Layer 1

Do rural dispensing doctors have a prescribing conflict of interest?

A study examined prescribing of four drug classes, including statins
A study examined prescribing of four drug classes, including statins

Many rural regions rely on dispensing doctors to supply medicines, but researchers claim they often prescribe higher-cost drugs. Could funding for community pharmacies help?

In the UK, almost one in eight (13%) general practices dispense medicines. In sparsely populated rural areas, dispensing doctors are sometimes the only route for patients to access medicines without having to travel substantial distances.

But researchers say that dispensing doctors are more likely to prescribe higher-cost options for four commonly prescribed drug classes, in the conclusion of the “largest study ever” on the prescribing patterns of this GP group. Seven researchers from London institutions and the University of Oxford published a paper on the subject in February in the BMJ Open. They argue that the findings should prompt the NHS to rethink how it commissions medicines supply in rural areas.

Led by Dr Ben Goldacre, senior clinical research fellow and director of the Evidence-Based Medicine DataLab at the University of Oxford, the researchers said they had found “clear evidence that many [dispensing] doctors are responding to a financial conflict of interest”.

These practices can make more money by dispensing high-cost medicines, because they can purchase them at a discount, the researchers said. They then receive the usual drug tariff reimbursement, which does not reflect the discount.

The research has reignited a long-running debate about how medicines are provided to patients in rural areas. The researchers claimed that if doctors in dispensing practices were to prescribe low-cost drugs with the same efficacy as higher-cost ones for four drug classes (see below), the NHS could save £7.5 million annually.

However, the Dispensing Doctors’ Association (DDA) responded that the study does not give an accurate picture.

High and low-cost options

The study focused on the four most commonly prescribed classes of drugs by prescription items, “where there is clear guidance that higher-cost items are no more effective than lower-cost items”. These were:

  • statins
  • proton pump inhibitors
  • angiotensin receptor blockers
  • angiotensin-converting enzyme (ACE) inhibitors.

The researchers compared prescribing data for January 2015 for all dispensing and non-dispensing practices in England, then inspected the cost of the drug to the NHS using NHS England figures.

They provided a list of higher and lower-cost options in each class. For example, with statins, rosuvastatin is a higher-cost option; whereas simvastatin is lower-cost.

They found more than 15 million items were prescribed overall across the four drug classes, costing a total of almost £31m. They split the drugs prescribed into a high-cost or low-cost category and compared the difference. This revealed that dispensing practices are “more likely to prescribe high-cost drugs” across all four classes. The class of angiotensin receptor blockers offered the greatest opportunity for cost-cutting, with an estimated £3.6m potential saving per year.

The researchers also looked at a league table of highest prescribers of the most costly drugs and found that, while only making up 13% of practices overall, dispensing practices were over-represented in the top 10 and top 100 practices. In fact, the top 10 high-cost prescribers for angiotension receptor blockers were all dispensing practices, they said.

For an NHS that spends billions every year on prescribed medication, much of which is “amenable to efficiency savings”, the findings have “important implications”, the researchers argued. They suggested that greater monitoring of practices routinely prescribing high-cost medicines could help.

"Consider funding pharmacies"

Co-author Dr Richard Croker (pictured below), an honorary research fellow in the Evidence-Based Medicine Datalab, says the researchers don't know for sure whether similar patterns would be found for other drug types, but it’s “certainly possible”.

“In our view, the NHS should look at how it commissions supply of medicines in rural areas,” Mr Croker says. “As these areas tend to be geographically large with a relatively small population, the costs for running these services will be relatively high. It may be worth considering whether there needs to be specific funding for the running of dispensaries or pharmacies, with the caveat that prescribing should be the same as in non-dispensing areas.”

Such changes would make the issue “far more transparent”, he explains. “However we arrange dispensing in rural areas, there is a bigger picture finding from our research, and it is worth repeating: when doctors are faced with a financial conflict of interest, many will change the choice of treatment that they are giving to their patients.

“This is a very interesting finding, and it is worth considering whenever planning services and reimbursement frameworks in the NHS.”

Comparing like with like?

Some critics of the study have pointed out that it only looks at one month’s worth of data and claim it oversimplifies the complicated nature of reimbursement for dispensing practices.

Professor Darrin Baines (pictured below), professor of health economics at the University of Bournemouth, tells C+D that directly comparing dispensing doctors with pharmacists is like “comparing apples and pears”.

“The dispensing doctor exists to solve a problem, which is a lack of services in rural areas. Some of these areas would never get a pharmacy there because the cost would be very high and it would not be viable. I don’t think we’re comparing like with like.”

Professor Baines also believes evidence from one year is not necessarily representative, as it cannot account for the various fluctuations and variables in drug prices, reimbursement and availability – practical considerations that might change from year to year.

