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Readers' Points

Bandolier recognises that there are other points of view to those that appear in these pages, and from time to time we will publish short abstracts of letters we receive from a different perspective. Issue 4 had a short piece on hospital-led prescribing which concluded that there was insufficient evidence to lay the blame for high GP prescribing costs on hospital loss-lead prescribing.

This has brought strong responses from Dr Tom Jones of the Oxfordshire FHSA and Sharon Hart and colleagues from the Bucks FHSA which express concern that this may undermine efforts to persuade hospitals to co-operate in helping GPs toward more cost-effective prescribing. Since there is insufficient space to print the letters in full, the following abstracts are printed with the approval of the correspondents.
  • Wiffen & Lauder showed that the cost to the community of a `basket' of the top 100 drugs by total expenditure was 7% higher than the cost to the hospital pharmacist. This is not insignificant, representing perhaps as much as £250,000 in one quarter in Oxfordshire. In addition, VAT is payable on hospital, but not community drug costs. Taking VAT out of the equation increases the differential above 7%.
  • The comparisons made underestimate the saving potential if alternative drugs were substituted. Thus an Audit Commission Report on prescribing in Buckinghamshire suggested a saving of £220,000 a year if there were full substitution of ibuprofen and naproxen for expensive NSAIDs such as fenbufen and diclofenac. Similar arguments could be used for Co-amilofruse and Co-amilozide being substituted by frusemide and bendrofluazide, and cimetidine for ranitidine.
  • Inevitably much GP prescribing is hospital driven, and rightly so, for hospital specialists are experts in the therapy of the conditions they treat. In most cases medicines are recommended solely for therapeutic supremacy.
  • However, if in even a small number of cases the Hospital Specialist chooses a medicine because of low hospital cost when a therapeutic equivalent would be more expensive but cheaper in the community , the community drug bill goes up unnecessarily. In cases like this, it is difficult for GPs to change prescribing when patients on long-term therapy return to the community. It is important to identify those drugs which do have cheaper community alternatives so that savings overall can be made through enlightened purchasing decisions and rational GP prescribing.
Some hospital staff and managers may take the Wiffen & Lauder article to imply that trying to make savings in the community drug bill through attention to hospital prescribing is unnecessary. This is unfortunate since there are a number of hospital initiatives that could reduce community prescribing costs without loss of effectiveness. The NHSE recently arranged a Prescribing conference for purchasers, in part because of this very point.

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