Meeting date: Tuesday, November 24, 2020
Meeting of the Parliament 24 November 2020
Agenda: Time for Reflection, Topical Question Time, Covid-19, Supply and Demand for Medicines, Business Motion, Period Products (Free Provision) (Scotland) Bill: Stage 3, Period Products (Free Provision) (Scotland) Bill, Business Motion, Decision Time, National Adoption Week 2020
- Time for Reflection
- Topical Question Time
- Supply and Demand for Medicines
- Business Motion
- Period Products (Free Provision) (Scotland) Bill: Stage 3
- Period Products (Free Provision) (Scotland) Bill
- Business Motion
- Decision Time
- National Adoption Week 2020
Supply and Demand for Medicines
The next item of business is a debate on motion S5M-23342, in the name of Lewis Macdonald, on the Health and Sport Committee’s report “Supply and Demand for Medicines”. I call Lewis Macdonald to speak, on behalf of the Health and Sport Committee.15:08
I am delighted to open, on behalf of the Health and Sport Committee, the debate on the report of our inquiry into the supply and demand for medicines.
I start by thanking all those who gave evidence to our committee in person or in writing, the committee’s clerks, the Scottish Parliament information centre researchers and other parliamentary staff who assisted. We could not have made the report without all those people. All our recommendations were agreed unanimously by all members from all parties.
I am sure that members will all agree that I should extend our thanks to all the people who work in health and care, who have done so much to keep so many people from harm in recent months. The report is focused on what needs to change to give those dedicated staff the best chance of success in the future, although the Health and Sport Committee has never lost sight of the vital work that is done every day in the care sector and in the national health service.
Our core job as a parliamentary committee is to support those who work in our public services and those who use them by seeking ways to strengthen services, both by improving services to the public and by delivering them more effectively and efficiently. That scrutiny is right at the heart of our parliamentary democracy.
The well-earned respect for our health and care workers must not be used as a barrier to scrutiny and constructive criticism of health and care systems as a whole. Our job is to ask difficult and searching questions, and to draw conclusions from the answers, which will help to make a difference.
The Government’s job is to respond to those conclusions; in this case, extracting a full response from ministers to this substantial report has proved to be a challenge in itself. It is important to put on the record that the Government’s full response to the recommendations of our report—which was published in June—was received by committee clerks and members only yesterday afternoon. The proper working of Parliament’s committee system requires the full engagement of Government ministers with the work that we do, and it is a fundamental requirement of a democratic Government that it be fully accountable to Parliament at all times. Ministers did reply to our recommendations before our debate today, but it is disappointing that it took them until the last possible day to do so.
This is a large and substantial report that covers a range of complex topics—drugs budgets, prescribing practice and dispensing and consumption of medicines. Each of those four areas could easily have justified a major report in its own right. However, we took the view that they are so interrelated that change in one area would inevitably lead to change in the others.
We wanted to shine a light on the reasons for the continuing rise in the cost of medicines to the national health service, which now stands at more than £1.8 billion per year. Our attention was soon drawn to a report by KPMG, which showed that up to half of all medicines that are prescribed and dispensed were not actually consumed as directed. That is clearly an enormous and annually recurring issue, yet we could find little evidence of anyone taking any concerted action to address it.
Altogether, we made 129 recommendations on how medicines management in Scotland can be improved—from straightforward adjustments to more fundamental changes in how the system performs.
Much of the process of approving new medicines is done at United Kingdom level. Therefore, we also looked at reserved areas. Scottish ministers, or their representatives, had a seat at the table in every area that we examined. The decisions that they take, the input that they make and the influence that they wield make a difference and have real-life consequences here in Scotland. They are therefore accountable for those actions to this Parliament. It is one of the great strengths of parliamentary committees that we are free to follow the evidence wherever it takes us, so I encourage ministers to welcome our scrutiny on that basis.
The most important conclusion of our report is that the system of supply and demand for medicines in Scotland does not focus on patients. It is therefore disappointing that at no point in the very substantial response from the Scottish Government is that conclusion addressed. Perhaps the minister will indicate in his speech whether he agrees with the committee on that central point.
Throughout our inquiry we were presented with issues that pointed to that conclusion, and many of the issues appeared to go beyond medicines to point to wider-ranging problems in the NHS. The most prominent of those are the way that information about the patient experience is collected and the infrastructure that is used to store, share and analyse the information.
Lack of information on the outcomes of prescribed medicines is of huge concern. The impact on individual patients of taking medicines is not examined and—even worse—is not routinely sought. Patients in primary care are not receiving follow-up care to ensure that the medicines that they have been prescribed are effective, or even to find out whether they are taken at all.
We found that the lack of effort to understand people’s experiences of taking medicines impacts on the system at every stage. Evidence described the improvements that could be gained from collection of outcomes data during research and development, through to consumption by the patient. As we stated at the beginning of our report, we are clear that gathering, analysing and sharing that information in a comprehensive and systematic way across Scotland would be the single most beneficial action to result from the inquiry, so we urge the Scottish Government to highlight how it will do that.
A lack of suitable data and information technology has the potential to cause harm to patients. Systems that are designed to transition people between primary and secondary care are not sophisticated enough: the then chief pharmaceutical officer told us that most harm happens on the crossing of boundaries between care settings. We welcome the work that is being done on that, but we are concerned about what is happening for patients in the meantime.
We found that patients who were ready for discharge from hospital could face hours of delay—sometimes resulting in an additional night spent in hospital—because of delays in preparing their medicines. When we challenged the lack of action on that, we were given a list of reasons to explain why a doctor’s prescription in hospital takes so many hours to fulfil. That glaring example of lack of patient focus seems currently to be beyond the ability of NHS leaders to resolve.
We have recommended that relevant medical records be made available to all health professionals who need them, and we have again emphasised that it should be patients who own that data. We note the speed with which record sharing has rightly been put in place to meet the challenges of the Covid-19 pandemic; we want to see equally swift and decisive action to make records fully available to all professionals at all times.
Our report considered the implementation of the hospital electronic prescribing and medicines administration, or HEPMA, system. Its commendable core purpose is to generate data and outcomes. The business case was agreed in 2016, but not a single health board is yet in a position to gather that data. Many boards are still in procurement and many are using different software. The few systems that are in use are not being fully utilised to analyse information on outcomes.
The cabinet secretary wrote to us earlier this month and said that
“good progress is being made in implementing HEPMA,”
and that the implementation date across the country is not, in fact, March of next year. Perhaps the minister could clarify when he expects all boards to have functioning systems delivering information and when they will all be using that tool to its full effect.
HEPMA is a perfect example of one of the other key concerns that arose throughout the inquiry: a lack of effective leadership in the NHS. Evidence that was presented to us by senior health leaders detailed issues and problems throughout the system, but rarely explained how those problems would be addressed. We heard repeated acknowledgements that systems and governance were not in place to cover the various aspects of a medicine’s journey from research to patient. We also observed a lack of willingness to take responsibility to deliver change.
We heard that reviews of prescriptions are not taking place as a matter of course, which contributes to potential harm to patients, as well as to waste. One director of pharmacy told us:
“A medicine that is prescribed but which goes to waste is, in effect, the most expensive medicine we could buy.”—[Official Report, Health and Sport Committee, 4 February 2020; c 2.]
We also heard evidence that a lack of knowledge about non-medicine options leads to a continuing failure to maximise the potential of social prescribing.
In this year’s budget inquiry, we found that just over £19.5 million out of £8.5 billion that was allocated to integration joint boards will be spent on social prescribing. That is less than 1 per cent. Our report in February recommended that that figure should be at least 5 per cent, and the Government accepted that recommendation.
We found in a number of areas gaps between Scottish Government expectations and what happens in reality in general practitioners’ surgeries. Those areas include prescription reviews, social prescribing and realistic medicine. That caused us to wonder how the policy objectives that are set by the Government are communicated, measured and evaluated.
The obvious vehicle for requiring behaviour change is, in the view of the committee, the general medical services contract. The contract does not, however, appear to require adherence to those policies. Evaluation of the contract seems to be a long-term project; it will be three years before monitoring and evaluation priorities are even determined, and not all the changes that were made to the contract in 2018 will be subjects of monitoring and evaluation.
We are concerned by the lack of evaluation of both the role that GPs play in our primary care system and of the freedom that they have to decide whether to adhere to national policy. They are the recipients of almost a billion pounds of public funding, but the levels of accountability for GPs are surprisingly low.
The report recommends consideration of how the contract can be amended to require better systems—for example, for prescription reviews. Similarly, the committee believes that the community pharmacy contract could do more to require pharmacists to undertake monitoring and evaluation to maximise the work that they do in communicating with patients on their medicines. Many excellent opportunities for data to be collected on the patient experience are not being taken, simply because that is not mandated by the contract.
I will not speak for the minister—he will speak for himself—but the Government’s response to many of our challenges appears to be defensive. However, I hope that, on reflection, ministers will agree with our central proposition, which is that if patients are truly put at the heart of the system for supply and consumption of medicine, we will get a more efficient system and deliver a better service to patients.
On that basis, I will move the motion in my name on behalf of the Health and Sport Committee.
That the Parliament notes the conclusions and recommendations contained in the Health and Sport Committee’s 6th Report 2019 (Session 5), Supply and demand for medicines (SP Paper 774).15:20
I start by agreeing with the convener of the Health and Sport Committee on that central and important premise of patient-centredness.
I want to put the report that we are discussing into context. With regards to timing, it is important to note that the evidence sessions on which the report is based concluded at the start of the Covid-19 pandemic. I take this opportunity to acknowledge the remarkable job that the health and social care system has done, and continues to do, in moving quickly and effectively to manage the threat that is posed by the Covid-19 pandemic. I think that the convener agrees with that point.
Since the evidence sessions closed, working practices across our health and social care system have adapted rapidly to minimise the threat to life. It is those very systems, under the same leadership that the committee’s report criticises, that have ensured that medicines have continued to be provided to patients safely and effectively in unprecedented times. In the face of heightened global demand for medicines as a consequence of the Covid-19 pandemic, Scotland’s NHS managed the tremendously difficult job of balancing supply and demand to ensure that it did not run out of medicines.
I echo the disappointment that the Cabinet Secretary for Health and Sport expressed in her response to the report when she said that it
“risks damaging the people of Scotland’s trust in the NHS and the care that it provides.”
I know that that was not the committee’s intention, as I think the convener made clear in his opening remarks. However, the Government’s view is that the report goes far beyond the published remit. Some of the evidence that was presented at the hearings has been misunderstood or presented inaccurately. Some of the highlighted areas are reserved to the UK Government and, much as we would like to act on them, we simply do not have the powers to do so at this time.
I acknowledge the points that the minister makes, but does he accept that it is for a parliamentary committee to determine how to interpret its remit, rather than for the Government? Does he accept that, where the Scottish Government has an input to UK-wide discussions, it is entirely legitimate for a committee to hold the Government to account for that?
Indeed—I was just about to make a point about the discussions that we have with the UK Government.
It is absolutely for the committee to set out its remit. My point was that perhaps the report goes beyond the remit as stated. The Government and others engaged with the committee on the basis of the remit as published and advertised, but the report perhaps goes to other places. However, Lewis Macdonald is absolutely right that it is for the committee to decide on that. That is why I was very clear in saying that that is our view. I hope that that is clear.
On discussions with the UK Government, we will of course continue to speak up for and protect the people of Scotland in discussions with our UK counterparts. However, it is our view that the report represents such issues unfairly and does not fully capture the nuances of reserved and devolved responsibilities.
I will move on to some of the key themes that are identified in the report. On the topic of research and development, we welcome the therapeutic advancements in these areas and, in particular, the opportunities that they offer to personalise medicines for individual patients and their transformative potential, as they offer the possibility of long-term remission.
We are working to ensure that an overarching approach to considering advanced medical therapies is in place to facilitate a once-for-Scotland approach wherever possible. That includes horizon scanning, payment models and budgetary planning considerations.
On licensing and the acceptance of new medicines, as the committee will know, the regulation of the licensing of medicines is currently reserved to the UK Government and is the responsibility of the Medicines and Healthcare products Regulatory Agency. Because of the reserved nature of licensing of medicines, the Scottish Government will seek to collaborate with the UK Government and other stakeholders to encourage and incentivise companies in relation to licensing.
In addition to incentivising companies to submit applications for licensing, there are other opportunities to use licensed medicines outwith their original indication when there is a clinical need, such as off-label use. The report notes that an off-label cancer medicines programme, supported by Healthcare Improvement Scotland, published advice for NHS board area drug and therapeutics committees on the managed entry of off-label uses of cancer medicines. The learning from cancer medicines will, of course, be used to inform awareness and improve the quality of governance of off-label use in relation to other medicines.
The Scottish Government will initiate discussions with the UK Government and MHRA on streamlining and shortening the process for additional licences and healthcare technology assessments for new indications for existing drugs.
The report raises issues around purchasing and procurement, and again, the regulation of that activity is reserved to the UK Government. However, again, it is a Scottish Government policy objective to achieve, within our devolved competencies, the best possible prices for medicines. Medicine pricing is reserved and is regulated through the UK voluntary pricing and access scheme. However, a key objective that was achieved during the negotiations on the scheme was the establishment of binding commitments on Governments across the UK and the pharmaceutical industry to greater transparency and parity in medicine pricing.
The Scottish Government is pleased to see an explicit undertaking in the new agreement that the detail of national commercial arrangements agreed in one country will be made available on a confidential basis to the other purchasing authorities in the UK.
Through better practices in prescribing. dispensing and consumption, significant reductions in waste and costs can be generated by the better use of medicines.
At the patient level, caring for patients with multiple morbidities is an increasing global challenge, and a number of prescribing strategies have been published that lead to structured reviews of appropriateness, efficacy, tolerability and treatment.
The inquiry references many of the findings of the independent 2016 Montgomery review of access to new medicines. We should note that many of the review’s recommendations have already been implemented, and steady progress is being made on the remaining recommendations.
The convener took some time to talk specifically about data. We are evolving our approach to medicines data with a view to enhancing Scotland’s international reputation in health data research. Dr Montgomery’s review recommends the development, agreement and implementation of a national cancer dataset, and the cancer medicines outcomes programme is a vital first step towards achieving that.
Good progress is being made across Scotland to improve the management of the supply of and demand for medicines, which was the intended focus of the inquiry. We have already significantly increased access to new medicines because of our recent reforms, and I look forward to continuing to work with the committee constructively to continue to make progress.
I should say that there is a little time for interventions.15:29
I begin by referring to my entry in the register of members’ interests, specifically those that relate to health technologies and pharmaceuticals.
I thank the members of and clerks to the Health and Sport Committee for a very thorough and detailed report. Having joined the committee only in September, I did not participate in the evidence sessions or in writing the report itself, but I subscribe to its findings, along with my colleagues.
It is a particularly robust report and although the Scottish Conservatives broadly welcome its findings we acknowledge that a wider debate needs to occur in relation to its recommendations. I have looked, briefly, at the Scottish Government’s response to the report, which was received yesterday. I find it disappointing that the Government did not respond more positively and I also have to say that it is inexcusable that its full response emerged only the day before the debate, leaving precious little time for it to be digested and properly considered before we debated it today.
As the convener alluded to in his opening remarks, the inquiry focused on the management of the medicines budget, including the clinical effectiveness and cost-effectiveness of prescribing. It honed in on the four key areas of purchasing and procurement, prescribing, dispensing and consumption. I will try to cover parts of those areas in my speech.
The report was scathing about what it described as
“the dismal failure of the NHS in Scotland to implement comprehensive IT systems which maximise the use of patient data to provide a better service”.
It went on to state that
“where a lack of patient focus was acknowledged this was not followed by a solution or plan to take action, but simply left hanging for us to add to the list of issues with medicine management.”
In my view, the report rightly called for the need to have
“consistent and uniform IT systems in operation”.
The Royal College of General Practitioners Scotland argued that IT systems need to be
“improved in terms of reliability, speed, and interoperability to allow health care professionals working in different parts of the system to share data quickly and safely.”
We agree with those findings. It is clear that there is an urgent need to drastically improve our IT systems in the NHS. They appear to be well behind systems used elsewhere in the UK.
The report also noted that significant action is required on reducing waste associated with the consumption of medicines. It noted several concerns in that area including overordering by patients, prescription of drugs that are ultimately ineffective, patients failing to adhere to prescriptions, and medicines that have been prescribed and dispensed but are then not taken and cannot be brought back into stock.
It stated that a PricewaterhouseCoopers report commissioned in 2016 noted that an
“estimated 50% of patients do not take medicines as directed”.
That is half of patients and is a worrying figure. Aside from the obvious concern that patients in that position are not fully benefiting from treatment, it is also a colossal waste of resources and is something that the NHS in Scotland must tackle. That has been identified as a long-standing problem.
The committee urged the Scottish Government to work more closely with pharmacists to help improve adherence and the British Medical Association argued that health technologies could be better utilised, including the use of dosette boxes, apps and text messages as a means of reminding people to take their prescribed medication.
Other interesting suggestions that came up in the report and should be considered include that of AstraZeneca, which noted its work with NHS Greater Glasgow and Clyde to introduce a “smart inhaler” linked to an app that would help patients to keep to their prescribed regimen, and the University of Strathclyde said that
“new sensor and monitoring technologies will enable key stakeholders from health care professionals through to the pharma producers to engage more effectively with patients”.
The report also raises issues around prescribing, arguing that the prescriber in Scotland wields “immense power” when it comes to making clinically effective and cost-effective decisions as to which medicines to prescribe. The committee took evidence that suggested that because
“prescribers have a significant degree of clinical independence to respond to patients’ needs the ‘system’ cannot ‘ensure’ patients receive the most clinically and cost-effective treatments”.
Perhaps most controversially, the committee said that prescribers are
“instinctively reaching for the prescription pad”,
and not taking the time to discuss medicines with patients. That has turned out to be a particularly controversial statement. I note the comments from the BMA, which argued that it is an unfair characterisation, and that any return
“to a system of incentivising particular actions, accompanied with a high degree of scrutiny… would be a substantial backward step”.
It is clearly a difficult area, requiring further discussion between the Scottish Government, the NHS and prescribers.
Would Donald Cameron agree that, while the BMA was very sensitive about comments such as
“reaching for the prescription pad”,
work has already been undertaken to look at improving certain aspects? For example, where pharmacists are now embedded in general practitioner practices, GPs can look at polypharmacy as a way forward.
I certainly acknowledge Emma Harper’s point about the BMA’s sensitivity. We must all acknowledge and accept that, because prescribing is a difficult issue and there is a tension there.
I accept that work is being done, as Emma Harper said, but the committee’s broad view was that more needs to be done. It argued, for instance, that—as Lewis Macdonald highlighted—the Scottish Government should examine the lack of leadership in
“proposing innovative, coherent and comprehensive solutions which ... would deliver efficiencies and savings”
in the system. In addition, it suggested that
“Little detail was offered as to how change might actually be brought about”.
Although much of the report is understandably critical of many of the systems that are currently in place, it also suggests several solutions and makes recommendations. In my view, it marks an important milestone in the debate and signals a starting point for further dialogue with those in NHS Scotland and in Government, and those in the various representative organisations, about the way forward.
Let us hope that the report does not gather dust but acts as a spur to action. I reiterate my thanks to colleagues on the committee and to the clerks for their work. Although none of the recommendations is set in stone, I urge the Government and the minister to take the report seriously and work proactively to ensure that policy around medicine works, first and foremost for patients.15:36
I am pleased to open for Labour on this important committee debate on the supply of and demand for medicines. As a member of the Health and Sport Committee, I read all the evidence and was present for all the witness sessions that formed the basis for our report.
As we have heard, the report is comprehensive and hard-hitting, and it does not pull its punches in respect of the Scottish Government. I would have hoped that we would have received a full response from the Government in ample time for the debate, rather than at the 11th hour. Perhaps ministers can explain and apologise for the delay and clarify why the Scottish Government felt that the committee had gone beyond the remit of its inquiry. That is not the Government’s role, and it crosses the line with regard to the independence that Parliament rightly provides to committees.
As the convener and Donald Cameron pointed out, the key point in the report is that
“the system of supply and demand for medicines in Scotland does not have a focus on patients.”
The report provides a damning analysis to support that assertion: It notes that the service
“is burdened by market forces”
“reported under resourcing, inconsistent leadership and .... an almost complete absence of useable data.”
Furthermore, the report states:
“The impact on individual patients of taking medicines is not being examined and worse, it is not routinely sought.”
The committee found few, if any, details of any practical steps that were being taken to achieve change. Gaps were identified—for example, why was there little mention of integration joint boards as part of the solution? A common and recurring theme was the almost complete failure of the NHS to implement and manage comprehensive IT systems.
As the convener said, the committee took a keen interest in, and saw the potential of, HEPMA—the hospital electronic prescribing and medicines administration system. There are obvious and clear benefits of the system, which collects and shares data on prescribing. Those include:
“Improving the quality of prescribing”;
a reduction in
“errors between primary and secondary care”;
“Removing the ... manual audits of prescriptions ... which are resource intensive for staff.”
The wider benefit is that HEPMA allows data to be compared across all hospitals in Scotland, which allows for improved management intelligence so that outliers can be identified and performance improved. That means better services for patients and more efficient use of resources, and it might also fight geographic inequalities.
The Scottish Government has made it clear, since the publication of its 2017 document “Achieving excellence in pharmaceutical care: a strategy for Scotland”, that it is committed to implementing HEPMA in every NHS board. However, as the committee report noted, progress has been “disappointing”. Some boards have not yet started, and their five-year timescale to implement a system that has already been developed in other areas seems to be “excessive”.
It is of course for each individual health board to procure and implement its own version of HEPMA. That appears to me to be inefficient; it does not allow for the economies of scale that would be part of a national procurement exercise.
The committee report said:
“In light of the benefits, it is disappointing to learn roll out of this system across Scotland is patchy, slow and proceeding at a snail’s pace with a variety of systems being considered and individually designed and procured.”
I will move on to social prescribing, which is a key area and was the subject of a separate inquiry by the committee. A number of submissions suggested that there was a culture of
“reaching for a prescription pad while failing to explore alternative options, which could be safer”
and that could bring more long-term gains for patients.
Argyll and Bute health and social care partnership suggested:
“Not all GPs support the concept of social prescribing”.
Some GPs argued that there was a “lack of strong evidence” making a clear link to long-term gains from social prescribing.
We have to be realistic about the current landscape. Both the BMA and individual GPs—certainly those who I have met—would argue that they are under tremendous time pressures, stresses and demands, which have been placed on our practices during the Covid-19 pandemic.
The evidence suggests that a cultural change was needed to achieve higher levels of social prescribing. As Rose Marie Parr, the Scottish Government’s chief pharmaceutical officer, said:
“We can educate people to not think that a prescription is the first thing. We have to look at not just self-care but aspects of talking therapies and social prescribing. That involves a mindset change for patients and the public”.—[Official Report, Health and Sport Committee, 21 January 2020; c 7.]
I would welcome the minister’s view and the Scottish Government’s view on how they propose to manage the change so that social prescribing is perceived as an equal partner to the prescription pad.
The report is a vital contribution to the medicines debate. The committee is providing a valuable service to the Scottish Government in a number of areas, not least social prescribing, HEPMA and the comprehensive review of IT systems. That, after all, is the role of committees and Parliament: to keep the Executive in check and to provide advice, guidance and assistance. As Benjamin Franklin famously said,
“The best doctor gives the least medicines.”15:42
I start by sharing the concern that has been expressed by other committee members at the very late hour and the contemptuous nature of the Government’s response to our inquiry, and particularly the suggestion that we have indulged in mission creep. I do not think that it is for the Government to tell committees of the Parliament how to conduct their business.
It is easy to take for granted the health advantages that we now enjoy, such as the eradication of smallpox and the development of the whooping cough vaccine that is given to pregnant mothers, protecting babies before they are even born. Modern medicine does not just save people’s lives; it can also totally transform them.
Members may remember a constituent of mine, Murray Gray, who turned eight in August. Murray suffered many violent epileptic seizures every single day, due to a rare form of epilepsy. At first, clinicians tried several existing medicines in an effort to treat him. Sadly, Murray suffered even more with the horrible side effects. Sodium valproate caused a blood disorder when Murray was not producing enough red blood cells. Steroids caused him to gain 2 stone in weight in just three months. Then, Epidiolex, a cannabis derivative, caused serious diarrhoea all day and did not even stop the seizures. Murray missed school and the fun of childhood that he should have been enjoying.
Murray’s mother, Karen, dedicated herself to researching a better way. She found that another cannabis derivative, Bedrocan, was a game changer. Murray has now not had a seizure for more than a year and a half. He is a happy boy, who has returned to a healthy weight and is enjoying school. That is entirely bankrolled by his parents, however, as the product is not legally prescribable at the moment. Legislation on medical cannabis is a debate that I would hope to have soon, but that is for another day.
My point is to illustrate the difficulties when our medicines supply system is not patient focused, when it gets entangled in wider criminal justice issues, or when it is market driven. Although we have come a long way, we can certainly do a lot better. As science better understands how we can treat illnesses and disease, we need to be fleet of foot in the supply of better drugs, while ensuring that we get good value for the taxpayer and good treatment for the patient.
I would like to thank all those, including health board staff and medical industry workers, who came to present evidence to the committee, which ultimately led to the publication of the report in June.
The Government responded to our report but not to all the findings in the depth that we had wanted or hoped for. When we finally got a more detailed reply to our recommendations yesterday afternoon, I was disappointed, as I said at the start of my remarks, by the tone of the response and the rejection of our recommendations. I do not agree that the committee went beyond its remit, and I am surprised that the Government felt that it had to suggest that we did.
The fact that the committee made 129 recommendations in and of itself shows the scale of change that is required. That is not tinkering at the edges. We need creative and bold long-term strategic thinking if we are to update how we supply our medicines and improve the patient experience and the working practices for staff.
I do not have time to cover all the ground, or all the recommendations, so I will focus my remarks on a few areas of concern to me.
It is incumbent on politicians of all stripes to grow policy from an evidence base. Without good data, we will not get good practice. Unfortunately, that is the diagnosis for one of the main problems that we face.
If there is one thing that the Government should choose above all else to do with the report, that would be to start gathering information about people’s experience of taking medicines and to analyse and share the information comprehensively across our territorial health boards.
We have 14 health boards. Managing them is hugely complex, but there is no need to operate in silos when it comes to good practice on medicines. We need to take a whole-systems approach. It benefits primary care to share pilot schemes and the data gathered. We can share the workload, ensure that there is not a patchy patient experience across the country and ensure that more up-to-date care is rolled out wherever possible.
I will give an example. When asked how often repeat prescriptions are reviewed, Dr Scott Jamieson from the Royal College of General Practitioners said in his evidence to committee:
“I do not know whether we have data on that at a national level. In primary care, it is an expectation of long-term condition care that medicines are regularly reviewed. I can say with confidence that that happens. Is there always the time to have the conversations that we would value? I cannot speak for every colleague in Scotland, so I cannot say whether that is the case.”—[Official Report, Health and Sport Committee, 28 January 2020; c 22.]
That shows the downside of squeezing 10-minute appointments into the working days of GPs. Our average appointment lasts 9.2 minutes, which is one of the lowest average appointments for economically advanced countries in the world. Sweden averages 22 minutes for a consultation.
If we can alter the system so that GPs can routinely offer 15-minute appointments, they might be afforded more time to discuss important matters, such as reviewing long-term prescriptions. I think that some of the IT developments that have been brought by necessity as a result of the pandemic, such as NHS Near Me and online appointments, could go some way towards meeting that objective.
Speaking of GPs, we know from our casework at constituency level that many parts of the country need more of them. Even with the Government’s commitment to deliver 800 additional GPs by 2027, there will still be a shortfall of more than 600.
Investing in workforce planning, looking to upgrade how much data we gather about the patient experience and making a real investment in better IT systems will help our beloved NHS handle the challenges of the demand and supply of medicines.15:48
The inquiry was of particular interest to me for a number of reasons. I will begin by going over some of the things that my committee colleagues have mentioned. David Stewart spoke about our work on social prescribing in tandem with our inquiry on supply and demand for medicines. The BMA might not like this, but one of the concerning things was that GPs were reaching for the prescription pad, rather than trying to deal with the person and their issue. That is one of the criticisms that is put to the BMA and to GPs. I say with great love and affection that there are other ways to deal with people’s situations.
In considering the report, we must look at the timeline of what has happened. None of our evidence was taken after the Covid-19 pandemic started. We in the committee know that many of the barriers that were in the way have come down and that it has been a lot easier for people to work across the health service. If we held the same inquiry now, we might see that some of the issues that were so obvious then are not so obvious now. The issue now is to ensure that, post-Covid, we are in a position to be able to deal with those matters.
Many of you will know that one of the other reasons for my interest in access to medicines is my wife, Stacey, who has multiple sclerosis. I do some work with the cross-party group on MS and I am quite sure that colleagues on the committee are sick of hearing various stories of Stacey’s adventures in navigating the national health service, but I now and again manage to get a few of them in. The problem for conditions such as multiple sclerosis, and probably other complex conditions, is their very complexity. Large pharmaceutical companies say that it takes years to do research and that it costs them an almighty shedload of money. However, they more than make up for their costs when they license the products and they go to market. We then have the decision as to whether the medicines do what the big pharma companies say they can. There is also the cost, which can be astronomical, and the Scottish Medicines Consortium needs to make the very difficult decision as to whether the results are worth the cost. That is not helped by the fact that big pharmaceutical firms have by that stage gone into full sales mode and promised the earth to those living with long-term conditions.
During our inquiry, I also kept asking about branded and unbranded products. The branded products are the new, shiny, generic, state-of-the-art, expensive products, and the unbranded products are those that the companies are no longer making a massive amount of money on and are no longer licensing. Many consultants in the world of MS are looking at those unbranded products as a way of managing the condition, and they are looking at them for other conditions as well. Obviously, there is the advantage that they are cheaper than the branded products. There is also the fact that some products that have been used for one condition can now be used for something else, which is what the consultants are looking at. However, there is resistance to that from the industry, because the big money is in the shiny new product.
I have long believed that we should have state provision of those unbranded drugs—that the state should produce them centrally and drive down the costs so that we are not being ripped off by pharmaceutical companies. Does George Adam agree?
We should perhaps continue to have that debate, and I think that the report is the starting point for it. That is one of the issues that we are dealing with because, at the end of the day, it is about people’s lives, and the problem is how they get on with their lives. I am not saying that there is not a space for new medicines that can make similar differences to people’s lives. The world has moved on considerably, with Covid-19 being the main topic of everyone’s conversations. In that case, it appears that the large pharmaceutical companies have come up trumps with a vaccine. All I am saying is that we need to find a way that we can balance it out, because, currently, the vast majority of the balance is with the branded products.
In 2018-19, NHS Scotland spent around £1.7 billion on medicines, and most medicines—just over 103 million items at a cost of around £1.3 billion—were dispensed in the community. Although the total number of items that are dispensed to patients has steadily increased over the past decade, we have seen a fall of £6 million in the net cost of medicines since 2017-18, which is surely an example of how the Scottish Government is dealing with the issue and moving forward.
There is also the fact that the Scottish Government has made progress on the collection and use of data to improve patient outcomes, particularly in primary care, and it is important that we move that further on. We have to make sure that we have data for individuals available so that they get the right medication at the right time. It is also the right cause for health boards and for everyone else, as an important issue that came up during our inquiry was the need to significantly reduce waste and cost by generating better use of medicines. NHS Discovery provides comparative healthcare information for quality improvement, benchmarking, and performance management across the NHS in Scotland. We need to make sure that the barriers continue to come down. If Covid-19 has taught us anything, it is possibly that we can make this work, that we can make these things happen, and that we can bring down the barriers.
Looking at this report, I think that there is work for the Scottish Government and for us to do. However, let us remember that we are living in a brave new world and that things are completely different from when we wrote this report. We need to look at that when we are dealing with this and use this report as the basis for debate from here on in.15:54
I am pleased to take part in the debate, having served on the Health and Sport Committee during the time in which it undertook its important inquiry into the supply of and demand for medicines.
The inquiry focused on a number of themes including, notably, the need to use data more effectively and the desire to monitor patients’ outcomes in order to reduce waste and increase efficiency, on which I will concentrate my remarks. As Alex Cole-Hamilton has said, the key message that we heard loud and clear from all those who gave evidence to the committee was, overwhelmingly, that data is king, and that improving the collection and understanding of outcomes-focused data was critical to being able to improve patient care and to delivering a sustainable NHS.
We know that the NHS’s ability to track certain patient conditions—and, in particular, how medicines impact on them—is really limited; that the ability to accurately capture patient outcomes and experiences is still a major challenge; and that, although some welcome progress has been made, there is still a real need to see a commitment and renewed focus from the Government in order to achieve that. If the minister takes away only one thing from listening to contributions today, I hope that it will be that call for data to be given a priority by the Government, because tracking a patient’s care, from initial presentation in primary care, through to treatment and discharge from secondary care, while measuring any social care implications, would be incredibly valuable to the NHS, patients and their families and carers. Capturing and using that data will enable the health service to drive even greater efficiencies, and the better utilisation of the medicines budgets.
We really need to see progress on the use of flexible commercial arrangements with industry, to connect the price of a medicine more closely with its real-world performance. As Donald Cameron outlined, reduced medicines wastage, through the identification of inappropriate prescribing and increased adherence, is also vital, as are fewer hospital admissions and delayed discharges, the ability to treat more patients in the community through the use of preventative treatments, and, perhaps more controversially, the ability to address the overtreatment of individuals in our health service and the delivery of realistic medicine in practice.
As co-chair of the Scottish Parliament’s cross-party group on cancer, I put on record some of the concerns that have been put to me by a number of the group’s members, which relate specifically to the lack of data being collected on secondary breast cancer patients in Scotland. Many believe that improvements to the collection of outcome data would deliver real benefits, including refined treatment pathways to ensure that medicines are better matched to patients in Scotland, increased use of complex patient access schemes to enable faster access to the latest treatments and, perhaps most important, improved pathways to clinical trials.
I hope that the minister will take on board that ask, agree to review the current lack of data collection for secondary breast cancer patients in Scotland, and address that specifically in his closing remarks.
In its briefing ahead of today’s debate, Cancer Research UK stated:
“Every person diagnosed with cancer in Scotland should have equitable access to the”
“evidence-based treatments for their condition”.
The impact of the pandemic on our NHS should not be underestimated, as George Adam has outlined. From what I have been told by patients, it is likely that we will see a significant negative impact on access to clinical trials—as we have already seen over the past nine months. My greatest concern is that the significant progress that we have made to date on cancer treatments, and the improvement of cancer outcomes, will have been undermined during the period and will be negatively impacted for years to come. That is why, at the start of the pandemic, I lobbied ministers to start urgently developing plans to restart cancer services and screening.
Perhaps most important, as we come out of the pandemic, is the need to address some of the known health inequalities that exist around hard-to-reach patients with lower screening attendance. I hope that ministers will look urgently to act on that issue, so as to address those growing concerns in the cancer sector in Scotland.
The committee’s recommendations from the inquiry into supply of and demand for medicines are important. I hope that ministers will genuinely look at what the committee put forward, and will press ahead on the concerns that we outlined, regardless of the pressures that the pandemic has presented to Government.
To date, there have been delays in progressing innovative pricing arrangements and outcomes-based reimbursement. I understand that the Scottish Government has yet to involve industry or establish a task group to drive progress in those areas. We need to see progress urgently, to ensure that NHS Scotland can access the new drugs and treatments that we are starting to see on the horizon.
Our Scottish NHS must be able to secure value for money. It makes sense for the system to make sure that the NHS pays for medicines for which there is evidence of clinical improvement and benefit to patients’ quality of life, while ensuring that industry can be involved in breakthroughs, which will continue to be rewarded. At the end of the day, patients will gain from that.
To ensure the best outcomes for patients, Healthcare Improvement Scotland should endorse National Institute for Health and Care Excellence guidelines while up-to-date guidance from the Scottish intercollegiate guidelines network is on hold because of the pandemic.
The global Covid-19 pandemic has demonstrated the positive relationship that can exist between Governments and the pharmaceutical industry. The sensational work to develop vaccines is an example of the pioneering and rapid progress that we all want to see.
More flexible medicines pricing schemes, such as outcome-based payment, must be taken forward, to give NHS Scotland an opportunity to target spending at the treatments that are most clinically effective.
In the spirit of working together collectively to deliver for Scottish patients, I hope that a new relationship will be developed that meets the medical community’s aspirations to deliver access to the world-leading medicines and treatments that we all want to see.16:01
I thank the Health and Sport Committee for its report, and I thank the committee clerks and others for their work and contributions.
In a short debate, there is no time to address fully the many issues in the report or the Scottish Government’s astonishing response. The Government has had the report since June, but it waited until the evening before the debate to tell us:
“Whilst the Scottish Government acknowledges that the report highlights numerous important issues related to the supply and demand for medicines, overall we believe that the report goes far beyond the published remit of the inquiry and contains misunderstandings, inaccuracies and inconsistencies.”
Given those claims, the Parliament should afford the committee an opportunity to address the Government’s response fully. The report should certainly not gather dust, as a member put it.
As an elected member who has spent many years campaigning for better medicine choices for sufferers of thyroid disease—and who has a personal interest, as a sufferer of Hashimoto’s disease—I will consider parts of the report that pertain to issues on which I have advocated, to show the need for change.
In paragraph 1 of the executive summary, the committee summed up the experience of many thyroid sufferers when it said:
“a fundamental problem has become apparent—the system of supply and demand for medicines in Scotland does not have a focus on patients.”
Unfortunately, for thyroid patients, the focus recently has been very much on cost. Let me briefly summarise the problems that many people with hypothyroidism face. The most commonly prescribed drug is levothyroxine—T4—but it is acknowledged that at least 10 per cent of patients do not do well on that treatment. The only effective treatment for those patients is liothyronine—T3—which is routinely prescribed in the rest of the world.
In 2016, the 28-day NHS cost of liothyronine increased from around £4.50 to £258.19. That is an increase of almost 6,000 per cent. At the time, Concordia had a monopoly on the sale of liothyronine in the UK. Concordia has since been investigated by the Competition and Markets Authority, which found:
“Concordia abused its dominant position to overcharge the NHS by millions”
when it supplied liothyronine.
A 2019 report in The Lancet found that in NHS England no major study or guideline has advocated a change in liothyronine prescribing and that a substantial reduction in prescribing seems to have been largely driven by cost. Three companies now produce T3, but the price remains high.
I am thankful that the committee’s report confirms the need for greater public control over medicines research, development, production and sale. We cannot deliver healthcare and keep to the founding principles of the NHS when profits take precedence over patients, as the T3 situation shows and as Neil Findlay said in an intervention.
A not-for-profit, publicly owned pharmaceutical industry would be a good start to a move to develop more medicines that cure conditions rather than manage symptoms. If we aim to control the medicines budget and maintain cost effectiveness, such an approach must be considered.
I commend the committee for recognising the fundamental importance of greater public control. We really have to give further attention to how an industry that is underpinned by substantial public funding for research can then sell innovations back to us at grossly exaggerated prices. That might be very pertinent at the moment.
Turning back to thyroid issues, despite the minister stating previously that the Scottish Government’s position is that T3 can be prescribed by an endocrinologist
“if it is considered to be the safest and most effective course of treatment for an individual”,
women are still struggling to get T3 prescribed. Many also have problems being diagnosed and in getting beyond their GP to a proper consultation with an endocrinologist. Even then, they might not be offered T3 due to the postcode lottery.
Another challenge for thyroid patients, who are principally women, is that the medical establishment often blames the menopause, routinely prescribes antidepressants or just does not listen and properly diagnose or treat the medical condition that is being presented. Of course, finding the right solutions for patients is not made any easier when, as the BMA points out in its response to the report, GPs are still working within the confines of 10-minute appointments due to ever-increasing demands on them. Women are left facing that additional obstacle to gaining the right treatment and prescription medicines. The inequality and disempowerment in health provision that women suffer can no longer be ignored. We must see major change.
To be able to measure progress, we need better collection of data. I note that that is acknowledged in the report, and other members have mentioned it. The report also correctly recognises that when we determine and cost the clinical effectiveness of a patient’s treatment, we must listen to the patient. The report says that
“there is not a strict adherence to the principles of realistic medicine, patients are not equal partners in discussions on their treatment.”
Thyroid patients not getting the correct treatment certainly struggle to be heard, despite the fact that they need suitable prescriptions to function or even stay alive. There is mention in the report of the benefits outweighing the cost, and that is clear with thyroid patients, who struggle to work without the correct medicine, which has a massive economic impact, both individually and for society.
