The Pharmaceutical Journal
Vol 273 No 7330 p931-932
18/25 December 2004

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How NHS prescribing was restricted

In this article, Peter Homan, explains how the limited list was introduced by the Government in 1984

Just over twenty years ago, on 8 November 1984, the Government delivered a bombshell: patients would, from 1 April 1985, no longer be allowed an almost unlimited range of medicines on their NHS prescriptions. Prescribing would be restricted to a “limited list”. By doing this, the Government hoped to save £100m a year.

Up to this point it had been possible for GPs to prescribe a wide range of proprietary medicines on an NHS prescription. This included many household names, such as Benylin expectorant, Actifed compound linctus and Senokot granules. Although over-the-counter packs were available, these medicines could not be advertised to the public and dispensing was usually from large “prescription only packs”. The size of pack on which payment would be made was controlled and stated in the Drug Tariff.

But it was not only proprietary products that would be affected by the limited list proposal. It would also be forbidden to prescribe standard British National Formulary medicines such as Gee’s Linctus, Mist Expect and Potassium Bromide and Nux Vomica Mixture.

The restrictions

Several categories of drug were affected. Patients would be restricted to a choice of five antacids, two laxatives, one inhalation, six antitussives, five analgesics (for mild to moderate pain), eight vitamin preparations, one “tonic and bitter” and three benzodiazepines (in the “sedatives and tranquillisers category”), of which none was a proprietary product. There was, however, to be no restrictions in other therapeutic groups. The Secretary of State, Norman Fowler, decided to allow until 31 January 1985 for consultation.

Kenneth Clarke, the health minister at the time, had made it known that he thought pharmacists were under-used and that this measure would give them a greater role in the treatment of minor ailments through counter prescribing. Frank Dobson (the then shadow health minister) told The Pharmaceutical Journal (17 November 1984, p597) that he was critical of the proposal that doctors should lose their right to prescribe brand name drugs altogether in selected areas. He said it was possible that there was a limited number of patients for whom the brand name drug was better than the generic.

Pharmacy responds

Pharmacy’s reactions were mixed. The then President of the Pharmaceutical Society, Hopkin Maddock, condemned the Government’s bureaucratic approach and considered the problems of administering the new system to be “clearly boundless”. However, the Society welcomed the Department of Health’s recognition of the pharmacist’s role in advising patients on the treatment of minor ailments. Alan Smith of the Pharmaceutical Services Negotiating Committee, welcomed the switch to generics but warned that there might be a problem with dead stock in dispensaries.

Peter Dodd of UniChem did not believe that the Government would go ahead in relation to Distalgesic and was worried about wholesalers being left with unsaleable stock. Tim Astill of the National Pharmaceutical Association pointed out what he considered important omissions: senna, folic acid and vitamin B12.

There was, of course, much anger in the pharmaceutical industry. Many of the large drug companies had high profile prescription products, such as Distalgesic (Lilly), Valium and Mogadon (Roche), and Equagesic (Wyeth). The Association of the British Pharmaceutical Industry declared its “ implacable opposition” and said it would “fight tooth and nail”.

Over the following weeks there was much debate. Members of the Society had their say in the letters pages of The Journal and the activities of various pharmaceutical bodies were reported in great detail. The ABPI began a campaign in the medical press against this “stupid and dangerous” proposal. The Guild of Hospital Pharmacists also strongly disagreed with limited list prescribing.

The PSNC raised further issues, which included:

· Would there be compensation for dead stock?
· Could an NHS prescription be treated as a private prescription?
· Who would pay for a disallowed item dispensed in error?

It also expressed concern that the list affected drugs that were considered essential by the World Health Organization. In addition, the limited list would be unfair to people who could not afford disallowed preparations, particularly the elderly.

