Examination of Witntesses (Questions 1-19)
NATIONAL HEALTH
SERVICE & DEPARTMENT
OF HEALTH
11 JUNE 2007
Q1 Chairman: Good afternoon and welcome
to the Public Accounts Committee. Today we are considering the
Comptroller and Auditor General's Report, Prescribing Costs
in Primary Care. We welcome back to our Committee David Nicholson,
who is the Chief Executive of the National Health Service. We
also welcome Professor Colin-Thomé, who is National Clinical
Director for Primary Care, and Dr Harvey.
Perhaps, Mr Nicholson, you could start
by looking at the Comptroller and Auditor General's Report. Figure
1 on page 8 tells us that: "88% of all prescription items
dispensed were free to patients." That, naturally, might
lead to a problem of wastage. How are you managing that risk?
David Nicholson: Obviously,
if you look at the people who are entitled to free prescriptions,
you see that it is quite an extensive list—people over the
age of 60—
Q2 Chairman: I am not in any way
questioning people's right to free prescriptions. I am just saying
that if you get something free, there may be a tendency not to
look after it as carefully—there is nothing wrong with that;
it is perfectly natural human behaviour. I am just asking how
you are managing the risk of wastage and trying to inform the
public of the huge costs of medicines. For instance, figure 1
says that: "£1.9 billion (almost a quarter of the total
bill) was spent on cardiovascular prescriptions" alone, and
I would not be surprised if a high proportion of those were, quite
rightly, delivered free. However, I am just wondering how you
are getting over the message that there is a cost to them and
to all of us in providing these medicines, that they should be
looked after and, if they are not used, that they should be returned.
David Nicholson: They should,
and there are lots of initiatives in the NHS to help us in that.
We have to understand, of course, that the really important relationship
here is between the general practitioner and the individual patient.
Making sure that the general practitioner has all the information
that they require and is able to talk through the issues with
patients is the most important part of the process of enabling
us to minimise waste. However, we have a whole series of initiatives,
some of which are reported in the National Audit Office Report,
in relation to the NHS. We have locally run publicity campaigns
and a whole series of things around the medicines usage reviews.
We have the medicines collaborative, where patients and clinicians
come together, and initiatives around pharmacists working with
general practitioners. So we have a whole range of things that
enable us to make sure that waste is minimised, but we are clearly
still very concerned about the issue.
Q3 Chairman: One idea that I would
like to put to you is, why do you not put on boxes of medicines
how much they cost the NHS?
David Nicholson: Yes, we
have done some research on that, which Felicity might mention.
Dr Harvey: We did some research
fairly recently on that to see whether, if we did put the cost
of the medicine on a box or a bottle, it would actually influence
people. Interestingly—this was from a literature research
plus some focus group work—we found that many patients took
the view that once they had the medicine, whether or not they
had paid for it, it was theirs to do with as they wished. In terms
of the medicine price being on the box specifically, we found
that if the cost of the medicine was very high, some people thought
that they should not take it, because it was too expensive. We
also had some feedback from the groups that indicated that if
the cost was very low, people thought that they should have had
a slightly more expensive drug. So rather than supporting the
view that we had had originally—that putting the medicine
price on the box might be quite helpful—the small piece
of research that we have done so far in fact indicated the opposite.
However, we will obviously be doing some further research on this
in terms of waste.
Q4 Chairman: Well, I will leave it
with you. It seems a fairly obvious suggestion to me. I do not
find the answer that you have given entirely convincing, but everybody
will no doubt have a view on that.
Can I just deal with the doctors, who
are obviously the key part of this? If we look at paragraph 2.8
on page 12, we see that there is a staggering variation in the
costs of medicines. For instance, we see that the proportion of
the lower-cost generic versions of statins prescribed varies from
28% to 86% across primary care trusts. Why does the proportion
of statins vary in that way? That seems such a high proportion.
Professor Colin-Thomé:
I suppose that what has happened is that it is only three years
since statins such as simvastatin and pravastatin went off patent.
Before that time, statins were about equivalently priced. Many
patients were put on some of the more expensive statins because
they were not expensive then, and taking people off them is quite
difficult. Starting people on new prescriptions is quite easy,
and at the moment nearly 90% of new statin prescribing is low
cost. There is no doubt that some PCTs have put more focus on
this than others, and that is why, with the National Institute
for Health and Clinical Excellence (NICE) and the other incentives
that we have introduced, we think that the position will improve.