“I don’t think we can draw a policy conclusion from this. There are lots of complicated issues.”

“Impossible to forecast from one month’s savings”

Dr Richard West, chairman of the DDA, also raised concerns about the methods used, in his written response to the study.

“Due to the continually changing reimbursement prices for medicines it is impossible, and disingenuous, to forecast one month’s estimated savings into a full year. The data can be further muddled by one-off occurrences. For instance, in January 2015 there was a shortage of the valsartan generic.

“Unlike community pharmacies, dispensing practices cannot use [the option of] ‘no cheaper stock obtainable’, and hence will always write a prescription for the brand if a generic medicine is in shortage.”

Dr West said he would never encourage nor condone the prescribing of costlier medicines and there are provisions within the GP contract which permit the NHS to act against dispensing doctors that do so.

Research using more recent figures may show a different picture, he pointed out in his letter, as the cost of the medicines in the chosen four therapeutic areas of the study have decreased significantly.

The researchers say they may well look at other areas of dispensing practice prescribing in the future.

But, Dr West added, no one is arguing the current system of reimbursement is working. “The DDA has been concerned for some time that the system of reimbursement for drugs is not fit for purpose. For the last seven years, we have tried to interest the Department of Health and NHS England to develop a better one,” he wrote. “To date, nothing has happened.”

Dispensing doctors and researchers may disagree on the causes of the problem. However, they all accept that there is one, and with millions of NHS pounds potentially at stake, a better solution to funding the provision of drugs in remote areas is needed.

20 Comments
Question: 
What do you make of the study's findings?

Benie I, Locum pharmacist

What do you make of the study's findings?

I'm scratching my head trying to figure this one out.

This could be a very difficult case to crack. Might have to get Columbo and the little lady from Murder She Wrote onto this one. 

A B, Community pharmacist

I've seen dispensing doctors dispensing less than 2000 items per month receiving giant bulk orders from wholesalers. 

I enquired with my wholesaler rep as to how this works. Let's just say the response was light on detail but my suspicions were pretty much confirmed (although I can't prove anything obviously).

mansour dadkhah, Superintendent Pharmacist

It's shambolic. They are prescribing branded products which cost the NHS millions. Just a few examples:
28 Zocor 40mg £29.69 ( generic cost 60p)
28 Losec 20mg £15.87 ( generic cost 39p)
This is when pharmacies having to dispense out of pocket.

Amit Patel, Superintendent Pharmacist

 

Don’t get me started on their £2.20 dispensing fee!! Wonder why they do more 7 day prescribing. Money in the bank!!

Along with our tax subsidising these surgeries and highly paid dispensers they all get the NHS pensions!!’

 

 

CCG Pharmacist, Primary care pharmacist

7 day scripts are the 'norm' for dispensing practices but I know of one which prescribes everything as individual units, where possible, and this, of course, is not the case for the pharmacies they send a small number of scripts to.

As an example, 10 Lantus pens = 10 prescriptions of 1 pen = 10 dispensing fees. The worst case is 56 bottles of Ensure Plus = 56 scripts for one bottle = 56 dispensing fees!

A.S. Singh, Community pharmacist

But the CCG would rather get into bed with him rather than castigate the GP like they would with pharmacist. Utter BS double standards

Amit Patel, Superintendent Pharmacist

 

why do we train if dispensing doctors don’t need a pharmacist? All they need is a receptionist to double check! PSNC can you stop bending over the round table and start respecting our vocation. 

 

Amit Patel, Superintendent Pharmacist

 

Well finally a topic that needs to stay at the top of the list. All our scripts get switched to branded generic which is fine but why are they not changing their own dispensing patients. A perfect example is sukkarto 500mg sr tabs. This is just the tip of the iceberg. They have a very strong body that works directly with PSUK(Phoenix wholesaler). Fostair 100mcg CFC inhaler costs us pharmacies £29.32 with minimal discount...dispensing doctors get a whopping discount of....wait for it...£14.37 that’s a 51% discount!! Why is the PSNC so useless and NPA does not fight for us!!

Now they can wholesale stock in new hybrid set ups and don’t have to disclose invoices between dispensary and pharmacy. Does the DDA know that they are selling to other companies and this cause a disruption to the supply chain! Oh and it’s profiteering!!

 

Crazy Hayz, Community pharmacist

Prescribing branded generics is absolutely not fine, it still circumvents the generics reimbursements.  Government uses spending volume data to aid reimboursement negotiations and drive costs down, if GPs prescribe volumes by branded generics, the generic prices do not fall as quickly and thus waste nhs money.  Classic example was Lyrica, when gps prescribed under every branded generic name rather than as pregabalin, it massively delayed the price reviews.  Drugs should be prescribed generically unless the is a clinical reason for a specific brand whether that be due to bioequivalence issues or patient side effects....that’s it.  Prescribers that do not, should be charged the extra costs.

