldn't choose patients who were confused, but for the average patient who is 46 years of age and isn't confused then surely £28 for 80mg rather something like £1.40 for two 40s - that makes financial sense.

NM: I've had relatives pinning me against the wall saying here I am, I read in the local paper that the local hospital is in crisis and redundancies are threatened and you tell me this medicine I'm on costs six times more than this other medicine I could be taking, so why aren't I being switched? And you know, that's the essence of it.

SA: The perception I've had is that there is much more awareness about the need to manage budgets across the health service. Whether its nice being on the front of the Daily Mail or not I don't know, but people no longer think it's all the Government's fault that they no longer throw lots of money at the health service.

MK: We gave the patients questionnaires and specifically asked them that question and they were quite happy being put on a more cost effective drug. It came across very clearly that they trusted their doctor's decisions, saying ‘its ok, we trust you'.

DR: The problem is that if you do make a change and someone has an event which could be totally coincidental, would be coincidental, you'd feel very uncomfortable explaining it to relatives.

NM: that's why consent is so important

PF: The first thing is it should always be done with the practice's consent and agreement. Some PCTs don't seem to understand the regulations. They cannot impose this, the only drugs GP's are not allowed to prescribe on the NHS are black listed drugs and those drugs on the grey list that are excluded for the particular conditions the patient may have. So PCTs are actually restricting and there's no right to ration.

And should we accept rationing? I don't think that we want to see a postcode lottery. I've got an assistant who had lymphoma and he needed a treatment and couldn't get it. The PCT refused. Eventually, under a lot of pressure, he went to London and for the first time in seven years he's now completely clear of it. I think that is immoral.

The debate was organised by ScriptSwitch.

Conflicts of interest:

Mike Kirby: Funding from industry for research, advice, conference fees and travel.

Sue Ashwell: Paid employment and consultancy work for Cambridgeshire PCT, NHS Employers, Department of Health; Customer of ScriptSwitch, occasional lectures or membership/advisory roles for Cambridge University Medical School, Cardiac Networks and other PCTs

Peter Fellows: BMA/RPSGB liaison member and member of the advisory council of the ABPI

Neal Maskrey: Paid consultancy for the Office of Fair Trading, including on statin prescribing. Paid a fee for giving five to 10 workshops a year to health care professionals on a variety of therapeutics or educational topic. Some of these workshops are funded by the NHS and some by one, or usually more than one, pharmaceutical company.

Gillian Leng: None

David Russell: None

Martyn Carroll: None

David Fisher: None

Dr Gillian Leng and Dr David Russell argue cost effective prescribing is vital Dr Gillian Leng and Dr David Russell argue cost effective prescribing is vital Professor Mike Kirby, GP and professor of health and human sciences, University of Hertfordshire Professor Mike Kirby, GP and professor of health and human sciences, University of Hertfordshire David Fisher, commercial director, ABPI David Fisher, commercial director, ABPI Sue Ashwell, director of medicines management, Cambridgeshire PCT Sue Ashwell, director of medicines management, Cambridgeshire PCT Dr David Russell, GP and prescribing lead for Darlington PCT Dr David Russell, GP and prescribing lead for Darlington PCT Martyn Carroll, head of medicines management, ScriptSwitch Martyn Carroll, head of medicines management, ScriptSwitch Dr Peter Fellows, member of GPC prescribing subcommittee Dr Peter Fellows, member of GPC prescribing subcommittee Dr Neal Maskrey Dr Neal Maskrey

I've had relatives pinning me against the wall saying: 'This medicine I'm on costs six times more than this other one, so why aren't I being switched'

Dr Gillian Leng: implementation systems director, NICE Dr Gillian Leng: implementation systems director, NICE Dr Neal Maskrey: medical director National Prescribing Centre Dr Neal Maskrey: medical director National Prescribing Centre Dr Peter Fellows Dr Peter Fellows

There are some things that are just nonsense. The classic one is the 40mg tablet which is cheaper. We had patients who were perfectly stable on 80mg once a day who were switched to two 40s and that affects concordance...

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