I am not a great fan of generic prescribing. As in most things medical there
is a sensible middle road. There may be some short term savings at local
level. The Pharmaceutical Price Regulation Scheme allows drug companies to
adjust overall profit levels in subtle ways, and in practice is too crude to
prevent companies recouping losses  from generic prescribing effects. On the
other hand our drug industry is a world beater, with export profits which
are an enormous asset to the country, more than covering the drug bill of
the whole NHS. Many generics are imported copies, with balance of payment
consequences. I know that much has been done to improve quality control and
standardisation, but there are grey areas. If we squeeze drug company
profits by switching to generics then the innovators will simply charge more
for new drugs which may then cease to be readily available for NHS patients
( consider Taxol for example). We need to allow sensible  profit incentive
if we are to continue the research and development lead. Ever heard of a new
drug from Russia? It is profit that drives development. That is a simple
fact of life. Encourage too much in the way of cheap copies of drugs out of
patent, and more of the basic development costs will be recouped while a new
drug is under patent. New drugs will be more expensive. They may also be
sold relatively cheaply abroad where generic competition is not such a
problem. We then have the more serious problem of parallel imports which so
many pharmacists have been quick to profit from!
Base ingredients, preservatives, colouring, texture, tablet size and shapes
often differ with generics. It's a bit like the baked bean effect! My kids
always turned their noses up if they were served anything other than Heinz.
( Similar effect with Pepsi too! )We couldn't deceive them with the cheaper
brands, yet the food value was probably exactly the same. I don't think they
would have been very impressed with giant green beans one week,  small white
ones the next, and then perhaps some mauve square ones for variety. It could
have become very confusing, let alone the taste difference!
Not only are the varying forms of generics confusing for the patient, but
the names tend by their intended group nature to be more similar, confused,
and also cumbersome. I have a patient who is addicted to lorazepam which the
pharmacist gave by mistake when lormetazepam had been prescribed. Drug
companies invest huge sums in naming new drugs with simple, easily
remembered, and usually uniquely distinctive names. ( There are glaring
exceptions such as Danol, De-Nol ). Some of my partners think they are being
very clever trying to achieve very high generic rates. I notice how often
they write the brand name in the notes! eg Prempak C while the computer
prints out a generic name. That confuses the receptionists when repeats are
requested, and can be dangerous. Patients seldom remember generic names, and
the packaging, rather than the label, usually also carries a more obvious
brand name to add to confusion.
One of my partners was alarmed at how generic co-proxamol had degraded to
powder in his case. The Distalgesic were still in perfect condition!
In spite of Medicines Control Agency advice, long acting preparations of
drugs such as nifedipine are still often dangerously prescribed in generic
form. Extreme caution is advisable with anti-epileptic drugs. It is likely
that all long acting preparations will be similarly treated, with MCA advice
to prescribe by brand name before long. That will influence companies to
concentrate on long acting preparations to avoid generic poaching,
regardless of the desirability of developing shorter acting preparations.
The Nurse Prescribing Formulary is farcical in it's generic emphasis.
Dressings are complex and are not readily generically defined. The obvious
motive of the DoH is to restrict the use of modern treatments. It has little
to do with good clinical practice.
Dispensing doctors have been criticised for low generic rates. There is good
reason (other than profit!). Consumer protection law passes the buck to the
manufacturer, in event of a problem, unless the manufacturer cannot be
identified, in which case the prescriber is liable. The record keeping for
dispensed generics is a headache, and records have to be kept for 11 years.
Prices of drugs fluctuate rapidly. Branded forms are often cheaper than Drug
Tariff costings of generics. It is not easy for the prescriber to keep
abreast of up to date cost information.
The old classics with drugs such as digoxin  are now well known and the
improved standardisation of generics is now unlikely to result in  such
major therapeutic differences. There are some differences, however. I have
noticed differences with branded thyroxine for example.
Take the middle road. Sensible carefully considered prescribing is what
matters, whether generic or branded drugs are chosen. Good prescribing is
cost effective, not necessarily cheap. Savings to the NHS are not as great
as the DoH would have you believe, and the long term threat to the golden
goose is considerable if generics are overdone!
Already I am hearing how practices who don't meet arbitrary and unscientific
generic targets which will inevitably be set by PCGs might be financially
penalised!


                    Peter Fellows.
Past chairman, Prescribing Subcommittee, GMSC.



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