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Mr. Bradley: Dr. Malcolm Patch told the Select Committee:
- "A lot of expensive drugs are initiated within hospitals. The patient then comes to us as their GPs for further prescriptions. It is very difficult to change this prescription even if there is a cheaper and equally effective alternative as the patient sees the consultant as the ultimate decision-maker on therapy."
- "The drug companies sometimes offer 'loss-leaders' to hospital pharmacies at an artificially low price so that the drug replaces others. . . Thus the drug companies get their products initiated by hospital based doctors and we GPs are left to foot the ultimate, long-term and more expensive bill."
- "I would be the first to acknowledge that we have been responsible in hospitals for creating problems for general practitioners."
- "It's relatively cheap in hospital and it is very expensive out there in the community--there is no doubt that hospital doctors have created problems for general practitioners because of that."
Dr. Howard Stoate (Dartford): My GP colleagues round the country will be interested to hear what my hon. Friend says. I am sure that many of them share his concerns. Many GPs are already trying to prescribe generic rather than branded drugs, and many health authorities offer incentive schemes for prescribing, to ensure best value. Those schemes allow GPs to have money to spend on equipment in their practices, if they can show genuine savings on the drugs budget.
Mr. Bradley: I thank my hon. Friend for that intervention, which prompts me to make it clear to the House and to general practitioners throughout the country that I am certainly not alleging that they are all out to exploit the national health service and to make a profit from branded drugs. That is not the case. I am speaking of a small minority of GPs, but of a very large sum, which belongs to the NHS, to the community, to patients and to the taxpayer.
As my hon. Friend suggests, there is a great deal of best practice, to which I hope to refer later. The problem is that it is not yet as widespread as it ought to be. I hope that, by raising the issue tonight, we can encourage and educate more doctors so that that best practice is more extensively adopted.
The price differentials between drugs dispensed in the hospital and those dispensed in the community can be staggering. Shropshire health authority tells me that the
cost of prescribing the diuretic Frumil in hospital is 6 per cent. of the cost of prescribing it in the community--6 per cent. In other parts of the country, Frumil costs 20p per patient per day in the hospital, but £6.20 per patient per day out in the community.
Mathematics has never been my strong point, but I calculate that as a differential of 2,800 per cent. Shropshire health authority tells me that the cost of Imdur in hospital is 2.5 per cent. of its cost when prescribed by a GP. In other health authorities, I understand that it costs 14p per patient per day to dispense in a hospital, but £11.14 per patient per day outside hospital. That is a differential of 8,000 per cent.
Giving drugs away in hospital makes good sense for the pharmaceutical companies, because only 20 per cent. of our drugs are dispensed there. The other 80 per cent. are dispensed in the community. That is where the profit is to be made. The drugs barons, whether they are in pharmaceutical companies or in a more illicit trade, know that first they must hook their victim--in this case, in the hospitals--so that then they can then take the money from him. For good measure, they provide a ceaseless flow of gifts for GPs--blotting pads, pens and calendars, which hang on the walls of surgeries--which serve as constant reminders of the names of the branded drugs that they want doctors to prescribe or dispense.
The drugs barons have another clever, but effective, means of achieving their ends. They give branded drugs names that are simple and memorable, compared with the Latin or Greek roots of the names of generic prescribed drugs. Thus diconal is a branded drug and di--I cannot pronounce that word; it is Milosevic hydrochloride. I was hoping that my hon. Friend the Member for Dartford (Dr. Stoate) would ask me to give way.
Dr. Stoate:
The correct pronunciation is dipipanone hydrochloride.
Mr. Bradley:
I am grateful to my hon. Friend for coming to my aid; I have been rehearsing all afternoon, but this has proved my point: it is a great deal easier to remember diconal than it is to remember whatever name my hon. Friend just--
Mr. Deputy Speaker (Sir Alan Haselhurst):
Order. I hope that the hon. Gentleman will not require simultaneous translation throughout the rest of his speech.
Mr. Bradley:
I will resist the temptation, Mr. Deputy Speaker.
There is a problem too in the pharmacies. When a GP writes a prescription with a branded name on it, the pharmacist is not in a position to dispense anything other than that brand. That is not the case if the prescription specifies a generic drug--the pharmacist can dispense whatever comes to hand or whatever he advises--whatever is cheapest.
The key point is that, in the vast majority of cases, there is absolutely no difference in effectiveness in terms of the patient's welfare between the branded and the generic drug, but there is most certainly a difference in price. That problem alone costs my health authority, Shropshire, about £400,000 a year. That money could, and should, be spent on cancer care or on the Cinderella services such as mental health and services for people with learning difficulties.
The second scam is a nice little earner for a small minority of GPs. This country has about 23,000 prescribing doctors in general practice and 4,000 doctors who are entitled to dispense. They practise, typically, in rural areas. They provide a dispensing service as a community service, which is very valuable for people in isolated communities who do not have access to pharmacies. Dispensing GPs have been providing that service for a long time and the vast majority of them do so with quiet efficiency and with no thought for anything other than the care of their patients.
