Medicines optimisation schemes are dragging prescribing ethics into the gutter and GPs should play no part in them, says Dr Patrick James McNally
Under our CCG’s ‘Medicine Optimisation Benefit Share Scheme’, practices are being asked to deliver prescribing cost savings. If we sign up, there’s a small pot of cash to start the process. Then, if we deliver sufficient savings, the CCG keeps half, and the other half comes directly to the practice. Undoubtedly an attractive proposition.
But – where does this money come from? A big chunk of the savings is to be made, somewhat counterintuitively, by switching our patients from generic to branded prescribing. Take the CCG’s example: ‘Co-codamol Tabs 30/500mg to Zapain 30/500mg’. Zapain undercuts the generic price by a whole £0.40 per 100 tablets; it turns out whenever we prescribe Co-codamol, our pharmacy colleagues have been dispensing Zapain, billing for Co-codamol, and pocketing the difference – the cheeky rascals! By prescribing Zapain, they can only bill for Zapain, and the CCG gets to keep the £0.40. At scale, this might save £1,000 per practice, or more.
Sounds ideal – until you appreciate that the Byzantine funding structures of community pharmacies are even more perverse than those for general practice. Just as we have Carr-Hill, Global Sum, QoF and any number of LES/DES/LISs, they have Advanced Services, Quality Payments, Drug Tariff and the ‘Retained Margin’. That £0.40 is the ‘element of purchase profit’ allowed for in pharmacies’ contracts with the Department of Health (DH), and at scale, it makes up more than a quarter of their total funding.
How would the average practice cope, if CCGs asked pharmacists to sabotage QoF, and offered them 50% of the savings?
Prescribing by brand to undercut the generic price is a case of ‘robbing Peter to pay Paul’ – funds that the DH intended for pharmacies, being retained within the CCG budget. GPs should play no part in this.
Where branded medication undercuts the generic or tariff price, the solution is for the tariff to adjust, or for pharmacies to be reimbursed according to their actual costs. Asking doctors to prescribe the brand is failing to understand the problem. Incentivising them to do so is perpetuating it.
A metaphor might be helpful here. Consider the guttering in my terraced street. The lowest point in the guttering is at my point in the terrace, so when it overflows, it pours all over my back garden. Using CCG medicines optimisation logic, the solution would be to hitch my side up, so that next time it rains, the water dumps all over the neighbour’s side of the fence, not mine.
But what I actually do is borrow a ladder from my neighbour from time to time. Between us, we empty out the blocked leaves so the guttering can keep draining.
My prescribing software asks me to justify myself when I decline a cost-saving generic-to-trade switch. Unfortunately, the following doesn’t quite fit in the box: