APPENDIX 5
Memorandum by Dr G Wilcox (GD 5)
Submitted by Dr Gregory G E Wilcox, full-time
Principal Partner in General Practice, 164 Harold Road, Hastings,
East Sussex. Chairman of Hastings & St Leonards PCG since
November 1998. Vice Chairman of the National Association of Primary
Care, a representative body for Primary Care Groups, and other
parties related to Primary Care, since April 1999.
My understanding of the shortage of generic
drugs is secondary to three possible causes.
Firstly there has been a move secondary to legislation
to prescribing drugs by patient packs whereby the medications
which were originally available in bulk quantities of, for instance,
500 or 1000's are now being packaged in smaller quantities, for
instance 28 or 30 day monthly supplies, or alternatively shorter
courses still for certain preparations.
Secondly, the loss of a significant manufacturer
of generic drugs has had an impact on the market.
Thirdly, there is speculation that stock-piling
of drugs is taking place following subsequent rises in generic
drug prices.
Prescribing issues created by generic shortage:
— Where drugs have become temporarily
unavailable they are moved to Category D prescription list in
which generic prescriptions may be substituted by a Pharmacist
with a Branded product, usually but not always, at increased cost.
The Pharmacist then receives reimbursement at the rate of the
Branded product. This cost is passed on to the original prescriber.
The number of drugs on the Category D list has risen dramatically
in the past few months and now includes many regularly prescribed
items.
The number and range on the Category D list
changes regularly from month to month causing confusion and instability
for patients who are likely to receive their regular prescriptions
in a different package and often in a different pill shape, colour
or form, from month to month. This creates uncertainty, anxiety
and a loss of confidence in the medicine being re-prescribed.
It also increases the chance of the patient requiring further
consultations in Primary Care in order to seek advice or reassurance.
Investigation of prescribing habits by General
Practitioners in my PCG indicate that there has been no significant
change in prescribing behaviour and that the recent crisis does
not appear to be part of an underlying trend of increased prescribing
costs or behaviour. This limits the opportunity to amend prescribing
to offset increases in cost.
The significant price rises in some generic
drugs, for instance Cimetidine tablets 400 mgs at a pack size
of 60 was less than £2.00 at the beginning of 1999 and is
now over £19.00, has created the need for substantial re-appraisal
of individual Practitioners most cost-effective options for treating
patients. This needs to be done in a systematic way and takes
time, certainly when considering changing treatments to more cost-effective
therapies. Whilst prices are very volatile, this process is almost
impossible to achieve.
Cost implications of the rise in generic prices
as the shortages of supply are as follows:
— Individual GP prescribing budgets
are consistently heading for an overspend in excess of original
forecasts. This process has been noted within every single Practice
of 25 Practices in my PCG and similarly in all six PCGs in my
Health Authority area. This overspend is creating significant
and currently unmanageable pressures on the total budget for health
care. East Sussex, Brighton and Hove Health Authority has currently
placed a moratorium on all health spending within the area, until
the problem of its total deficit is resolved. The financial deficit
related to prescribing at approximately £1.5 million, forms
the major proportion of the current overspend.
The prescribing overspend may be compounded
by the fact that some PCGs have received less than the full prescribing
uplift resource from Health Authorities in the hope of bringing
to bear pressure on the prescribing budget so as to free resource
for other parts of the health economy. This other money has since
been committed and with a prescribing spend in excess even of
the original intended figure, the resulting financial situation
is very serious.
Our situation in East Sussex is that some money
for prescribing growth was required to satisfy the NHS nurse salary
increase. Substantial overspends in prescribing have the ability
to scupper any developments that are likely to occur within PCGs
at a time when they are still very fragile organisations which
have been promoted, perhaps beyond their capacity to deliver,
as a means to better services for patients and for Primary Care.
If their first substantial action is to bring about restrictions
in services to patients or restrictions to Primary Care itself,
since General Medical Services budgets have been suggested as
a possible source of funds for prescribing overspends, then the
still delicate process of introducing PCGs to the Health Service
and particularly to Primary Care may be in peril.
It is my belief that this situation could not
be foreseen by Health Authorities or Primary Care Groups and whilst
they should be encouraged to exercise their normal processes of
financial self-regulation, this is an exceptional situation which
requires an exceptional form of resolution. If the National Health
Service is not to suffer a crisis either of loss of services or,
more importantly, loss of confidence in a time of intense change,
then I would suggest special arrangements are made to resolve
this financial situation.
October 1999
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