Official Report: Minutes of Evidence

The Chairperson (Ms Boyle): With us are Mr Richard Pengelly, accounting officer from the Department of Health, Social Services and Public Safety (DHSSPS); Dr Mark Timoney, the chief pharmaceutical officer for the Department of Health, Social Services and Public Safety; and Mr Joe Brogan, the head of pharmacy and medicines management for the Health and Social Care Board (HSCB). We also have Mr Kieran Donnelly, the Comptroller and Auditor General (C&AG), and Mr Jack Layberry, the Treasury Officer of Accounts for the Department of Finance and Personnel (DFP). I thank the witnesses for joining us. You are all very welcome. I will move into my line of questioning to Mr Pengelly.

Mr Pengelly, expenditure on primary care prescribing is significant, at £460 million. That represents 10% of the entire Health and Social Care (HSC) spend each year. Whilst the Committee acknowledges that progress has been made in GP prescribing efficiency savings, the Audit Office report points out that there is scope for further improvement in that area.

I would like to take you to figure 2 on page 11 of the report, which gives a comparison of prescribing costs from 2007 and 2013, showing that spend here was higher. There was a bit of a rise and a slight dip over that period. Figure 2 shows that the spend per head here is higher in comparison with England and particularly with Scotland, where it is £40 per head cheaper. There seems to be a bigger issue that we need to get to grips with, Mr Pengelly, or Mr Brogan — whoever wants to take that question.

Mr Richard Pengelly (Department of Health, Social Services and Public Safety): I will start, and my colleagues may want to come in with some of the detail. I absolutely acknowledge your point, and the figures clearly do not mask that we are more expensive than England, Scotland and Wales. We certainly do not claim to be delivering the service at the cost that we would like to.

I would like to make a couple of points. It is important, as the report acknowledges, to reflect the journey that we have been on for about the last 10 years. We have made very significant progress in the shift from branded to generic medicine, and we have gone from a 41% use of generic medicines to 71% in 10 years. Over the past six years, we have reduced the cost by 18% in real terms.

The point that I want to convey to the Committee — it may want to explore this in more detail — has two dimensions. From a fairly poor starting position about 10 years ago, I think that we have made some very good progress. Having said that, more remains to be done, and we are committed to doing that. That is the issue that I would like to explore and explain today. We feel that we can get better. The one caveat that I would add to that, particularly as regards comparisons with elsewhere, is that primary care physicians are, in many ways, the gatekeepers to health and social care in Northern Ireland, and the actions and interventions they perform have a very significant influence on the pathway that follows. At one extreme, it is possible to go for what you could pejoratively term as "cheap and nasty prescribing", which means going very cheap. That would bring primary costs down. As you said, that is about 10% of the total cost. However, secondary care is very expensive.

One of the interesting statistics that I would lay alongside our performance in managing the cost of primary care are our hospital inpatient rates, which are in many ways fundamentally impacted by what happened in primary care. The Nuffield Foundation report from earlier this year compared England, Scotland, Wales and Northern Ireland. It found that, of the four areas, we have the lowest hospital inpatient rates per thousand of the population. I read that as a very strong endorsement of the quality of our primary care. The reality is that you sometimes pay a price in primary care for that quality, but there is a very significant payback in better health outcomes for the individual and reduced costs in secondary care.

That said, we cannot rest on our laurels, and we must seek to drive forward, particularly on moving from branded to generic prescribing. Section 4 of the report also brings out the possibility of switching therapies that are of equal and equivalent clinical value.

In summary, I think that we have done well. There is more to do, and we remain focused on doing it.

Dr Mark Timoney (Department of Health, Social Services and Public Safety): If I could maybe make a remark about the journey that we have been on. Richard talked about the rise in generic prescribing and dispensing rates in Northern Ireland over quite some time. That was first brought to our attention back in 2005, when we had a very low generic rate. We have put a number of initiatives in place over that time to focus on the quality and safety of prescribing in the first instance, rather than looking at the cost first off. We believe that in engaging with clinicians and ensuring that the public understand that we are looking at transparent and defensible initiatives we can make cost very important in the agenda. However, we are looking to quality and safety to drive the health gain that will deliver those efficiencies in the programme.

We took a number of approaches over that period. As we began those, we saw generic rates increasing by 4% year-on-year to their current rate of 71%. We note that we are now travelling at a faster rate than some of the other UK countries in reducing costs per head and cost per item that we have identified.

There has been a lot of activity. It has been very focused on patients' needs and has demonstrated some changes in trends that we feel have resulted in a reduction of at least 18% in real terms in the cost of medicines for our population in the past six to seven years.

The Chairperson (Ms Boyle): OK. Dr Timoney, with respect, the quality and safety aspect of prescribing is paramount, but was there not a lost opportunity at that time for looking at costs?

