Letters

Controlling the NHS drugs budget Recommendations may not help

BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6956.738 (Published 17 September 1994) Cite this as: BMJ 1994;309:738
  1. C M Harris
  1. Prescribing Research Unit, University of Leeds Research School of Medicine, Leeds LS2 9NZ20
  2. St James's University Hospital, Leeds LS9 7TF
  3. National Council for Hospice and Specialist Palliative Care Services London W1A 2AZ.

    EDITOR, — Andrew Herxheimer is unstinting in his praise for the recommendations of the House of Commons health committee but does not say why he thinks that they would control drug costs. All his hopes are pinned on the cost effectiveness of prescribable drugs being established.

    Some of the drugs listed in the British National Formulary are now widely regarded as not efficacious for anything. These may be deemed not cost effective, but they do not make up much of the drugs bill and their deselection would do little to control it. Other drugs are efficacious when used appropriately and would therefore have to be deemed cost effective unless widely overpriced, but they are not cost effective if they are misused or given when a cheaper alternative would serve the purpose equally well.

    Unnecessary costs in prescribing in general practice arise in two main ways. The first is through too much prescribing. This is a complex problem that is far from being fully understood, and it will not be solved simply by focusing on doctors. The second way is through the use of unnecessarily expensive drugs. This may be dealt with either by educating doctors better or by imposing tough budgets - both approaches bring their own difficulties; “whitelists” are largely irrelevant.

    Herxheimer is incorrect is believing that the current selected list is a whitelist - apart from the section relating to benzodiazepines it is a blacklist.

    If the NHS becomes willing to pay for only some of the drugs that meet the three criteria of efficacy, safety, and quality then the introduction of cost effectiveness as a fourth criterion five years after a drug is launched may have its disadvantages. A company that brings in a mediocre “me too” product may be tempted to price it high and advertise it heavily to recoup development costs or make a profit before it is deselected at the five year review. As for a review of all existing products as a basis for deselection, the cost effectiveness of using an exercise needs careful evaluation itself.

    It is possible to welcome many of the health committee's recommendations without believing uncritically that they will bring the NHS drugs bill under control.

    References

    1. 1.

    Combine old “proplist” with BNF

    1. I W Marshall
    1. Prescribing Research Unit, University of Leeds Research School of Medicine, Leeds LS2 9NZ20
    2. St James's University Hospital, Leeds LS9 7TF
    3. National Council for Hospice and Specialist Palliative Care Services London W1A 2AZ.

      EDITOR, — Andrew Herxheimer's editorial on controlling the NHS drugs budget reminds me of the activity and purpose of the Standing Joint committee on the Classification of Proprietary Preparations (the Macgregor committee) from the late 1960s. This was a committee of the then Central and Scottish Health Services Councils. It produced a classification of proprietary medicines (the “proplist”) that embodied both the blacklist and “whitelist” of the present day. The categories into which drugs were placed ranged from acceptable to “no proved efficacy,” with subcategories clearly defined. The category code was listed against each medicine reviewed.

      My impression is that the committee operated as a national drug and therapeutics committee, evaluating the therapeutic usefulness of individual proprietary preparations more critically than the British National Formulary does. Perhaps the ultimate guide for prescribers would be a combination of the old proplist and the current British National Formulary. Choice would not be overtly restricted, but rational selection would be encouraged. Are we going full circle yet again?

      Now, however, many pharmacists and doctors in the health service accept the joint responsibility for evaluating existing and innovative treatments. The work of the Macgregor committee could be achieved much more easily and responsively with present resources. A mechanism is outlined in the NHS Management Executive's report of the advisory group of health technology assessment, which recommended that research coordination centres should help to “assemble registers of published, unpublished, and ongoing studies, to stimulate, co-ordinate and assist those reviewing evidence on the effects of health technologies.” This includes medicines.

      References

      1. 1.
      2. 2.

      Specialised dressings are not available to general practitioners

      1. J Gaffin
      1. Prescribing Research Unit, University of Leeds Research School of Medicine, Leeds LS2 9NZ20
      2. St James's University Hospital, Leeds LS9 7TF
      3. National Council for Hospice and Specialist Palliative Care Services London W1A 2AZ.

        EDITOR, — The report from the House of Commons Select Committee on the NHS Drugs Budget makes some sensible and important recommendations1 but has looked at drugs narrowly, ignoring evidence on dressings presented by the National Council for Hospice and Specialist Palliative Care Services. Many patients with large wounds are now cared for in the community. The dressings they need are available free in hospital, and voluntary hospices buy them for inpatients. A range of large specialised dressings is available for fungating wounds, wounds that will not heal, and wounds resulting from radiotherapy, but they are not available under part IX of the drug tariff, so general practitioners cannot prescribe them and patients at home must pay.

        The move from inpatient care to community care will be effective only if the resources saved are made available to patients cared for at home. It is disappointing that the committee did not take this opportunity of correcting a major anomaly.

        References

        1. 1.
        View Abstract

        Sign in

        Log in through your institution

        Free trial

        Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
        Sign up for a free trial

        Subscribe