A Diamond Jubilee: Sixty years of NHS prescribing
A Diamond Jubilee:
Sixty years of NHS prescribing
As the NHS reaches its sixtieth birthday, Steve Ainsworth looks at how changing pressures on prescribing have dramatically altered the relationship between the industry and healthcare professionals.
This month the National Health Service celebrates its Diamond Jubilee.
The birth of the NHS on 5th July 1948 was far from being a painless event. Nor would the ensuing six decades be pain-free ones, for either the NHS or those working in the pharmaceutical industry.
A shaky beginning
‘Joy Day’, as the politicians optimistically dubbed the start of the NHS, almost didn’t happen. The medical profession was universally hostile to the creation of a National Health Service. GPs thought the terms on offer to be so derisory that the BMA advised its members simply not to participate.
Minister of Health Aneurin ‘Nye’ Bevan, however, split the medical profession by buying off the hospital consultants; in his words, “I stuffed their mouths with gold”. Only at the very last minute did significant numbers of panicked GPs break ranks and make the NHS possible.
Pharmacists predicted chaos once everyone in Britain became eligible for free prescriptions with no limit placed on what or how much GPs might prescribe. It was estimated that the average cost of a prescription would be 2s 5.3d. The annual cost to the NHS was expected to be in the region of £17.5 million.
“A rep’s standing in those innocent days could be immeasurably enhanced by sharing wartime experiences, and by remembering what brand of cigarettes a GP smoked”
The Ministry of Health assumed that around 140 million free prescriptions would be dispensed annually in England and Wales. Until 1948, however, most doctors had done some dispensing themselves, and no figures on the volume of that activity were available. In the absence of hard data no accurate assessment could be made of the number of prescriptions which would come to pharmacies for dispensing within the NHS.
It did not take long to discover that the estimate of 140 million prescriptions was going to be very wide of the mark. In the first year of the NHS 202 million prescriptions were dispensed; the totals for the next few years would fluctuate between 215 and 229 million.
Understandably, the Treasury was less than happy. Cuts would have to be made. The Government also came under enormous pressure to begin repaying the massive war loans Britain owed to the USA: free teeth, free glasses and, of course, free prescriptions would have to go.
In June 1952 the one shilling (5p) per form prescription charge was introduced. Other patient charges were introduced for NHS dental treatment and glasses. For a short time, the number of prescriptions presented for dispensing fell sharply.
Of course, as we now know, numbers recovered, reaching 300 million annually by 1980 and passing 600 million in the opening years of the new millennium. During the 1950s, however, prescription numbers would increase by very little.
The Golden Age for pharma
Yet despite such apparent stagnation, the Rock and Roll years were in fact a Golden Age for pharmaceutical company representatives.
In 1948, just 18% of all prescribing was for proprietary products. By 1956, however, that proportion had soared to over 40%.
At the start of the decade, the value of proprietaries had amounted to around two fifths of the total budget; by 1957 that proportion had risen to two thirds. Two groups of drugs, antibiotics and hormones, were between them responsible for almost 35% of the total ingredient cost of proprietary preparations. Newer, better products had, in a large part, been responsible for the increases in prescribing of proprietaries, but sales were also aided by the relaxed relationship between GPs and reps. A rep’s standing in those innocent days could be immeasurably enhanced by sharing wartime experiences, and by remembering what brand of cigarettes a GP smoked. GPs were under astonishingly little pressure to restrict prescribing. Their NHS contracts merely required them not to prescribe excessively. And any allegations of over-prescribing were to be investigated not by the NHS authorities, but by their peers in the Local Medical Committee – a system hardly calculated to worry GPs.
But the party could not last forever. In 1959 the Hinchliffe Committee for England and Wales, and its Scottish counterpart the Douglas Committee, concluded that although “there is no evidence of widespread and irresponsible extravagance in general practitioners’ prescribing, there is scope for economy”.
A Voluntary Price Regulation Scheme was by now already in place, but the Hinchliffe and Douglas Committees went on to recommend that: “Everything possible should be done to prevent public money being wasted in inflated and expensive sales promotion. The [pharmaceutical] industry should be asked to consider… whether anything further can be done to limit the more extreme forms of advertising.”
Remarkably, however, for the first four decades of the NHS, very little would be done to restrict GPs’ freedom to prescribe almost anything they wished.
Prescribing questioned
‘Encouragement’, rather than enforcement, was the order of the day. In pre-computer days part of the problem faced by the authorities was the absence, or at least the very limited quantity, of data on individual GPs’ prescribing habits. Rather than pressurise individual GPs, the main thrust of government activity would be towards price controls aimed at the industry as a whole.
By the 1970s, however, systematic sampling of all prescriptions did produce sufficient data for pressure to be brought to bear on individuals. And to counteract the baleful influence of drug reps now armed with novelty desktop toys, the Department of Health instructed its Regional Medical Officers to pay regular visits to each GP whose prescribing habits were deemed to be questionable. Exhortations to GPs to do better had relatively little impact. GPs liked their freedom to prescribe whatever they liked – not even being restricted to preparations listed in the BNF, which, by the early 1980s, contained some 2,700 items.
Calls for change were growing. The start of the modern era can be dated to the new GP contract of 1990. For the first time, regulations were issued expressly listing preparations which GPs were not permitted to prescribe under the NHS.
Furthermore, computerised data processing now made it possible for a detailed analysis of the cost of each GP’s prescribing to be generated every month. ‘Indicative prescribing budgets’ were now produced – and what were for now merely ‘indicative’ might all too soon become real drug budgets.
GP Fundholding, introduced shortly after the appearance of indicative prescribing budgets, would begin the still-evolving process of focusing GPs’ minds on the relative cost of drugs.
Steve Ainsworth is a writer specialising in the history of medicine, the NHS and Primary Care. He spent 25 years working in NHS management.
Steve has qualified as a member of the Institute of Chartered Secretaries and Administrators and the Institute of Healthcare Management.
He has been a Lay Chairman of Independent Review Panels for the NHS and a Lay Panel Member for the Healthcare Commission. |
In parallel with cost-containing initiatives came renewed emphasis on clinical effectiveness. The National Prescribing Centre, for example, was formed in April 1996 by the Department of Health. Its aim was to “promote and support high quality, cost-effective prescribing”. By the start of the new millennium, ‘evidence-based prescribing’ would take its place alongside cost as the main driver for change in GP prescribing.
Today the annual number of prescriptions dispensed by the NHS is approaching four times the number dispensed in its first year of existence. ‘Joy Day’ in 1948 led to many years of joy for industry reps when it seemed that generics were set to disappear. That once unstoppable trend has been sharply reversed, with generics once more taking the lion’s share.
In the early years of the National Health Service, a shared cigarette and regimental tie might have been quite enough to gain a GP’s trust. Today, however, in the diamond-tough world of the 60-year-old NHS, only cost and clear clinical effectiveness are likely to do the trick.