BRITISH BROADCASTING CORPORATION Ìý
RADIO SCIENCE UNITÌý
CASE NOTES 2. - Prescribing DrugsÌý
RADIO 4Ìý
THURSDAY 17/08/04, 2100-2130Ìý
PRESENTER:
MARK PORTERÌý
CONTRIBUTORS:Ìý
BAKUL PATANI
DR CHAAND NAGPUL
JENNIFER RICHTERÌý
JOHN D'ARCY
BARBARA STUTTLE
PRODUCER:
HELEN SHARPÌýÌýÌý
NOT CHECKED AS BROADCAST
PORTER
I'm in the Pill Box - a pharmacy in Walthamstow, East London where pharmacist - Bakul Patani - is busy dispensing prescribed medicines.Ìý
PATANI
Well after checking the name and address is correct we check if the patient is exempt from paying for prescriptions. At the moment the charge is £6.40 per item. There are certain exemption categories, for example, if that person is over 60 years old or a person is under 16 years old, certain medical conditions such as diabetics are exempt if they have a certificate.Ìý
PORTER
Today's programme is all about prescribing. An average British couple can expect to take as many as 28,000 tablets, prescribed by their doctor, throughout their lives. Last year GPs in England alone issued 650 million prescriptions, costing the NHS over £7 billion.Ìý
I'll be finding out what steps the Government is taking to reduce the NHS drugs bill and the impact that cost cutting has on both doctor and patient. I'll also be discovering just how unpopular prescription charges are - not just with the public but with doctors and pharmacists too. And why the current system of who pays and who doesn't is unjust.Ìý
CLIP
It's very unfair that I have to pay because the drugs I take actually save my life and without them I would die.Ìý
PORTER
And I'll be finding out why, in today's NHS, it's not just doctors who are doing the prescribing - nurses are fast stepping into the role.Ìý
CLIP
Patients seem to be amazed we've not been able to do it previously because years ago we used to - certainly in my own practice - I used to diagnose what I thought was with the patient, decide the treatment and then say to the GP this is what's wrong, this is what I'm going to have and he signs it. So I think they were quite surprised that we legally couldn't do that. We also know that they feel that nurses explain why they're having the medication clearer than perhaps some of our medical colleagues. But prescribing is a partnership, it's not about nurses doing doctors' jobs or we want to be doctors, it's about working in partnership to ensure patient gets appropriate care and treatment.Ìý
PORTER
But let's start with the doctor and the pressures that he or she is coming under to trim their prescribing costs. Chaand Nagpul is the senior partner in a group surgery in Stanmore, Middlesex and on the British Medical Association's prescribing sub-committee. Chan does an annual drug budget of £450,000 for medicines to treat the practice's 6,500 patients - a budget carefully monitored by the authorities who oversee his practice - the primary care trust or PCT.Ìý
NAGPUL
Each practice is given a budget and its expenditure is monitored on a monthly basis. So what we receive on a monthly basis is a statement showing how much we've spent each month and whether we're actually spending in keeping with our final budget target or whether we're heading for an overspend or an underspend. Now there are no such things as underspends in reality because for all the GP practices in our patch, like I suspect nationally, the prescribing demands on GPs because of newer drug technologies, improved levels of patient care within GPs' surgeries, we are all finding that the budget we've been given is inadequate for the needs of our patients.Ìý
PORTER
What happens to you if you go over that budget then?Ìý
NAGPUL
There is pressure, there is pressure because the going over the individual practice budget collectively means for the primary care trust an overspend. Now a government does not allow primary care trusts to incur an overspend, so it's their legal obligation to balance the books. And one of the biggest difficulties for our primary care trust and many others nationally is that they are overspent and they have identified that the prescribing budget of GPs is one of the main areas that is causing this overspend.Ìý
PORTER
Jennifer is on a repeat prescription for her migraines but it's one of the latest migraine treatments and at nearly £5 a tablet her GP is keeping a close eye on the amount that she's using.Ìý
JENNIFER