Many of the recommendations in the report have the potential to make great improvements for patients, but I fear that without brave and radical actions at both the UK and the Scottish level, we will struggle to put patient health at the forefront. We need many of the reforms that are laid out in the report to ensure that the supply of and demand for medicines in Scotland actually has a focus on patients. Once again, I find it regrettable that the Government waited until the 11th hour to respond.
I thank the Health and Sport Committee for its hard work.16:07
As a member of the Health and Sport Committee, I welcome the opportunity to speak in the debate. I offer my thanks to the clerks and the Scottish Parliament information centre, as well as to my fellow committee members for their hard work in contributing to the report. I also thank everyone who contributed to the inquiry and gave written and oral evidence to the committee.
As a committee, it is crucial that our work is informed by a wide range of experiences and views—especially when that information comes from those who are most directly affected by the issues in question. It is vital that we hear comments and thoughts from people from a wide range of backgrounds. I was pleased at the level of engagement and views from an extensive range of bodies and individuals in response to the committee’s call for submissions late last year. It is only by listening to all those voices that we can effect real and meaningful change.
As we have heard, the committee’s inquiry focused on four specific areas: purchasing, prescribing, dispensing and consumption. With an annual spend on medicines by NHS Scotland in 2018-19 of around £1.7 billion, most of which was dispensed in the community, we can see just how important it is that the health service, general practitioners and pharmacists all work to deliver effective prescribing for patients. The number of items issued in the community has steadily increased over the past decade from 89.3 million in 2009-10 to 103.4 million in 2018-19. It is testament to the work of healthcare professionals that, despite that increase over the past decade in the number of items dispensed to patients, there was a fall of £6 million in the net cost of medicines in 2017-18.
As a Fife MSP, I was particularly interested to read the written submission from NHS Fife area drug and therapeutics committee, which noted that
“other non-pharmacological treatment options would be preferable but access to those resources can be limited, constrained and challenging to access.”
The committee has recently reported on a separate inquiry into social prescribing, and interest in the subject has continued to be prevalent during our work on medicines. A number of submissions suggested that we have a culture of instinctively reaching for a prescription pad and failing to explore alternative options that could be safer for patients and represent cost savings for the NHS.
Speaking on the subject of social prescribing, the Scottish Government’s chief pharmaceutical officer said:
“We can educate people to not think that a prescription is the first thing. We have to look at not just self-care but aspects of talking therapies and social prescribing. That involves a mindset change for patients and the public, and a discussion about that needs to happen.”—[Official Report, Health and Sport Committee, 21 January 2020; c 7.]
That is an important point, and it must continue to be addressed. The links between the benefits of physical activity and improving overall health and wellbeing are well documented and widely acknowledged.
Medicines are the most common intervention in our healthcare system, so it is important that we get the most from them for patients and for the NHS. It is clear that a significant reduction in waste and costs could be generated by better medicine use, and it is vital that we challenge inappropriate prescribing, overprescribing and waste.
A substantial component of waste is where medication is not taken when prescribed, which is often referred to as “non-adherence”. In Fife, that problem has been acknowledged, and positive action has been taken to reduce the estimated £2.1 million annual cost of medicine waste. The action includes the take stock communication campaign for the public and staff; a non-prescription order model that has been introduced for selected products; an improved care home medicine returns process; a trial of pharmacy support workers in 12 care homes to support the ordering process; and a one-stop dispensing model that has been introduced in hospital settings. GPs and pharmacists are carrying out visits to look at residents’ medication. The aim is not only to save on waste; deprescribing and considering what medicines a patient is on can make a huge difference to their safety, wellbeing and frailty and to their ability to be better aware of what is going on around them, which can improve their general quality of life.
The NHS Fife submission also highlighted the desire of health boards to treat people closer to home in a more patient-centred manner by working with companies to make higher-cost and more specialised medicines available through local community pharmacy networks, rather than have the patient travel to what are often considered distant hospitals to access treatment.
I strongly agree that any strategy that seeks to reduce demand by promoting patients’ greater involvement in their treatment is a far more promising approach than adding more financial resource to meet ever-increasing demand.
Scotland is leading the way in community pharmacy service provision. Our community pharmacists are our most accessible primary care providers, with 1,257 pharmacies all over Scotland and a higher concentration of pharmacies in deprived and highly populated areas. The pharmacy is a good place to have a conversation about the use of medicines, why people are taking their medication and, if they are not, why that medication is still being dispensed to them.
There is also a communication issue around ensuring that the right messages get to the right people. It was interesting to hear Claire Fernie, who is a public partner volunteer with NHS Fife, highlight that point during an evidence-gathering session. She discussed the impact of the absence of a joined-up approach to clinical issues and cost effectiveness, particularly in relation to IT systems and the sharing of information between general practices, community pharmacies and hospital services.
As we make progress and move away from only doctors having prescribing powers towards an increasing number of health professionals having such powers, effective communication will be key. We will achieve an integrated approach that is consistent and relevant only if the conversation is broad and inclusive.
I welcome the report, its recommendations and the response from the Scottish Government. I welcome the progress that has been made in the collection and use of data to improve patient outcomes, particularly in cancer treatment and primary care. I look forward to the Scottish Government’s continuing commitment to improving the health and wellbeing of people and communities across Scotland.
We move to the closing speeches; I hope that those who took part in the debate will shortly be back in the chamber. We have a wee bit of time to spare, so it is fine if members want to take interventions.16:13
This has been an excellent debate with considered and thoughtful contributions from across the chamber. I had assumed in advance that it would be a warm and consensual discussion on the supply of and demand for medicines. However, it would be fair to say that the Scottish Government’s 11th-hour response to the committee’s deliberations caused some ripples in the calm waters of the debate.
The Scottish Government says that the committee has gone beyond the inquiry’s remit and strayed into reserved areas, but it has ignored our main findings on the lack of patient focus in the NHS medicines structure. As the convener, Lewis Macdonald, said, scrutiny is the heart of our task on the committee. The committee’s job is indeed to ask the “difficult and searching questions” and to “shine a light” on the costs. He identified the £1.8 billion cost of medicines, with half of all medicines not consumed correctly. The committee had a duty, rightly, to follow the evidence.
Donald Cameron made appropriate comments. He thinks that the report is thorough and detailed, and he subscribes to its findings—of course, he is a member of the committee now. He, too, was disappointed that the Scottish Government’s response appeared only a day before today’s debate. He was also scathing about the IT reforms and the lack of patient focus. A consistent approach is needed to IT.
Alex Cole-Hamilton made the strong point that there was no question of mission creep in the committee’s activities. His strong speech included the vivid example of a constituency case that involved medical cannabis. He made the strong argument that we need better drugs that are good value to the taxpayer and benefit our patients, which is the key point. He said that the report’s 129 recommendations showed the scale and scope of the problem.
George Adam made strong points about social prescribing, which is the other important form of prescribing. He talked about his experience from the CPG on MS and his first-hand experience with his wife, Stacey. He talked about the important distinction between branded and unbranded drugs and about the key issue of the licensing regime.
Miles Briggs said that data is king. Of course it helps with patient care; capturing patients’ outcomes is crucial and challenging.
Elaine Smith described the delay in providing the Government’s response as astonishing. She is well recognised for her campaigning work for thyroid sufferers.
The debate has been excellent. I echo the convener’s thanks to our witnesses and the clerks for contributing to this comprehensive piece of work. I have always felt that a great strength of the Parliament’s committee structure is that it keeps the executive in check, irrespective of who might form the executive, and provides advice, guidance and assistance to the Government—[Interruption.]
I believe that the philosophy of all committees is reflected in the words of Michael Specter, who said:
“Be sceptical, ask questions, demand proof. Demand evidence. Don’t take anything for granted. But here’s the thing: When you get proof, you need to accept the proof. And we’re not that good at doing that.”
I am unaware of what the interruption was during Mr Stewart’s speech, but I apologise if it was from this end.16:17
I am pleased to close the debate for the Scottish Conservatives. The Health and Sport Committee’s report is comprehensive and raises issues of which the Scottish Government should take cognisance, many of which members have raised in the debate.
The convener, Lewis Macdonald, highlighted that the Scottish Government took far too long to respond, which is a concern, given that committee scrutiny is a key driving force of Government policy. I hope that that does not indicate that the Scottish Government is not prepared to listen to the Parliament.
