Practice Dilemma: Generic substitution

The Dilemma: A disgruntled patient comes to see you unhappy that he has been changed, without discussion, from a branded drug to a generic equivalent.

It is best to give a full and honest explanation of the reasoning behind the switch to a generic drug (Photograph: SPL)
It is best to give a full and honest explanation of the reasoning behind the switch to a generic drug (Photograph: SPL)

He shows you a newspaper article about how GPs are prescribing 'cheap' drugs and expresses his disgust. A letter was sent to him with his new prescription highlighting the need to change because of the growing economic burden on the NHS, but the new drug is no less effective. He feels he has paid his taxes and is entitled to the best quality drugs. He demands he has the original prescription or he will complain to the PCT and expose the practice to the press. The generic drug costs 10 per cent of what the original branded prescription costs each month. What do you do?

A GP's view
Dr Alison Glenesk is a GP in Aberdeen

It is sometimes tempting to give into patients' demands, but this is neither fair, nor reasonable in this case.

Patients are entitled to their opinion, even if it seems misguided, so it is important that you listen to what he has to say. Do not under any circumstances counter his annoyance with irritation.

It is best to give a full and honest explanation about the circumstances of the switch, hoping to appeal to his better nature and his sense of citizenship.

You should explain that drug companies have several years to recoup their research and development costs and that, after that, other companies are free to market the same drug.

Because the initial work has been done, the identical drugs are appreciably cheaper, but still have to be rigorously tested. This gives the NHS, a cash-limited organisation, a chance to obtain cheaper medicines, which are just as effective, and thus they are able to treat more people.

By accepting the change, he will be doing his bit to help other people.

If he gives further attention to the newspaper article, you could explain that it is not necessarily a fair account of the situation.

You also need to point out that all practices are obliged to review their medications from time to time, and that this review is often initiated by the PCT, to whom he wishes to complain.

If he is still unhappy, try not to back down, as this is neither fair nor equitable. Suggest he tries the 'new' medication, and hope the placebo effect does not work in reverse. Remember, you print the prescription, so it is ultimately your decision.

A medico-legal opinion
Dr Jonathan Bernstein is a medico-legal adviser for the Medical Protection Society
Switching a patient's medication from a known and recognised branded product to its generic equivalent is a common trigger for one of the more difficult conversations that a GP may have with a patient.

Even with good explanations, many patients see such change as compromising their care for financial expedience.

The difficulty is, of course, that there is a financial imperative driving the move. While the use of generics (with a few exceptions) should not affect the patient's treatment, their choice is governed by a desire to seek the cheapest version of that drug.

This does not make the decision to contain costs as far as possible irrational or wrong. To maximise treatment for the maximum number of patients, some rationing is inevitable.

According to the GMC guidelines Good Medical Practice, the choice of drug by a doctor should 'serve the patient's needs' and be 'based on the best available evidence'.

When a number of versions of the same medication are available, the GMS contract regulations (and equivalents for PMS practices) require the GP not to choose a treatment for a patient whose cost is 'in excess of that which was reasonably necessary for the proper treatment of that patient'.

It is important to seek a frank discussion with the patient about his treatment needs and your prescribing decisions. This should include an exploration of his anxieties about generics.

It should not be forgotten that for a small group of patients inconsistency of appearance of their medications and packaging, particularly if they have poor literacy skills or visual impairment, could be a valid reason to consider that a non-generic choice is in that patient's best interests.

A patient's response
Antony Chuter is an expert patient

I think this is where patients need to be reassured that the procurement of medication in the UK is regulated well and that a generic drug in the UK will be a copy of the branded drug, but with a different price.

When changing a patient's medication to a generic one, GPs need to take into account that the patient may need reassuring, especially if they have been taking a drug for some time. A letter sent with the new prescription may not be enough to convince the patient that his health is not being compromised.

As a patient, my medication gives me control of my symptoms and pain. Any threat to that control can create anxiety and fear about a loss of control and a drop in my quality of life.

I would reason with the patient, explaining the huge cost saving that the introduction of the generic drug would allow and reiterate the fact that there is no difference in the effectiveness of the new drug.

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