I had a dream last night. In it I was trying to persuade a mother that we should change her son’s prescription so that we could issue tablets (which we had established he was able to swallow) rather than the liquid suspension. The issue was that the main reason for wanting to make this switch was for cost. The drug was the same and no harm would come to the child, yet the mother was concerned that a cheaper drug might not be as good for him.
The dream is remarkable in that it is very close to the reality of what I often find myself doing. General Practice has, for many years, taken on responsibility for being cost effective as well as clinically effective. Prescribing has been a key area where we have seen this. As a patient you may notice the brand of drug you are prescribed may change from time to time. An old example would be when we consciously made an effort to change people from prescriptions for Ventolin to prescriptions for salbutamol. For those who don’t know, salbutamol is an inhaler used by people with asthma and other respiratory conditions and Ventolin is a brand of salbutamol. In other words, Ventolin IS salbutamol, and if you look on the packaging of Ventolin inhalers, it will say so. Prescribing salbutamol was cheaper for the NHS than prescribing Ventolin. As far as I am concerned they are the same drug. As far as I am concerned we should stop prescribing the more expensive brand and always go with the cheaper, but equally effective one. This does not stop patient’s complaining that salbutamol doesn’t work as well as Ventolin. There are numerous other examples. Before I continue there is a point worth drawing out here. People frequently make the mistake of thinking that ‘you get what you pay for’ applies to medicines. It does not. Costs of drugs do not vary according to quality, but according to what the manufacturer believes they can charge. A more expensive drug does not necessarily mean a better drug, and vice versa. Please do not make this mistake yourself, and please spread the word about this!
As we all know, the NHS is struggling financially at the moment. We are therefore continually looking for ways to be more efficient so that we can provide the best healthcare possible within the resources we have available. Cost efficient prescribing is one way to do this, and is appealing because changing drugs from one brand to another, or encouraging patients to buy their own paracetamol should not result in any adverse clinical scenarios, yet should save money. This feels like a no-brainer. It nevertheless feels like hard work.
In my experience most patients accept changes to their medication without question. I should point that that we do not change prescriptions without a corresponding letter of explanation. There will always be a few individuals, however, who are unhappy, and a disproportionate amount of time tends to be spent on these few. It seems to me that we have not done a very good job of changing the culture of our society to be more responsible. Instead we seem to have a society which is quick to offload responsibility to others with a backdrop of litigation and blame when things do not go according to people’s wishes. This leaves me with the awkward conversations tying to persuade people that is it ok to change their prescription, rather than one where everyone recognises the need to prescribe appropriately and cost effectively and to do their part. We need to move from a sense of entitlement to one of joint acceptance of the responsibilities. Clinical Commissioning Groups up and down the country are encouraging GPs to encourage patients to take some responsibility and buy what they can from the pharmacy. There is push back from other doctors about how this is being done, and while I recognise that the language and ‘mandate’ need to be correct I do think it is unfortunate that CCGs are being criticised and referred to the Advertising Standards Authority rather than helped to get this right http://www.pulsetoday.co.uk/clinical/prescribing/ccg-reported-to-advertising-watchdog-for-misleading-patients-on-otc-prescribing/20034946.article.
While this level of collective responsibility remains lacking we will continue to get push back from GPs about their willingness or otherwise to have these conversations. Doctors and other health care professionals will say that their responsibility is to the person in front of them, and that cost should not be a consideration. I disagree with this, and would quote General Medical Council duties to them which make it clear that we need to make appropriate use of the resources we have available to us . I was once at a public meeting where we asked if we could provide assurance that doctors would not be making decisions thinking about cost and resources. The response, provided by one of my fellow GPs on our Governing Body, was that of course doctors should be considering financial resources. It would be completely irresponsible to do otherwise.
I have long thought that we should just let all our patients know that they should expect their medications to change from time to time. We should reassure that any change is not expected to result in any detriment to their condition, but make it clear that we all need to collectively accept some responsibility for managing the NHS budget, and for appropriately spending money from the public purse. Every GP is aware, I am sure, that every time they sign a prescription, they are essentially signing a cheque and committing resource. I want to be clear in saying that I don’t think we should stop prescribing appropriately, but that we should continue to prescribe cost effectively, and that our patients and public have a role to play in facilitating this.
Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire, and Clinical Chair of NHS Vale Royal Clinical Commissioning Group.
Follow Jonathan on Twitter @DrJonGriffiths
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