NHS England’s plan to reduce wasteful and ineffective drug prescriptionsBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3679 (Published 01 August 2017) Cite this as: BMJ 2017;358:j3679
The NHS in England must make around £22bn (€25bn; $29bn) of efficiency savings by 2020. Prescribing costs in primary care, currently around £9.2bn annually, are a key component of the NHS budget in England. Inevitably, the NHS has begun to look at the drugs prescribed by general practitioners to identify areas in which savings could be made, ideally without compromising patient care or worsening health inequalities. This process was initially led by clinical commissioning groups (CCGs), focusing on drugs that are either of limited clinical value or which patients can buy from retailers without a prescription (“over the counter” drugs).1
However, this locally based approach is flawed.2 Firstly, CCGs have no legal power to limit the prescribing of drugs by GPs. As CCG policies on restricting prescriptions are not backed by statutory guidance, the inevitable result will be variation between GPs in the use of the drugs that CCGs are proposing to restrict—thereby leading to “postcode prescribing.”
It also raises legal issues—if there is a complaint about a refusal to issue a prescription it will be the GP who will have to defend any complaint made by the patient, and not the CCG. Each CCG carrying out its own evidence review and public and professional consultation, and developing its own implementation policy, also results in duplication of effort and is a poor use of NHS resources.3
NHS England has now launched its own consultation process to identify areas where “wasteful or ineffective” prescribing can be reduced.4 However, although a national process is better than local processes, NHS England has not stopped CCGs from continuing to roll out their own restrictions on prescribing—even though some of these will inevitably conflict with the guidance produced by NHS England when it completes its consultation process.
In its consultation document, NHS England proposes restrictions on prescribing for a range of drugs. Stopping prescribing in some areas—such as homeopathy and herbal remedies—will not be controversial, but will not save much money either. Some other drugs that NHS England is proposing to restrict, such as liothyronine, have limited evidence for their benefits, but some patients do find them useful, and patients and some clinicians will express resistance to the proposed restrictions on their use.
The two most controversial areas will be around NHS prescriptions for gluten-free foods—for which there was a separate consultation5—and for drugs available over the counter. Gluten-free foods are essential for people with coeliac disease, and although they are now more widely available from retailers than in the past, many patients continue to receive NHS prescriptions and will resist strongly any restrictions.6 Regarding drugs available over the counter—for example, treatments for head lice or hay fever—many patients will be able to pay for these themselves. Some poorer patients will, however, struggle with the costs of buying such drugs.
NHS England is to be congratulated for launching its public consultation and not just leaving decisions about eligibility for NHS treatment to individual CCGs.7 However, it needs to ensure that its recommendations are accepted by CCGs and that the restrictions on prescribing that some CCGs are trying to impose fall into line with national recommendations. NHS England also needs to make the necessary changes to the National General Practice Contract and to the NHS Drugs Tariff, to ensure that any prescribing restrictions it imposes have a firm legal basis. If this is not done, it places GPs in the invidious position of being at clinical and legal risk if they adopt NHS England’s prescribing guidance when this is finally published, at a time when they are already under considerable workload pressure.89
Restrictions on prescribing and the reduced availability of drug treatments on the NHS will have adverse consequences. For example, unintended effects are a risk, such as codeine based analgesics being used in place of simpler analgesics like paracetamol or ibuprofen if the use of the latter is restricted. We also need to ensure that prescribing restrictions do not affect patients with very serious conditions. For example, if restrictions are imposed on NHS prescriptions of laxatives because these are available to buy from retailers, this will affect patients with cancer, in whom constipation is a common and distressing symptom. A further risk is that poorer patients, who are less able to pay for their own drugs, will suffer disproportionately from these restrictions, thereby exacerbating health and social inequalities.10 Ultimately, however, politicians and the public must understand that the financial savings the NHS in England needs to make are so large, they cannot be made without substantial cuts to the provision of publicly funded health services; or without patients making a greater financial contribution to the costs of their own healthcare.1112
Follow Azeem Majeed on Twitter @Azeem_Majeed
Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: I am a GP principal in an NHS general practice in Clapham, London.
Provenance: Commissioned, not peer reviewed.
Acknowledgments: Imperial College London is grateful for support from the NIHR Collaboration for Leadership in Applied Health Research and Care Programme.
Contribution: AM wrote the article and is the guarantor.