Mr Pengelly: I think the point that we are making is that you cannot separate the two: you must look at cost and quality together. In retrospective mode, I am told that one of the mistakes that we made prior to 2004 was to focus purely on cost and to not bring in the qualitative dimension.

Against that, I might say that, prior to 2004, we did not seem to be terribly good at cost. So, I question how good we were.

Mr Joe Brogan (Health and Social Care Board): Chair, can I come in on that? Ultimately, it is the GPs whom we have to influence in prescribing. GPs will have an interaction with a patient. They will see the patient in front of them, and their focus is on how to make that patient better. Cost is not necessarily paramount in their clinical decision-making. So, in that influence, we provide guidance that is quality- and safety-focused but that inevitably also address cost. In that way, it is a sweeter pill for the GP to take, in that we are focusing not just on a cost argument. I am a pharmacist. They will respond to me as a clinician, and, if I go to them with an argument about quality and safety knowing full well that there is also a cost efficiency at the back of that, they will be much more accepting of that advice.

The Chairperson (Ms Boyle): But will you agree that, in switching from generic to less expensive generics, there was room for savings?

Mr Brogan: Absolutely. We accept that. Mr Pengelly mentioned that we have made really good progress. There is more to do, and we continue to work hard to yield as much efficiency as we possibly can, ultimately for patients' benefit.

Mr Girvan: — it was the safety aspect. I am eager to find out why, if drugs have the same chemical make-up, the same strength and everything else, there would be a safety issue associated with prescribing a generic drug as opposed to a branded drug. If that drug is deemed to be exactly the same chemical and to have the same strength and everything else, why would there be a safety issue?

Dr Timoney: One reason that patients flagged up to us on a regular basis throughout this campaign is that, when generic medicines are presented to patients, they are often presented with a different appearance. They may be a different colour, may be in a different box and may have other elements that lead the patient to believe that it may not be the same drug that they had the previous month. Multiply that for a patient that is on four, five, six or 10 medicines and you can maybe see where a lot of confusion can arise. Add a vulnerable patient into that picture and you will then find perhaps that the patient's ability to take the medicine — what we call adherence to the prescription — may be impaired. If the patient stops taking medicine that is designed to improve some long-term condition that they are being treated for, the chances are that that condition will deteriorate and the patient may need to seek an additional service or, indeed, hospital.

Mr Girvan: Does that not lead back to a point where the GP, as the gatekeeper responsible for informing a patient, will say, "By the way, I am going to prescribe a certain drug to you. It is different from the previous one, but it does exactly the same job and I want you to take it"? You can either tell the patient or whoever administers their drugs that because some people are not even doing that for themselves. They are maybe on antidepressants and suchlike and so might not necessarily be in control of giving themselves the medication. Does that not fall back on the GP, who should ultimately be up to speed with what he is supposed to be doing?

Mr Pengelly: Absolutely. The GP is the decision-maker for the drug therapy for the individual. The point that GPs make — we all acknowledge this — is that primary care is under intense pressure through the volume of patients and the time allocation. It has to be said that human nature comes into play at times. When a GP is facing a patient and the patient is particularly uncomfortable with the change in shape or colour of a pill that is chemically identical to another — that is the point that you made — GPs sometimes feel that they do not have sufficient time to do that. I am not offering a value judgement on whether that is right or wrong.

Mr Girvan: That brings me back to what Mr Brogan said.

Mr Pengelly: The point that Joe is focusing on through the work of the board and the medicines management advisers (MMAs) is about dialogue with and education of GPs and other projects that we are doing to educate the public. You made a point about generic and branded, and I accept that, in the vast majority of cases, there is zero difference. I have two experts either side of me. The caveat is that, with some compounds, the simple fact is that the tablet may be a different colour and, although the colour itself is inert and neutral, it can have a reaction with the chemicals, and that can make it perform less effectively for some patients.

Mr Brogan: Perhaps I could expand a little bit. I will draw the Committee's attention to paragraph 4.1, which talks about the two kinds of interventions that we want GPs to make. What various members are talking about is the straightforward branded medicine to a generic equivalent. There should not really be any issue in the vast majority of cases.

The other element to note in the second bullet point of paragraph 4.1 is that that is probably where we are at, because we have expanded mainly our generic prescribing reasonably satisfactorily, although we have a few percentages to go. The other key area of efficiency that we are really going after is shifting the actual drug name to a different drug. It will be a different drug that will be available in generic form; it will be moving from a different drug that is a branded form and is not available in the generic. We are shifting it to an equivalent medicine that does reasonably the same job but is generic. Detailing that is a more difficult engagement for the GP to have with the patient. We try to provide support for the GPs and information for the patients. We talk to the patients, and we encourage the reception staff and the community pharmacists to support that change where it is clinically appropriate to do so. That is the real challenge moving forward. We have kind of cracked the generic dispensing issue, although we have a few percentage points to go on that, and we are now moving to focus on moving branded products that do not have a generic equivalent into a different medicine.

