Examination of Witntesses (Questions 40-59)
NATIONAL HEALTH
SERVICE & DEPARTMENT
OF HEALTH
11 JUNE 2007
Q40 Dr Pugh: I am sorry to interrupt
you, but I have a few more questions. You have convinced me that
you are doing some of the right things. The NAO Report suggests
that £200 million can be saved. It says that that is for
only 19% of the budget, so if we were to extrapolate from that
figure, we could say that £1 billion could be saved on the
whole budget. Is that fair speculation, or does the Report deal
with an area in which savings can easily be guaranteed, whereas
they could not be guaranteed to the same extent in other areas?
Dr Harvey: Our view is that
we would agree entirely with the NAO's examples for those areas.
Particularly in areas where there are generic as well as brand
drugs, there is a lot of evidence that the effectiveness for patients
of the medicine would not be affected by changing that medicine.
In other areas that make up the other 80% of the drugs budget,
such as diabetes, respiratory medicine and so on, you need to
have a variety of medicines that are equally efficacious. You
also need an evidence base behind that, and you need some of the
medicines that have come off patent.
Q41 Dr Pugh: So £1 billion might
be jumping to conclusions?
Dr Harvey: I do not think
that we have any evidence at the moment that there are many other
drugs that could have equal impact that are about to come off
patent.
David Nicholson: We certainly
need to save the £200 million.
Q42 Dr Pugh: You make some savings.
I turn now to the NAO. The Committee has received criticism of
the methodology for determining efficiency, describing it as:
"overly simplistic, utilising low prescribing as a proxy
for efficient prescribing". That has come from a drugs company.
I understand that low prescribing cost in an area is not necessarily
identified with low need, but has there been a further evaluation,
not simply of prescribing differences between PCTs, but of clinical
outcomes? Has that been taken into account in the overall assessment?
Sir John Bourn: I think that
it has been taken into account. The point that I would make about
the criticisms by the companies, although I can understand why
they felt that they had to make those criticisms, is that, first,
in the analysis that we made and the work that we did, we agreed
the facts that emerged with the Department. So it was not simply
a case of the NAO working this all out on its own.
The second point that I would make is that
what we are advocating in our Report is not reduction in prescribing;
we are advocating thoughtful prescribing, in the way that the
Department seeks. We are not saying, in some kind of thoughtless
cuts way, that doctors should alter their practice, but we are
saying that there is information, as in the Report and as the
Chief Executive said, that would help doctors to carry forward
their work in a properly professional way and, as I put it, in
a more thoughtful way. So I think that the analysis behind our
Report stands up in that sense.
Q43 Dr Pugh: Just on the specific
recommendations of the Report, I think that the Report suggests
for my local PCT that it can save about £3 million on a £50
million budget. From speaking to my PCT, I understand that it
has the largest projected underspend in the North West; it has
already saved £2 million. Is a £5 million saving on
a drugs budget a realistic expectation?
Chris Shapcott: Is the suggestion
that the trust does not need to save the money because it has
enough already?
Q44 Dr Pugh: No, not precisely that.
I suppose you could suggest that research on statins is a relatively
easy hit—the trust itself has suggested that to me—because
everybody has done a lot of work on statins. Squeezing out a few
more savings is a bit more complex.
Chris Shapcott: What we are
saying is that, for certain drugs that we are looking at, some
very substantial savings can be made by changing the prescribing
practice. If you move, say, from a branded statin to a generic
one, you can reduce the cost of the medicine by a factor of 10
at times; the same thing is true of some of the other drugs too.
Clearly, we are making estimates about
the scope for savings; the figures that we give are not definitive,
in the sense that an account might be. However, we think that
that is a reasonable target to aim at, and then perhaps the savings
could be recycled into increasing prescribing in more appropriate
cases, finding other people in unreached populations and so on,
who would benefit from increasing use of these drugs.
Q45 Mr Mitchell: Can I deal with
the NAO Report first, Mr Shapcott? We have had a memorandum from
Sanofi-Aventis & Bristol Myers-Squibb, 2[2]
and it makes several points; I would like to raise some of them
with you. I shall quote from the letter: "Many of the PCTs
that the NAO deem to be inefficient prescribers have successfully
reduced the incidence of heart attacks and strokes through implementation
of effective prescribing policies based on national guidelines.
If they were to be encouraged to reduce their prescribing, this
success could be jeopardised." Is there a correlation between
the level of prescribing and the incidence of heart attacks and
strokes?
Chris Shapcott: Sanofi-Aventis
& Bristol Myers-Squibb has not given us detailed work to support
that.
Q46 Mr Mitchell: Have you looked
at that issue?
Chris Shapcott: That is not
something that we have gone into.
Q47 Mr Mitchell: But you could look
at it?
Chris Shapcott: The advice
that I have had is that getting the information on the outcomes
is quite difficult. We have used the approach that we did because
that was what the data was available to support. We have agreed
with the Department that that was an effective way of working.
Q48 Mr Mitchell: But Sanofi-Aventis
& Bristol Myers-Squibb is making an assertion, rather than
stating a verifiable fact.
Chris Shapcott: Yes, it is.
