NHS England’s plan to reduce wasteful and ineffective drug prescriptions
BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3679 (Published 01 August 2017) Cite this as: BMJ 2017;358:j3679
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Professor Majeed correctly points out that restrictions on prescribing and the reduced availability of drug treatments on the NHS as well as stopping prescription of gluten free food products for patients with coeliac disease can be expected to generate unforeseen negative consequences, particularly in vulnerable groups such as children (1). These may well increase health care costs in the longer term. Although CCG cannot enforce prescribing restrictions on GPs, this is likely to change as national guidance is rolled out. He states that the financial savings required from the NHS mean that publicly funded health care must be cut or patients pay more for their own treatment.
In fact this is not a dichotomy as one will inevitably follow the other, at the same time creating inequity related to ability to pay, a fundamental undermining of the basic principles of the NHS. A recent report from a group in Oxford has indicated that as many as 30,000 excess deaths may be related to dismantling of health and social care by this government (2). The unprecedented slowing down of increasing life expectancy has lead Michael Marmot to comment that: “We need to recognise that you can’t keep cutting and cutting and cutting and expect nothing to happen . . . even length of life could get worse if you keep cutting things that improve people’s lives” (3). Surely it is time to end austerity, fund health and social care properly, and get rid of the market in health care, freeing up billions of pounds for treating patients? Is this not what politicians and public really need to understand?
1. Puntis JWL, Tighe M. Should patients with coeliac disease pay for their treatment? Arch Dis Child 2017;102:691-2
2. Hiam L, Dorling D, Harrison D, McKee M. What caused the spike in mortality in England and Wales in January 2015? JRSM 2017;11:131-7
3. Marmot M. What’s going on with life expectancy? Podcast: http://bmj.co/life_expectancy_2017
Competing interests: No competing interests
I thank Jackie Applebee for her comments on my editorial. Dr Applebee is well-known for her support of the NHS and she is correct when she states that that paying higher taxes to increase spending on NHS is another option. But Dr Applebee will also know that the budget for the Department of Health and NHS England is allocated by Parliament, and that there is currently no sign of any increase in NHS spending above what is already planned by the government.[1] Hence, the most likely future scenario for the NHS in England is one in which NHS services are scaled back and people make a greater contribution to the costs of their healthcare. The restrictions that many CCGs are trying to impose on drugs available over the counter and for gluten-free foods are one part of this process, as are the restrictions that CCGs are imposing in other clinical areas such as IVF treatment and elective surgery.[2,3]
References
1. Majeed A. Primary care: a fading jewel in the NHS crown. London J Prim Care (Abingdon)2015;7:89-91. doi:10.1080/17571472.2015.1082343
2. Marsh S. IVF cut back in 13 areas of England to save money, new data shows. The Guardian 6 August 2017. https://www.theguardian.com/society/2017/aug/06/ivf-cut-back-in-13-areas...
3. Iacobucci G. London commissioning group plans to restrict cataract surgery to “exceptional” cases BMJ 2017; 357:j1875
Competing interests: I am a GP principal at a general practice in Clapham, London.
Sir, Prof Majeed states that "politicians and public must understand that the savings that the NHS needs to make are so large, they cannot be made without substantial cuts to provision of publicly funded services; or without patients making a greater contribution to the cost of their health care."
There is a third option which he fails to mention ( though it is possible to interpret his second option as paying more tax but he does not make this clear). We are a rich country with a government who insist on pursuing the discredited policy of austerity. We can afford to pay for a properly, publicly funded and provided NHS, free at the point of delivery and the government should stump up!
Competing interests: No competing interests
I thank Trevor Bhatt for his helpful response. The high cost of generic drugs is an important issue for the NHS. Many generic drugs have increased in cost substantially in recent years.[1] If these increases in cost could be reversed, this would generate substantial savings for the NHS and help the NHS meet its target for efficiency savings.
Reference
1. Pym H. Generic prescription drugs: Are prices excessive? BBC News Online. 3 June 2016. http://www.bbc.co.uk/news/health-36449913
Competing interests: I am a GP principal in an NHS general practice in Clapham, London.
The current high acquisition cost of liothyronine should be tackled via the recently passed Health Service Medical Supplies (Costs) Act 2017 (http://services.parliament.uk/bills/2016-17/healthservicemedicalsupplies... ) - A mechanism with a firm legal basis and not a flawed locally based approach which will be time-consuming for NHS clinicians.