The Chairperson (Ms Boyle): Thank you. Mr Pengelly, you talked about what was going on in 2004. Obviously, there is a lot of room for improvement. Do you agree that there has not been such an improvement and that, compared with England, Scotland and Wales, there is a significant difference between the cost per head in 2004 and that now?

Mr Pengelly: A difference remains, and we would like to eliminate that gap, if appropriate. There are two comments in your point to consider. I genuinely feel that we have performed very well since 2004 in improving what was a very poor position, particularly in the level of generic prescribing. I think that we have done well. Is there room to do more? Absolutely, and we want to drive on and do that. I do not want to undermine the progress that has been made over the last 10 years, Chair. However, I do not want that to come across as saying that we have done a great job and that we should sit back and rest on our laurels.

The Chairperson (Ms Boyle): OK. Thank you.

Mr Girvan: The report states that GPs could have saved £73 million if they had followed the same line that was used in Wales. There are times when we tend to use regions as comparisons, and there are times when we set that aside. We seem to hang on to it only when it suits us, but that is for another day. Paragraph 4.6 acknowledges that prescribing per head of population is still much higher than it should be. Do you agree that it could be reduced to £73 million in line with Wales? By how much do you think we could reduce it, and what is the timescale for achieving that?

Mr Pengelly: There are two points. Do I believe that there is scope for us to reduce our costs to closer to the Welsh position? Absolutely and unconditionally. Do I believe the gap of £73 million? Equally, absolutely and unconditionally, no, I think that it is a very simplistic analysis. There are fundamental structural differences between prescribing in Northern Ireland and Wales. One of those is acknowledged in the report, and it is the impact that secondary care clinicians have. Typically in Northern Ireland, as you leave hospital, the consultant gives you a note to take to your GP, who dispenses your drugs, whereas in Wales, the drugs are given to you from the hospital at a cost to secondary care. There are other elements, such as oxygen and some others, that are handled separately that account for a figure approaching £10 million. The National Audit Office's 2012 report stated that there was a 4% need differential between Northern Ireland and Wales.

We do not have a precise figure for that secondary impact as a result of the structural issues between Northern Ireland and Wales. It could be as much as £30 million of a difference. The other fundamental point that I mentioned to the Chair is that —

Mr Girvan: So, £30 million —

Mr Pengelly: Of the £73 million.

Mr Girvan: Is that a £43 million saving?

Mr Pengelly: It could be. Plus the 4% need would account for about £13 million. The other issues would account for £6 million or £7 million, so there is a range of issues. It is useful to make a comparison with Wales at a high level to ask whether we are better or worse. Clearly, we are worse than Wales. By how much is, I think, irrelevant. You can then use that figure as the basis for getting into what happens on a monthly basis, with the MMAs looking at the detail of what happens in an individual GP practice and at its prescribing habits.

That is where the rubber should hit the road on this, because the big comparison just says that there is an issue.

Mr Girvan: I think that some will maybe focus on the MMA support and advice that is going out to surgeries, but within —

Mr Pengelly: Sorry for interrupting, but the big point that I mentioned to the Chair is hospital inpatient admissions, which are a fundamental indicator of the quality of primary care. In Wales, the figure is 144 per 1,000 of the population; in Northern Ireland, it is 131 per 1,000. That suggests to me that better care is given in primary care in Northern Ireland compared with Wales. Sometimes —

Mr Girvan: That argument fits OK whenever you want to make that case, but whenever you want to make a case on A&E — I am using that just as an example, because those are A&E admissions you are talking about —

Mr Pengelly: No, these are hospital inpatient admissions.

Mr Girvan: Inpatient admissions.

Mr Pengelly: So, the pathway for that is that you will visit your primary care physician and get some treatment. If that is unsuccessful, you continue on the pathway through to a consultant with an outpatient appointment.

Mr Girvan: Would that not then bear out figure 10 of the report, where we made reference to having probably better underlying health than maybe some of those other regions that you are talking about? I know that that is beside the point, because I know we make the point that we are a lot worse than everywhere else, yet we have suffered this, that and the other. We will deal with that too when we come to it.

Mr Pengelly: All I would say at this stage is that this is unique. This is the first place where I or any of my colleagues in the health system have ever heard it said that Northern Ireland has lower health need than the rest of the UK.

Mr Girvan: I know, but we are always good at sounding as though we are always poor and down in the mouth about everything. We blame everything that happened in the last 40 years on the Troubles and say that, as a consequence of that, we need to be dealt with as a special case in every area, never mind just in health. I am making a point here.

