The implications for medical practice and National Health Service budgets of introducing new medicines on to
the market were discussed in a session at the British Pharmaceutical Conference on September 11.
Dr Richard Smith (editor, British Medical Journal) was in the chair
The days of whimsical prescribing were over, said Mr JONATHAN SHAPIRO (senior fellow, health services management centre, University of Birmingham). They had been brought to an end by pressures to save costs, to have evidence based decisions, and to reduce variations in prescribing per se. This last point could be described as either a herd mentality or a thought police mentality.
Mr Shapiro said that he had misgivings about a more technocratic future where treatments were only used if there was evidence for them. Such a future had less room for mavericks, and many developments had arisen as a result of experimentation and unlicensed use of medicines.
These pressures would affect the way pharmaceutical companies developed new medicines, tipping the balance away from bringing forward more expensive medicines in new therapeutic areas if there was a higher risk of failing to earn an adequate return for the investment made.
In order for new drugs to be prescribed it was necessary to create a "climate of need". Direct-to-consumer advertising was not permitted, so who else should be influenced? Individual prescribers might not have much flexibility in future. The prescribing lead within a primary care organisation would become a powerful point of influence, but health authorities and regional offices would continue to hold the purse strings.
The National Institute for Clinical Excellence would become even more powerful and the influence of the media and the internet should not be underestimated.
Mr Shapiro felt that the current system for recommending the prescribing of new drugs was untenable, since the NICE was making judgments at the point when a drug was licensed, on the basis of trial data. This was unfair on pharmaceutical companies as there had not been time to build up a good base of data in clinical practice.
He said that the climate for introducing new drugs over the next few years would be tough. The aim for pharmaceutical companies would be to have their drugs creep quietly on to the market in the hope that the NICE would not notice them.
However, he had sympathy for the NICE which, he said, was stuck between the rock of the professions and the hard place of the Government.
The political implications of prescribing were further discussed by Mr BRYAN STATEN (chairman, Warwickshire health authority). Postcode prescribing had put politics at the heart of the whole prescribing issue, he said.
The goal of health authorities was to get the greatest benefit for the greatest number of people from a fixed budget. This brought up the issue of individual needs versus the general good. Health authorities had a requirement to provide acceptable care for all not superlative care for the poor and needy.
Prescribing had grown by 10 per cent a year (13.5 per cent in Warwickshire) in part because modern medicines worked. One example of this was the use of statins in coronary heart disease. Implementing national service framework guidance on their use in full would cost £10m in Warwickshire alone, he estimated. Then there was the introduction of new drugs such as Viagra (sildenafil) which had started a debate about medical versus recreational use of medicines.
Turning to pharmacy, Mr Staten said that he wanted to see pharmacies providing more than just a passive dispensing service on every street corner. He wanted pharmacists intervening when general medical practitioners prescribed drugs of limited value. Around £0.5m worth of these were prescribed in his area a year.
Real partnerships would have to be formed between dispensing pharmacies and their local GP practices not the relationship between the rider and the horse. Proactive pharmacists working to a shared strategy with health authorities and, soon, primary care trusts were needed. Local pharmaceutical committees would need to start representing their members in a more proactive way if this was going to happen, he said.
Patient power was a much used term, but patients did have power, Ms MERCY JEYASINGHAM (chief executive, Afasic) said: they had consumer power at time of greater self-management of health and they had voter power at a time when the National Health Service was a key political issue and an election was approaching.
Ms Jeyasingham was a member of the National Institute for Clinical Excellence's partners council. She said that, in her experience, the NICE did take patients' views into account and it was much less "ivory tower" than she had feared. One example of this was the recent guidance on the use of taxanes in breast cancer. There had been considerable variance in the side effects experienced by patients on different drugs and as a result the NICE had included two different drugs in its final guidelines. She also felt that the decisions being taken by the NICE were more about equity of access than funding, as far as she could see.
Patients turned to many sources for information on health and medicines, Ms Jeyasingham said. The problem they had was assessing the risk or relevance of the information they obtained.
The media were a common source of health information, but they had a tendency to go for "miracle cure" stories or to be strongly for or against an idea. Often articles contradicted each other. Friends and family were another source which people frequently turned to.
People were tending to ask more questions about the non-prescription medicines they took, partly due to the growth in the use of these medicines and the greater accessibility of pharmacists.
Patient organisations offered a lot of information and often worked with pharmaceutical companies on health promotion.