Q49 Mr Mitchell: Okay. I would like
to make a second point. To quote from the Sanofi-Aventis &
Bristol Myers-Squibb memorandum again: "The Report suggests
that all patients receiving clopidogrel should have their treatment
stopped after 12 months. This is inconsistent with the clinical
trial evidence... Stopping clopidogrel therapy for all patients
at 12 months may jeopardise the safety of patients who require
longer-term treatment." Why did you fix on that provision,
to stop at 12 months? There is another letter from the American
Pharmaceutical Group, 3[3]
which is based in Basingstoke—presumably because Basingstoke
is closer to America. It says: "The NAO Report implies that
the alternative anti-platelet treatment of aspirin can be substituted
for clopidogrel. In fact, aspirin is not a generic equivalent
of the patented medicine clopidogrel (brand name Plavix); the
two are entirely different". So why did you suggest that
it was stopped after12 months and aspirin substituted?
Chris Shapcott: Because we
did not suggest the things that are being attributed to us there.
Q50 Mr Mitchell: Say that again.
Chris Shapcott: We did not
say that you should stop clopidogrel after 12 months in every
case. The guidance from NICE allows for it to continue in appropriate
cases where people are aspirin intolerant, and we allow for that
possibility in the Report.
Q51 Mr Mitchell: Okay. Are those
appropriate cases a small minority or are they a substantial proportion?
Chris Shapcott: The estimates
we have seen are that between 6% and 20% of people with the appropriate
indication will be aspirin intolerant and so you would expect
them to continue, but in other cases it should be stopped after
12 months.
Q52 Mr Mitchell: Returning to the
Department of Health, why should doctors not register gifts, inducements
and things that they get from drug companies? It is all very nice
to get invited to do research on prescription for stress on yachts
in the Mediterranean, but we have to register all our trips and
so why should they not do so?
Dr Harvey: In fact they do.
Q53 Mr Mitchell: There is a register
of what Grimsby doctors are getting from drug companies that I
can consult at the PCT?
Professor Colin-Thomé:
I would need to have some written evidence of this, but above
a certain amount of money, which excludes Post-its and
a few pens, you need to put into the PCT—
Q54 Mr Mitchell: And it is published?
Professor Colin-Thomé:
It is up to the PCT to publish it, but the GPs have to report
that they have—
Q55 Mr Mitchell: Should it not be
published? I would like to go round and compare foreign trips
with Grimsby doctors.
Professor Colin-Thomé:
I think there is a good case for it to be published. I think you
are right. But above a certain minimal level of free gifts of
small things, you have to declare what you have received.
Q56 Mr Mitchell: You talk about small
gifts. I do not know many doctors these days. I used to have a
lot of doctor friends. Some of my best friends were doctors, indeed.
But since they have got so well paid they have gone up a social
class and they do not speak to me much. Should not drug companies
be required to register the gifts they are sending out and their
expenditure on free samples to get people hooked through inducements
of every kind? Are they required to do that?
Dr Harvey: There is an Association
of the British Pharmaceutical Industry (ABPI) Code of Practice
and that was made far more robust in 2006 after the Health Select
Committee had looked at the influence of the pharmaceutical industry.
They are now extraordinarily careful about what they can and cannot
do. As for inducements, hospitality and things like that, whereas
20 or 30 years ago that might have been something that the pharmaceutical
industry would do, there is now a strict code of conduct in terms
of what they are and are not allowed to do. Indeed, that is policed
by the Prescription Medicines Code of Practice Authority. If anybody
says that they think that something has happened that is against
the code of practice, it potentially means that a company could
be excluded from the ABPI. It is fairly serious if they do. It
is also underpinned by European regulations—the Medicines
(Advertising) Regulations 1994.
Q57 Mr Mitchell: Thanks. I stop you
when you say European regulations. Just to pursue the point made
by the Chairman, why should not chemists be allowed to prescribe
generic drugs? For instance, I get the Daily Mail under
plain cover and it is constantly telling me that I should be taking
statins. My wife is very keen that I should take statins. Why
should I have to go to a doctor just because he will get a cut
for prescribing it? Why should I not be able to go round to my
chemist and say, "I want two and a half tonnes of statins."
Dr Harvey: In fact, as part
of the changes to non-medical prescribing, we have been looking
at independent prescribing by non-doctors. Recently we brought
in independent prescribing rights for pharmacists.
Q58 Mr Mitchell: We are still very
snotty about that in this country. I am addicted to melatonin.
It makes me go to sleep in the Chamber downstairs. But in America
I could just go into a supermarket and buy it. Here there is all
sorts of rigmarole.
Dr Harvey: It rather depends
on whether the drug is a prescription-only medicine, a pharmacist-only
medicine or one that you can buy over the counter. It depends
on which classification the market authorisation has as to whether
it can be given only by prescription, although a pharmacist who
has prescribing rights—one who is under contract with the
PCT—can prescribe.
Q59 Mr Mitchell: But folk are getting
it all through the internet, are they not? It is all flooding
in, whatever you say about doctors prescribing; people are getting
it through the internet.
Professor Colin-Thomé:
You can buy statins over the counter. You can get low-dose simvastatin—
2 2 Ev 16 Back
3
3 Ev 13-15 Back
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