I want to move to paragraph 1·14. We have made relatively slow progress in going from branded to generic drugs. There seems to be some more flexibility with new medications, in that we are sometimes using new medications that are a lot more expensive to prescribe. That is higher than in other regions of the United Kingdom.

Mr Pengelly: Joe will come in with some detail on that. I am not sure that we are, as it states in the report, much quicker off the mark than the rest of the UK. I think that the pharmaceutical industry made that assertion. We are very much plugged in to what happens on a UK level. Joe can talk about the detail of that.

This goes to the quality issue. New drugs are developed at huge cost to the industry, tested and brought to market because they are demonstrably clinically more effective than the old drugs. Yes, new drugs tend to be dearer, particularly because they are under brand and could be replacing a generic alternative, but by and large and almost wholly and exclusively, they are much more clinically effective. Sometimes it is the right thing to do to pay a bit more for a treatment.

Mr Girvan: But you would agree that we prescribe more new drugs than any other region of the United Kingdom.

Mr Pengelly: No, I would not. Joe will deal with that point.

Mr Brogan: I do not think we can make that assertion. There are certainly trends in practice historically where a new drug came to market and, because of its clinical effectiveness, a GP may have taken it on more rapidly. That is an individual clinical assessment with the patient. In the past couple of years, we have tried to develop a system of managed entry in which we bring forward a clinical and cost-effectiveness test on all new drugs that come to market. From April, we been running that managed entry process and have partnered with Scotland. It has a health technology appraisal system called the Scottish Medicines Consortium (SMC). In the absence of the National Institute for Health and Care Excellence (NICE), we use the SMC to give us advice about whether a drug is clinically and cost-effective for our population, and we then provide guidance to general practitioners.

Through the introduction of that managed entry arrangement, we manage the new drugs that are really good, cost-effective and clinically appropriate for our population — that is a good thing to do — but we also manage where there is less of an argument or an evidence base for new drugs when, frankly, there are sufficient generic or branded medicines on the market. That allows us to say that they do not need to use that drug in a Northern Ireland setting. So, we have progressed by creating a formal managed entry process. That is important to emphasise.

Mr Girvan: The second part of the paragraph deals with secondary care prescribing and the impact on GPs here as opposed to those in the rest of the United Kingdom. You obviously did not agree with that point.

Mr Pengelly: That is absolutely a factor in GP prescribing, but our position is that we do not think that it is more of a factor in Northern Ireland than anywhere else in the UK. Through their dialogue with GPs, our MMAs make the point that there is sometimes a frustration among GPs that patients come out of hospital having been prescribed a certain drug therapy, and it is very difficult for GPs to say to them that they have been prescribed one drug but that there is maybe an alternative generic version or an alternative therapy that would be equally efficient. The view of the patient tends to be that they have been in hospital and have been treated by a highly experienced consultant who has given them that drug. In our view, that is UK-wide issue, and it is the focus of that MMA/GP debate across the UK. It is not more of an issue in Northern Ireland than anywhere else.

Mr Brogan: To emphasise, we have no evidence that that has a bigger impact in Northern Ireland than in other parts of the UK. We know that approximately 60% of GPs' prescribing choices are influenced by secondary care. We try to manage the whole system and to engage with hospital clinicians in secondary care and GPs to formulate what the right decision is for the vast majority of patients. That is why we have established the 'Northern Ireland Formulary', which contains a list of all the first- and second-line choices that have been agreed by primary and secondary care. That means that we are all on the same page with the treatment and pathways for individual patients.

Mr Girvan: I appreciate where you are coming from on that point, but, from what I can see, I am of a clear understanding that we are missing out on tens of millions of pounds of savings. Whether it is £70 million or £50 million, it is tens of millions of pounds of savings that could be used effectively in the health service.

"Efficiency" is a very broad term, and I do not see much in the line of efficiency in the report. I will go through the report in much detail, and it probably gives far more information about what is going on in the health service than I believed was possible. There is abuse going on in one area or the other. However, that has nothing to do with prescribing, and I want to focus on —

Mr Pengelly: I absolutely accept your point. There are millions, if not tens of millions, of savings in the prescribing budget. There is clear evidence of that. One of the things that I am working on at the moment is our financial plan for 2015-16, in which we need to make in the region of £160 million of savings. At this stage, we are planning for something in the region of £20 million of that to come from prescribing. Clearly, if we are putting that in, it is on the basis that it is achievable and we feel that it is there.

For us, the issue is the pace at which we get there. Fundamentally, the thing that drives the prescribing bill in Northern Ireland is GPs' clinical behaviour. They can rightly say to us, "If you are not in the room when I'm facing the patient, you do not know the whole dialogue and you don't know the circumstances".

