Archive | July 2015

Displaying the cost of prescribed drugs: what’s the evidence?

Health Secretary Jeremy Hunt has announced that

we intend to publish the indicative medicine costs to the NHS on the packs of all medicines costing more than £20, which will also be marked ‘funded by the UK taxpayer’. This will not just reduce waste by reminding people of the cost of medicine, but also improve patient care by boosting adherence to drug regimes. I will start the processes to make this happen this year, with an aim to implement it next year.

These plans risk causing real harm and may not work, so I asked the Department of Health to tell me: whether the plans will be trialled; the evidence supporting the plans; and details of any planned research. They helpfully sent me some of the evidence they considered and some information about planned research. This is, sadly, entirely inadequate to support rolling out the policy. To show this, I will go through the examples they offered. The Department first referred me to

A study by Fogarty, Sturrock, Premji and Prinsloo (2013) which showed that provision of feedback on the cost of a particular diagnostic test (C-reactive protein assay) to physicians can prevent unnecessary tests being ordered.

This is an interesting study, but it does not look at the impact of publishing medicine costs and it measures responses of clnicians rather than patients.

The Department then mentioned that

Work is currently underway at Nottingham City Hospital to test this concept of cost feedback to physicians further – in particular looking at the impact of adaptions to the electronic prescribing system in use at the hospital, to include details of cost, on physicians’ prescribing decisions. Initial results will be available in early 2016.

This sounds like fascinating work, but won’t tell us how patients respond to this information. Also, as not even initial results are available, we don’t yet know whether this intervention (in physicians) works.

The Department also told me that

this concept of feedback on costs will also be tested with patients, in relation to increasing medications adherence. This study tests the use of a commitment sticker, which aims to create a commitment between the patient and the pharmacist by asking the patient to sign the commitment to take their medication at the point that the medication is dispensed. A range of stickers will be tested, one of which includes a message about the cost to the NHS each year from wasted medication. The study is due to go into the field later in July 2015, with initial results available at the end of 2015.

These are all interesting things to test, but this doesn’t constitute a trial of Hunt’s proposal (which would actually be simpler to trial than the combination of a signed commitment statement with various other stickers). Also, while adherence is important, Hunt specifically claimed that this policy would reduce medicine waste. From the description above, this planned trial will not test this claim.

The last thing the Department referred me to was

The “Evaluation of the scale, causes and costs of medicines waste” report, published in November 2010  by the York Health Economics Consortium/The School of Pharmacy, University of London, estimated the gross cost of unused prescription medicines in primary and community care to be in the region of £300 million a year in England in 2009, with around half of that being avoidable.

However, this report, (p84) found that

Some sources have advocated putting the supply price on every NHS medicine pack in order to raise awareness of costs, and so perhaps to reduce wastage and/or increase consumption…Some interviewees said it would ‘make patients realise the cost of medicines’.But in rather more cases, service user respondents and others felt that pack pricing might cause some patients in need of effective treatment to become worried about its cost to the public purse. One GP said that the people who he most wanted to target probably would not care about the price of their medicines

This might be a reason to trial this policy of printing the supply price on NHS medication. However, it’s certainly not robust evidence for rolling out the policy. We don’t know what the harms and benefits of this policy might be, and it should be properly tested to see if it works before its introduction.

Appendix I quote from an e-mail exchange with the Department of Health above. For the sake of transparency, I’ll reproduce this in full below (with e-mail addresses/names removed).

Dear Dr Mendel

Thank you for your e-mail of 2nd July. I am sorry for the delay in replying.

The Department has considered a range of evidence in relation to making health service users aware of the costs of their care leading to better use of health services. This includes:

•        A study by Fogarty, Sturrock, Premji and Prinsloo (2013)[1], which showed that provision of feedback on the cost of a particular diagnostic test (C-reactive protein assay) to physicians can prevent unnecessary tests being ordered.

•        Work is currently underway at Nottingham City Hospital to test this concept of cost feedback to physicians further – in particular looking at the impact of adaptions to the electronic prescribing system in use at the hospital, to include details of cost, on physicians’ prescribing decisions. Initial results will be available in early 2016.

•       In addition, this concept of feedback on costs will also be tested with patients, in relation to increasing medications adherence. This study tests the use of a commitment sticker, which aims to create a commitment between the patient and the pharmacist by asking the patient to sign the commitment to take their medication at the point that the medication is dispensed. A range of stickers will be tested, one of which includes a message about the cost to the NHS each year from wasted medication. The study is due to go into the field later in July 2015, with initial results available at the end of 2015.

The “Evaluation of the scale, causes and costs of medicines waste” report, published in November 2010  by the York Health Economics Consortium/The School of Pharmacy, University of London, estimated the gross cost of unused prescription medicines in primary and community care to be in the region of £300 million a year in England in 2009, with around half of that being avoidable.

I hope this is helpful.  Please let me know if you have any other queries.

[redacted]

MPIG

From: Jonathan Mendel [redacted] Sent: 02 July 2015 15:45 To: MPIG Support Subject: Plans to publish cost to NHS on medicine packs

Dear Sir/Madam, Jeremy Hunt has announced that “we intend to publish the indicative medicine costs to the NHS on the packs of all medicines costing more than £20, which will also be marked ‘funded by the UK taxpayer’. This will not just reduce waste by reminding people of the cost of medicine, but also improve patient care by boosting adherence to drug regimes.” I’m e-mailing about these plans, as suggested by the Department’s Twitter account. I would be grateful for several pieces of information. Firstly, given some lack of clarity in the media coverage, it would be helpful if you could confirm whether the plan is to roll out these plans nationwide or whether they will be trialled first. Secondly, I would be interested in seeing the Department’s evidence for the claim that this move will “reduce waste by reminding people of the cost of medicine [and] also improve patient care by boosting adherence to drug regimes”. If you hold unpublished research that is relevant to this claim, I would be grateful for a copy. If the research has already been published, a link/reference would be very helpful (and apologies for not having found this myself). Finally, if additional research is planned on this issue, I would be interested in seeing detail re what this is. All the best, Dr Jonathan Mendel PS: I am interested in discussing the interplay between research and policy, and think it is important to do so as openly as possible. With that in mind, please assume that all replies are potentially for publication.