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Rational rationing?

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Currently, GPs and other prescribers must navigate through a complex maze of advice, guidelines and restrictions when prescribing drugs to patients. Some medicines are licensed in the UK but blacklisted by the NHS, some are subject to a set of rigid national rules based on eligibility criteria (e.g. phosphodiesterase type-5 inhibitors for erectile dysfunction) while others are not (e.g. dapoxetine and lidocaine/prilocaine for premature ejaculation).1,2 The National Institute for Health and Care Excellence offers advice and guidance on the use of medicines through its guidelines and appraisals. In addition, NHS clinical commissioning groups may issue local guidance and complicated prescribing quality schemes that steer, cajole and even incentivise prescribers into using the latest most cost-effective treatments. Yet despite all these levers, sticks and carrots, primary care prescribers reportedly waste £400m (4% of primary care prescribing expenditure) per year on a range of products that are considered to be of low value.3

As a result of the financial problems facing the NHS, commissioning organisations have trumpeted a wide-ranging review and called for national support to tackle expenditure on medicines that they believe could be better used in areas of higher clinical priority.3 They are not alone in suggesting that the current piecemeal approach has resulted in duplication of effort across the country and led to a postcode lottery of drug entitlement that patients find confusing and troublesome.4-6 Drugs targeted for review include those thought to offer little or no clinical value, those that have an equally effective alternative at lower cost and those that are thought to be a low priority.

For some time, DTB and others have suggested that rationalising (or rationing) access to medicines requires a national approach.5-7 Although well-developed processes exist to inform the NHS of new medicines and technologies that must be commissioned, there has been no attempt to develop a national process to decommission medicines that represent poor value for money. Such a process must include a meaningful equality impact assessment and consultation on the costs, consequences, harms and benefits of each proposed change, and the production of clear policy statements that are shared with prescribers, pharmacists, patients and their carers. Ultimately, it will require far greater openness and clarity over what drugs the NHS is not prepared to fund than we have had so far. However, it remains to be seen whether there is an appetite to extend the existing blacklist, rather than leaving primary care prescribers in the difficult position of deciding whether to implement national eligibility criteria. Key questions, as yet unanswered, include, what are the unexpected consequences of additional restrictions and is £400m truly wasted or does it simply represent prescribing in areas of complex uncertainty where patients and GPs have worked together to improve their wellbeing and health?

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