That is an education process, but we need to respect the clinical judgement of GPs.

Mr Girvan: We are allowed to question it.

Mr Pengelly: You cannot question it after the event. We cannot say to GPs that they have a budget of x to prescribe this year and, once they hit that budget, they cannot write any more prescriptions. However, it is absolutely challenged.

Mr Clarke: You might not be fit to say it retrospectively, but the challenge from the Department could come beforehand and suggest a more generic approach. I do not necessarily accept what you say, Richard, about none of us being in the GP's surgery and looking at the client. Many of us have been in that surgery when doctors prescribe. Well, I have certainly heard stories about doctors prescribing a particular drug. There is a chance that the client may have to go back if that drug does not work, but they have gone for an alternative. There seems to be a direction with GPs that they go with specific drugs first and, if they do not work, they go with a different one. Surely, if they went with the best and most efficient one at the start, they could cut out the other one. I know that you are new in this post, but I think that you have a role to change that culture.

Mr Pengelly: I absolutely accept that point, but my point is that we discharge that responsibility every month.

Mr Clarke: How? The financial evidence is not there.

Mr Pengelly: I would say that the evidence is there. We have reduced costs by over 18% in the last six years. That has to be an indication of some progress.

Mr Clarke: Sorry, Chairperson, I hope you do not mind if I continue.

Are we saying that GPs in London are different from GPs in Northern Ireland? Are we saying that, in their prescribing methods, GPs in London have got it wrong and GPs in Northern Ireland have got it right? If you look at the trend and the comparison between the two regions, you see that London is at £169 per head of population and Northern Ireland is at £244. Even if you take the 18% away from the £244, it still leaves us in somewhat of a catch-up position in relation to London.

Mr Pengelly: There are a whole lot of factors at play. Outside the individual behaviour of GPs, there is the nature of the patient, and that touches on our concerns about the QOF data. Aside from a patient's particular illness, their age, their socio-economic background and the level of deprivation they have to endure all influence prescribing behaviour.

The important bit is that our MMAs look every month at the actual prescribing behaviour of GPs. They look at their trends, their average costs and the percentage of certain types of drug therapies. They question that and speak to GPs. That happens.

Mr Brogan: It does. We absolutely challenge GPs. We challenge them on a monthly basis and seek an explanation when there is variation that is beyond expected norms. We expect that there will be action from that.

I have brought graphs along that show the kind of things we do. It you are an outlier, we expect that there will be activity and we will reduce the amount of variance. I know that will probably come up later on. We will be there. We cannot be in with the patient and the GP — that is a sacrosanct interaction. However, we want to influence GP prescribing behaviours so that we get quality, safety and cost-effectiveness.

You are absolutely right: there are millions of pounds worth of opportunities that we need to yield and reinvest in the service.

Mr Clarke: That is where I fundamentally disagree. You may be trying. I have done a quick calculation, but there is a 69% difference. I accept the point that the two areas are different and that the types of things that are presented may be different, but the general illnesses will be very similar and, whatever seems to happen there, we seem to follow behind that. You said that, through your model, you have driven 18% of efficiencies, but that still leaves you another 50% to try to catch up on.

Mr Pengelly: But the point, and I will not repeat —

Mr Clarke: You did. There is nothing to back up the point that you made at the start. You are talking about outcomes, and I think that you talked about the outcomes in primary care. It is easy to do that for statistical purposes, but you cannot directly relate that to that figure.

Mr Pengelly: It is easy to do the bit I have done. It is easier to make a very trite comparison between Northern Ireland and England, as has been done in this report. We had fundamental concerns about this.

I made the point to Mr Girvan about the comparison with Wales and why we believe that it is not entirely valid. That is more so with England. More of the primary care budget, in comparison with England, takes place in secondary care. So, the £30 million figure would be a lot more significant in comparison with England.

Mr Clarke: Do you believe that the Minister got it wrong in 2011 when he agreed with the comparative nature of the figures? It is on record in the House.

Mr Brogan: Could I draw your attention to —

Mr Clarke: Sorry, no; just stick to that one first.

Mr Pengelly: I am not aware of what the Minister said.

Mr Clarke: It was the Minister's quotation. He recognised that Northern Ireland was not London. The English model and the prescribing costs were read into the record. However, with regard to cost comparison, the Minister is on record answering a question on rural pharmacies on 11 October. So, he is on the record accepting those figures, and he is on the record accepting that there is a parallel to be drawn between them, and there actually is a discrepancy. What has changed between 2011 and 2014?

