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Milking the NHS

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Have you ever met the pharmaceutical advisor for the Pharmacy and Medicines Optimisation Team of your local Commissioning Support Unit?  I have. Her job descriptions may be long-winded, but her point was punchy: cut your drugs spend by 2% this financial year. Period. 

Drug costings intrigue and frustrate me in equal measure.  Why is naproxen £6.50 for 56 tablets, but only £3 if you give the patient 2 packs of 28? A slip of the mouse and you’ll spend twenty quid on nystatin suspension whilst the branded Nystan is £1.80.  I know, its pharmaceutical giants being clever and canny, but it’s really quite sad.  Lesson number one then: be aware of industry tricks, and turn on ScriptSwitch. 

That wasn’t all.  The bright little chemist from the CSU had other ideas:

Tip 2. Prescribe generic finasteride instead of dutasteride (Avodart) – fine, a quick report and a bulk mail to affected patients can sort that. £2 a month per item rather than £28.  Certainly worth an hour of admin time. 

Tip 3. Increase generic prescribing.  Sounds simple, but try prising entitled GORD sufferers from their Nexium and you’ll regret it pretty sharpish.  One hyperlipidaemic lashed out with her bingo wing when I tried to take her off Crestor. 

Tip 4. Consider self-care items.  These are those Oilatum shower gels and Doublebase body washes that the sensitive skinned lather up with.  Aveeno’s a personal favourite of mine.  With its natural oatmeal ingredient, a surefire alternative when they’ve reacted badly to aqueous cream.  Practices can blow up to £19,000 a month on these scripts.  That’s certainly eye-watering enough for me to deny little Jonny his FP10 for Cetraben.

Tip 5. Reduce glucosamine, omega-3, quinine for night cramps, and anything else without a smidge of an evidence base.  See 3 above: patients don’t like change.  They’ve had it for years, they can’t get an appointment, and they bloody well want their Maxepa. 

There it is then, a quick guide to cutting prescribing costs.  Common sense really, but it can make for a challenging consultation.  Patients become attached to their repeats.

Of course, despite best intentions, there are always those patients that’ll slip through the medication review sieve.  A GP colleague in Scunthopre recently received a script query.  A two-year-old’s Mum wants 6400g of Nutramigen 1 Lipil, can she have?  Hold on, he thought: that’s 16 tins of baby formula… for a 2 year old?  He delved deeper: she’d had 16 tins, every month, for 16 months.  That was 256 tins in just over a year.  Market value being £14 a tin, her ravenous pup appeared to have guzzled £3,500’s worth of NHS sponsored milk. 

I wanted to find out more about Nutramigen 1 Lipil so I Googled it. Now I’m not here to cast aspersions on the young Mums of Scunny, but there’s literally gallons of the stuff for auction on eBay.

Tom Gillham is a GP in Hertfordshire and Specialty Doctor in A&E. You can follow him @tjgillham.

Readers' comments (10)

  • You might pause to consider how your GORD patients got onto es-omeprazole ( branded or otherwise ) in the first place. Then have a look thru' your patients' med charts for levo-cetirizine, dex-ibuprofen, des-loratidine, es-citalopram and any of the other clinically meaningless patent-extenders that Big Pharma market so forcefully.

    Grow a pair and remind your patients that the prescription form has your name at the bottom, not theirs.

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  • Thomas Gillham

    Fair point. Most of them are started by an over-zealous gastro SpR after an equivocal gastroscopy. Once "the hospital" have started the wunder-med, it makes it that much harder switching or stopping it.

    I'll cultivate my pair though.

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  • Anonymous is absolutely right about most of the es-, levo-, des- drugs, but es-citalopram is proving itself dramatically better than boring old citalopram, and is now the SSRI of choice.

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  • Please add up all the extra appointments, phone calls and letters you do because of switching then bill the drugs budget for your time.
    Other than that all good stuff!

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  • My pair is as big as the next man's. I've no problem stopping an expensive isomeric drug, I rarely (if ever) start them in the first place. I've often found engaging the patient in high level banter regarding the prescribing predicament we face at present tends to afford you their understanding. But as a GP and patient who takes esomeprazole for symptoms of a large hiatus hernia, you'll be dragging those tablets away from my cold dead hands before I'll go back to omeprazole.

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  • I think the trick's not prescribing it in the first place and communicating with secondary care about their prescribing habits. I recall a recent letter from a speech therapist asking me to change a patient to a more expensive PPI for their laryngopharyngeal reflux. Thanks, but no thanks.

    Interesting observation re: baby milk. I've seen more requests for Aptamil Pepti in the last year for unproven cow's milk protein intolerance than I have breast feeding mothers. It makes you wonder...

    Re: escitalopram/citalopram, neither are my first line SSRIs due to their effects on the QT interval. If I have to prescribe, which I seldom do, I tend to go with sertraline or even good old fashioned fluoxetine.

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  • I've recently looked at my legal position should I refuse to prescribe non generic when patient believes a branded version works better. I'm told there is no legal stance as technically,I can prescribe any medication on bnf.

    This of course translates to patient wins, doc losses if it came to a more formal review (such as complaint to gmc or court). I'm afraid this is another example of government saying one thing to the profession and another to the voters.

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  • on the Australian goverment script scheme: no baby formula, no gluten-free foods, no expensive anti-histamines, no anti-funga; creams - you can buy it all yourself at the chemist. Prescribed items are for 1 month at a time with 5 repeats, and each item costs around 3-4 pounds if you're a pensioner or 15 pounds if you're employed. There's a lot less waste, as there are few free scripts and as people can't stock-pile like they do in the NHS. Basically less of the entitlement culture.

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  • Re: escitalopram/citalopram, neither are my first line SSRIs due to their effects on the QT interval. If I have to prescribe, which I seldom do, I tend to go with sertraline or even good old fashioned fluoxetine.

    Beware sertraline - just had a massive price hike to over £6! Fluoxetine still cheap!

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  • Give patients what they need not what they want! I do like the Australian prescription rules. Prescribing Advisors are a useful source of expertise-much needed and appreciated.

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