GPs are used to balancing two huge responsibilities, that to the individual patient in front of them and that to patients as a whole, and therefore have a duty to prescribe cost effectively. Working with medicines management teams is an important part of this.
However, I believe that the significant gains from medicines’ optimisation have already happened, either because projects have been done in earlier years or because drugs which previously were the target for changes are now off patent. This has led to some changes being suggested that are inappropriate.
Although prescribing budgets are being squeezed, we need to recognise that any change is disruptive for the patient, can reduce concordance, or expose patients who are settled on one medication to a new set of side effects, so changes must be significant in value, be sustainable, be infrequent, and must always be to a drug of similar effectiveness.
Savings should also always consider the total cost to the NHS, not just the drug price, and the cost of pharmacy and increased monitoring also needs to be taken into account.
Changes to the cheapest branded generic applied across the country can rapidly produce supply problems.
Other initiatives such as recommendations to halve tablets when lower doses are available, to use a number of lower strength tablets instead of one of higher strength, or to change patients to simvastatin, when it is likely that new NICE guidance will no longer recommend this as first line, can also have adverse consequences in the long run. GPs need to be particularly careful to assess each patient for their suitability before making these kinds of changes.
It is also unfortunate that GPs can do a lot of this kind of work with many patients in order to save relatively small amounts of money, then find any saving blown out of the water by a single request from secondary care for a high cost medication that previously would have been prescribed from the hospital directly, with ‘specials’ particularly problematic in this regard.
Many secondary care clinicians appear unaware of the cost of these preparations. Clearly any resource allocation formula needs to be sophisticated enough to allow for this happening, as it would be unethical for a GP to decline to prescribe for a patient a necessary prescription wholly on the basis of cost.
Dr Andrew Green is chair of the GPC’s clinical and prescribing subcommittee and a GP in Hedon, East Yorkshire