By mid-January, it had been confirmed that an FP10 could not be dispensed as a private prescription. Only the pharmacist would be responsible for a disallowed item and it would not be acceptable to supply a disallowed item and charge the difference between its price and that of an allowed item. And there was no way round the list. For example, when asked whether a GP could order a medicine by writing the ingredients, such as codeine phosphate 8mg, paracetamol 500mg and caffeine 3mg, for Solpadeine, the answer from the Minister of Health was an emphatic “no”.

In February 1985, The Journal featured the Society’s comments on the provisional limited list. For each therapeutic group the Society discussed the preparations proposed, their suitability and their limitations. It also suggested additions to the list. In discussing the nature of a list, the following appeared: “Any limited list would need to be a black list, ie, it would need to include the names and product licence numbers of all products not approved for prescribing in the NHS.” The Society also proposed a “white list”. This was a list of approved products, under category headings (such as “antacid”) to indicate the groups being limited. Comments on how this would be administered followed.

Two lists

The Society’s proposal for two lists was accepted and, at the beginning of March 1985, the white list and the black list were published in The Journal. The white list was a revised version of the original provisional list. Comment in The Journal was that it was “ better but still bad”. It now contained 20 antacids, 26 laxatives, 35 analgesics, 22 cough and cold remedies, two bitters and tonics, 44 vitamins, and 14 benzodiazepine sedatives and tranquillisers. This time a number of proprietary medicines were included. The black list of disallowed items ran to 24 columns.

Later in March The Journal included a pull-out supplement: “The limited list — a special guide”. The black list now ran to 26 columns. This increased again, to 28 columns, in October, when an updated guide was published. Instructions in October’s guide were: check the white list. If the product is on it dispense the prescription. If not on the white list, check the black list. If the product is not on the black list dispense the prescription.

Impact on patients

How would the patients react? Would there be rioting in the pharmacies? One company thought that difficulties would arise and launched a training session for all chemist counter staff. A video was produced which featured various scenarios of patients, reactions when they found out that they could not have their usual prescribed medicine. They promoted the limited list as a challenge and an opportunity. By sympathetic and informed counselling, not only would patients be reassured but, possibly, more patients would bring their prescriptions to that friendly pharmacy. Product knowledge would be essential and the pharmacist should be ready to spring into action.

Outcome

In the event, 1 April 1985 was an anticlimax. The Journal of 6 April bore the headline “It was quiet: almost too quiet”. The number of prescriptions presented on Monday morning were well down on the immediately preceding weeks. Doctors had been well informed and most had told their patients of the changes. Patients had stock-piled disallowed products.

A further quote from The Journal: “It was possible that the preparatory action of some pharmacists resulted in a smooth April Fool’s Day. Mr E. P. Moffitt had spent time over the past few weeks consulting with local doctors within a small mining community in Northumberland where his pharmacy is situated. The advanced discussions with the doctors had resulted in 120 prescriptions being presented on Monday morning, and they were all written correctly; that in itself was unusual, said Mr Moffitt.”

Something else happened on 1 April 1985 — the prescription charge was raised from £1.60 to £2.00 per item. In fact, the only reported complaint of the day was of a patient in Oxted, Surrey, who was “horrified” at the rise and stormed out of the pharmacy, leaving the prescription behind.

The limited list was responsible for the introduction of “co-” products. For example, Distalgesic tablets were blacklisted but the generic version was allowed. To avoid the prescriber having to write “dextropropoxyphene HCl 32.5mg, paracetamol 325mg”, the formula was shortened to “co-proxamol”. Other abbreviations for products quickly followed, including co-codamol, co-amilofruse and co-danthrusate.

The numbers of prescriptions diminished but there was an upturn in the sales of over-the-counter sales of proprietary medicines, certainly in cough remedies.

Changes in the limited list and correspondence about it continued for many months. Week after week, more items were added to the black list. Any new proprietary medicine (within the limited list categories) was added. Some (eg, Mucodyne) were deleted and others, such as Asilone, were added. Now updates to the two lists are published monthy.