Peter Fellows wrote:

> 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.

But these savings may be substantial and sufficient to allow us to 
stay within allocation,  fund new treatments or both.  
Current annual potential savings from increased generic 
prescribing are probably in excess of UKP 15 M for England.  Also, 
generic prescribing is not a short term fix 
either.  The savings are recurrent with each patent expiry.

> 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.

The last figure I saw quoted was that the industry had net export 
revenues of UKP 2 bn.  The primary care drugs bills for England is 
now approaching UKP 4.5 bn.  Hospitals probably add a further UKP 0.5 
bn.

> 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.

No. My understanding is that most generics are made by 
UK-based multinationals.  There are *very* few grey areas.  There is 
no evidence of an excess of defects or adverse reactions in 
generic drugs reported to the MCA or CSM.

> 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.

Even if it's true,  this is a matter, as has been said before, for 
Government to address, not individual prescribers.  There is no 
evidence that recent increases in generic prescribing rates have 
inhibited pharmaceutical innovation.

> In spite of Medicines Control Agency advice, long acting
> preparations of drugs such as nifedipine are still often
> dangerously prescribed in generic form. 

Intra- and inter-patient variation in response to modified release 
drugs is enormous.  It's most unlikely, however,  that there would be 
a loss of efficacy whereas different nifedipine preparations 
might well give you a headache at different times and perhaps 
of varying severity.

> Extreme caution is advisable with anti-epileptic drugs.

Because of their narrow therapeutic ratio, minor 
differences in bioavailability may indeed have clinical 
significance for aniconvulsants.  Therefore, it's reasonable to 
maintain patients on the same brand.  There is no objective evidence 
that generic anticonvulsants are inferior.

> 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.

Strict product liability applies equally to generics as to branded 
drugs.  In practice, this usually means keeping records of purchases 
from wholesalers.

> Prices of drugs fluctuate rapidly. Branded forms are often cheaper
> than Drug Tariff costings of generics. 

A short-term trick to encourage their use.  Once use is established, 
the price *will* return to a level above the Tariff price.

> 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.

Agreed.  However, generic prescribing is a feature of good 
prescribing.

> 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! 

In fact, financial incentives linked to generic prescribing targets
have been in use for a few years now.  They appear to effective in
promoting unnecesarily expensive prescribing and, as a consequence,
returning the savings for investment in primary care services.

Mark Campbell


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