Examination of Witntesses (Questions 60-79)
NATIONAL HEALTH
SERVICE & DEPARTMENT
OF HEALTH
11 JUNE 2007
Q60 Mr Mitchell: Can I?
Professor Colin-Thomé:
Yes, so you should go straightaway.
Q61 Mr Mitchell: I will.
At paragraph 3.3, the Report states: "56%.
of respondents to our GP survey said that over half of their consultations
result in a prescription". We are given the impression that
doctors are just doling out prescriptions and drugs in order to
keep people happy and quiet. Has that proportion gone up? What
would that figure have been 40 years ago?
Dr Harvey: I do not know
what it would have been, but David might have more information.
Certainly there has been a change over time—
Q62 Mr Mitchell: But is there a greater
propensity to prescribe—to give the patient something in
order to get rid of them?
Dr Harvey: I think that that
practice is changing.
Professor Colin-Thomé:
I think it is anecdotal. Many of us have done studies over some
years. I was a GP a long time ago, as well as more recently, and
the figure was roughly 50%. What has changed is the number of
drugs taken by people with chronic disease; there are far more
items rather than more patients getting drugs. Now if you have
a type 2 diabetes, you are on several drugs. The items per patient
for those with chronic disease has gone up significantly. That
is where the biggest rise has been. A young child still gets only
about three to four drugs a year, and some of them are things
like Calpol or paracetamol. It is because of the chronicity
of the problem that the number of items has rocketed.
Q63 Mr Mitchell: I get the impression
from the Report that doctors tend to like prescribing advisors
for the primary care trusts. Do you keep any record or a league
table of who are the most effective prescribing advisors and who
are not? If I were a prescribing advisor wanting to get on in
the world, what would I have to do?
David Nicholson: We certainly
do not keep league tables of their performance, although PCTs
do keep league tables of the performance of GP practices in prescribing.
It would be straightforward to deal with. However, there is no
doubt that prescribing advisors who can demonstrate significant
changes in the prescribing activities of GPs get on better in
the system.
Q64 Mr Mitchell: I have a lovely
table from the National Audit Office, for which I am grateful.
It shows that our PCT in North East Lincolnshire, which is excellent,
would save £865,000 if it prescribed at the level of the
most efficient authorities. Are records kept that show any correlation
between the work of prescribing advisors and those potential savings?
Dr Harvey: We certainly do
not use any correlation centrally. All the prescribing advisors
are supported through the National Prescribing Centre, which runs
quite a lot of courses and provides lots of information for all
prescribing advisors. We do not benchmark the individual prescribing
advisors, although we do the trusts.
Q65 Mr Mitchell: The Report indicates
that there will be a lot more prescribing by nurses. What kind
of problems do you anticipate will arise from that? Will it make
the problem worse, or will the nurses be more diligent and better
informed than the doctors?
Dr Harvey: So far, the proportion
of prescriptions in primary care from nurses is only 2%, so it
is very small. In fact, if you look at the sort of things that
they are prescribing, there is nothing at this stage that would
lead us to have any concerns. It is clearly something that we
will need to look at, because every individual prescriber has
a prescribing number, and that means that when the ePACT
data—the electronic prescribing analysis and cost data—is
provided, it can be done for every individual prescriber. PCTs
will therefore be aware at local level of the prescribing patterns
of all their prescribers, including nurses—and, indeed,
pharmacists.
Q66 Mr Mitchell: So it is to be watched.
You cannot impose a discipline such as practice-based commissioning
on them, can you?
Dr Harvey: They will be working
as partners.
Q67 Mr Mitchell: In so far as they
are working in the practice, you can, but in so far as they are
not, you cannot.
Dr Harvey: It depends on
the circumstances in which the nurses are working—whether
they are in community teams, or part of the practice. We would
expect the PCT to keep an eye on the prescribing all of its prescribers.
David Nicholson: What we
do know is that nurses generally keep to guidelines much better
than doctors.
