We move on to the next item, which is an oral evidence-taking session for our inquiry into the Auditor General's report "Supporting prescribing in general practice—a progress report". I welcome to the meeting Mr Trevor Jones, the head of the Health Department and chief executive of NHS Scotland; Mr Bill Scott, chief pharmaceutical officer; and Dr Hamish Wilson, head of the primary care division at the Health Department. I understand that Mr Jones is going to make an opening statement.
I thank the committee for allowing me to make a few opening remarks, which will be brief. The report is very good and we welcome its findings. Its conclusions and recommendations will help us to take forward the agenda to improve prescribing practice throughout Scotland. I was particularly pleased to note that the report acknowledges the progress that the NHS has made since Audit Scotland's original report was published in 1999. That progress is down to the efforts of GPs, pharmacists and other NHS staff in driving forward the improvement agenda and I record formally my thanks to the service for that.
Our pharmacy strategy, “The Right Medicine: A Strategy for Pharmaceutical Care in Scotland", sets out a clear vision of how we should relate to community pharmacists. A lot of work is going on in that area and the committee might wish to ask about it as the meeting progresses. As we implement the pharmacy strategy, we will see a better outcome for patients. We will see less opportunity for waste in drug prescribing and, critically, we will see better use of the skills of the GP and the community pharmacist. That will free up more time for the GP to spend with their patients and it is an important part of the direction that we are moving in.
Thank you. That was useful. As you know, the themes that we want to pick up, which I will outline for the record, are maximising the benefits of computerisation; repeat prescribing and reducing waste; managing patients' expectations; and patient compliance. We might also wish to ask about the GP contract and its effect on prescribing.
There is no simple answer. A vast range of clinical information systems is being developed, in secondary care in hospitals, in primary care, and between primary care and the social work sector. I cannot say when that big programme of computerisation will be complete—in fact it will never be complete, because the process of refreshing computer systems is on-going. My colleagues might wish to talk about specific projects. Specifically, Hamish Wilson might wish to describe projects around electronic communications in primary care and Bill Scott might wish to give you information about systems that are being developed with community pharmacies. As I said, there is no simple answer to the question when will we have computerised the NHS; the situation is not like that.
The ECCI—electronic clinical communications implementation—programme covers a number of clinical communications areas, such as referrals to hospitals, laboratory tests and discharge letters. Implementation is taking place through project management throughout Scotland. One specific target is to ensure that by the end of the year all GPs have access to laboratory tests. An independent evaluation of the ECCI programme is being undertaken through the University of Dundee, which will report at the end of the year. That will allow the local and national projects to take stock of what has been successful and what has not worked, and the programme to continue. As Trevor Jones said, the programme is on-going. In a sense it will never be complete, because there will always be developments that IT needs to catch up with. Do you want me to turn to the internal IT issues in primary care?
Yes, because that might answer questions that we were going to put.
As Trevor Jones said, general medical practice has probably been fairly well developed in terms of implementing information technology. Almost every practice in Scotland has a computer system that is linked to NHSnet, which allows them to communicate with other bits of the system, whether primary care or hospitals. GPs use their computer systems in a variety of ways, but the new GMS contract, which I suspect we will return to later, will encourage practices to make even greater use of information technology in communicating with patients as well as with others in the system.
That is helpful. Why does "The Right Medicine" suggest that the electronic transfer of prescriptions will not be in place throughout Scotland until 2005?
That time frame will allow the development of practice to ensure that practice is not driven by technology, but that technology underpins practice. The pharmacy supplier systems are privately purchased and we have to work with them and get agreement to develop support within the pharmacy and then links between the pharmacy and GPs and between the pharmacy and the Common Services Agency. That is complicated by changing practice at the same time as trying to introduce the new technology.
I want to follow up the point that was made by Dr Wilson about community pharmacies. Given the enhanced role of community pharmacies, what access to patient information will they have? You talked about a sort of technical store. What is the actual conduit and how far will it go, from the community pharmacists' point of view?
In the current ETP pilot scheme in Ayrshire and Arran, agreement was reached between GPs and community pharmacists whereby—with the consent of patients, which is fundamental to the whole process—some limited but appropriate clinical information could be passed at the same time as the passing of a prescription, to be held with the prescription and drawn down by the community pharmacist. The pharmacist receives information not only about the medicine that may be required on the prescription, but about the diagnosis of the patient, which helps the pharmacist to give better advice and service to the individual patient when they use that pharmacy. We wish to continue to develop that principle as part of the wider e-pharmacy programme for both chronic disease management and acute management.
