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Is the drive to cut drug bills going too far?

Drug switching and generic prescribing schemes are booming, but concern is growing over how they are run. By Nigel Praities investigates.

By Nigel Praities

Drug switching and generic prescribing schemes are booming, but concern is growing over how they are run. By Nigel Praities investigates.

The year is 2006, the NHS has just slipped into more than £500 million of deficit and then health secretary Patricia Hewitt is not a happy woman.

She orders PCTs in no uncertain terms to get their financial act together – and so the era of drug budget cutbacks begins in earnest.

Fast forward two years, and the NHS is back in surplus [check], but there is no sign of an end to the drive for low-cost prescribing. Indeed, a Pulse investigation reveals there has been a dramatic expansion in the number and scope of drug switching and generic prescribing schemes over the last year.

Swayed by legal concerns, PCTs are finding ever more sophisticated ways to influence GP prescribing and reduce the £8bn it costs the NHS each year.

While most GPs appreciate the need for controls over the way NHS funds are used, there is growing disquiet in some quarters about how schemes are run – with doctors often left to square an impossible circle by meeting generic prescribing targets while ensuring optimal patient care.

In previous years, incentivising GPs to switch patients to cheaper treatments has worked extraordinarily well, with NHS figures for 2007 revealing a record 83% of prescriptions were for generic treatments.

Statins – as the most widely prescribed drug class in the UK, were the primary focus for PCTs and many hit generic prescribing rates of over 80%. The move had at least some evidence base, with a trial based at a GP practice in Hertfordshire showing that it was possible to switch patients and not affect long-term outcomes.

But NHS managers are increasingly hungry to find more cuts. Pulse revealed earlier this year [check] that the powerful NHS Institute for Innovation and Improvement was tightening up the existing statins indicator for trusts and was introducing targets for generic proton-pump inhibitors, ACE inhibitors and antiplatelets from April 2008.

PCTs have reacted to increased scrutiny by introducing more money-saving schemes for many classes of drugs this financial year.

Findings obtained by Pulse under the Freedom of Information Act from 131 PCTs show huge jumps in the number of schemes for antiplatelets, bisphosphonates, antihistamines, ACE inhibitors and ARBs – in some cases by as much as 80%.

These enormous increases are concerning for many GPs. A Pulse survey of over 400 GPs found 65% said they were placed under pressure from their PCT to co-operate with drug switching schemes. A third thought their freedom to do the best for their patients was compromised.

Dr Alun Cooper, a GPSI in osteoporosis in Crawley, West Sussex, and chair of the National Osteoporosis Society's primary care forum, says GPs are often risking patient care by trying to insist on the use of the cheapest bisphosphonate.

‘The danger is that patients are switched to another drug, they come back and say they have indigestion and the GP then starts them on a PPI. But we have increasing evidence that PPIs are bad for bones,' he argues.

Dr Cooper says NICE has compounded the problem with bad advice on bisphosphonates, making it difficult to prescribe alternative treatments to generic alendronate.

Just over half of PCTs used NICE guidance as the justification and basis of their schemes – which has not stopped some experts from questioning the evidence base for switching.

There are particular concerns over schemes to move patients from clopidogrel to aspirin, following publication [check] of a trial suggesting a ‘rebound effect' from stopping clopidogrel treatment.

Professor Martin Cowie, chair in cardiology at the National Heart and Lung Institute and a consultant cardiologist, says PCTs often chose the ‘easiest targets for short-term gains', rather than thinking long-term.

‘The arguments for statins are clear, but for a lot of the others the benefits from one year to the next are relatively small. Drug prices change and for ARBs for instance, there is a very weak argument and the cost savings are not enormous.

‘PCTs need to be looking long and hard about whether this is an area where they should be putting their effort and resources,' he says.

Professor Cowie's concerns are shared by many other specialists, with a survey of 50 consultants showing 84% were slightly or very concerned about drug switching schemes and 42% saying there was not suitable evidence to support switching schemes in their area.

Drugs manufacturers are determined to take advantage of such doubts. A legal challenge to PCT prescribing incentive schemes brought by the Association of the British Pharmaceutical Industry was granted a judicial review last year.

The fight is currently being transferred straight to the European Court, and focuses on the legality of payments made to GPs to prescribe a particular drug.

The Department of Health responded to the legal moves last summer by issuing urgent guidance to PCTs, insisting patients must be individually assessed and warning against inappropriate payments to GPs for switching patients to cheaper drugs en masse.

Many PCTs seem to have taken this advice to heart and most are now reluctant to use the term ‘drug switching', with many referring to ‘prescribing review schemes' or ‘discussions in line with national recommendations'.

The Pulse investigation reveals nearly 60% of PCTs offered incentives of some kind to GPs this year, but the form payments take is changing.

Bolton PCT this year discontinued a number of schemes that actively encouraged practices to switch to cheaper drugs and is now focusing on locally-based agreements to encourage cost-savings through practice-based commissioning.

Andrew White, assistant chief executive of Bolton PCT, says drug switching incentives for practices worked well in his area last year, but the trust was now developing local agreements with practices.

‘We are not specifically incentivising switching this year, apart from antibiotic prescribing.

‘Our plans for PBC clusters are more ambitious this year and we are developing individual targets with practices based on their QOF medicines management points,' he says.

Bolton joins a number of other PCTs who have cancelled direct payments for switching and are shifting more towards PBC agreements or joint primary and secondary care formularies to encourage GPs to prescribe generically.

But the focus on PBC to make cost-savings is controversial, with some regarding the financial gain for GPs in switching patients as a dangerous incentive that distorts the doctor-patient relationship.

Dr Peter Fellows, a member of the GPC clinical and prescribing sub-committee and a GP in Lydney, Gloucestershire, says it is ‘immoral' for GPs to profit from shifting patients from a drug they might need.

He adds: ‘I hate PBC. I don't think it is fair and I am very worried about the influence of PBC clusters where doctors are trying to save money on the face of it to benefit patients, but are lining their own pockets. That cannot be beneficial for patients' he says.

Professor Cowie also has concerns over PBC agreements, saying they are against the ethos of the NHS: ‘This is getting more towards a German approach where GPs have their budgets cut - a rather draconian way of forcing change,' he says.

South Gloucester PCT has shifted from a switching scheme to a local enhanced service agreement, where practices are paid a proportion of the money saved by increasing the number of first-choice formulary dugs prescribed.

‘If a change was being made, the PCT would want to encourage the first-choice formulary choice to be selected [but] this is not a drug switching scheme in the sense of offering incentives for GPs to switch patients from one drug to another,' a spokesperson explains.

Initiatives such as joint primary and secondary care drug formularies are less divisive and have the benefit of ensuring GPs do not have to switch patients from more expensive drugs initiated in hospital. But some still have concerns they are based on the same cost-cutting premise

‘As long as they are voluntary and make their doctors think more carefully about prescribing they are OK, but many are just put together by pharmacists who don't have a clue,' says Dr Fellows.

As the battle over incentives for GPs reaches the European Courts, the controversy over prescribing controls looks set to rumble on. What began as a emergency response to spiralling deficits, looks likely to permanently change the balance between responsibility for the individual patient and society as a whole.

PCT drug switching schemes, in numbers

83% of PCTs have schemes to promote cost-effective prescribing
8% have plans for further schemes this year
52% say their schemes are based on NICE guidance
56% admit to providing financial incentives
20% have received complaints or enquiries about their schemes, mainly from patients
5% had reports of adverse events, mostly just one or two, but in one case more than 20

Is the drive to cut drug bills by switching more patients onto generics going too far? Statins

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