PATIENTS could soon be forced to pay for some of the tried and trusted drugs they get from their family doctors, following a government review of GP prescribing.

The Department of Health has announced a package of measures to reduce the soaring cost of drugs to the National Health Service. Last year drugs cost the country pounds 3.2bn, and the bill is growing at 12 per cent a year. This year, with increases to NHS spending limited to 2 per cent, the department is determined to cut costs.

One of the methods of cutting drug costs is to ban GPs from prescribing certain drugs. Blacklisted drugs are only available on private prescription or over the counter from chemists.

In 1985 the Government announced overnight that 600 drugs were no longer available on the NHS.

Last month Virginia Bottomley, Secretary of State for Health, announced a review of 10 categories of drugs, covering nearly 1,000 products, which she felt could be added to the blacklist. She has referred the list to the Government's Advisory Committee on NHS Drugs.

Patients who currently receive prescriptions for the contraceptive pill, for some mild tranquillisers, for allergies, diarrhoea, anaemia, vaginal and vulval conditions, obesity, skin conditions, rheumatism, and ear and nose conditions could be affected.

None of the preparations on the list is a 'lifesaver', like a heart drug, but Britain's leading patient pressure group says there is cause for concern.

Linda Lamont, director of the Patients' Association, says the poor and old would be worst affected by the move to over-the-counter prescribing.

'The present prescription cost is enough for some low-income families. If they have to pay for drugs over the counter the cost could be prohibitive. Elderly people get their prescriptions for free at the moment; they would have to pay if they wanted to stay on a blacklisted drug. The difference that a couple of pounds a week can make to some of these people is enormous. It would be hard for most Independent readers to imagine.'

But giving the old responsibility for paying for more of their drugs would also make a large difference to the Government's drugs bill. Four out of five prescriptions a GP writes are issued free. Most of those free prescriptions are issued to old people, according to the health department. The potential for savings in this area is large.

Ms Lamont believes the proposed additions to the blacklist are part of a strategy to put the main burden for paying for drugs on to patients. 'Where you stand on this depends on whether you see yourself as a patient or as a taxpayer. You could say it is a risk for the Government to cut back on drug company profits, or you could say it's wrong for them to impinge on patient choice.'

GPs too are concerned about the consequences the blacklist will have on their patients. Ron Singer, an inner-city London family doctor, says the GP's prescription form is in effect a blank cheque payable by the exchequer. Traditionally GPs could prescribe mostly what they liked - their clinical judgement overriding considerations of cost. Dr Singer sees the proposed limitations on prescribing freedom as another step on the road to a two-tier health service. He says: 'The Government is offloading its responsibility. It is saying you can have the drug you want, the one that suits you, but only if you are willing to pay. But some people will not be able to pay, it's as simple as that. This is more than just a few doctors being funny about their freedom to prescribe what they want.'

Some experts fear that if GPs' choice of drugs is restricted they may be unwilling to see patients pay the full expense of their drugs. GPs may prefer to prescribe more powerful, potentially less appropriate drugs than to see a patient pay at a chemist's.

Tim Dean, editor of The Prescriber magazine, says: 'Current policy is to encourage patients to make greater use of products available over the counter at the pharmacy. But most patients do not pay prescription charges, and if GPs are unwilling to put the onus on the patient then they may be forced to move up the therapeutic ladder and prescribe more costly and perhaps less appropriate medications.'

The drug companies also complain that banning GPs from prescribing drugs on the blacklist will do more than just dent their profits. The Association of the British Pharmaceutical Industry says opting for cheaper medicines brings short-term savings for the taxpayer but in the end adds to the cost of the NHS as patients stay more ill longer. They also say pharmaceutical research in areas covered by the blacklist will grind to a halt.

Ben Hayes, an association spokesman, says the price of some medicines would be prohibitive for poorer patients to pay themselves. He says a typical gel for rheumatic pain would cost pounds 7.77 a week - a great deal of money out of a state pension of pounds 54.15. 'If we are not careful we will reach a position where, in a large number of categories, only older, cheaper drugs will be available on the NHS. Anything more expensive you will have to pay for.'

These arguments do not impress the health department. A senior civil servant in the department said spending on drugs was to become a major focus of debate in the NHS.

He said the Government had to take defensive action against drug company hard-sell tactics, which boost the cost of drugs to the exchequer.

'There are so many 'me too' products, where a drug company brings out a drug very like an existing product but prices it differently. If you have two drugs doing very much the same thing but priced differently, isn't it right we should only agree to pay for the cheaper one?'

The civil servant said efforts to limit prescribing costs - including persuading GPs to prescribe cheaper generic drugs instead of the more expensive brand name varieties - would definitely continue. 'There is a growing recognition that we can't see prescribing as an issue apart from the rest of the NHS, from funding for day surgery or for Tomlinson (the report on reorganising the NHS in London). We can't say it is sacrosanct, immune from being put in a list of priorities.'

Following this line Mrs Bottomley has said the Government is willing to pay for the 'Marks and Spencer' versions of drugs, but if patients want the 'Harrods' variety they will have to pay for it themselves. She says there is no question of patients being denied drugs they need.

And Dr Brian Mawhinney, the Health Minister, says his department is taking professional advice as to which drugs can be safely removed at no inconvenience to patients. He says: 'We are saying that there are ways patients can get what they need in a way that costs less to the NHS.'

He points to the success of fundholding GPs in reducing their drugs spending. These GPs can invest any savings they make to their drugs budgets in other parts of their practices. As a result their drugs costs are 3-4 per cent lower than their non-fundholding colleagues.

These GPs, says Dr Mawhinney, are finding effective ways to cut costs without disadvantaging patients: 'There is absolutely no evidence to suggest that the patients of fundholders are any less happy with the drugs they are getting than the patients of other GPs.'

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