However, dispensing is also an income supplement for those GPs and it was intended to be so from the beginning of the national health service, when it was recognised that GPs in rural communities had fewer patients than their counterparts in urban communities. They therefore tended to earn less, and deriving a fee--and therefore an income--from dispensing was regarded as a sensible way of equalising their pay.
The income that GPs derive from dispensing consists of four elements: a dispensing fee, a container allowance, a value added tax allowance and a payment of 10.5 per cent. of the cost of the drugs that they dispense. The problem is the built-in incentive for some GPs to abuse the system. It is clear, particularly in respect of proportionate element of remuneration, that the greater the volume of drugs dispensed, the higher the cost of those drugs, the more frequent the prescription and the larger the income supplement that doctors are able to derive.
The GP community has been concerned about thatissue for many years. In 1996, the British Medical Association's General Medical Services Committee discussion document "Dispensing Remuneration" stated:
Mr. Bradley:
That is an important point. We are doing our best to dismantle the internal market in the national health service--to some effect, I think--but all too many rivalries, factions and hostilities persist. There are conflicts between one type of doctor and another, between doctors and pharmacies, between general practitioners and hospital consultants and between medical practitioners in general and administrators. Only when we ensure that everyone working in the health service works for the health service will we see the progress that we all wish to make. It strikes me at times that some people in the NHS--I stress that I am talking about a small minority, but that minority can wreak considerable damage--are more committed to their own interests than to the interests of the health service and the patients whom, they ultimately serve.
The incentive to which I have referred is clear and irresistible. Among non-dispensing GPs, the average prescribing of branded drugs is about 34 per cent.;
the remaining 66 per cent. consists of generic and cheaper drugs but, among dispensing GPs, the average is 74 per cent. In other words, only a third of non-dispensers' prescriptions consist of branded drugs, while the figure for dispensing GPs is virtually three quarters. The average cost of a prescription per patient per year is £118 in the case of dispensing GPs, while in the case of non-dispensing GPs it is as little as £78.
The question is this: is the original purpose of the scheme whereby doctors in rural communities were entitled to derive a supplementary income from the scheme being fulfilled? The answer is no. Between 1995 and 1997, the average GP's income was £47,000. The average for prescribing GPs was lower, at £45,800. However, the average for dispensing GPs, whose incomes had originally been considered to be falling below those of their urban counterparts, was £53,400--over £7,500, or 16 per cent., more than that of their non-dispensing colleagues. Dispensing GPs can make a profit of as much as £50,000 from dispensing. Some of them bank the money, as they are entitled to; others invest it in securing locums or other partners in their practices, and can therefore enjoy a rather more leisured life than other doctors.
In Shropshire, 21 of the 66 general practices dispense. Although they account for only 28 per cent. of the drugs budget, they account for 36 per cent. of its overspend. The Government have set a target: they intend 72 per cent. of all drugs dispensed to be generic by 2002. Shropshire's average is currently 57 per cent. Prescribers are working towards the 72 per cent. target, and are currently at 63 per cent., but the dispensers are way down the order at 30 per cent.
As I have said, I am not arguing that rural doctors, particularly those in isolated areas in, for example, Scotland and Wales, do not need that valuable income supplement. If we are to recruit and retain doctors who perform such a valuable duty in those communities, we must find a way in which to help them to supplement their income. Nor do I by any stretch of the imagination claim that all dispensing doctors are exploiting the system.
I pay tribute to the only dispensing practice in my constituency, the Wellington Road surgery in Newport. In the context of his intervention, the following information will be of particular interest to my hon. Friend the Member for Dartford. The practice dispenses to some 5,000 of its 12,500 patients, but its generic prescribing rate is as high as 70 per cent.--well in excess of the county average in Shropshire and more than double the rate of dispensing colleagues throughout the county. The rate can be achieved if a practice is committed to keeping costs as low as possible on behalf of the NHS. The cost to Shropshire health authority of wasted dispensing of drugs is about £500,000. Two years ago, its deficit was £1.5 million. This year, it will be close to £1.2 million. Next year, it will be little better.
I should like to mention briefly some of the solutions that we might apply. It is to be hoped that peer pressure to contain budgets will be brought to bear when primary care groups are introduced on 1 April, but that in itself will not be enough. Shropshire health authority is pursuing a number of initiatives. It is seeking agreement between consultants in hospitals and GPs in the community to identify the costliest brands for the local NHS and to replace them with generics in hospital. Collaborative working is important in the NHS.
The health authority is introducing software packages, so that GPs can identify in their surgeries not only the most appropriate drugs for their patients, but how to secure them at the lowest possible prices. It is introducing incentives that my hon. Friend the Member for Dartford mentioned earlier for reducing drug budgets among GPs.
"unfortunately the on-cost arrangement is open to the criticism that a dispensing doctor can increase gross earnings from dispensing more expensively".
That is absolutely true. Unhappily, the BMA concluded, somewhat complacently, that there was
"no clear evidence of this."
Mr. David Drew (Stroud):
The situation is not helped by the fact that there has been something close to a state of war between dispensing general practitioners and pharmacists in rural areas. Until that is sorted out, problems will continue, and, inevitably, it will be the patients who suffer in the end.
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