Really? Wow, Superintendent Pharmacist

It is a ridiculous situation, and the notion that a lot of them are providing services where they would not be otherwise viable or possible is in many cases a fallacy. 

Just consider two towns that I am aware of personally, I am sure there are more. 

Oakehampton Medical Centre has 11 GP's , at least 2 pharmacies in the town, and the practice is dispensing. Do you think that this is providing pharmaceutical services that wouldn't otherwise be viable?

Another town in a similar situation is Oswestry.

To an outsider looking in the situation is laughable! 

Shane Masterson, Hospital pharmacist

There is also the issue with DD not issuing more than 28 day scripts in many cases. Unsure if this means more profit of course.....

Adam Hall, Community pharmacist

I accept that historically there was an issue for patients in rural areas to access services. Then the motor car was invented and those  areas still affected in this way have dwindled to almost zero. Where it becomes utterly farcical is when patients have to walk past a pharmacy to collect their medication from the dispensing doctor. Is there a conflict of interest when you control the ordering of an item AND the supply of that (or an equivalent/alternative) item? Hhmmm, let me think. That would be a resounding "Yes" - unless the BMA can prove that all dispensing doctors ignore all inducements and "extra margin" when prescribing (I don't think so!). Also, bear in mind something touched upon by others. DDs know when the script will be produced so can order stock "just in time" and so have negligible cash tied up - only, that system doesn't work, as they don't order it so patients have to go back again (true, pharmacy is not faultless in this but we are being reactive, rather than potentially proactive). Added that DDs are closed on Saturdays & Sundays - and very often at lunch-time and at least one afternoon a week and never open the dispensary late - thereby strangling the life out of the "Service" part of "NHS". Patients dare not complain as they risk being delisted and having to change to anothet practice, potentially miles away - which rather punctures the argument of patients shouldn't have to travel miles to access services!  Regulations on DDs are outdated and nee to be brought in to line with the modern world. I am no fan of internet pharmacies but if you are with a DD, you are denied access to that service because DDs do not use EPS - and if that doesn't breach the NHS constituition on patient freedom of choice, I don't know what does!

Stuart Beer, Superintendent Pharmacist

“Unlike community pharmacies, dispensing practices cannot use [the option of] ‘no cheaper stock obtainable’, and hence will always write a prescription for the brand if a generic medicine is in shortage.”

 

Ha ha ha ha!  Or does he really think NCSO is still in operation?!

Amit Patel, Superintendent Pharmacist

They are abusing NCSO!! Branded generic- only for pharmacies to reduce the budget the CCG requires. Has any of the bodies checked what dispensing doctors put on the prescription- well it’s not branded generic!! PSNC and NPA are weak

N O, Pharmaceutical Adviser

May be he is going by the report date of 2015 :-))

Also, he has blatantly accepted the truth that the GPs will go to any extent to protect their own income (like prescribing a brand) but don't extend the same to community Pharmacy when asked to change the generic to a Brand (reson given is that we should dispense the brand for the generic under the service contract)

And despite most of the rural areas now having at least one Pharmacy available the NHS does not give S*** to cancel the dispensing practice contract. So all this saving money for NHS/ efiiciency seem to apply only to community Pharmacy. Why don't they call for a local tender to replace the dispensing practice and see how many applications will pour in. It is not just in rural areas but also in NOW town areas (but the contract being held when the area was a rural area) where there are 2 Pharmacies nearby!!! Any comments from DDA, NHSE or the DoHSC??

Kevin Western, Community pharmacist

So there is a lack of pharmaceutical services because 

A) the poor GPs  oppose it as they feel they have to continue to run a service at a loss for their patients scrupulously avoiding any cinflict of interest 

Or

B) they are raking it in, ignoring any inconvenient rules and dont give a stuff...

They are running a business which has poor oversight and huge profits...what would you do?

Paul Dishman, Pharmaceutical Adviser

Not surprised. Dispensing doctors have a blank cheque signed by the NHS. They always dispense to maximise profit: either for kickbacks from companies who produce spurious ‘named’ generics or proprietaries to max discount. Never is a rep seen without free stock or samples for the dispensary and as for EPS- not a chance-in case those nasty chemists “steal” their prescriptions

Benie I, Locum pharmacist

Editor is this allowed? Accusing Doctors of defrauding the NHS. Just asking.

A.S. Singh, Community pharmacist

It's not untrue is it?

C A, Community pharmacist

I thought they weren't doing EPS becuase they weren't being paid for it ;)

Job of the week

Pharmacy Manager - Bridlington
Bridlington
Competitive plus benefits (GPhC fees incl)