11. The pharmaceutical industry spends more than £850 million annually on marketing its products to GPs. The Department provides useful information to patients and practices, and there is good partnership work between NHS organisations, general practices and the pharmaceutical industry. Nevertheless, in the NAO's survey of 1,000 GPs, one in five respondents said they felt that pharmaceutical company marketing had more influence on prescribing behaviour than official NHS prescribing advisers did.[12]

12. The industry's promotional efforts must comply with the code of practice drawn up by the Association of the British Pharmaceutical Industry, which was strengthened following the Health Select Committee's 2005 inquiry into the influence of the pharmaceutical industry. Furthermore, GPs are required to notify their PCTs of any gifts or inducements they receive from pharmaceutical companies, above a certain minimum level. Currently PCTs are not required to publish this information.[13]

13. At the time of the last renegotiation of the Pharmaceutical Price Regulation Scheme (PPRS), in 2004, the prices of branded drugs in the UK were at the top of the European range. The 7% price cut negotiated at that time brought prices 'within the range' for other European countries. The Department for Business, Enterprise and Regulatory Reform has recently stated that it will discuss options for reforms in drugs pricing with the pharmaceutical industry, following the Office of Fair Trading's review of the PPRS.[14]

14. To support GPs on prescribing issues and to spread best practice, PCTs employ prescribing advisers, specialists with pharmacy qualifications. Guidance and training for prescribing advisers is provided by the National Prescribing Centre. Most GPs report having a good relationship with their prescribing adviser, and feel that prescribing advisers have more influence over their prescribing decisions than pharmaceutical companies do. There are about 1,200 prescribing advisers employed in England. The Department quoted independent research which suggested that prescribing advisers increased clinical and cost effective prescribing and could save at least £2 for every £1 of salary costs. There has however been no work to assess the individual effectiveness of prescribing advisers or how prescribing adviser effectiveness correlates with the potential savings identified in the Comptroller and Auditor General's report.[15]

15. Other incentives for GPs to prescribe cost effectively are financial incentive schemes operated by PCTs; the 'medicines management' points in the Quality and Outcomes Framework that underpins GPs' pay; benchmarking and peer review of their prescribing patterns; and the introduction of Practice Based Commissioning.[16]

16. Individual PCTs may operate financial incentive schemes that reward practices, with extra income to be used for patient care, for staying within an agreed prescribing budget or increasing the proportion of more cost effective drugs being prescribed for certain conditions. There are two indicators in the Quality and Outcomes Framework which reward practices for meeting a prescribing adviser at least annually, and agreeing up to three actions related to prescribing. The NAO found that the vast majority of practices achieve the maximum of 4 points on these two indicators,[17] despite the large variations between PCTs in prescribing efficiency.

17. Benchmarking prescribing patterns involves comparing indicators of prescribing, such as volume and cost, across GP practices or PCTs, making allowances for differences in patient demographics. 'ePACT' (electronic prescribing analysis and cost) data is produced by the NHS Business Services Authority's Prescription Pricing Division. It is available to all PCTs to help them with benchmarking. Showing GPs how their prescribing compares with that of their peers has proved in the Department's view to be an effective way of influencing prescribing behaviour.[18]

18. Practice Based Commissioning (PBC) is the Department's initiative to give GPs more control over their PCTs' financial resources, and allows GPs to reinvest a proportion of any efficiency savings they make into their practices. By June 2007, 96% of GP practices had taken the incentive payment to become involved in PBC. The Department expects the drugs budget to be an integral part of PBC, and that PBC will bring practices together into consortia which will increase the amount of peer review and drive positive changes in behaviour. In the NAO's survey of GPs, however, 37% of respondents did not know what impact Practice Based Commissioning would have on their drugs bill, and 20% said it would not encourage their practice to make any savings. 36% said it would encourage small savings, and 8% said it would encourage significant savings.[19]

19. Dispensing doctors operate predominantly in rural areas where pharmacies are often in short supply, and are remunerated for dispensing drugs they have prescribed to their patients. The Department's data shows no evidence of higher levels of prescribing for dispensing doctors compared with non-dispensing doctors, and very little difference in average costs, except for a few cases where dispensing doctors were prescribing more expensive drugs. Recent changes to dispensing doctors' remuneration arrangements have meant that any incentives for them to prescribe expensive drugs over cheaper versions have been removed.[20]

13   Qq 52-56 Back

14   Qq 29-32, 71-72, 89-91; Department for Business, Enterprise and Regulatory Reform News Release 2007/034, 2 August 2007 Back

15   Qq 33-38, 63-64 Back

16   Qq 20-26, 80 Back

17   Qq 24-25; C&AG's Report, paras 3.31-3.33 Back

18   Qq 20, 25, 65; C&AG's Report, paras 3.34-3.36 Back

19   Qq 21-23, 26, 65-66, 80; C&AG's Report, paras 3.9-3.10 Back

20   Qq 14, 86 Back