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Angus Thompson is an independent prescribing adviser
based in Somerset
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The Broad spectrum feature is
open to any reader. Contributions of around 1,100 words commenting
on topical issues
may be posted to Graeme Smith, managing editor, or
e-mailed to graeme.smith@pharmj.org.uk for consideration
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With the recent criticism
levelled by the Office of Fair Trading at the Pharmaceutical Price Regulation Scheme (PJ, 24 February, p208), it looks likely that attention will once again revisit the mechanisms used to set NHS drug prices. It is to be hoped that any review will have a remit wide enough to embrace the whole picture — not just brands — because the recent overhaul of generic pricing mechanisms leaves a great deal to be desired, especially in respect of category M.
Although the “M” is intended to reflect the link with manufacturers’ prices,
alternatives could be mayhem or, perhaps, even madness or mischief, because
from whatever standpoint taken it is difficult to see who has gained
from its creation. Essentially a mechanism to divert resources from drug
reimbursement to new services in the new community pharmacy contract,
it appears to have created more problems than it has solved.
The Drug Tariff defines category M as: “Drugs which are readily
available, where the Department of Health calculate the reimbursement
price based on information submitted by manufacturers. Endorsement of
pack size is required where more than one pack size is listed. Broken
Bulk may be claimed if necessary.” One does not have to look far
to find examples where category M bears absolutely no relation to real
life trade prices and thus its definition is immediately undermined.
Among
the most startling is the category M price for a pack of 32 paracetamol
tablets, currently £1.90, when the going rate for over-the-counter
pharmacy sale is less than half this and supermarkets sell smaller packs
at prices as low as a penny a tablet. To think that the NHS, which spends
over £10 billion per annum on medicines, is willing to pay almost
six times more than Joe Public for such a widely used medicine beggars
belief.
Category M price setting
The reimbursement prices of category M medicines
are set quarterly in accordance with the following equation: (see PDF 40K) |
Although this may be an extreme example, it amply demonstrates
that the current arrangements need to be challenged. Communications on
this subject
with the Department of Health, via my member of Parliament, recently
introduced me to the formula which the DoH uses to set category M prices:
it is reproduced in the Panel. Now, although I am no great mathematician,
I think it is fair to say that this is complex and the idea that such
a formula justifies the current arrangements is of concern.
While the NHS has benefited from price reductions in generic statins,
calcium antagonists and bisphosphonates, among others, there has been
a rise in the cost of many long-standing traditionally cheap drugs. Phenytoin
is a classic example, with the price of 100mg tablets rising to the dizzy
heights of £62.29. The impact of this is so significant that the
drug now frequently appears in the top 20 drugs by cost for many in general
practices.
However, not only do we have a situation whereby the state pays grossly
excessive amounts for common drugs, but we have an increasing issue with
generic prescribing no longer reliably offering best value for money
for the NHS. The humble tube of hydrocortisone cream 1 per cent illustrates
the point better than anything, with the generic costing the state over £10,
while GlaxoSmithKline’s Efcortelan comes in at a mere 75p.
There are many other examples of this and these extend beyond the realm
of modified release preparations, where this situation has been common
for years. As if the situation was not bad enough already, the fact that
the Drug Tariff frequently includes more than one pack size, with a huge
variation in unit cost, accentuates the issue. Enteric-coated sulfasalazine
is a good example: packs of both 100 and 112 are included in category
M, but a prescription dispensed from the former will cost the NHS around
four times more than one dispensed from the latter, and almost nine times
more than if the brand Salazopyrin EN has been prescribed.
We also have the bizarre situation where inflicting a higher tablet burden
on patients helps reduce NHS expenditure. The doubling of simvastatin
40mg tablets, rather than prescribing 80mg tablets, is a prime example.
Although a regimen of two tablets at night is unlikely to be detrimental
to compliance, it is against what is intuitively logical in terms of
best practice in medicines management.
Prescribing budgets have, with good reason, been milked as a cash cow
for many years, often by switching to less expensive generic equivalents.
As a direct result of the category M arrangements, the boot is on the
other foot and many primary care organisations are recommending switches
to brands — a total reversal of what for many was a mantra of best
practice. For some, such moves are a step they are not willing to contemplate.
Reasons
often cited for not following such recommendations include a view that
it is someone else’s problem, concerns centred on the
patient’s understanding, worries about the longevity of savings
from such changes, reliance on single suppliers and the impracticality
of prescribers adhering to mixed messages about brand and generic prescribing.
For
others, however, the opportunity to make savings that may run into
the millions is too attractive a proposition to pass over and in some
areas prescribing support staff working in general practice are engaged
in making mass switches, both to and from generic medicines, according
to current pricing arrangements. At the same time, dispensing contractors
are increasingly using small pack sizes to maximise their profit margins,
routinely filling prescriptions for 100 tramadol capsules with packs
of 30 and the like.
Although both primary care organisations and contractors are, of course,
permitted to manipulate the arrangements to their own advantage, I
perceive an increasing frustration from those on both sides of the
fence and a
growing recognition that there is something wrong with the current
arrangements.
It is impossible to estimate the amount of time that is being spent
by primary care organisations calculating the potential savings, then
getting
agreement from prescribers and implementing such switches, just as
quantifying the time spent by dispensing contractors to select, label
and package
multiple small packs would be a challenge. Nonetheless, it is clear
to someone who operates within both environments that considered nationally
it must be significant.
If only the DoH could step back from the mayhem it has given birth
to in the form of category M; then prescribers, their advisers and
dispensing
contractors could get on with the job of improving patient care through
effective medicines management, rather than playing a shambolic system
which is little short of a national scandal. |
The
Pharmaceutical Journal