It is unfortunate that, instead of listening to the issues that this significant piece of work has raised, the minister seemed to retreat into the Scottish Government bunker and to suggest that the Government should tell cross-party committees what they should and should not investigate. I say to the minister that committee work is the foundation of our Parliament and should help to drive policy. The Scottish Government’s response remains far from satisfactory.
Given the complexity of the issues that have been examined, I will focus my short speaking time on a couple of key points. The first is the committee’s conclusion that
“the system of supply and demand for medicines in Scotland does not have a focus on patients”,
which Donald Cameron and David Stewart raised. I link to that the committee’s conclusion that
“The lack of data collection and analysis on outcomes achieved via the prescriptions of medicines is of huge concern.”
Those points are crucial. Surely the purpose of prescribing any medication is to alleviate or help with a medical condition.
Without doubt, there is an overmedicalisation of conditions and not enough measurement of appropriate outcomes. There is significant wastage in prescribed medicines: something like 50 per cent of prescribed medicines go unused. That is increasingly important against a prescribed medicines bill of £1.4 billion, which has risen by more than 4 per cent since the previous year. To compound that, there has been an increase of more than 16 per cent in the items dispensed over the past decade. When we are always looking for ways to improve the funding in our health service, those numbers are significant.
Of course, the majority of those prescriptions are necessary but, without a proper and measured understanding of the effectiveness of those medicines on a patient, it is difficult to come to appropriate conclusions. That is one of the biggest criticisms of the current system in the committee report, which states:
“We found the lack of care taken to understand people’s experience of taking medicines impacted the system at every stage. We are clear that gathering, analysing and sharing this information in a comprehensive, systematic way across Scotland would be the single most beneficial action to result from this inquiry.”
Other Health and Sport Committee investigations have come to similar conclusions about the lack of an IT infrastructure policy that would allow the gathering and extraction of appropriate data. To sustain quality healthcare, free at the point of need, the Scottish Government can no longer leave that issue unaddressed.
That takes me to the appropriateness of treatments that are prescribed, and at this point I will refer, as George Adam did, to the committee’s report on social prescribing. Too often, patients are prescribed medication without alternatives being considered and, time and again, we hear evidence that tells us that an active, healthy lifestyle can have a huge impact on our physical and mental health. Members know that I have frequently asked questions around access for doctors to prescribe alternatives to medicines. In far too many cases, we look at the symptoms, not the underlying causes. Obesity, type 2 diabetes, addiction, poor mental health, chronic obstructive pulmonary disease, musculoskeletal conditions, arthritis and heart disease are often treatable or preventable, but we do not always give our healthcare professionals the tools that they need for their tool bag. It is not a new issue, but there is a lack of leadership and will from the Scottish Government to make those changes.
As two specific illustrations, I take the prescription of antidepressants for those who suffer anxiety and methadone for those who suffer addiction. Over and again, we hear evidence that patients remain on those medications for too long without a treatment plan to reduce the patient’s need to remain on that medication.
I will make two key points. First, to ensure that prescribed medicines have the intended impact on patients requires an IT system that follows the patient. The HEPMA system in secondary health care is being rolled out across certain health boards and early indications are that hospital pharmacies will have a positive impact on delayed discharge. However, once a patient leaves hospital and moves into the jurisdiction of primary care, that prescription record does not follow them; that must change as soon as possible.
Secondly, when medicines are prescribed, it is important that all other options to treat the patient are considered, that other treatments that could augment medication are prescribed to ensure that the need for that medication is minimised, and that patient outcomes are of primary concern.
Of course, in addressing those issues, it stands to reason that the cost of those treatments will reduce, which will allow the Scottish Medicines Consortium to justify the costs of more medicines, thereby opening up further treatment pathways.
The Health and Sport Committee report, “Supply and Demand for Medicines”, is a significant body of work and I join my colleagues in thanking all those who gave evidence and the clerks for their work. The report highlights where the Scottish Government needs to go and I hope that the Scottish Government takes the report seriously and acts on it.
The report is only one piece of a bigger jigsaw. Its conclusions directly link to all other reports that the committee has published, giving a three-dimensional look across health and sport in Scotland and shaping healthcare in the future. I mentioned the social prescribing report, but we could include addiction, primary care, social care and many other investigations. None of those reports should be considered in isolation. As the “Supply and Demand for Medicines” report states, patient outcomes should be what we measure.
I call Joe FitzPatrick to close the debate for the Government. You have around seven minutes, minister.16:24
I thank members from all parties for their contributions to the debate, which, as David Stewart said, has been a good one.
A number of members mentioned the fact that the Government’s full response was issued only yesterday. As Alex Cole-Hamilton said, the cabinet secretary initially responded to the high-level items on 11 September. I also point out that the debate was originally due to have been held later, so had we nevertheless managed to respond yesterday, it would not have been only on the day before the debate.
I put on record my thanks to all the Government officials who ensured that we could get a full response to the committee before today’s debate. I also point out that they are the same officials who have been working day and night on our Covid strategy. Nonetheless, I recognise that it was unsatisfactory for the Parliament to receive the Government’s response only the day before the debate and I apologise for that. Clearly, it would have been much better had there been the opportunity to consider the response for a longer period before the debate.
The debate has been informative, with much detailed questioning about why Scotland is not moving faster on a range of issues raised in the Health and Sport Committee’s report. I will be clear that in the Scottish Government there is no lack of ambition regarding the supply of and demand for medicines. As I noted earlier, the devolution settlement does not provide the Scottish ministers with full powers to act in many of the areas highlighted by the committee’s report. However, we remain fully committed to progressing such important areas as far as is possible within our devolved powers and within the context of increasing capacity constraints as a result of the Covid-19 pandemic.
I was struck by the point that George Adam quite rightly made, that most of the evidence was gathered before the pandemic. He also said that that might have oiled the wheels and that during the pandemic some progress seemed to have been made on a number of issues. I absolutely understand the timescale constraints under which committees operate, but it is perhaps unfortunate that some of that evidence did not appear in the committee’s report. I know that it was not the committee’s intention, but a number of people who have been working really hard across our NHS felt that the report was unduly critical of them.
Lewis Macdonald rose—
That is why it was good to hear the convener’s words at the start of the debate, and also George Adam’s recognition that, despite all the challenges presented by the Covid-19 pandemic, progress has been made. That is helpful.
I thank the minister for taking a further intervention. I reiterate that the committee’s intention was to draw attention to the shortcomings in our health and care systems; it was not an attempt to demean or to take away from the fantastic work that is done by our health and care staff. Nonetheless, it remains critical that the Government and NHS leadership are willing and able to take on board constructive criticism that can improve services.
The debate, which has been much more balanced, will help people to do so. In talking about the NHS, it is important that we remember all its levels, including its leadership. Folk at all levels of our health service have been working tirelessly for months now, and they really need our support. We should also recognise that the report came out just as staff were coming out of the toughest part of the pandemic. However, as I said, on balance, the debate has been positive and I am sure that it will be taken in that spirit.
Donald Cameron and others spoke about medicines data. I assure members that we are fully committed to improving that and to recognising the benefits of using real-world data to better patient outcomes. We have been taking a phased approach to improving data systems in Scotland. It is important to ensure that such systems are in place. Equally, though, achieving that aim will require cultural changes, staff changes and an understanding of real-world applications. Making steady progress will be key, as will be ensuring that we bring stakeholders with us. The programme for government announced a refresh of our digital health and care strategy in spring 2021, followed by the publication of our first data strategy, both of which will set out our plans for making Scotland a leader in the ways in which data is captured and utilised for the benefit of patient care, which must always be our central aim.
The convener and David Stewart asked about the HEPMA system. In order to support that system, officials continue to work with health boards to ensure that local and regional approaches are taken to delivery across all our boards, and we have established a national HEPMA implementation oversight board, so good progress is being made. To put that into context—
Will the minister take an intervention?
I am right in the middle of my point, which I will finish, because it might answer the question.
I will say what that means. A number of health boards are already on board, and we expect the remaining boards to have implementation under way, but not necessarily completed, next year. That is the timescale. I expect full implementation to take two or three years. It is a really important piece of work, and it is good that all boards have a pathway to that work.
I have seen the HEPMA system at work in NHS Ayrshire and Arran. As the minister rightly said, it is an incredibly important piece of work. Does he agree that the prescriptions in secondary health care need to follow the patient into primary health care? Currently, that does not happen, so that work needs to be done.