More generally, when do you think that we will be able to link prescribing information with patient-based information to facilitate audit and better clinical governance?
In a way, that already happens at the level of the individual practice. The individual practice records can be used—and are used—for audit purposes in considering the effectiveness of the use of medicines in treating specific diseases in specific patients. That also will develop further with the implementation of the GMS contract. The information that practices will be incentivised to keep and transmit to central systems will allow much clearer linkage between the medicines that are prescribed and the patients' needs. That can happen already, but the new system will allow it to happen more easily.
What are the links between "The Right Medicine" and the NHS strategy for information? What will be—or is—the overlap and interface?
"The Right Medicine" should not be seen as a stand-alone document: it is part of our overall strategy for improving care in our health service. Therefore, "The Right Medicine" will be built into the IT strategy and general communications strategies.
On the general issue of governance, how does the NHS strategy link with wider Government IT developments? Are any benefits coming through? Are there any barriers to the strategy?
At the highest level, there is a modernising government committee in the Executive. The principal parties to that committee are the Executive, local authorities and the NHS. The chief executive of an NHS trust and I represent the NHS around that table. We are in discussions about, in particular, the issue of single shared assessment for older people and establishing systems that support both the NHS and local government social work departments to ensure that we have a common IT system in place.
Margaret Jamieson has some questions on repeat prescribing—
—and reducing waste.
I shall begin to answer those questions, but my colleagues will want to add to what I say. I guess that there are different levels to the way in which we are addressing the problem of waste. At the highest, strategic level, NHS Quality Improvement Scotland reviews the effectiveness of drugs and issues guidance to the service about how drugs should be used effectively. The Scottish medicines consortium brings together all the area drugs and therapeutics committees of all the NHS boards in Scotland to review the introduction of new drugs. QIS therefore conducts detailed reviews of specific drugs, whereas the Scottish medicines consortium conducts a review of all new drugs that are introduced. The consortium's review is slightly less complex but it deals with a bigger volume of drugs.
The most expensive drug that is ever prescribed in the NHS is the one that is dispensed but not taken. We are very concerned about waste. Surveys that were undertaken in Aberdeen and in Ayrshire show the same trends. Around 33 per cent of the medicines that are returned to pharmacies are returned because the patient has died; around 33 per cent are returned because the therapy has been changed; and around 33.5 per cent are returned because the patients have stopped taking them. How do we tackle that? We must tackle it at the front end by improving our prescribing.
Can you say more about the quantity of drugs that are returned unused to community pharmacies? What are you doing centrally to ensure that there is some reclaim?
We are encouraging the use of patients' own medicines when they come into hospital. There are two reasons for that. First, it makes economic sense. Secondly, it gives the patient the opportunity to be in control of the medicines that they are taking. If you break your leg and go into hospital, you are sometimes treated as if you have broken your head, and your medicines are taken away from you. We are trying to put in place systems where patients are in control.
You indicated that the preliminary findings of the on-going pilot for repeat dispensing are quite positive. Can you say more about the model and its expected benefits? If it is being flagged up as successful, why are you not planning to roll it out until 2005?
The first pilots that we funded were in Aberdeen and Tayside. They were very successful, but there was a technical problem. When a pharmacist was given a prescription to be repeated for 12 months, they could not cash it in to the pricing division for 12 months, so the pilots had to come up with quite a bureaucratic system to get over that. We then looked into a master-and-slave system, in which there is only one prescription but there are unsigned copies, which are the receipts that go to the pricing division. We want to make the slaves electronic and get rid of that paper to start with. One of the problems—and it is a UK issue—is that of the electronic signature on prescriptions. We have no solution to that yet, and it is a reserved matter.
You mentioned reimbursement of pharmacists. In the first session of the Parliament, we examined how pricing interfaces with that system. Is the problem that we have still not got that system up and running to provide a straight-through audit process from the issue of the prescription to the pharmacist being paid? There could also be a problem with fraud if individuals say that they are entitled to free prescriptions when they are not. Is the problem that the system is not joined up?
Our intention is to ensure that the IT systems that we discussed earlier underpin all the things that Bill Scott has been describing, so that the whole process has a much better audit trail. It will also make the identification of possible fraud much easier. In fact, it will eliminate many of the checks that have to be done. When the community health index number goes on to prescriptions, that will allow people in certain age categories automatically to be regarded as exempt, with no need for any further check. By introducing sensible IT behind existing paper systems, we can make the process much more effective and patient friendly, although, as Bill Scott said, there are still some problems to be overcome in relation to such practical matters as signatures, which we must work out on a UK basis.
Is that a professional issue or is there some other problem?
It is a legal issue. The Medicines Act 1968 requires a handwritten signature on the prescription, as does the Misuse of Drugs Act 1971. The technical issue surrounds what an electronic signature would be.
When was the legislation last updated?
There are new statutory instruments all the time, but the act itself was passed in 1968.
Before the electronic age.
I would like to follow up on a number of the issues that have been covered in response to Margaret Jamieson's and George Lyon's questions. We have heard a great deal about the range of work that is under way, but could Trevor Jones and the other witnesses tell us how satisfied they are with the pace of developments in general?
I guess that we would all like to move faster, but we have to think about the history of IT development in the NHS. Until relatively recently, it was for individual NHS bodies to develop their own IT solutions, but I can give you a simple example of what has happened as a consequence of that. For financial ledgers—a very basic system for any organisation—we have 27 different systems working in the NHS in Scotland. We have a disparate range of systems performing similar functions in NHS bodies, which slows down our ability to develop a national IM and T strategy as fast as we would like.
I appreciate your answer and I understand the complexity of the situation. However, it is striking that the Auditor General's report gives a number of examples of systems that have not been rolled out at the pace that might have been expected, such as the master-and-slave repeat prescribing model to which Bill Scott referred, which was reported on in 2001 and seemed to be widely accepted as a way forward.
That is absolutely the direction in which we must go. I understand that people have justified concerns and frustrations.
As we are coming to the end of this subject, I ask for clarification on one point. Bill Scott talked about how reduced dosage might allow more regular monitoring, which would be helpful. However, there was of course the difficulty that that would lead to more prescriptions being issued—and more levying of the prescription charge. Irrespective of the impact on the individual, who might be paying for their prescription as opposed to receiving it free, are you saying that although reduced dosage might lead to initial savings because monitoring would allow GPs to change people's drugs or decide that certain drugs were not needed and so on, such savings would be lost because the increase in prescriptions would eat into budgets elsewhere?
The chemist remuneration aspect would not be affected, as we would have to change that anyway. There might be some small effect on costs of ingredients. I emphasised that the patient who pays for a prescription would consider it unjust and unfair if they were given only a fortnight's supply of a drug when they were used to getting a supply that would last two or three months.
Your point was about the impact on the patient rather than on budget transfers. That is helpful.
You said in "The Right Medicine" that, during 2003, you would run a number of major public awareness campaigns about the safe use, storage and disposal of medicines. Where are we with those public awareness campaigns? Are they likely to cover issues such as the overuse of antibiotics?
We have had campaigns about the use and overuse of antibiotics. This year, we also plan to have what is known as a dump campaign, to encourage patients throughout the country to return their unwanted medicines.
When is that dump campaign happening?
We plan to run that campaign before December.
I would like to go on to look at section 3.2 of the main report. We all agree that patient compliance is important, but there is also a need to use NHS funds as effectively as possible. Will your public awareness campaigns highlight to the public the extra cost of some types of preparations?
We had not intended doing that. There is a balance between helping the public to understand the cost of medicines and ensuring that people who are taking certain medicines do not feel inhibited about taking them because they feel that they are far too expensive. On the other hand, they may feel that not enough is being spent, so we have to be careful about costs.
Would you not see it as helpful to be able to highlight those costs to patients?
The helpful thing would be to highlight the cost of the overall waste.
Maybe you would want to highlight some of the associated costs in a public way, rather than to individual patients.
Yes. In fact, the schemes in Aberdeen and Ayrshire made health care professionals aware of the costs and of the type of medicines that were most frequently being disposed of unused.
We would be interested to find out how GPs can be encouraged to consider the extra cost of premium-price products against the likely improvement in compliance by individual patients.
I notice from the report that there were some major savings on premium-price products, and I can see good reason why that was said. On the other hand, if you are on four medicines, or if you are a forgetful person, premium-price medicines such as slow-release agents or patches are cost-effective because you are actually taking them. If doctors give medicines that have to be taken three times a day and the patient does not take them, that is another waste. A balance must be struck, and a clinical decision must be made by the GP at the time of prescribing.
That is important.
Very much so.
I would like to find out what the Health Department is doing to build up a body of evidence to assess the effectiveness of new medicines compared with existing medicines.
Let me start by saying that they are not doing the same job; they are all doing different jobs. You must remember that we are talking about £800 million worth of expenditure, so having sophisticated systems is justified, as the report shows.
That is postcode prescribing.
Yes. Yesterday, we had a debate about whether it should be compulsory for the national health service to take up the SMC's recommendations. If a medicine is effective, the debate should not be about whether it is available throughout the country, but about when it should be available and how it should be introduced. Following yesterday's meeting, I will be having discussions on that with the wider NHS.
When a medicine is licensed, either through the European scheme or in this country, what we are interested in is that it is of good quality, does what it says and is safe. We do not have a fourth hurdle. One could argue that building a fourth hurdle into the licensing process might save all the other processes down the line. However, it costs about £350 million to develop a medicine and, if we built in a fourth hurdle, we would add not only a substantial extra cost, but a further delay in getting those new medicines to the marketplace.
Have you not in fact introduced a further delay by having consideration by the SMC, boards and all the rest? Trevor Jones said that there is a sophisticated process, but I do not think that the system is sophisticated, because we still have postcode prescribing.
I believe that what is missing in the chain is the cost in terms of improved quality of life for the patient. Consider the social aspects: if a doctor prescribes drug A, the individual will be absent from work for a shorter time and, during that time, their quality of life will improve day by day and week by week. That does not seem to be included in the cost; only the cost of the product is considered.
The reason why that factor cannot be included initially is that, when a medicine has its licence and is launched, there is often a paucity of data about its cost-effectiveness and cost outcome. The SMC has to work with the information that it is given by the industry and from clinical trials. The SMC is an important development in Scotland and it has not yet been duplicated in the UK. The SMC allows a group of experts to look at the data that we have and then to give an indication to all the health boards about where that new medicine lies in the armamentation of clinicians. If it were not for the SMC, every health board would have to try to duplicate that process, but the current arrangement is an efficient use of resources. We do not have enough specialists in Scotland for all the new medicines, but every health board could conduct the same process if it wanted to.
It is worth adding that the SMC was created in 2001, and that before that, individual area drug and therapeutics committees were reviewing the same drugs. Sometimes they came up with different conclusions, which reinforced postcode prescribing.
Another issue is that, when some medicines are launched, they might not seem to be performers, so one must gather some clinical experience. Statins are a good example and they are now at the top of the league table in our drug bill.
We need to complement a national approach with an individual patient approach. We have been talking about clinical effectiveness and cost-effectiveness on a Scotland-wide basis and sometimes on a UK-wide basis. It is important that that information is available to the prescriber—normally the GP—when they have a consultation with a patient, so that when the decision is made to prescribe a medicine, the individual prescriber considers all three aspects—the clinical and cost-effectiveness of the drug and the individual circumstances of the particular patient. The third element cannot be dealt with at national level; it can be dealt with only on an individual basis between the GP and the patient.
That takes us back to the new GP contracts. It is for the GP to determine to which drug they put their signature. Is it not true that GPs are now being forced down a road where their independence and professionalism are somewhat compromised? If, when a GP enters the name of a drug that they want to prescribe into the IT system, a red light starts flashing and an alternative drug is flagged up, will they prescribe the amber drug, rather than the one that they believed would be better for the patient, if they know that they are getting to the edge of the budget?
That takes us back to the discussion about audit, which is a peer-based system that allows others to check whether what is being prescribed by an individual GP for his or her patients is clinically appropriate. That system will include the issues that you mention. You are right—we need to complete that full circle to ensure that clinical audit is part of that process.
Has the effectiveness of alternative treatments been evaluated?
Are we talking about alternative drug therapies such as homoeopathy?
Yes, anything like that.
I was not sure what you were after, so I will pass that question to Bill Scott.