However, it was only three years ago that the patent went, and
it was only in January 2006 that NICE gave the recommendation
that we should be prescribing the statin with the lowest cost.
Some of it is history, but some of it is because some PCTs have
focused more on that than others. We want to look at outliers
and help them.
Q5 Chairman: Obviously, generic medicines
are much cheaper. We read in case study 6 on page 25, at paragraph
3.40, that there are hospital limits on the freedom of consultants
to prescribe drugs. Yet we know that GPs are allowed to prescribe
any drug they wish. Why is this?
David Nicholson: Partly it
is the different position in hospitals. I am sure you understand.
One of the things about working in hospital is that when you have
a formulary, which many of them do—in fact I think all of
them do now—you have a mechanism for controlling that formulary,
which is the hospital pharmacy. Patients can only get their drugs
from one particular place, and that is the way in which you control
and police a situation like that. In general practice it is quite
different, of course, because patients have the right to go to
any community pharmacy to get their drugs. The ability to control
is much more limited in that event. Plus, of course, GPs are independent
contractors and we operate with them through a contract of service,
whereas we directly employ hospital consultants.
One of the issues for us is that one of
the big drivers for primary care prescribing is secondary care
prescribing. I think there is research in the Report that shows
that every one prescription in hospital can produce 15 in the
community. What is clear—and we need to do this much more—is
that we need to get agreement between secondary and primary care.
A primary care formulary on its own would by its nature be too
extensive and difficult to police, but a primary and secondary
care one would be much better. That is one of the reasons the
National Prescribing Centre recently published their work on area
prescribing committees, to reinforce the secondary and primary
care link. It seems to me that that is the way in which we will
drive costs down and quality up.
Q6 Chairman: What we read in paragraph
2.6 on page 12 is that advice from NICE is often not being followed
by doctors. For instance, "NICE's Technology Appraisal 94,
Statins for the prevention of cardiovascular events, states
that: `when the decision has been made to prescribe a statin,
it is recommended that therapy should usually be initiated with
a drug of low acquisition cost'." Why is that guidance not
being followed adequately by doctors? There is no suggestion,
is there, that patients' lives are being put at risk?
Professor Colin-Thomé:
No, but if you look at new prescriptions—
Q7 Chairman: I know that you have
made the point already about new ones, but surely doctors can
talk patients through this and explain that there is nothing in
the new generic drugs that is in any way inferior to what they
have been getting up to now. But as far as the taxpayer is concerned
they are massively cheaper, are not they?
Professor Colin-Thomé:
But in fact I have spent a long time as a general practitioner,
and it is not as easy, even though I think that we had a good,
trusting relationship, because there is a view that: "I have
been used to these drugs already; why would I need to change?"
When patients are already on drugs, there is quite a lot of evidence
on this; there is a case study in the Report about a PCT where
it took two years to switch only about 1,000 patients. It is easy
with new prescriptions to get NICE guidance in place. That is
what we do very well, but for existing patients it is much tougher,
given patients' views on prescribing.
Going back, in a way, to an earlier question
about cost and charges, worldwide 50%. of people with chronic
diseases do not take their medication as recommended, whether
they pay for the prescription or not. One of the issues is that
often the patients choose not to take them—it is not carelessness—because
they have side effects and so on. The real issue is that getting
concordance with patients on taking drugs is quite a difficult
art, and it is not as easy when they are already on something.
Q8 Chairman: We know from paragraph
3.11 on page 20 that the pharmaceutical industry spends £850
million a year marketing its products to GPs. How do you know,
Mr Nicholson, that that does not influence the decisions of GPs?
David Nicholson: The document
talks about a contest. I do not believe that it is a contest,
because a lot of the information is really valuable and useful.
A lot of really good partnership work is going on in the NHS between
organisations, general practices and the pharmaceutical industry.
That gives good information to patients and practitioners. So,
in that sense, I do not think that it is all bad. There is a lot
of useful information.
Q9 Chairman: But you have got to
be convinced that they are prescribing for the benefit of patients,
and not to add to the profits of the pharmaceutical industry.