The member is absolutely right. We are making considerable progress in that area. If someone gets a prescription, any relevant person in our health system who needs to access their medical records should be able to do so. We have made considerable progress through the work on the pharmacy first service, but the member is right that what he said would make a huge difference. We recognise that primary care is far wider and involves far more than just GPs; a range of people work in the system. Enabling them to access appropriate data is important.
Alex Cole-Hamilton made some points about repeat prescriptions. The chronic medicine service, which was first introduced in community pharmacy in 2009 to promote a partnership approach between pharmacists and patients, is intended to help with that issue. We are refreshing that process, and it will get a new name: the medicines care and review service. A small number of enhancements to how the service will operate are under way. Serial prescriptions will be an important tool in the remobilisation of our NHS through supporting GP practices and community pharmacies to more effectively manage workloads in relation to prescriptions.
Brian Whittle talked about social prescribing—as he often does, and rightly so—and David Stewart asked how we would change the culture to put non-medical treatment on a par with drugs. Both members should be aware, I hope, that we have committed to establishing a short-life working group to examine the social prescribing of physical activity. The aim is to identify and communicate examples of best practice and to co-produce resources for practitioners in the many roles that make up the overall system. We need to ensure that we are able to share best practice right across our system.
I put on record my recognition of Elaine Smith’s personal and long-standing work in relation to thyroid patients. She raised the issue of T4 and T3 prescribing. The Government and I have been clear with clinicians that the prescribing of T3 should be based on patient need and that cost should not be a reason to not prescribe T3.
I see that I am at the end of the Presiding Officer’s patience. In spite of some of my earlier contributions, this has been a good debate. There is a lot in the report that we can take forward in a constructive way and I assure the committee that we intend to do that. The Government and clinicians think that this work is really important, and we will be sure to keep the committee updated on progress.16:34
As the deputy convener of the Health and Sport Committee, I welcome the opportunity to close the debate on its behalf. I remind the Parliament that I am still a registered nurse.
I thank all members, including committee members, for their contributions. I also thank the committee clerks, and acknowledge the work that they have done in preparing for scrutiny in the inquiry, and for preparing the report that we are discussing.
I also echo the thanks that were conveyed by the convener to all the people who provided evidence. It has been positive to have cross-party consensus on the report and its extensive recommendations, of which there are 129.
The report discusses medicines in great detail. We covered various areas—from the point of purchase and procurement through to prescribing, dispensing and consumption. It could easily have been four separate reports.
I want to take this opportunity to touch on some of the report’s key findings and recommendations, and I will comment on the contributions from members. It is worth noting that the report and inquiry were, largely, carried out before the pandemic and during its early stages. Therefore, some practices and recommendations might have been expedited because of the challenges that have been posed by the pandemic.
It is a large report, and the committee convener and members have already presented much of the detail about what the inquiry found, including on the person-centred approach, HEPMA, joined-up leadership approaches, supply and demand, waste and prescribing. I welcome the minister’s comment on a once-for-Scotland approach.
I also note the distinction between matters that are reserved to Westminster and those that are devolved to the Scottish Government, and I agree that it is important to make clear in communications and reports what is reserved and what is devolved. That will certainly help to give me greater understanding as, I am sure, it will do for others who read the report.
I accept the minister’s apology for the late response to the report, and thank him and his officials for all their work since Covid-19. I am sure that they are working flat out to tackle the many issues that the pandemic has thrown at them.
Dave Stewart and Brian Whittle spoke about having a more connected HEPMA system. Dave Stewart mentioned that geographical inequalities might be addressed if we had a more connected HEPMA system, and both Dave and Brian spoke about social prescribing and mentioned our other report, which focused in more detail on social prescribing. George Adam talked about that, too.
Many committee members are keen that progress be made on further delivery of social-prescribing approaches. We have heard, for example, evidence on how type 2 diabetes can, through programmes of social prescribing, be mitigated to the point at which no type 2 meds are required.
Miles Briggs spoke about secondary breast cancer and access to new drugs for people who have it. I welcome his comments and his work on that in the cross-party group in the Scottish Parliament on cancer.
Donald Cameron spoke about the required improvement for IT systems—I will also speak about that—and Alex Cole-Hamilton talked about medicine prescription reviews. I want to thank Donald Cameron for taking my intervention. My point was to clarify that a lot has happened since Covid and that we know that work is already being undertaken to embed pharmacists in general practices.
In undertaking the inquiry into supply and demand for medicines, the committee anticipated exploring issues relating to the efficiency of the system and the levels of waste that are generated by it. It is a stark fact that 50 per cent of medication is not taken as prescribed.
However, in considering the themes that were raised, the fundamental became apparent, which is that the system of supply and demand for medicines does not focus on patients—at least, it did not at the time of the inquiry. Dave Stewart described that well when he quoted the report, which says that the system
“is burdened by market forces”,
by public sector
“under resourcing, inconsistent leadership”
and by a lack of comprehensive strategic thinking and imagination that is allied with
“an almost complete absence of useable data.”
That was highlighted in paragraph 84 of the report, which suggests that drug companies and cancer voluntary sector organisations feel that the Scottish Medicines Consortium’s processes are too long, and deny patients access to drugs for longer than should be the case. That is again conveyed when the report talks about how the processes of the SMC restrict patients’ access to new treatments. Given that, the committee unanimously questioned whether market forces should dictate drug procurement.
The committee was also concerned throughout its inquiry by the lack of data collection and the lack of analysis of the outcomes that are achieved via prescribing. The impact that taking medicines has on individual patients was not being examined at the time of the inquiry, and evidence was not being routinely sought.
We heard that pharmacists are working directly with GPs and in general practice sites. I welcome that. They engage with patients on medication review and they address the issue of polypharmacy. That was highlighted by Alex Cole-Hamilton. It would be encouraging to hear that patients in primary care are receiving follow-up care to ensure that the medicines that are prescribed for them have been effective and have been used appropriately.
Lindsay McClure of NHS National Services Scotland said that better IT systems are required in order to collect outcomes data. The Association of the British Pharmaceutical Industry and the Medicines and Healthcare products Regulatory Agency spoke of the need for data on patients who would benefit from innovations in gene therapy and in medicine licensing.
The inquiry found that the lack of care that is taken in trying to understand people’s experience of taking medicines has an impact at every stage of the system. Gathering, analysing and sharing that information in a comprehensive and systematic way across Scotland would be the most beneficial action that could result from the committee’s inquiry. We agree that that should be urgently prioritised.
It is encouraging that the chief pharmaceutical officer stated that the Scottish Government is considering how the voluntary pricing and access scheme could contribute to innovative pricing, but problems of collecting data about patients’ experiences were again raised. That was emphasised by Community Pharmacy Scotland’s director of operations Matt Barclay, who noted that conversations with patients are taking place, but outcomes are not being recorded. Mr Barclay suggested that that could be contractualised.
During our evidence sessions, those whom the committee members considered should have the responsibility for solving problems and developing innovative solutions often recounted and identified the issues for us, but did not go on to propose accompanying ideas for change. The statements that we heard spoke of the need to do something, but they came without accompanying detail about how that could be achieved. That cannot be effective in driving forward innovation and change.
That was particularly clear with reference to collection of data and evidence. For example, the Right Medicine Pharmacy stated that the process for licensing medicines could be shortened, but did not state how to achieve that or what the role of the Scottish Government would be in doing so.
Area drugs and therapeutic committees and health board directors of pharmacy stated that they do not have power over the drugs that are in their formularies, but they failed to say who has that power and how that situation could be improved or changed.
Throughout the inquiry, the committee was offered little detail as to how change might be brought about, let alone how it might happen at a pace that is in proportion to the prize that is to be gained.
The committee urges the Scottish Government to consider strategically the IT and data requirements of the NHS across Scotland and, as a matter of urgency, to design systems that have long-term utility. The committee recognises the size of that undertaking, especially given that we are still in the midst of a pandemic. However, we cannot keep producing reports that conclude that savings and efficiencies and, above all, better patient care are possible with modern IT that can gather, analyse and share data, unless we also expect urgent action.
The report clearly shows that better data collection, along with improved IT systems, will deliver improved outcomes for patients and improved access to and use of drugs and medicines.
That concludes the debate on the supply and demand for medicines. We will shortly move on to the next item of business.