As you know, the efficacy and safety of alternative medicines have not been evaluated as rigorously as those of conventional medicines. However, the European Parliament is considering licensing certain homoeopathic and herbal remedies. People in the homoeopathy hospital in Glasgow have told me that they are conducting trials of products. I understand that the chief scientific officer is funding four different trials, but I do not have the details. The CSO would look favourably on funding applications from practitioner specialists or academics who are interested in assessing products and practice.
That is interesting. Thank you.
I want to explore that area a bit further. If a patient asked their GP for herbal or homoeopathic treatment, would the GP give it to them?
Yes.
That would depend on the patient's clinical condition.
Absolutely.
It would depend on whether the GP agreed that there was a clinical need. Some GPs are particularly interested in alternative therapies and will provide them directly, but they can and do refer patients.
Is such referral part of GPs' training? Is there postcode prescribing for alternative treatments or does prescribing depend on a particular GP's interest in, for example, homoeopathy?
There is no postcode prescribing, but it probably helps if a GP is interested in alternative treatments such as homoeopathy. However, a GP can refer a patient to other practitioners. In fact, prescriptions are given on the NHS for homoeopathic preparations.
What about the new practice of GPs referring patients to, for example, health clubs? How common is that practice and how is it evaluated? Is that sort of practice now included in GPs' training? I am interested in the whole business of value for money and why we rely so heavily on drug therapies rather than alternatives to them. It seems to me that one barrier to using alternative treatments is that they have not been evaluated in the same way as drugs that pharmaceutical companies produce have. What can we do to open up the situation and provide more choice for patients and doctors?
We now take a much wider view of health. For example, prescribed exercise in health clubs is now encouraged. Hamish Wilson may be able to indicate where that is available. In the Borders, where I live, a patient can be referred to a fitness centre—indeed, I suspect that some of us should be referred to fitness centres. It is critical to take a wider view of health. Rather than think traditionally about the illness side, we should think about critical preventive issues such as exercise and diet. We must find all sorts of ways of encouraging the population to adopt different lifestyles. The NHS and GPs are good sources of health improvement advice.
There is an increasing use throughout Scotland of alternative outlets, if I can put it that way. That does not necessarily mean writing a prescription for alternatives, although some GPs give prescriptions to a patient that they can take to their local exercise club, for example. GPs are increasingly working among themselves and with others, such as local authorities, to promote healthier lifestyles, as Trevor Jones mentioned. Those schemes work best where they are carried out in partnership between the NHS and other local bodies, including voluntary sector organisations and local authorities.
I promise that this will be the last question, convener. What barriers still remain? Are alternative therapies being evaluated in terms of value for money? It strikes me that we talk all the time about comparing different drugs, but we do not take a value-for-money approach to comparing those drugs with the different approaches and techniques. Are we not missing a trick?
I am not sure that there are barriers. As with all new developments, it takes time to develop momentum and to move on, but I do not think that there are particular barriers.
Who pays for the trials of the drugs that are produced by pharmaceutical companies? How difficult is it for alternative therapies to compete?
For clinical trials, there is a mixed economy, in that the industry pays for materials and NHS staff get involved in undertaking the trial with the patient's consent. For alternative therapies, there is a need for an academic infrastructure to help to get a balanced trial. There are issues about how one gets a true double-blind clinical trial with some of those therapies. As momentum builds up and we see more practitioners of such therapies taking an interest academically, we may get a body of people who will want and will have the skills to undertake those trials.
I have a brief supplementary to Margaret Jamieson's question on the safe storage, use and disposal of medicines. Some time was spent talking about public awareness campaigns and measures being taken at a national level. I want to ask Bill Scott about the measures that are being taken at a local level and, in particular, about domiciliary visits by community pharmacists. I am aware that, where such visits have been developed, they have been effective at the level of the individual patient in terms of both safety and cost-effectiveness. I think that a commitment was made in "The Right Medicine" to develop those visits. Has progress been made on that?
"The Right Medicine" indeed contains a commitment to develop those services. Sadly, pharmacists who carry out such home visits do so after work because of the need to get the right manpower balance in our pharmacies. However, we are committed within our contractual process to allow pharmacists to undertake domiciliary visits where that is appropriate. I should also say that most pharmacies in Scotland will take back unwanted medicines. The local health board will pay for the uplift and safe disposal of those from the pharmacies.
We move on to the subject of how prescribing by GPs and independent contractors can be influenced.