The 2017 act was introduced to:
1. put beyond doubt that the government can require companies to make payments to control the cost of health service medicines
2. enable the government to require companies to reduce the price of an unbranded generic medicine, or to impose other controls on that company’s unbranded medicine, even if the company is in the voluntary scheme (the Pharmaceutical Price Regulation Scheme) for their branded medicines
Competing interests: No competing interests
NHS England’s plan to reduce wasteful and ineffective drug prescriptions: Response to Kathryn Potter
I thank Kathryn Potter for her response. Patients with hypothyroidism who are currently taking liothyronine are understandably very concerned about the proposed restrictions on its future use in the NHS in England. Guidelines from specialist societies do not generally recommend routine use of liothyronine in patients with hypothyroidism but it is possible there are some specific groups of patients in whom it may be helpful. Previous trials of liothyronine need to be reviewed carefully to examine the inclusion and exclusion criteria to determine if these studies were sufficiently well-powered to examine outcomes in these subgroups. NHS England also needs to address the high cost of liothyronine in the UK, as the drug is considerably expensive here than in many other countries.
Competing interests: I am a GP principal in an NHS general practice in Clapham, London.
NHS England’s plan to reduce wasteful and ineffective drug prescriptions: Response to Dr Anne Murphy
I thank Dr Anne Murphy for her comments. I agree that the cost of GPs’ time in implementing prescribing changes is invariably overlooked. This kind of work adds to the administrative load on GPs and is one of the factors contributing to problems with the recruitment and retention of GPs.[1] As Dr Murphy states, there is also a risk of unintended consequences from health policy initiatives and these are often overlooked by policy-makers in the planning phase.
Reference:
1. Majeed A. Shortage of general practitioners in the NHS. BMJ2017;358:j3191. doi:10.1136/bmj.j3191 pmid:28694250
Competing interests: I am a GP principal in an NHS general practice in Clapham, London.
I can understand the NHS having to save money but they really need to think carefully about stopping prescriptions of liothyronine.
This drug is crucial for many of us who have the defective D102 gene and who don't convert T4 in to T3 adequately.
With T4 being the prohormone and T3 the active hormone, five times more active than T4, surely it is the T3 that all our bodies cells need.
Without Liothyronine we are a huge drain on the NHS.
We are given antidepressants, statins (as no T3 makes your cholesterol rise), Veniafaxine for anxiety, Candestartan for hypotension, Betahistene for vertigo, Ramipril for blood pressure...
The list goes on.
All these medicines are needless if we get T3 which would be a vast saving.
There are lots of studies that show a huge link between low T3 and heart disease, why are the NHS not looking at this evidence??
NDT was prescribed very successfully until the 1960s until T4 treatment became the new fashion. I wonder how much heart disease has risen since then?!
If the NHS really wants to stop Liothyronine then NDT should be available. In some form we need T3.
Why doesn't the NHS source cheaper Liothyronine? In Europe it is a fraction of the cost.
Competing interests: No competing interests
Following this excellent article, it was disappointing to read that NHS England has already set out its 'action plan' to 'drive out wasteful and ineffective drug prescriptions, saving NHS over £190 million a year.' https://www.england.nhs.uk/2017/07/medicine-consultation/
Given that we are still in the middle of the consultation programme, announcing that 'helping to trim hundreds of millions from the... drugs bill, will create headroom to reinvest all savings in newer and more effective NHS medicines and treatments' surely risks jumping the gun.
Some medications are considered safe enough for over the counter purchase - of small amounts, for short term use, with restrictions on co-morbidities and age. This does not obviate the need for such drugs to be available on prescription too.
We already have three mechanisms for limiting NHS prescriptions of certain drugs. These are the ACBS list which restricts 'borderline' substances such as sunscreens; SLS status which restricts indications, and the absence of many products from the NHS prescription reimbursal system.
The BNF's clear designation of some products as ‘considered by the Joint Formulary Committee to be less suitable for prescribing' is an additional hurdle. And GP practices in England have regular input from CCG pharmacists, with their spreadsheets, graphs and bar charts regarding how our prescribing costs compare with other practices.
There is an elephant in the room that no-one is mentioning. GP prescribing costs can undoubtedly be tweaked downwards. But the opportunity costs of clinical time spent doing this are massive. And many of the proposed 'unnecessary' drugs are hugely cost-effective in the bigger picture. Cheaply, efficiently and kindly managing people at home reduces the demand on secondary care for referral or admission.
A bottle of simple linctus at the bedside may soothe a cough for only a couple of minutes. But that tiny benefit can protect an exhausted, frail, poverty-stricken patient from a serious fall. In a system as complex as ours, I think even apparently minor service changes need to 'do no harm'.
Competing interests: No competing interests
NHS England’s plan to reduce wasteful and ineffective drug prescriptions: Response to Dr John Puntis
I thank Dr John Puntis for his response to my editorial. I agree with Dr Puntis that the reduced availability of drug treatments on the NHS and stopping prescription of gluten free food products for patients with coeliac disease could exacerbate health inequalities, particularly in children. I also agree that the NHS should look elsewhere for efficiency savings – such as through abolishing the internal market in healthcare and addressing the problems caused by the Private Finance Initiative. Unfortunately, unless there is a dramatic change in the government’s NHS policy, the negative consequences that Dr Puntis fears may well become a reality.
Competing interests: I am a GP principal at a general practice in Clapham, London.