Well the last time I went to see the GP about getting a prescription renewal she asked me how many headaches per month I have and I do tend to regularly get these once or twice a month, there are months that are more stressful or have more migraine triggers, for instance, and then I might have maybe four headaches. Usually a pill will be sufficient to get me through an episode, however, sometimes two pills are required. In the US I would receive a prescription of nine pills, which was usually good for three to five months. In the UK I had received a prescription for 12 pills which was good for about six months on average, however, she reduced my prescription to six pills because, as she said, she wanted to monitor how many headaches I got because if I got more than a certain number then she wanted to examine less expensive methods of treatment. The idea of changing my drug regime troubles me because I have never had any other course of treatment that has actually worked, and I've tried several other drug therapies and none of them have had the kind of results that this has. The idea of having to lose my failsafe method of treatment is very disturbing.Ìý
PORTER
How do the patients take to receiving a letter from you saying that their medicine's been changed - I mean do a lot of your patients think that you're doing it purely on cost purposes, that you're giving them a cheaper less effective pill?Ìý
NAGPUL
There's no doubt that we and every practice that I know of have received several complaints or feedback from patients who have at times been suspicious of the reasons for changing drugs to cheap alternatives. Some believe the newer drug, even though it may be identical in terms of its drug content, believe they don't work as well. So there are all sorts of problems. Many actually suspect that the drug is an inferior drug and these suspicions aren't helped because the public, by and large, don't trust governments, they don't trust politicians and they see many of these changes are being political decisions. So it doesn't help us as GPs to have patients coming back to us, sometimes making an appointment specifically for that purpose, it's a wasted appointment for us, and also having a sense of sometimes mistrust. When in fact we as GP - as a GP practice are following the guidance of our local NHS.Ìý
PORTER
If you have difficulty persuading somebody that the change is only going to save money, it's not going to have any other effect on them, what happens if they insist on taking their old medicine?Ìý
NAGPUL
Ultimately, as a GP, I'm responsible to the patients I treat and provided the request is reasonable, provided I feel that it's in the patient's interest to continue taking a drug, which I may feel they may not take otherwise, I am duty bound to treat them and if a patient tells me that they feel that this new drug they can't swallow as easy because it's powdery, for example - I've had that sort of complaint - I will have to give them what they're going to accept.Ìý
PORTER
And it's not just the drugs that have come under scrutiny - the amount you are given and the way you order and pick up prescriptions are likely to change too.Ìý
NAGPUL
Another initiative in our primary care trust has been prescribing drugs for 28 days, rather than for longer periods, and this has created much disquiet. Now the reasons for this the PCT advise us is because it saves a lot of money due to less wastage of drugs when drugs are changed by having 28 day supplies in people's houses you don't waste a whole amount of drugs if they have a change of treatment. The difficulty for many patients is they're having to come to see us twice as often to request their drugs twice as frequently.Ìý
PORTER
I saw a poster in your waiting room that said that in the last year something like half a million pounds had been wasted in [indistinct word] on prescription drugs ...Ìý
NAGPUL
Yes.Ìý
PORTER
And that's presumably what you're trying to stop.Ìý
NAGPUL
That's precisely what the PCT feels is that by giving 28 days supplies of drugs there's less scope for wastage and in particular when drugs are changed.Ìý
PORTER
But it's a waste of your time, isn't it, having someone come back who's on high blood pressure medicine, they've been on it for three years, they're stable, they're coming back into see you every month, or at the very least they're having to request a repeat prescription and some of them will be having to pay for that prescription every month as well.Ìý
NAGPUL
The PCT's policy is to exclude paying patients, so it only applies to patients over the age of 60 who get free prescriptions and those who are exempt from payment. Having said that it's still inconveniences patients on the basis of age or in fact whether they pay for their prescriptions or not. And what has not been costed is the increased time for my staff and for myself in processing twice as many prescriptions. The PCT is looking to ease this burden by developing a repeat dispensing system in pharmacies, so although the patient will continue to get 28 days supplies they will be able to do so without coming to their GP practice but just go to the pharmacist to collect their prescriptions on a monthly basis without the GP being involved, except for the GP agreeing say a six or 12 month schedule of monthly prescriptions. So this repeat dispensing scheme, which has the support of government, it's a government policy now, is something that we're looking to pilot locally.Ìý
PORTER