I have three questions on the new GP contract, which is to come into force next year. One health board chief executive described the new contract to me as the most fundamental and far-reaching change in the NHS. I do not know whether he is right or wrong, but the contract will clearly have a role in influencing the way in which GPs prescribe. Hamish Wilson said that it will incentivise GPs. Can you explain how it will do that and what impact you believe it will have?
It might be useful if Hamish Wilson gave the committee a brief overview of the GMS contract—it is not just a GP contract; it is for all staff in primary care—and how that relates to prescribing. That will put the discussion into context.
Certainly. Go ahead.
It is interesting to hear the GMS contract described as one of the most fundamental changes to the NHS. It is a significant change to the way in which general medical services will be delivered by GPs and other members of the primary care team.
What impact do you think the contract will have? Will it be positive? What is the likely outcome? What is the hope?
If we start with the patient's perspective, the quality and outcomes framework is based on good clinical practice, as evidenced by international standards. The more a GP performs in line with the quality and outcomes framework, the more effective the clinical service will be. The contract is seeking to do nothing more than to reinforce what is already available, but to do so in a specific and structured way. The implementation of the contract can be helped by the advice and support mentioned in the Audit Scotland report; those areas of support will still be available, whether it be community pharmacists or practice pharmacists working with practices or prescribing advisers working with primary care trusts or boards. From the point of view of the patient, clear benefits in quality of care and appropriate prescribing ought to flow from the new GMS contract.
We should be able to see greater emphasis on the quality of care and greater reward for high quality. Whereas the old contract rewarded volume—items of service—there is a much harder focus in the new contract on improving the quality of the service provided.
I understand and acknowledge what you are saying, but what impact will there be on your prescribing costs? Will they be increased or decreased? Will waste be eliminated? What is your view on the likely impact?
We will get more effective prescribing, with the right drug being prescribed in the right quantity for the particular patient's needs. The measures are not being introduced just to save costs. They are not about reducing prescribing costs; they are about improving the quality of prescribing.
I understand that, but what impact will they have on the budget? You must have some idea.
We have not assessed that and it would be wrong to put figures on it. A complex equation would be required to answer that question.
Could we have an idea of the additional cost of the new contract?
We know the additional cost of the GP contract. Do you have the figure in your head, Hamish?
Yes—but not in relation to prescribing, which was being asked about. Additional funding is being allocated to support the implementation of the new GMS contract through delivery of services at practice level. The increase is one of approximately 33 per cent over the next three years over the current investment in general medical services. A whole lot of that increase relates to improvements in premises and in IT. It also relates to employing more staff in primary care—not just GPs, but nursing and support staff. A specific amount for any changes that might occur as a result of changes in prescribing is not, however, included in that increase. That amount is a separate cost, which does not come under the GMS contract.
So you have not evaluated that cost.
Given the issues involved, I do not think that we can. The report identifies a potential £14 million of savings, but recognises that that amount will always be tiny compared to the variation in drug costs, given changes in the products that come on to the market, which will continue. History tells us that drug costs will rise at a rate of about 9 or 10 per cent a year over the longer term—although that figure has been slightly higher over the past three or four years. New products will continue to come on to the market, and it is not possible to forecast what they will be. That is why I will not try to put numbers on changes relating to prescribing, which would be nonsense. The contract should help to ensure the most appropriate drugs being prescribed in the most appropriate quantities. It does not matter whether that increases or decreases cost; that will depend on what is coming into the system and on the needs of patients.
I seek further clarification about the position with regard to salaried GPs. Is it easier to influence what they do than what independent contractors do?
There are currently very few salaried general practitioners, the vast majority of whom are employed within practices. We therefore do not have a large cohort of salaried GPs on which to base anything. All GPs, whether they are salaried GPs or independent contractors, go through the same training system, have the same ethical code and have the same requirements. Whether they have a terms-of-service contract or an employment contract, they are there to provide the best clinical care that they can for the patient. They have also to take into account the needs of the whole community that they serve. There is always a balance to be struck. In that context, a salaried general practitioner is no different from an independent contractor with regard to the clinical requirements that are placed on them.
