Examination of Witntesses (Questions 20-39)
NATIONAL HEALTH
SERVICE & DEPARTMENT
OF HEALTH
11 JUNE 2007
Q20 Ian Lucas: Turning to doctors
and the cost of drugs for doctors, do they receive the information
themselves on the cost of the drugs?
Professor Colin-Thomé:
Our current IT system, which some 90% of general practices has,
flags up the cost. When someone prescribes, the total cost comes
up on their computer, so we get that feedback. We also get feedback
on prescribing data analysis from something called ePACT.
We get quite a lot of feedback. GPs often compare information
with each other, and peer review is a good way of looking at costs
and effectiveness.
Q21 Ian Lucas: They are allocated
and prescribed in budget? Is that correct?
Professor Colin-Thomé:
Only if people have practice-based commissioning, of which prescribing
is an integral part. As you know, we are just developing that.
It is not fully up and running, but GPs are certainly engaged
and have business plans and so on. That will be a key incentive
for two reasons. First, it brings the budget nearer to where clinicians
are. Secondly, many people work in groups of practices and, as
I have said, all the research evidence is that peer review is
a far more powerful way of getting change than being told by somebody
on high.
Q22 Ian Lucas: There is a financial
incentive for those particular practices. Do they get 30% of the
money saved?
David Nicholson: No, 70%.
Professor Colin-Thomé:
But that is to provide for other services and is only to release
money for other services.
Q23 Ian Lucas: I understand that.
Has that had any impact on prescribing budgets?
Professor Colin-Thomé:
It is too early to say. All we can say is that previous examples,
such as the system in the old fundholding days, which was a similar
model although not quite the same, did have an impact on prescribing.
David Nicholson: We have
run prescribing incentive schemes for some time, which reflect
reducing costs.
Q24 Ian Lucas: So, at the moment,
there is no effective incentive for a general practitioner to
use a cheaper generic drug rather than a more expensive drug?
It makes no difference at all to someone's practice whether they
use one or the other.
Dr Harvey: If there is a
primary care trust incentive scheme for a particular package or
individual switch that it is seeking—for example to increase
the prescribing of generic statins—some PCTs are providing
incentive schemes to practices to do that, which gives some additional
income to the practice for patient care.
Q25 Ian Lucas: So, that would be
an incentive for patient care rather than a direct financial incentive
for doctors?
Dr Harvey: There are also
quality and outcomes framework points in terms of medicines management.
For example, two of the QOF (Quality and Outcomes Framework) measures—six
and 10—are about having meetings with a prescribing adviser
and then taking action. Evidence of at least three actions that
someone is taking forward and implementing leads to QOF points
for the practice.
David Nicholson: I would
not underestimate the issue of peer review. Our experience is
that once faced with the prescribing data of other GPs, most will
move their prescribing practices in line with that.
Professor Colin-Thomé:
The high percentage of generic prescribing that we have achieved
without incentives is proof that there are other ways of working
with GPs rather than simply offering incentives, although incentives
help.
Q26 Ian Lucas: To use a crude analogy,
there seems to be huge resistance to having a menu listing the
prices that the practice actually pays for drugs.
David Nicholson: I do not
think so. The drugs budget will be an integral part of practice-based
commissioning, and 96% of GPs have signed up to do it. We were
with some GPs on Friday who have signed up to do it, and they
have all sorts of plans to enable them to reduce their expenditure
on drugs so that they can reinvest elsewhere in health care. I
think that there is a real opportunity to take this forward.
Q27 Ian Lucas: But the level of the
cost of drugs in the NHS budget has rocketed—the figure
is 60% in real terms over the past decade. Is that explained only
by an ageing population or is a bigger issue involved?
Professor Colin-Thomé:
There is a 55% increase in items, which is to do with an ageing
population, but it has much more to do with conditions being diagnosed
earlier. For instance, the threshold for diagnosing high blood
pressure or diabetes is much lower than it was, so we are actually
treating people earlier, because we know that that will produce
better outcomes. Drivers include the national service framework,
the ageing population and, unfortunately, the general rise in
illnesses such as diabetes because of lifestyle. There are many
drivers.
We want to be cost-effective, but it should
be pointed out that prescribing is one of the most effective therapeutic
interventions that doctors make. Things such as ACE inhibitors
and statins actually increase longevity—they do not just
alleviate symptoms. The much bigger push to increase prescribing
is valid.
Q28 Ian Lucas: So is it a good thing,
therefore, that there has been an increase in prescribing? The
Committee of Public Accounts might see it as a bad thing, from
a narrow point of view.
Professor Colin-Thomé:
Yes, but we need to be specific about whether prescribing is effective.
That is why we have NICE and other systems, but the answer is
that prescribing is a very effective therapeutic intervention.
There is evidence from many places, including my own practice,
that prescribing has resulted in fewer admissions to hospital,
because people get better treatment through primary care.