Mr Pengelly: Just to be clear: what I am saying, and what I hope to have made clear, is that I feel that the absolute comparison is flawed. The general nature of the comparison, as all three of us said, is that, on a reasonable comparison, we are above the cost of our colleagues across the UK and there is work to be done to reduce that. However, the point that we were debating was the extent of that gap. I do not believe that it is as wide as suggested.

Mr Clarke: So, you do not accept that it is 69%, but you accept that there is a lot of work to be done.

Mr Pengelly: Yes.

Mr Clarke: Because of the difficulties and the complexities of the Department and everyone, how quickly are you going to get to a comparative figure that we can all agree?

Mr Pengelly: The more important issue is what GPs are doing day and daily in Northern Ireland and whether that is clinically and financially effective. The comparison with England, Scotland and Wales is interesting, and it gives us the sense of whether we are worst in class or best in class. However, we will effect change in the dialogue with what is happening in GP surgeries, and we are doing that.

With regard to the difficulty about the pace at which we fix it, it is necessarily not as quick as we would like, because it has to be done through education. If we were to change it immediately, every GP should see a patient, write out a script and send it to the board for approval before it is dispensed so that we can question whether it is clinically appropriate and financially effective. We simply cannot do that; we cannot delay treatment. So, the only option open to us is the examination of prescribing patterns and behaviour and a process of education, and we are doing that.

I assume that we will come to the number and extent of our MMAs later. I think that there is an issue there, and that we could intensify our investment in MMAs to allow more of that dialogue with GPs. I think that that would help our pace a bit, but it is fundamentally an education process.

Mr Girvan: I appreciate the line that has been taken there. I understand the benefit of having MMAs to inform about the new drugs that are coming through, the new drugs that are coming on to the list as generic, and making sure that they are aware of them and that they do not necessarily have to prescribe the branded on. However, we are dealing with people who are learned and should, at least, realise that we are trying to deliver on our budgets. They should be trying to achieve savings as well.

I want to talk about the savings that could have been made across three areas, and the illnesses are the same in England as here. For example, in areas such as hypertension, where the medication is the same and where generic drugs are available, savings of £8·3 million could have been made in 2012 and a saving of £6·5 million could have been made in 2013. That is in part 4 of the report. A fairly reasonable saving of nearly £15 million could have been made across three therapeutic areas if a little bit of concentration had been applied. It always leaves it open for people to think, and I am only just floating this in. In the past, you have heard people say that they are going away with one of the big pharmaceutical companies that is running an information programme for doctors or fund managers in health centres and that it is being held in Bermuda or whatever. To be honest, it leaves itself open for those sorts of questions to be asked.

Why would somebody prescribe a drug that costs £35 a month when he could have got away with prescribing something that costs £2·53 and does exactly the same thing? Is there an alternative? Is there an ulterior motive in some of those guys doing that? Yes, they are supposed to be there to look after the patient and to make the patient better — was that the term you used? Yes. Some of us think that it is just about getting them out the door. They just reach for the pad and say, "Away you go. You have your prescription. We do not care what medication you are on, but that is what you are getting anyway". I am just saying that there is a perception that that goes on, we are not focusing in on those areas. We could have one health centre in a demographic area dealing with a number of patients and another one four miles down the road with a similar type of background yet it could have twice the prescribing rate.

Mr Pengelly: I absolutely take the point and absolutely accept that there could be a perception out there about those external influences on prescribing behaviour. One drug costs £30-something and another drug costs a couple of pounds, and the view is that they may both be fit for purpose. Equally, in some cases, they may not both be fit for purpose. There may be clinical reasons. The point that I made about not being there when the prescribing decision —

Mr Girvan: I accept that, but it would not be 70% of a difference. I could understand 1% or 2% of people maybe having a reaction but not 70%.

Mr Pengelly: Absolutely. That is the reason why we are focused on that area and why we want to drive it down. The issue is fundamentally about which of those patients we can do that with, because, for some of them, that differential is appropriate and, for many of them, it is not appropriate.

Mr Girvan: You do not know until you try it.

Mr Pengelly: We cannot inject ourselves into the room beside every GP when they make every prescribing decision. We do a process of education. I am not sure, Chair, that you will want to get into the granularity of this today. It might be helpful if we produce a note to set out what happens on a monthly basis in terms of the interrogation.

Mr Girvan: Yes, that would be helpful.

The Chairperson (Ms Boyle): You could send that evidence to us.

Mr Pengelly: Yes, we can. It will illustrate that. We look at practices that are more than two standard deviations away from the mean. We look at where there is a high percentage of certain types of drug and comparisons with GPs in the same area, where you assume there is a broadly similar population cohort. So, we can set that out and give a sense of —

Mr Clarke: I hope that I am not taking someone else's area, but look at figure 17. Richard, why have you not picked up on that? I suppose that I will probably have to try to pronounce that word.