Professor Colin-Thomé:
Can I say also, even though I have a self-interest, that British
doctors are not bad? We have the highest generic prescribing,
as has been said, and we also have some of the lowest drug costs
in western Europe. Even though we could always do better, and
there is variation, British doctors do pretty well on prescribing.
Q68 Chairman: Professor, Mr, Mitchell
was asking about statins, which is a new wonderdrug that doctors
are pushing like sweeties at the moment. Does that worry you?
If there is a tidal wave of fashion—at the moment it is
statins—how do you try to control that, or do you think
that it is not your job?
Professor Colin-Thomé:
The evidence is that if you prescribe statins for people who are
at high risk, you will lessen fatal and other heart attacks. The
guesstimate—it has to be a guesstimate—is that we
could save 3,000 lives a year of people who die of ischemic heart
disease at the moment if they got statins early. Because of a
particular medical condition that I have, I am on a statin and
feel quite comfortable about it. They represent a huge improvement
in the decrease in the mortality rate from heart disease in this
country and abroad, so I have no concerns. There are some rare
and spectacular side-effects, as there are other drugs; but they
happen rarely and, of course, the drug will be immediately stopped.
However, I think that they are an excellent drug to prescribe,
which is why we have said that you can buy low-dose statins over
the counter. Their side-effect profile is tiny, and saving lives
and quite significant morbidity is a great bonus. I do not want
to get too excited, but it is a spectacular advance in therapeutics.
David Nicholson: It is also
a good example of spending more in some areas to get benefits
elsewhere in the system, because the impact on hospital bed-day
usage is impressive.
Q69 Mr Curry: We are fascinated by
our own health, and no doubt, my wife would say that men tend
to more fascinated by their health than women are about theirs.
There is a huge amount of psychology in getting better from something,
is there not? When we are looking at own brands against generic
drugs, or branded against own label, I think that, psychologically,
people think that the branded drug is better. I use two drugs
from time to time. In the hay fever season, I use Ventolin. Nothing
will persuade me that the generic equivalent does the job as well
as Ventolin does. I have tried both, and I am convinced, on the
empirical test with myself, that I breathe easier after Ventolin
rather than the generic.
When I do my back in, gardening, windsurfing
or being too energetic with grandchildren, I go to my toilet bag
where I have a supply of Voltarol bought over the counter in France.
I cannot buy it in the UK. It does the job better than any medicine
that my doctor in the UK is willing to prescribe—although
under pressure, with a gun at his head, he will prescribe Voltarol,
or he will give me an equivalent with the same ingredients. However,
the equivalent does not fix my back in the way that Voltarol does.
Is there not a problem persuading people that the generic drug
is actually as good as the other one? Is there not a real psychological
barrier when facing, as it were, the Kelloggs against the Tesco
own brand?
David Nicholson: I am sure
that David will be able to tell you what turned out from what
you said in terms of proof. However, it only reinforces the point
that we are trying to make, which is that on one level, shifting
from branded drugs to generics sounds a straightforward and simple
thing to do, but it is terribly complex. It goes to the heart
of the relationship between the GP and the patient, and you have
just underlined that well. That is why I think that more than
80% at present is a pretty impressive result for the NHS in this
country.
Professor Colin-Thomé:
It comes back to the point that I made to you, Chairman, about
it sometimes being hard to dissuade patients, despite having a
good relationship. There is no evidence that Voltarol is better
than diclofenac, which is the generic name, and so on. As a doctor
of many years, I know that what is really important and makes
GPs effective is having a good relationship with their patients.
If it was the deal that we struck on, I would prescribe Voltarol
and Ventolin for you, Mr Curry, but the majority of patients are
not so obsessed about those drugs. The relationship with the patient
is what makes general practice effective—in other ways as
well, not just prescribing. There is more to life than simply
prescribing, although it is an important part of our work.
