NHS will publish national list of “low value” drugs to curb GPs’ prescribing costsBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1613 (Published 30 March 2017) Cite this as: BMJ 2017;356:j1613
All rapid responses
“NHS will publish national list of "low value" drugs to curb GPs' prescribing costs”.(1) This soft diplomacy is bad news, it will have almost no effect. NHS should have read the BMJ highlighting the French Choosing Wisely initiative.(2)
The French independent drug bulletin Prescrire advises clinicians how to choose treatments wisely, ranking them on a 7 level scale, from “bravo” to “not acceptable” (http://english.prescrire.org/en/115/727/52691/5140/ReportDetails.aspx). Prescrire also published the list of “drugs to avoid”: drugs with adverse effects that outweigh their benefits or drugs that have been superseded by others with a better harm-benefit balance. As regulatory agencies do not act or do delay acting as long as possible,(3) they are now 91 “drugs to avoid”!(http://english.prescrire.org/en/2E7D1F64A7BCA9110350CFD2BA4AF951/Downloa...)
Payers can act. Why has the NHS not chosen to axe funding of “low value" drugs, as in the case of homeopathy?(4) Be sure, I do not want to shame the NHS, as a Frenchman I can’t. On the one hand, homeopathy is reimbursed by the mandatory healthcare scheme, on the other hand, varenicline has been banned from reimbursement by Bertrand, a minister of health, without scientific assessment.(5) As expected, with an effective method, the number of people treated with varenicline fell from 283,000 in 2010 to almost zero. Coincidentally, Bertrand, three times minister of health (total of 4,3 years since 2004), has never increased tobacco taxes despite smoking prevalence plateauing at 34%.
Last, “low value” seems a misleading term: perhaps no value for patients (alternative exists) but possibly a high value for industry.
1 Iacobucci G. NHS will publish national list of "low value" drugs to curb GPs' prescribing costs. BMJ 2017 Mar 30;356:j1613.
2 Toussaint B. Prescrire: France’s Choosing Wisely initiative. BMJ 2015;350:h3325
3 Bolland MJ, Grey A.. Ten years too long: strontium ranelate, cardiac events, and the European Medicines Agency. BMJ. 2016 Sep 30;354:i5109.
4 Iacobucci G. CCG axes funding for homeopathy. BMJ 2016;355:i5448.
5 Braillon A. When will French smokers be concerned by varenicline's benefit-to-risk ratio? Lancet Respir Med 2016;4:e13
Competing interests: No competing interests
Julie Wood’s words (“This is not about cutting essential services or restricting access for patients to services they need—it is about allowing local clinical leaders to make the best and most efficient use of the money . .”) won't cut much ice with coeliac patients, but fit nicely with the current philosophy of getting local teams to make the cuts in services while government absolves itself of any responsibility for the chaos caused by NHS underfunding. Distractions such as ‘low value prescriptions’, along with charges to overseas patients also draw attention away from the massive waste associated with running the NHS as a market, profligate use of management consultants, cost of PFI, etc. It is estimated that 1 in100 of the population have coeliac disease, although many are undiagnosed. Not adhering to strict gluten free diet presdisposes to long term complications such as growth failure in children, osteoporosis, anaemia, micronutrient deficiencies, infertility and lymphoma. A key aspect of management therefore is promoting strict adherence to a gluten free diet. This is not as easy as it sounds, and the withdrawal of gluten free prescriptions will act as a barrier to achieving this goal in some patients (and further costs to the NHS down the line). Following a recent ‘head to head’ in the BMJ (1) a mother of a child with coeliac disease clearly outlined some of the difficulties including the high cost of gluten free food in supermarkets, and the inclusion of gluten as a bulking agent in cheaper brands of some foods such as baked beans (2). The arguments against prescribing related to the bureaucratic process, and the relatively high cost of prescription gluten free products, neither of which should represent insoluble problems to the NHS.
Coeliac UK (https://www.coeliac.org.uk) has pointed out that Simon Stevens has misrepresented the situation with regard to gluten free prescriptions (whether through ignorance or mendacity is unclear). Suggesting that patients could shop for gluten free food in Lidl is misleading when this outlet does not routinely stock such products. Furthermore, budget and convenience stores, which are relied upon by the most vulnerable such as the elderly, and those on low incomes, have virtually no provision. He also misleadingly implied that significant sums are spent by the NHS on biscuits and cakes, while guidance (supported by Coeliac UK) for many years has rejected such spend. His argument that ‘the price of gluten free alternatives has come down substantially’ is not backed up by the evidence. Industry data since 2008 shows that gluten free bread costs about six times as much as its gluten containing equivalents and this has not reduced.
Abandoning gluten free bread by switching to rice and potatoes poses the risk of nutritional deficiencies. Hippocrates is credited with the injunction: “Let food be thy medicine and medicine be thy food.” We should continue to treat those with coeliac disease on the NHS, and stop blaming patients for the problems of a cash starved service.
1. Kurien M, Sleet S, Sanders D, Cave D. BMJ 2017;356:i6810 doi: 10.1136/bmj.i6810
2. Gleed G. Commentary: we’re under financial strain without prescriptions for gluten free food.
Competing interests: No competing interests