David Nicholson: Absolutely,
and it is heavily regulated in the way in which it can advertise
and communicate with general practitioners. However, the real
way in which to do all of this is through GP training, the activities
of the National Prescribing Centre, the variety of bulletins that
we send out and the important work of the prescribing advisers.
Those things make the difference to GP prescribing.
Q10 Chairman: Why not allow pharmacists
to dispense generic medicines, even if a doctor has prescribed
a brand name?
David Nicholson: My understanding
is that that is illegal. It is against the law.
Q11 Chairman: Why do you not allow
them to do it? Why are they not allowed to do it?
Dr Harvey: May I come in
here? In fact, the generic prescribing rate in this country is
83%, which is the highest in Europe.
Q12 Chairman: Yes, but I read in
the Report that the costs of brand variations are still very high.
They are so much more expensive, are they not? I cannot find the
reference right now.
Dr Harvey: They are more
expensive, but—
Chairman: The reference is in paragraph
2.5.
Dr Harvey: Because we have
such a high rate of generic prescribing—
Q13 Chairman: Three quarters of the
cost comes from brand names.
Dr Harvey: Indeed. If a doctor
or any prescriber prescribes generically, the patient will be
given a generic product, if one is available. If a medicine is
new and innovative and still in patent, the patient will get a
medicine of that generic chemical entity. Actually, getting more
general practitioners to prescribe in that manner—the percentage
has increased from 51% in 1994—is a very effective way in
which to ensure that the drug dispensed by the pharmacist is the
most clinically effective and the most cost-effective.
Q14 Chairman: Are you sure that doctors
who can dispense as well are not over-prescribing in rural areas?
Professor Colin-Thomé:
There is no evidence that the average number prescribed by dispensing
doctors differs from the average among GP prescribers. In a few
cases, the more expensive drugs have been prescribed by dispensing
doctors, but that is a very tiny percentage of the total cost,
and even that has been reduced since we made changes to the remuneration.
However, it is not true to say that it is a major cause of over-prescribing—it
is a very tiny percentage.
Q15 Ian Lucas: We have heard that
88% of prescription items are dispensed free of charge. Only 12%
of prescription items are paid for by the public. How much income
does that 12% bring in?
David Nicholson: Just over
£400 million.
Q16 Ian Lucas: Do you know the cost
of administering the system and dealing with the paid prescriptions?
Dr Harvey: I do not have
the costs with me, but I know that it is relatively low in comparison
with the large amount of income that it brings in. Certainly,
we can get that figure for you from the prescription pricing division.[1]
Q17 Ian Lucas: It would be a useful
figure to have, because it would tell us whether it is worth doing.
Dr Harvey: Yes it would.
We looked at it a little while ago, and it is relatively low.
In fact, the cost of administering the whole of the prescription
system is less than £10 million.
Q18 Ian Lucas: Right, so it brings
in a net profit of about £390 million?
Dr Harvey: In fact, some
£425 million should be coming in this year from prescription
medicines and the money that we get back from charges. So that
leaves us with £415 million.
Q19 Ian Lucas: Has any assessment
been made of the impact that charging for prescriptions has on
levels of prescribing?
Dr Harvey: Not specifically.
We will look quite carefully with colleagues at areas in the United
Kingdom that have got rid of prescription charging, such as Wales
as of April, to see what sort of impact it might have. Clearly,
a prescription charge might make people think twice, for example,
about medicines that could be got on prescription as well as over
the counter from a pharmacist. There might be some switching to
prescriptions. We will be keeping an eye on that.
Professor Colin-Thomé:
I suppose that pre-payment is one way of obviating some of the
rest of the impact on people who have to pay. For at least about
5% you can—
Ian Lucas: Get a discount.
Professor Colin-Thomé:
Yes. It is cheaper to have got the season ticket rather than pay
per item each time.
Dr Harvey: In fact, we have
just brought in the ability to have that on a monthly direct debit
as well as a three-month pre-payment certificate—before
it was just four months or a year. We understand that that is
a large amount of money for people to pay out at one time.
1 Note by witness: The figure forecast for
2007-08 is £8,085,000 and covers the total cost of issuing
pre-payment, medical and maternity certificates, low income scheme
charges certificates and tax credit exemption certificates for
England. The latter two also provide help with dental, optical
and travel costs. It does not include the cost of processing prescription
forms by the NHS BSA to reimburse contractors for the provision
of pharmaceutical services. Back
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