Well Bakul Patani from the Pill Box is one of the pharmacists that could become involved in that form of dispensing. Patani, how does it work for you?Ìý
PATANI
I actually would prefer this way of dispensing. A, it offers the patient easy access to the repeat medication they require, which cuts out one of the journeys to put in for a repeat prescription at the GP. It offers the patient the choice to come in and see a professional once a month, whereas if a repeat prescription is for two or three months they would not see a health profession for two or three months at a time. Whereas when they come in to see us we can offer them advice on any medication problem, compliance problems and generally synchronising the prescription so they just have to come in once a month.Ìý
PORTER
Now you're pretty busy often in the back of pharmacy dispensing, do you get time to come to the front and talk to people if they have inquiries about their medicines?Ìý
PATANI
I think that is the major role of the pharmacist, medicines being our forte we should be able to talk to pharmacists and any pharmacist who's not able to come to has to change their routine to make that possible.Ìý
PORTER
Do you envisage that it'll be a popular change with patients because it's saving them leg work basically isn't it?Ìý
PATANI
Definitely. I think it'll be popular with the GPs, the pharmacists and the patients - it's a win/win situation for everybody.Ìý
PORTER
What about the financial implications for the pharmacist?Ìý
PATANI
This is what we're waiting to hear with the new pharmacy contract to come through. We're hoping that the Government recognises the role the pharmacists play in looking after the patients once they've been to the GP and recognise us as part of the healthcare team.Ìý
PORTER
So Bakul how is it actually going to work? The GP will give you a prescription for how long?Ìý
PATANI
Once the GP has seen a patient and he will decide whether the review period is six months, 12 months, three months and he will issue a prescription accordingly. And the patient would bring that prescription, we will dispense it every month.Ìý
PORTER
So they'll only get a month's medicines at a time. Will you get a dispensing fee each time you dispense, so it doesn't matter that you've got one prescription that lasts 12 months?Ìý
PATANI
That's correct. At the moment when we get a three month prescription we get one charge, one fee, whether it's one month, three month, whether the item's worth 30p or a thousand pounds we get one fee.Ìý
PORTER
This is presumably going to affect a significant number of your customers?Ìý
PATANI
Yes 80% of the prescriptions are repeat prescriptions issued by a doctor's.Ìý
PORTER
So these are people with chronic long term conditions, often on medicines for many years but presumably it's not going to be popular with people who are paying for their prescription charges because instead of perhaps getting three months of medicine at a time they're now having to pay to get it every month.Ìý
PATANI
I can well appreciate that I wouldn't like to pay my prescription charge every month if I could avoid it but I would say it affects a very few percentage of people, in my pharmacy probably less than 1 or 2%.Ìý
PORTER
But to work at peak efficiency and to avoid duplication patients really need to be dealing with just one pharmacy and at the moment because of concerns about vested commercial interest doctors are not supposed to recommend a particular pharmacy and patients are encouraged to exercise their right to choose where they go to fill their prescriptions. So how will the system work? John D'Arcy is chief executive of the National Pharmaceutical Association, NPA, representing pharmacists across the UK.Ìý
D'ARCY
You're right that there is freedom of choice of where patients go to a pharmacy. I think to be honest that's a strength really because one of the key issues at the moment is about giving patients access and giving patients choice. However, although patients do have a free choice and clearly they will, in some cases, exercise that, most patients tend to return to the same pharmacy. And I think the kind of newer roles we're describing, where there's a greater interaction between patients and pharmacists and a greater interaction between pharmacists and GPs, we'll see, particularly long term therapy type patients, using the same pharmacy and going back to the same pharmacy because they'll get continuity and they'll get understanding and they'll build up a relationship. So there'll be greater team working between pharmacists and GPs and greater interaction between the GPs and the pharmacists and the patients. So it'll be all part of a greater integration of pharmacy into the primary care team.Ìý
PATANI
One of the main benefits the PCT would get is a saving of their drugs budget, anecdotally it's been shown that a PCT can save a month's worth of prescribing budget, in the case of Waltham Forest that's something like £2 million a year, that is a huge saving which the PCT can use the money.Ìý
