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Who's on guard?

PAC report encroaches on ABPI territory, but it is barking up the wrong tree

The powerful all party Public Accounts Committee (PAC) in parliament has been casting a beady eye over prescribing in primary care and published its report last week. The report is wide ranging and has many possible implications for GPs and pharma companies.

MPs on the committee suggest that the NHS could reap savings of over £200 million a year in GP prescribing by greater use of generic over branded products. They point out that generic prescribing increased from 51 per cent of all GP prescribing in April 1994 to 83 per cent by September 2006. Despite this increase, only 59 per cent of items taken by patients were actually dispensed as generics. One apparent problem is that not all products were available in generic form.

"One in five GPs said that pharma company marketing influenced their prescribing more than the opinions of official advisers"

The report finds stark differences in generic prescriptions for common conditions across PCTs. The prescribing of statins varies between 28 per cent and 86 per cent. It recommends that SHAs should use prescribing indicators more rigorously to hold PCTs to account for prescribing costs. It also recommends a renegotiation of the quality and outcomes framework to give greater incentives for GPs to contain prescribing costs.

This degree of variation in treating common conditions is inexplicable and suggests that there is room for greater efficiencies in primary care. The problem lies in how PCTs can effectively call GPs, as self-employed contractors, to account for prescribing behaviours. The SHA can shout at PCTs as much as it likes, but if the PCT has no effective leverage over GP prescribing, it is hard to see how this will work in practice. The MPs are sanguine about revisiting the quality outworks framework (QAOF), but forget to mention that negotiating with GPs is like herding cats. This recommendation, though fine on paper, is likely to be tough in reality.

The report refers to a survey of GPs undertaken by the National Audit Office, the public spending watchdog. One in five GPs said that pharma company marketing influenced their prescribing more than the opinions of official advisers. This outcome vexed the PAC members, who suggest that the DoH should set a minimal level of gifts or hospitality that can be offered to GPs by companies and that such expenditure must be declared by GPs to the PCT. The PCT should then publish such data.

I am not sure how aware the PAC members are of the recent changes in the ABPI Code of Conduct. In the past two years, the ABPI rules on marketing to doctors have become much tighter. Expensive gifts and overseas junkets are long gone. If the PAC believes for one moment that a free computer mouse or a conference in Coventry is the reason behind GP prescribing behaviour then it is a bit wide of the mark.

What might be behind the GP views is a lack of trust of official advisers. If a significant number of GPs feel that cost containment is the primary agenda of official advisers, then it is hardly surprising that many will look to research-based pharma material to aid their decisions. I have heard many doctors, including GPs, express scepticism over some decisions from NICE, including the use of anti-dementia drugs and the rulings on certain drugs used in cancer. If many doctors fail to trust official advice, then this will not be solved by a DoH cap on an already tight set of rules from the ABPI. The more important issue to address is why there is a lack of trust in the first place.

"The PAC points out that hospital consultants in secondary care can be bound by formularies, whereas GPs, as self employed contractors are less constrained by PCT formularies"

The idea that GPs can be compelled to declare a free mug or mouse to the PCT strikes me as far-fetched. PCTs already carry enormous workloads and, as commissioning changes over the coming years, this will grow. Keeping a register of declared goodies from pharma companies on every GP in a PCT patch is going to take somebody an awful lot of time. What is then going to happen to the data gathered? What action is the PCT supposed to take where a GP accepts more than the DoH minimum? All this is as clear as mud and I doubt that many PCTs will see these tasks as a huge priority. On this point, I suspect that the esteemed members of the PAC are barking up the wrong tree.

The PAC points out that hospital consultants in secondary care can be bound by formularies, whereas GPs, as self employed contractors are less constrained by PCT formularies. The PAC recommends the use of jointly agreed formularies across primary and secondary care. In short, this could amount to the secondary care tail wagging the primary care dog in matters of prescribing. I cannot see GPs accepting this easily. The PAC recommendations challenge GP freedoms and do not seem to fully recognise the pivotal influence of self-employed contractor status. If these changes were to go ahead, I suspect that the DoH would have to end this status and force all GPs to become salaried NHS employees. This would create mayhem in the GP community and be strongly resisted by most.

Finally, the report focuses on unused and wasted medicines, and it is here that real savings could be made. The report claims that this costs the NHS £100m a year and suggests that the DoH should undertake research into unused and wasted products. The PAC may not be aware that there has already been a good deal of research conducted in this area. In the early 1990s, Merk Sharpe and DoHme, in conjunction with the Royal Pharmaceutical Society, compiled an excellent report on why patients did not take their drugs and why they were discarded ineffectively. This report was full of very practical guidance to patients and professionals on how to reduce wastage. Pharma companies would do well to revisit this and other reports and look at what they could do to better inform GPs and patients on the best use of medicines. It is not in the interests of responsible pharma companies to have their products taken in a clinically non-effective manner.

Many companies have healthy and open relationships with patient groups, especially in the treatment of long-term conditions. Information to patients needs to be written in plain English and from a patient perspective. If ever there was an opportunity for effective partnership between pharma and patient groups, this is surely a prime area for action. The committee also recommends that all products prescribed by GPs should have the price displayed so that patients can see the real costs of the drugs and products they use. Given that the great majority of prescriptions are free to patients, it makes sense to raise awareness of their true costs. It might help people think twice about how they use and dispose of items.

When a select committee of the House of Commons publishes a report the government is required to publish a response, this will be from the DoH. Companies would be wise to ensure that senior teams read the PAC report in detail and keep a close eye on the DoH response. Government does not have to accept the PAC recommendations, but does need to indicate its reasons for rejection.

The government has a lot on its plate at the moment and is likely to get into tricky negotiations over GP out-of-hours services to improve access and further reduce waiting times. I doubt that the government will want to make these negotiations tougher by throwing in additional items that might be perceived as further eroding GP freedoms.

Will the DoH want to start doing the job of the ABPI and change the concept of self-regulation in pharma by setting DoH limits on gifts and hospitality to GPs? They might, but it will place greater burdens on an already stretched DoH. The PAC report does not go into much detail about non-doctor prescribing in primary care, but one must assume that any restrictions on GP activity would also apply to the many thousands of non-doctor prescribers. This would, again, have cost implications for PCTs and the DoH. The PAC report has many good ideas that GPs, patient groups and pharma companies could work on together to bring down the costs of inappropriate use and the disposal of prescribed products, and smart companies would do well not to wait for government action. Instead they should do what they can to support and improve the quality of prescribing in primary care.

"Companies would be wise to ensure that senior teams read the PAC report in detail and keep a close eye on the DOH response"

The report points out that pharma spends around £850m a year on marketing products to GPs. That is a vast amount of money and the public and the PAC members can assume this amount of money would not be spent without expecting some return on investment.

In light of this important report, smart companies should look at GP marketing and education programmes over the next year and see what they might offer GPs to help them reduce waste in this area and target PCTs who are at the extreme ends of the spectrum on the cost of products to the NHS. Where public money is involved it is right to question the wide ó and often inexplicable ó variations in GP prescribing behaviour. If the industry and the professionals are not prepared to explore such issues, they must not be surprised if others do.

The Author
Ray Rowden

19th February 2008

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