Mr Brogan: Esomeprazole and omeprazole.

Mr Clarke: Do you want to say it?

Mr Brogan: Omeprazole is available generically. Esomeprazole was brought to market and was branded until very recently. There is now a generic of esomeprazole available. It is still two to three times more expensive per month than omeprazole.

Mr Clarke: I think that it is worth reading into the record that esomeprazole costs £17·03 and the other one costs £2·27. If you look at the pattern across the UK, it seems that our GPs have got carried away with the one at £17 as opposed to the one at £2. Why is the work that you are talking about, Richard, not picking that up?

Mr Pengelly: I will read into the record that we knew about that long before the chart was produced for this report.

Mr Clarke: So, what have you done about it? Those are last year's figures.

Mr Pengelly: There is ongoing dialogue with GPs. I am sorry for repeating, but, until we put ourselves beside the GP and say, "We are taking your pen off you because you are not writing a script for that drug", they will continue to do it. We will continue to examine their prescribing behaviour, visit them, sit down opposite them, talk about their prescribing patterns, educate them and talk about the difference in the drugs.

Mr Brogan: Just to go over that: esomeprazole and omeprazole is one project area that we have been working at for the past three or four years. You will say, "Well, why have you not delivered on it?"

Mr Clarke: Are you reading my mind, Joe?

Mr Brogan: When I go into a GP surgery, I lift all their pens. If it says "esomeprazole", I replace it with an omeprazole pen. You are right to say that we are using more of that more expensive drug and ask why we are not using omeprazole.

Mr Clarke: That one switch would save £2·7 million.

Mr Brogan: It cannot be done overnight. It is about individual patient review on an annual basis and moving them over from one drug to the other. If you have ever suffered from heartburn, you might know that this is the drug that is used in severe heartburn right through to Barrett's oesophagus. The GP will want to assess the individual clinical responses to moving from one to the other. He does not want to upset somebody who is already on a stable drug. We —

Mr Clarke: If I was the Minister and I saw that, I would have had heartburn.

The Chairperson (Ms Boyle): I want to bring in a couple of other members.

Mr Beggs: It is inappropriate that the dear drug is allowed to be promoted and advertised on a pen on a GP's desk that you are so keen to have removed. It should not be there is the first place.

Are there other structural process differences between GP operations in Northern Ireland and in England that puts real pressure on them to make the right decisions for the benefit of our National Health Service? What differences are there other than GP prescribing? Are there other pressures on GPs from the health system in England, Scotland and Wales that mean that they do things differently from you?

Mr Pengelly: On the issue of the pen, I respect what you say, but I do not think there is a way I can stop a GP from using a pen of his or her choice, as much as I would like to.

Mr Beggs: Yes, but it is a symptom of the success of the billion pound advertising of pharmaceutical companies.

Mr Pengelly: I absolutely accept the sentiment of that. Our issue is that we want to stop that from having an undue influence on prescribing behaviour. However, we need to remember that, fundamentally, GPs are independent contractors. They are not employees of the health service.

Mr Beggs: And you can set the contract for them.

Mr Pengelly: We have been trying to negotiate a contract with them since about 2006. I think that is a point we will explore later.

Mr Clarke: But somebody else is picking up the tab for this, Richard.

Mr Pengelly: It is not something that I am comfortable with.

Mr Beggs: Can we deal with the issue of the process? Are different processes and pressures coming from the health service in England, Scotland and Wales that are getting a different result from what we are getting?

Mr Pengelly: Joe or Mark will say something on the detail of that. The fundamental answer is no. These are GPs who are licensed to operate on a UK basis. We have, by and large, the same set of clinical prescribing tools. We operate within the BMA with NICE guidance.

Mr Beggs: Have you asked your English colleagues why we are getting a different result from that in England, Scotland and Wales?

Mr Pengelly: That dialogue will happen on an ongoing and regular basis, and Joe or Mark will say a bit more about that. We need to focus our energy and attention on what our GPs are doing to make sure that they are making the right clinical and financial decisions about prescribing patterns.

Mr Clarke: But they are not.

Mr Pengelly: When they are not, we educate them, highlight the differences and push them —

Mr Beggs: But it is not working.

Mr Pengelly: We cannot direct a GP on how to prescribe. I cannot say to a GP, "I do not like the drug you've prescribed".

Mr Clarke: England, Scotland and Wales definitely seem to be getting the message on the cost of the two drugs. There is a big switch there. Wales, in particular, has done exceptionally well, albeit they are using it to a lesser degree. The other three regions are using it to a lesser degree. You are the paymaster here, Richard. Take that as one example, where one drug is £17 and the equivalent is £2·27. Can you not say, "We are taking that off the list. We are not going to fund that drug any more"?