PORTER
And why is that saving being made, is it simply because less drugs are being dispensed or less drugs are being wasted?Ìý
PATANI
Less drugs are being wasted. I mean you want to see some of the returns we get when a prescription for three or four months has been prescribed and a patient has been hoarding medicine.Ìý
PORTER
But why are they hoarding medicines, I mean what's actually happening, presumably a doctor prescribes something and then changes his mind two weeks into the treatment course or the patient has a side effect or something?Ìý
PATANI
It's the cycle that goes on is when a repeat prescription is issued sometimes everything is issued in one go whereas everything is not required, especially when it's when necessary or when required medication. And sometimes due to drug changes, hospitalisation - where the whole regimen of drugs is completely changed - and drugs are returned because they are no longer used.Ìý
PORTER
So under the current system somebody might be prescribed three months worth of perhaps five different types of medicines, something may happen to them - their condition may change - and the doctor three or four weeks later may decide to scrap the whole lot, so there's two and a half months of five medicines at home there can we not reuse those?Ìý
PATANI
There is no way we can reuse those, those are dumped.Ìý
PORTER
And what should patients do with those?Ìý
PATANI
Patients should bring them back to the nearest pharmacy, each pharmacy has a dupe service, which is used to get rid of unwanted medication.Ìý
PORTER
You're listening to Case Notes, I'm Dr Mark Porter and we're talking about prescribing in the NHS.Ìý
Nurses have been able to prescribe for over 10 years now but the list of permitted products really isn't that exciting and has done little to expand the role of the nurse. But all that's set to change. Barbara Stuttle is chair of the Association for Nurse Prescribing.Ìý
STUTTLE
We can prescribe some vaccinations and we can prescribe things for gastric reflux but to take it a step further then we're unable to proceed with that. The thing that concerns more so is that in relation to first contact care or emergency care nurses would know if a patient is in a diabetic coma or an asthma attack and yet would be unable to prescribe insulin or an inhaler and that just seems so frustrating when nurses have the skills to do that.Ìý
PORTER
And what changes are in the pipeline to correct that because it seems to make sense that if for instance a nurse with a special interest in asthma if she comes across someone who is in the middle of an asthma attack should be allowed to prescribe and dispense suitable medication?Ìý
STUTTLE
Well they can prescribe for the emergency but what they couldn't do is prescribe for ongoing care, it would have to be referred back to an independent prescriber to agree the clinical management plan.Ìý
PORTER
Which is the doctor basically.Ìý
STUTTLE
Yes it is. And their argument is that when you have people in an attack is the time that they are prepared to listen to that advice and information that a nurse prescriber could give and I just think it's a missed opportunity to continue that follow on treatment at that time.Ìý
PORTER
Are changes in the pipeline?Ìý
STUTTLE
Yes they are. We currently have a consultation, I mean it's just about to close, around extending the [indistinct word] to another 30 conditions and 60 prescription only medicines. Again from the Association point of view we don't consider that goes far enough, it's still - oh you know you've shown that you can do this so we're going to extend it a little bit more. We know that nurses are undertaking much more education and training to support their practice and their diagnostic and clinical judgement skills and yet they're being hampered having the appropriate tools to do the job completely. And in our response we have said it's time we had - that nurses were able to prescribe to their competency, which is the Nursing Midwifery Council code of conduct, to enable them to prescribe to that competency and the condition the patient has which they would be expert in.Ìý
PORTER
One of the big problems historically has always been that the nurse might form a diagnostic opinion about a patient, suggest some treatment, maybe even provide that treatment, but ultimately, in many situations, particularly in general practice, the responsibility fell to the doctor who was on duty at that time - is that still the case, if a nurse was to make a mistake either in diagnosis or in prescription would he or she take full responsibility for that or would it still fall on to the doctor who happened to be in the building?Ìý
STUTTLE