Q29 Dr Pugh: May I start with a slightly
left-of-field question? According to the NAO Report, although
only 20% of the drugs that are prescribed are patented, branded
drugs, they make up three quarters of the total NHS drugs budget.
I wonder whether you know or could give some kind of feeling for
what that cost might be, or how it might be reduced, if we were
charged in the UK at the European average cost for branded drugs,
as opposed to the UK cost. Has any calculation been done?
Dr Harvey: There has not
been a specific calculation across the piece about what impact
that would have.
Q30 Dr Pugh: Of course, the markets
are different, are they not?
Dr Harvey: They are indeed.
There are various analyses of the prices, some of which indicate
that our prices are towards the top of the bundle of prices for
all European countries.
Q31 Dr Pugh: We are towards the top
of the range.
Dr Harvey: When we had the
last pharmaceutical price regulation scheme negotiation in 2004,
our prices were at the top of the European prices. The 7% price
cut that we negotiated brought them down within the range for
other European countries. We are looking at present to see exactly
where we are in terms of all the European countries, but, as I
have said, there are various ways of calculating that.
Q32 Dr Pugh: Can you give me an assurance
that the UK is not paying top whack for branded medicines?
Dr Harvey: I do not think
that we are paying top whack for branded medicines. This is something
that we keep a close eye on, but we are also keen to ensure that
we have innovative medicines for UK patients to use.
Q33 Dr Pugh: Okay. May I now turn
to the prescribing adviser? I did not know what a prescribing
adviser was before I read the Report, but there are 1,200 of them.
What are they paid?
Dr Harvey: I am afraid that
I do not know.
Q34 Dr Pugh: You do not know, but
I would like to persist with these questions. Clearly, if there
are that many advisers, there is one for every 25 doctors. We
would want them to be very effective, and there are statistics
in the Report that show that doctors think that they are effective.
Have you done any research to find out whether they are actually
effective?
Dr Harvey: There is quite
a lot of evidence about prescribing advisers and the impact that
they have. For example, the Report often highlights their impact
on increasing clinically effective and cost-effective medicine
utilisation at a local level in the PCTs.
Q35 Dr Pugh: The problem is that
there could be disaggregation of other sorts of things that drive
down the price of drugs, such as PCT incentive schemes, peer review
and the general circulation of information. We want to know, as
we want to know of the NAO, what we are paying advisers for, and
how effective they are. Do you have a feel for that?
Dr Harvey: To go back to
your earlier point, prescribing advisers are paid between £40,000
and £50,000 per annum.
Q36 Dr Pugh: So they are costing
us quite a lot. I wonder how much they are saving us. Can we identify
how much they really are saving us, as opposed to all the other
things that might be saving money?
Dr Harvey: There are many examples
of individual PCTs that have invested in prescribing advisers
and of the sorts of savings that they have made as a result of
the work that the prescribing advisers have done within the PCT.
The advisers can save at least £2 for every £1 of salary.
Q37 Dr Pugh: They can? Is there independent
research that says that they definitely save such amounts?
Dr Harvey: Yes.
Q38 Dr Pugh: I am comforted. The
Report also says that 24% say that they visit each GP once a year,
which is not too stretching a demand on them. What do the other
76% do? Do they work without seeing GPs for years on end?
Dr Harvey: I visited a prescribing
adviser last week, to find out how they were working. As they
described the process to me, they look at all the drugs and prescriptions
in the entire area of the PCT, from which they identify particular
issues that they need to take forward, and particular practices
in which they feel there needs to be quite a lot of intervention.
It might be that advisers do not make many regular visits to many
practices on their patch, although they provide benchmarking information,
for example. They might feel that spending more of their time
in face-to-face meetings in a few practices will be beneficial
for achieving the sort of clinical, cost-effective prescribing,
and the improvements in prescribing, that they feel are needed.
I therefore think that it will differ across PCTs, depending on
what the advisers find from their benchmarking information.
Q39 Dr Pugh: Can I ask you about
the medicine use reviews? The NAO Report also says that some academic
research says that many PCTs felt that they were of limited value,
or were unconvinced by their benefits. There are two methods—the
advisers and the reviews—neither of which is guaranteed
to work and neither of which is impressing the people it should
impress.
Dr Harvey: You need to remember
that the number of medicines use reviews, which are advanced services
under the new community pharmacy contract, is now starting to
increase. In January and February of this year, for example, there
were about 60,000 medicine use reviews a month. It is still fairly
early on. The intervention was initially trialled in the medicines
management collaborative; Coventry PCT took it forward and found
that the medicines use review had huge benefits. The review involves
talking to patients about how easy they find it to take their
medicines, and establishing whether there are fairly minor interventions
that the pharmacist can carry forward which will have a major
impact on patients. Patients can be helped to understand why they
are on all their medicines and how to take them, which could mean
talking to them about when to take water tablets so it is convenient
for their lifestyle, for example. There are lots of similar examples
of that sort of intervention. We know that pharmacists have quite
a good relationship with patients, which allows them to act in
that way to increase compliance—
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