In general, the service has a very good relationship with GPs, and we do not have a major problem with influencing them. They want to work with their colleagues in secondary care and to think about how care might change. The direction in which we are going is to think much more about the total patient experience. We are developing managed clinical networks to link primary care with the care provided in district general hospitals and specialist centres. We are finding new mechanisms to bring clinical staff together in those groupings to address the patient experience. That work is going remarkably well. Like other health care professionals in Scotland, general practitioners are keen to work on that agenda. The way in which clinical professionals are working together in the Scottish health service is positive.
I would like you to clarify something. Will the new GMS contract change clinical practice in respect of prescribing practice? If we say that the relationship with GPs in Scotland is such that things will progress by means of co-operation, influence and so on, the implication is that contractual change is neither relevant nor necessary. Hamish Wilson said that salaried GPs are no different to independent contractors in terms of clinical practice. The logical implication of that statement is that any change to the contractual mechanism would be neutral in terms of its impact on prescribing practice. Is the contractual arrangement germane to prescribing practice?
Yes it is. In order to improve the health service in Scotland, the key issue for staff is that the right remuneration be geared to the right set of issues. That is why we are bringing in new contracts not just for GPs but for all NHS staff. The GP contract, with its focus on quality, is another tool to help us move that agenda forward. Although the GP contract is not our only tool, it is an important one and I have no doubt that it will help.
Perhaps I should clarify that the contract will be made available and applicable to the whole spectrum of GPs. We do not seek to distinguish between independent contractors and salaried GPs. In future, for a range of reasons that are outlined in the GMS contract, some GPs might choose to go down the salaried route.
I have one more question. Earlier this morning we heard about limitations on existing IT systems and about the need to improve those systems—Trevor Jones acknowledged that. Given that background, how will the department know whether a GP has achieved the performance targets that are set out in the quality framework?
As we speak, all of the main GP system suppliers are working hard to ensure that the IT systems that GPs use in their practices are of good enough. Practices and health boards need to be able to log on to access the information that they require and we need to ensure that the information is available and that it can be audited.
Will that be done in the form of a yearly audit of the system and a tallying-up at the end of the year of the points and payments that have been made?
Yes. The GP system will do certain things, but there will also be an independent audit of the result.
Thank you for that. We have a couple more questions on costings. George Lyon will ask the first, which is in reference to section 4.2.1 of the main report.
To what extent does the Health Department share with the health boards the assumptions about increases in drug costs in calculating the budget uplift every year?
We publish trends in prescribing practice on NHS Scotland's information and statistics division's information system. That information is available to NHS boards.
That is the total sharing of information.
Yes. That is how the budget varies. Some detailed documents are published—one came out this morning—about overall trends in drug costs. That information is made publicly available to health boards to help them to understand what trends might be in their budgets. They also have to take into account local variations. For example, if there was a cancer treatment centre in its area, a health board's rate of drug inflation could be different because of high-cost cancer drugs. Budgeting for that would be done locally.
What action are you taking to ensure that there is a full costing of evidence-based guidance on the implementation of new medicines?
We will have some idea of the impact that the SMC's decisions will have on NHS boards. When the SMC writes to NHS boards with its decisions, they can see how that impinges on the boards.
Does anyone have a final question?
I would like to explore a little further the business of comparisons between different medicines. When the effectiveness of different medicines is compared, are those trials called head-to-head trials? I read an article in the British Medical Journal on a proposal in the United States to conduct more such trials. It talks about the use of diuretics being as effective as other treatments for hypertension. Where are the head-to-head trials going on? Do they involve just new drugs that are being tested by the drug companies?
I am sorry, but I am not familiar with the phrase "head-to-head trials". The sort of trials that have been conducted in the past have involved testing a medicine against the gold standard. We are now interested in the relative efficacy of medicines when they are tested against other groups in a pharmacological class. Some of those trials are conducted in the health service or in our university departments.
Does the National Institute for Clinical Excellence look for evidence that a treatment is appreciably better than what is already available before it advocates its use in the NHS?
I could say that that is an English Department of Health initiative. NICE looks at the cost-effectiveness of a product and its economic impact and judges that against what is already in the marketplace.
Are the results of that are used in Scotland?
QIS would examine that evidence and come to a view on its relevance to the Scottish health service.
There being no further questions, I thank Mr Jones, Dr Wilson and Mr Scott for giving us evidence this morning. It has taken a little bit longer than we anticipated, but it has helped to satisfy the demands of the committee. Thank you for your time.
Meeting suspended until 12:12 and thereafter continued in private until 13:08.
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