10 Feb 2010
C+D Senate - Generic Substitution
By Administrator of the site
Will government plans for generic substitution really work? C+D’s Senators weigh up the evidence and deliver their verdict. Zoe Smeaton reports
Generic substitution will be challenging, could lead to friction with the public, and is not the most effective way for pharmacists to help the NHS save money, the C+D Senate believes.
The conclusions came as 10 industry leaders met in London to form a position on the topic, and they spell bad news for Department of Health (DH) plans.
The Department wants pharmacists to be allowed to swap selected branded products for their generic versions, unless GPs have ticked a box to say they don’t want it to happen. It might sound straightforward enough on paper, but many Senators are not convinced.
The main issue for Jay Patel, an area manager at Day Lewis, is the added distraction that generic substitution would bring. “It’s the mental fog – it’s just one more thing to have to worry about,” he says. And Tricia Kennerley, group healthcare public affairs director for Alliance Boots, agrees: “I’m concerned that pharmacists are so busy and this is yet another thing that we’re asking them to manage. We’re going to have to think very carefully regarding the training and support we give.”
Generic substitution - at a glancePros• Speeds the shift from branded medicine to generic use as drugs go off patent • Presents an opportunity to engage with patients about their medicines • GP prescribing of generics could increase further as they know patients will get generics anyway Cons • Introduces yet another potential distraction for pharmacists • Patients may feel that pharmacists are profiting by switching medicines • Generic substitution is small fry compared to the benefits of increasing patient compliance |
How big an issue is this?
The DH thinks the initial impact on pharmacy in volume terms will be low, as only around 40 drugs would be eligible for substitution. It could affect only five to 10 prescriptions per day per pharmacy, according to Jonathan Mason, the DH national clinical director for pharmacy.
The other Senators agree this may be the case, but are concerned the workload for those few prescriptions could be onerous depending on how patients react.
John D’Arcy, commercial director at Rowlands, says: “We’re going to get different attitudes. It’s the same as with Kellogg’s cornflakes: somebody would say, ‘Are they Kellogg’s? Because if they’re not I don’t want them,’ whereas someone else will say the generic equivalent suits them.” And Mr Patel agrees: “If Mrs Jones’s tablets are different, she could be thinking, ‘They aren’t the same, they aren’t going to work and why didn’t he give me what the doctor wrote down?’.”
Substitutions could even reduce compliance, warns Ash Soni, a community pharmacist in London. “We do have patients who will turn around and say ‘I won’t take that because I always have the one that’s brown rather than orange and I prefer that,’ or ‘I do not take yellow tablets’,” he explains.
From Mr D’Arcy there are also concerns about how the move could affect the public’s perception of pharmacy. “However you put the message across, are patients going to think, ‘He’s doing this because he makes more money,’ rather than seeing it as part of a government cost containment strategy?”
Georgina Craig, pharmaceutical services commissioning network lead at NHS Alliance, says to move forward we need to understand these issues better. “We’re stabbing in the dark a bit about how patients are going to react to this. I think it is the responsibility of the DH to understand what some of the issues might be and to support pharmacists by giving them access to that information so they can anticipate in advance what some of the issues are likely to be.”
In response, Mr Mason stresses that pharmacists have dealt with most of the issues already, such as when a branded medicine comes off patent and patients have to switch to using generics. “When something comes off patent pharmacists already have to explain to the patient that the drug has come off patent and is in different packaging even though it’s the same drug.” He says with the proliferation of parallel imports and generics, patients are already used to medicines coming in different packaging.
But even if this is the case, the Senators warned pharmacists needed to be allowed to opt out of substitutions in some cases. “If I feel the patient is in such a position that I do not feel it is appropriate to substitute and it is the right thing to give them the brand, will I be penalised? That then takes away my opportunity to make a good clinical decision on behalf of the patient,” says Mr Soni. Liability is also a concern for Ms Kennerley, who asks if pharmacists would be liable for changes they make that lead to adverse reactions. And others are concerned about the possibility of friction with GPs. As Mr Soni says: “It will be interesting to see what GPs think; I suspect they will come out against this because of the perception that it’s weakening their power base.”
Will it affect funding?
The C+D senators were undecided on how the switches might affect pharmacy income, but agreed the matter needed serious consideration.
Ms Kennerley said: “If we’re switching more products into generics, we’ve got more going into supply chain margins so it will have an impact on funding overall and we need to think that through.”
And Mr Soni questioned whether the move would have an impact on branded generics. “It might diminish this market which has been used by PCTs as a lever to push prices down. That may help to relieve some of the pressure on some pharmacies who are theoretically not getting their share of the shared pot of generic margins we’re supposed to have.”
Focusing on the positives
Whatever the problems with generic substitution, though, the DH is convinced it will bring benefits. Mr Mason explains that there will be a longer term benefit as new drugs can be added to the list when they go off patent, speeding up the shift from branded medicines to generics. “There is a big time lag at the moment between [a medicine going off patent] and getting a big volume of medicines through generically to make the big savings,” he says.
And it could also bring opportunities for pharmacy. Mr Mason suggests: “If you’re having to explain to the patient why it is that you’re changing what the doctor has prescribed, it is an opportunity to talk to the patient about their medicines and engage in dialogue.”
Martin Crisp, Superdrug’s superintendent pharmacist, agrees: “Pharmacists are seasoned at doing this and it could be that generic substitution might create an opportunity for an MUR.”
Most of the Senators are unconvinced, though, and feel other moves could bring more benefit. Ms Craig asks: “If it’s going to cost more time for pharmacy to do this, and if this additional time is going to bring a small return on investment, is there something better that pharmacists could be doing with that time?” Improving compliance is seen as a higher priority, as Mr Soni explains: “Compliance is a much bigger issue. Compared with the amount of money we’re talking about there, this is like a drop in the ocean.”
Another option is to introduce substitution further up the chain, with GP surgeries taking responsibility for prescribing generically. “For each GP surgery there are around three pharmacies, so for one practice manager to take control makes more sense,” Mr Patel says.
Mr Mason backs a role for GPs, but insists generic substitution could create opportunities for engagement with the two sectors. Maybe it’s an opportunity to go to GPs and say, ‘Well if you don’t prescribe generically it’s going to be switched anyway. Do it now so you won’t have to go through the hassle of explaining to patients when they come back and say the pharmacist has switched it and they have told me x, y and z’.”
Whether this will work or not remains to be seen, but the Senators are certainly united on one front: the need for a full discussion on the matter. They are keen to get patients involved in that, as Peter Cattee, managing director of PCT Healthcare, says: “It’s time that we had a broader discussion about the cost of medicines in society involving patients as well.” But above all, they want the profession to have its say and respond to the DH consultation to ensure that if generic substitution is introduced, it works.
The Senate ruling
- Generic substitution is not the most effective way for pharmacy to help reduce NHS costs
- Patients should be involved in making decisions about drug spends
- If generic substitution goes ahead, pharmacists need the ability to opt out where appropriate
- The financial implications for pharmacy must be considered
- Pharmacists must respond carefully to the consultation
See what the Senators had to say
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Next week in C+D: The Senate dissects the thorny issue of commissioning, and questions whether the RPSGB can deliver a new leadership body