Q70 Mr Curry: What other drugs are
coming off patent soon and might well offer themselves as generic
alternatives, and where are those generic alternatives likely
to have been made?
Dr Harvey: In fact, the ones
that have been highlighted in the NAO Report are the ones that
are around. We are not expecting any other major brands to come
off patent in the next year or so.
Q71 Mr Curry: The reason I ask is
that in my constituency I have the principal plant of Johnson
& Johnson. It does not make that sort of medicine, it makes
bandages and very sophisticated wound dressings. Its concern is
that the more pressure it comes under on the price of its products,
the harder it is to persuade its American parent to maintain investment
in the UK.
What sort of balance do you come to when
you are looking at the prices you pay for drugs and there are
products, presumably often made in the far east, that are good,
even if not at quite the same level of excellence, but are significantly
lower in price? Is your concern a purely financial, cash-flow
one for the NHS, or is there an element of considering the broader
economic issues of having a vigorous pharmaceutical industry in
the UK and the science base and so on that it generates?
David Nicholson: When we
are involved in negotiations on pricing, a key priority is obviously
what it will cost the NHS. I do not think that you would expect
me to say anything else. But we are very interested in the development
of a thriving pharmaceutical industry in this country—one
that attracts overseas investment and is a centre for research
and development. We do take that into account when we are involved
in our negotiations. Settling on a price is a matter of quite
tough negotiation.
Q72 Mr Curry: When a company says
to you that it is faced with what it describes as an arbitrary
demand to cut a price, what type of negotiation takes place? We
have faced that issue.
Dr Harvey: May I give some
context to that? We have a good working relationship with the
pharmaceutical industry and the device industry. A shared goal
between the Government and the pharmaceutical industry is to have
fast uptake of NICE positively appraised drugs. We know that those
are clinically effective, cost-effective, innovative drugs—the
sort that help us to reduce morbidity, hospital days and so on.
That is very much a shared goal. As you say, it is a balance,
and we are conscious of that in the PPRS (Pharmaceutical Price
Regulation Scheme) negotiations and in our work with the pharmaceutical
industry.
Q73 Mr Curry: In all sorts of political
areas, governments effectively model constituencies of one sort
or another. What sort of modelling has been done, if any, on the
right level of prescribing for a PCT, taking into account what
one might describe as its sociology? You cite those in North Yorkshire,
which by and large has a relatively elderly but relatively healthy
population. If you looked at one of the London boroughs, you would
find wholly different sociology and a wholly different structure
of GP surgeries. In my constituency we tend to have big surgeries,
sort of mini-factories, with perhaps a dozen GPs. London is characterised
by—I was going to say poor quality, but rather a handful
of small surgeries without any of that sort of polyvalence that
you get in other places.
David Nicholson: There have
been a number of attempts to do that sort of thing, but it has
proved a holy grail in the sense that every community has its
own unique history, sociology and clinical and service needs.
We have tended not to try to go after that holy grail but to focus
on the benchmarking information that we have had and use it as
an opportunity to examine cost and prescribing habits, rather
than go for a model that we genuinely do not believe is ever attainable.
Professor Colin-Thomé:
There is another issue, which is fact that 70% or so of prescribing
goes into six therapeutic areas, one of which is pain relief and
another mental health. Some of that is about a judgment by the
clinician and the patient about what drugs are used—are
any needed, does the patient need antidepressants, and so on.
It is hugely impossible to model that, because it is about the
clinical interchange between patient and doctor. It is much easier
with some things, such as statins, but I would argue that it is
pretty impossible to have a package for comprehensive modelling.
I am aware of nowhere in the world that has even attempted that
because of its impossibility. NICE does make some assessment,
but it is very much a guesstimate—a guide rather than an
absolute, which would be almost impossible to produce because
of the very nature of how you prescribe for individual patients.
Q74 Mr Curry: We are talking increasingly
of patients dealing with their clinician electronically. Do they
have to come back to the hospital for the second prescription?
