The Pharmaceutical Journal
Vol 278 No 7440 p217
24 February 2007

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Letters to the Editor

Statins

Switching is based on evidence

From Dr B. P. Curwain, MRPharmS

I would like to reply to some points made by John Woodward (PJ, 17 February, p188). Of course I am interested in saving money, not so much for the taxpayer, as Mr Woodward suggests, but so that it can be reinvested by the primary care trust into other local health services for which there is a clear need. There is currently a debate over whether the extra investment made by our Government in the NHS is actually resulting in better health care. Thus, measures that increase the efficiency with which all care, including medicines use, is delivered, are both timely and important. I repeat that we have never, and would never, recommend switching medicines if there has been, or was, any decent scientific evidence that it would lead to poorer care. I can reassure him that many of these decisions no longer lie in the hands of PCTs since we now have a set of national indicators, backed and researched by the central NHS, called “Better care better value”. The use of low acquisition cost statins included in this set and PCTs will be assessed on their performance. The National Prescribing Centre is producing a “toolkit” to help PCTs make the change.

Mr Woodward implies that to do anything that is against the wishes of consultant cardiologists (in North Staffordshire) is wrong. He also asks why I do not leave these decisions in the hands of health care professionals. My medicines management colleagues and I are health care professionals and, in this case, the relevant expertise is in the interpretation of the evidence base. Being a specialist physician or surgeon is no guarantee that one has this skill. There is, after all, the first law of expertise which states that for each expert, there is an equal and opposite expert. My own experience is that the views of consultants in, eg, Bournemouth, Southampton and Salisbury hospitals will not always coincide. That is why we rely on expert appraisals of the evidence, written by highly trained and skilled NHS personnel. Our local district prescribing committee, consisting largely of health professionals from four pre-October 2006 PCTs, two major hospitals and the mental health trust, makes such decisions based on the best evidence available.

There is of course a hierarchy of evidence that determines the weight that it is given. At the top of this is a meta-analysis of well-conducted randomised controlled trials. A single letter to The Lancet would carry much less weight. It is also worth remembering that many doctors in secondary care have significant relationships with the pharmaceutical industry, receiving support for research and clinical work, as well as funding to attend international conferences. There is nothing wrong with this as long as it is transparent and all possible conflicts of interest are declared, especially when attending prescribing committee meetings or publishing letters and articles. The industry spends a lot of money supporting opinion-leading clinicians and it would, in my opinion, be naive to imagine that it is done entirely out of altruism.
 
Brian Curwain
Chief Pharmacist
Hampshire PCT (West)

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