Dolla Dolla Pills

Today’s Daily Record reported on something I’ve been seeing for months as a pre-registration pharmacist.

If you’ve ever seen Michael Moore’s documentary Sicko, you’ll have seen how capitalism causes many Americans to have substandard or even a total lack of health care. In the Scottish pharmacy I work in, however, I have seen capitalism’s effects on medical care a lot closer to home. From manufacturer, to wholesaler, to pharmacy and finally to patient, there is plenty of opportunity for money to be made. Overall this means greater cost to the NHS and a decreased supply of medication available.

Pricey Pills

Lets start with a little quiz. These are Zyprexa 10mg tablets.

Zyprexa is one of the most common drugs currently prescribed for schizophrenia and the 10mg strength is the most commonly used. In practice, I dispense this drug just about every day. It comes in boxes of 28 tablets, each tablet about the size of a 5p piece. It isn’t a new drug, having been released 16 years ago. So how much does one single box cost? Take a guess before reading on.

…

…ready?

The exact price will vary between wholesalers. But for one box of 28 Zyprexa 10mg tablets, the pharmacy would pay around £81 (almost £3 per tablet). Once the pharmacy has dispensed the medication against a prescription, the cost of the drugs supplied is reimbursed to them by the NHS. This means that every year, NHS Scotland spends £12.1 million on Zyprexa tablets alone, making it the drug with the 9th greatest cost to the NHS in 2009-2010. This drug is by no means the most expensive medicine dispensed by pharmacies, and it leads to the question: why are drugs so expensive?

Looking at the case of Zyprexa, we can eliminate some reasons. Bringing a drug to market is a long and expensive process, but considering how much they receive each year from NHS Scotland alone, consider what they’ll be making from the rest of the world! Its pretty safe to say they’ve made back their expenditure. Its not a rarely used drug, so the price won’t have to be inflated to recoup manufacturing costs. By looking at the story of Zyprexa, we can get some clues into the real reason. For a long time, the most effective treatment for schizophrenia was a drug called clozapine. This meant that in order to gain control of this difficult condition, patients had to suffer some very nasty and potentially lethal side effects. So in the 1990s, when new antipsychotics like Zyprexa were developed, they allowed patients to gain control of their condition without the high level of potentially lethal side effects. The drug companies realised that due to the benefit posed by these drugs, health care systems like the NHS would be willing to pay large amounts of money for them. And so, to this day, as with many other drugs, the NHS pays an inflated price to keep people healthy.

Keeping people healthy isn’t a particular concern of drug manufacturers. Ask any GP about drug reps and they’ll tell you that until recently, they would have done anything to get their drug prescribed, regardless of the actual evidence. Thankfully legislation has now prevented drug companies sending GPs on golfing trips and buying them dinner to prescribe a certain drug, but health care professionals still frequently get sent graphs with no numbers and a handful of pens from drugs companies trying to prove how good their drug is.

Missing Medication

Drug companies don’t sell their products directly to pharmacies; they sell their overpriced wares to pharmaceutical wholesalers. It is around this step that the drugs get lost. You see, they may have patient information leaflets, but they don’t have maps and so they take a wrong turn and end up in Europe. Because of the value of the Euro in relation to the Pound, wholesalers can get a much better price for medicines in Europe than they can in Britain. And so why sell a box of cancer medication in Scotland for £20 when you can get £30 in France? Never mind the fact that people in Scotland will then die of cancer. Which is where we are now. For months now it has been a constant struggle to get many common medicines, drugs for conditions from breast cancer to addiction that used to be freely available. Patients have been waiting for weeks to get tablets they need now, people have to make do with less effective drugs because they can’t get what they really need and pharmacists have been spending hours every week chasing up manufacturers, wholesalers, phoning other pharmacies to borrow stock and fighting quotas on what little supplies are available. These drugs are all being produced in their millions in the UK every day, but they go straight out the country for a little extra cash, leaving us with nothing. We’re in the middle of a massive drugs crisis here in Scotland, and its caused by pure greed.

Pharmacy Profits

Despite providing NHS services, all community (i.e. shop) pharmacies in the UK are run by private companies or individuals and not by the NHS. This means that they are run, you guessed it, for profit. While the individual pharmacists who work in each shop will have the best interests of the patient at heart, they are under tremendous pressure from the company or individual owning the shop to make profit. This may often include being encouraged to take part in illegal practices such as claiming money from the NHS for dispensing prescriptions that they did not actually dispense (eg. if the patient didn’t want one of the items on the prescription) or registering patients for services without their consent. It often means that pharmacists are forced to take on as many services as possible, leaving them little time to properly carry out the services and often making them too rushed to speak to patients about how to take their medication or to effectively check that prescriptions are safe and effective and that dispensed medication is correct. Many pharmacists, if not the majority, are not entitled to any form of break during the day, as this would mean that no prescriptions can be dispensed and thus money would be lost. In an 8 hour day, the average pharmacist, almost always the only pharmacist in the shop, may be expected to check around 300 dispensed prescriptions (one every 90 seconds!), on top of any other services and speaking to patients. Its pretty easy to see how making pharmacists and pharmacy staff so rushed compromises patient care.

One of the activities that keeps pharmacists rushed off their feet is a little trick learned from wholesalers. It seems crazy, but while so many patients struggle to get their medication, it could well be in the pharmacy all along. Of course those medicines aren’t intended for NHS patients. Pharmacy owners have pharmacists doing everything they can to order them, phoning wholesalers, phoning manufacturers, ordering one box each day so as not to arouse suspicion, telling supplies they really need it for a prescription. Except this time its not for a prescription. Because much of the medicines that wholesalers don’t sell to Europe are bought by pharmacies. And sold to Europe. No drugs for patients, but lots for profit.

Yet after all of this, some drugs finally make their way through to actually get dispensed by a pharmacy against a prescription. When pharmacies dispense a drug, the NHS pays them the cost of the drug back, plus a small dispensing fee. This fee isn’t very much, so pharmacies have sorted out a way with wholesalers to make some profit on the cost of the drug. In exchange for ordering from them, wholesalers will charge pharmacies a massively inflated price for the drug. Doesn’t seem like a very good deal does it? But the pharmacy then has a really highly priced invoice that they can use to claim back the drug cost from the NHS, while the wholesaler refunds the pharmacy a lot of the cost at the end of the month. This means that while a pharmacy might only end up paying 50p for a drug, the NHS will pay them £10 for it. Multiply this by however many times it happens in a day, multiply by all the pharmacies in Scotland and you’ll see just how much money the NHS loses every year.

Cut Capitalism

Of course, I’m really not having a go at the profession of pharmacy here. I know that the vast majority of pharmacists have patients as their main concern and that they hate having to fleece the NHS and patients our of medicines and money. Its the business types pulling the strings who force our profession down the road of profit, not patients. Pharmacists are health care professionals, they have 5 years of University education and training before they can practice, they are experts in medicines, yet if they want a job they must put patients in harm’s way to make someone else money. And with all this going on, our government’s best idea to save money is to further cut services and further damage patient care. When we think of easily preventable deaths, we think of malaria, tropical diseases in the third world, HIV etc. Maybe we should be looking a bit closer to home.