No that's one of - I think - one of the most brilliant things about this is the nurse is fully accountable for the whole prescribing procedure, from diagnosis, providing it's in the regulations in the limitations that we can prescribe, what they prescribe and why they've prescribed it. And even in a supplementary prescribing context the independent prescriber or the doctor is responsible for making the diagnosis but the nurse would be accountable and responsible for why and what they have prescribed in reading that management plan. This is really about making sure that all of the professions own what they do and I think that's better for the patient and it's better for the professions. We have pharmacists coming online to do this as well, they are also supplement prescribing and there's about a hundred across the country that are now registered to prescribe. Next year it'll be physiotherapists, radiographers, optometrists and podiatrists and chiropodists. So it is growing, it isn't about who can do what, it's about how do we actually improve the care to patients by the appropriate person with those skills.Ìý
PORTER
Now prescription charges - currently £6.40 in England and Scotland, the levy is being phased out in Wales. And they swell the Exchequer's coffers by around £550 million a year, not surprisingly they're unpopular.Ìý
D'ARCY
The actual cost of medicines - prescription charges - is of course a political decision and it's one that we actually - we would like to see patients not having to pay prescription charges.Ìý
PORTER
Is that the NPA's - is that the National Pharmaceutical Association's official position that they shouldn't be there in the first place?Ìý
D'ARCY
That is our position. We believe that if healthcare is to be free at the point of delivery then you shouldn't put a barrier in the way of that by having prescription charges. And further, the prescription charge system at the moment is pretty arbitrary - you're exempt in some conditions not other conditions. So at times it does act as a barrier to treatment.Ìý
PORTER
Because the prescription charge has been dropped in Wales - or been lowered in Wales - and is I gather being waived next year probably, have your members from Wales noticed any difference?Ìý
D'ARCY
Still too early to say, as you say it's being phased out over a period of time, I think it's too early to call whether there will be a difference. But I mean I think one of the areas where they will see a difference is, it doesn't happen all the time, but from time to time you'll get a patient that might have three prescription items on a prescription and they'll say to the pharmacist I can only afford one or maybe two, which ones do you think I should knock off, which, to be honest, puts pharmacists in an impossible position because if treatment is prescribed then it is felt to be necessary for that patient.Ìý
PORTER
A situation Katherine is all too familiar with.Ìý
KATHERINE
I was born with asthma, it's actually acute, chronic brittle asthma. I've been in and out of hospital most of my life in the intensive care. When I become ill I can stop breathing very quickly within minutes. Sometimes there's warning, sometimes there's no warning at all. So I have adrenaline injection to help with that and oxygen and I've got a nebuliser at home. I'm also on permanent steroids - oral tablets. So it helps keep it at bay but it isn't overly controlled because it's brittle. So my symptoms basically when I do have an asthma attack it can go from being like I am always - which is pretty wheezy - to almost not breathing at all and intensive care and emergency hospital treatment. So the quality of life and life itself is dependent on my drugs and I think it's very unfair that I have to pay for them and definitely quite frightening when sometimes we haven't got the money and we have to risk it or have to choose which ones I can afford and which I can't, which is not fair really. If the doctor thinks I need them all to choose one is a bit ridiculous.Ìý
PORTER
Back in Stanmore Dr Chaand Nagpul isn't happy about prescription charges either.Ìý
NAGPUL
We're advised nationally about 75% of prescriptions are exempt from payment - that's not the number of people. It can vary from area to area. I suspect in my practice probably less than half, probably about a quarter or a third of patients may not pay for their prescriptions. In other areas, inner city areas, deprived areas, it could be higher.Ìý
PORTER
Does it make any difference to you whether a patient is paying for the drugs that you're prescribing or not?Ìý
NAGPUL