Cannot that be done electronically? Presumably that would make
it even harder to make an assessment of what that patient really
needs.
Professor Colin-Thomé:
Yes, but it is up to the doctor to make a judgment about when
a patient needs reviewing. It is the same in the non-electronic
repeat prescribing that we do, but we have reviews to make certain
that the patient is taking the drug, that their blood pressure
is controlled, or whatever the treatment is for. It is a convenient
way of getting drugs that are already acceptable to be prescribed
with the doctor's agreement, but if the doctor, or whichever clinician
is prescribing, thinks there is need for an assessment, that has
got to be done. The responsibility is on the clinician to make
certain that the review takes place.
Q75 Mr Curry: Is there any correlation
between the size of the GP surgery and the pattern of prescription?
A big surgery is likely to have more doctors coming in who are
perhaps younger and more up to date with the latest technologies
and new ideas. A very small surgery might have had the same GP,
who is getting a bit long in the tooth, for the last 30-odd years.
Has any investigation been done into that? Is there an optimal
surgery, with its own pharmacy attached, of course?
David Nicholson: If you look
at the data from the quality and outcomes framework the only big
data that we have, it is more likely that in the bigger, combined
practices you get better scores. There are some small practices
that have great scores, which do really well, but you are more
likely to get a better score in a bigger practice.
Professor Colin-Thomé:
On the other hand, you also have a higher percentage of smaller
practices in socially deprived areas, where it is much more difficult
to prescribe so it is very difficult to separate. Previous work
by people such as Professor Pringle at Nottingham University suggests
that the quality in small practices was not as poor as people
claimed and in fact QOF is helping to narrow the gap between those
areas. We have some evidence that it is already happening.
Patients love small practices because of
the continuity and personal care, which is often stronger than
in some of the more impersonal, big practices. There is a lot
of variation in what quality means, and lots of variables. I do
not have any detailed figures; the biggest issue is social deprivation,
which accounts for a lot of the prescribing differences.
Q76 Mr Dunne: Mr Nicholson, in the
financial year that ended at the end of March, what proportion
of the reduction in deficits would you attribute to increased
efficiency and savings from prescribing?
David Nicholson: I have not
got that figure to hand.
Q77 Mr Dunne: Do you have a sense
of it?
David Nicholson: There is
a figure in my head, but I would have to check it before I said
it. I have a figure.
Q78 Mr Dunne: Could you write and
give us an indication of it?
David Nicholson: Yes. I will
be happy to do so.[4]
Q79 Mr Dunne: The reason I asked
the question is because in the reconfiguration of the primary
care trusts in my area two years ago, it was set out as the holy
grail—the easiest quick win for the management of the PCT
to reduce the deficit in that area. My sense from talking to the
GPs is that it is a great deal more difficult to effect savings
than management at the centre think. Is that your experience at
the centre of the NHS since you have taken over?
David Nicholson: It is always
more difficult than people imagine to make savings in this area
against a background of saying, "We want to improve services,
so there are some things that we want to spend more money on,
not less." Most of the primary care trusts that were in the
turnaround group would have had a prescribing element of savings
attributable to that turnaround. The ones that I have seen certainly
all delivered it, but, to be frank, they were all at the end where
they could have delivered it, because there were significant opportunities
for saving, although I agree with you that it is often overestimated
how easy that is.
4 Note by witness: We believe measure to control
prescribing expenditure has played a significant role in the financial
recovery of the NHS. We have introduced a number of initiatives
to support more efficient prescribing practice-such as performance
indicators published by the NHS Institute on the generic prescribing
of statins, and the negotiation of a price reduction on generic
drugs. The precise impact of these measures is difficult to measure,
but overall we believe there has been a net saving of around £150m.
This is based on a comparison of the provision outturn figures
for drug expenditure and the level of drug expenditure that NHS
bodies believed would be needed at the start of 2006/07. Back
| 