It does make a difference, there's evidence that patients do not collect their prescriptions on the grounds of cost, many don't come back to us for repeats on the grounds of cost, some patients with asthma don't get refills of their inhalers. And I think the system is absolutely unfair, I'm amazed that the Government has not changed it to a fairer system. It's a point that has been made by GPs repeatedly, it's completely unfair that a patient who has asthma, for example, who is dependent upon their inhalers to prevent them getting into hospital with uncontrolled asthma should have to pay for their inhalers on a monthly basis, sometimes incurring a cost of up to £20 when you add in all their prescriptions whilst another patient who happens to have a low thyroid level can get all their prescriptions for free, not just for their condition of having a low thyroid but for any prescription. And the system is totally unfair, in fact it penalises a lot of our illest patients.Ìý
PORTER
The BMA have been lobbying for years yet we've not seen a change, what do you think it's going to take to push it through?Ìý
NAGPUL
I think the public should be made aware of how unfair and unequal this system is, I think many simply do not understand that there is a system of prescription charge exemption but that it's unfair. Once the public begin to understand, if we can allow the population of this country to appreciate how unfair it is.Ìý
PORTER
But it's already highly unpopular with them isn't it, I mean if you stop most people in the street they really don't like prescription charges, the public, either, so it's public and the profession.Ìý
NAGPUL
Absolutely, the public don't like it but what they won't like even more is that there are large numbers of ill people who are being penalised by this whilst others, for no logical reason, are not having to pay for their prescriptions. And it's that unfairness, if it was fair for everyone it could be acceptable but it's unfair because it penalises some people and it actually benefits others. And I think if they could understand that we have a chance of changing the system. I think the Government's worry is that it may cost them more but this is a government that has pledged what they say is unprecedented amounts of new money into the NHS, well I think a small portion of that new money should go the way of patients who are chronically ill and are having to pay a monthly tax on their illness.Ìý
PORTER
So you see the ideal solution as being?Ìý
NAGPUL
I have no problems with a person like myself, fortunately without a chronic illness, having to pay a prescription charge should I need a drug. However, a patient who has chronic asthma, chronic lung disease, who has heart disease, who is dependent on medication to keep their illness treated should receive recompense or really not pay for their prescription charges in order to maximise the chances of them taking their drug and receiving the treatment they need.Ìý
PORTER
Ninety seven per cent of GPs surveyed recently by Doctor magazine said they wanted to see prescription charges changed with the favoured option being to retain some form of charge but to exempt all medicines for chronic illnesses like asthma, high blood pressure and heart disease.Ìý
The Department of Health aren't keen to alter the status quo, we invited them on to the programme they responded with a written statement:Ìý
STATEMENT
Our policy is to use the finite resources of the NHS to give priority to helping people who may have difficulty in paying charges, rather than extending the exemption arrangements. Eighty six per cent of all NHS prescription items are dispensed free of charge. Many people on a low income automatically get free prescriptions, for example, those getting income support, as well as all those under 16 or under 19 in full-time education, pregnant or over 60. Other people on a low income may be entitled to help from the National Health Service low income scheme, more information about the scheme and appropriate forms can be obtained from our help line.Ìý
Well we've heard about the cost cutting steps the NHS are taking to try and reduce the ever growing NHS drugs bill but what can patients do to save themselves money. Bakul?Ìý
PATANI
One, make sure first of all that if they are exempt they're claiming the exemption. Secondly, there is a thing such as a pre-payment certificate, it's like a go-as-you-please pass.Ìý
PORTER
A season ticket.Ìý
PATANI
A season ticket - a four month season ticket would cost £33.40. So if you have more than five items in a four month period this would work out cheaper. There is a 12 month version available at £91.80 and if you have more than 14 items a year, which most people on a chronic condition would, this would obviously work out a lot cheaper.Ìý
PORTER
And can people buy these from the pharmacist?Ìý
PATANI
There are some pharmacists registered but you can get it by ringing the hotline number or by going to your local post office.Ìý
PORTER
That number, along with other useful contacts, will be on our help line - 0800 044 044 and on our website bbc.co.uk/radio4 where you can also listen to the programme again.Ìý
Next week's programme looks at autoimmune diseases, like rheumatoid arthritis, lupus and ankylosing spondylitis, including an update on some of the latest treatments.
ENDS
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