Mr Pengelly: No is the short answer.

Mr Clarke: I will take the long version as well in a minute, because that is obviously —

Mr Pengelly: Joe will expand on that.

Mr Brogan: We cannot say no currently. We cannot say no to esomeprazole, whose branded form is Nexium, because it is clinically available and licensed. We would have to go through a particular process —

Mr Girvan: It is too dear.

Mr Brogan: It is appropriate in a small proportion of cases. It is being used in a percentage of patients throughout the UK. Would you want us to say no to people with extreme disease such as Barrett's oesophagus, which is a pre-cancerous condition? Would we wish to go down that route? I would argue probably not because that is not clinically appropriate. So, we have to influence what is clinically appropriate.

Mr Beggs asked about structural differences. It is the same GMS GP contract across the four nations, so the levers that are available in other parts of the UK are available to us in Northern Ireland. You will make the argument as to why we are not doing the same as other parts of the UK, and I accept the point. We have not done as well as other parts of the UK, but we have made good progress over the past number of years to set that right.

In the graph at figure 16, the £4·14 is the cost per head of population for that group of medicines. Compare that with Scotland, where it is now £3·85. If you want to go down the route of comparing populations, which is arguable anyway, you see that we are starting to deliver efficiencies here through the work of my staff, who have been absolutely brilliant.

Mr Clarke: I would say that they are not. You could look at the graph in a different way and say that the population in those other regions are much higher, so the efficiencies should be greater.

Mr Pengelly: The cost per drug per patient will be the cost per patient regardless of the population size.

Mr Clarke: Yes, but the higher percentage of numbers affects that figure as well, does it not?

Mr Pengelly: No, because it is the cost of the drug. It is the unit cost of the drug going by how many patients are on it.

Mr Beggs: You have not given an explanation for figure 17. As highlighted by Trevor, what that shows is quite stark.

Mr Pengelly: Figure 17 absolutely underpins the point that we still have some distance to travel to get to the place we want to be. The issue, to the understandable frustration of members, is the pace at which we get to that. We are not saying that we are in a perfect place. However, beyond our approach of routinely, regularly and ruthlessly monitoring GP prescribing and educating GPs, talking to them and highlighting differences, I cannot envisage what else we could do at this stage.

Dr Timoney: We have talked about the need to be in the room and to be present at the point at which the clinical decision is reached. It might be suggested that we need to build on that capacity and have the medication review that has been discussed more figuratively delivered at the patients who are being retained on those medicines to determine whether they are still cost-effective and clinically effective for their condition.

Mr Clarke: There is something else that the figure does not say that I would be intrigued to know. Richard has told us that you knew about that before the Audit Office brought it to his attention. Did you do any work or analysis in those areas? It is like everything where a handful of GP surgeries make up the highest percentage of that. As you are familiar with it and will have looked at it in detail, is there is a geographical problem in Northern Ireland on top of that?

Mr Pengelly: There will be a detailed analysis of that by each of the 351 GP practices in Northern Ireland.

Mr Clarke: So, we know who the offenders are.

Mr Pengelly: Yes.

Mr Clarke: The picture is not as stark, because I assume that there is a minority of cases.

Mr Pengelly: To be clear: we know where the high prescribing costs are. We do not know where the offenders are. Some high prescribing costs are clinically justified. My GP colleagues would not forgive me if I did not put in that caveat.

The Chairperson (Ms Boyle): You talk about offenders, but you know who is making savings in the areas. You are well aware of Dr Brendan O'Hare in my constituency and the savings he has made. Have you talked to him about how he does it?

Mr Brogan: Certainly. I know Brendan and I know the practice very well. I was their first prescribing adviser in 1996, so I hope that some of my influence has been brought to bear within that practice. Brendan made significant inroads in 2011 and 2012. Forgive me if I am speaking for Brendan, but I know what he would say, which is that it is an ongoing issue. Brendan's practice is practice 616 — I know the numbers off the top of my head. It had higher costs and has a particular higher need as it covers a rural population in Castlederg and beyond. They made significant efficiencies, but have slipped in certain areas and know that they need to continue to work at it. It is an ongoing issue, and our medicines management adviser goes in every couple of months and tells him that he needs to do this, this and this. One of the drugs that is listed in the report, rosuvastatin, is a target for that practice. They will know that and work very closely with our medicines management advisers to identify what they need to address to move it on. Maybe, at the end of it all —

The Chairperson (Ms Boyle): He is a GP who recognised that it is a work in progress. He has identified savings and has made the initial move to make those savings. Would it not be excellent if all our surgeries were doing the same?

Mr Clarke: You will have no problem getting an appointment the next time you want one.

The Chairperson (Ms Boyle): He is not my doctor.

Before I bring in the Deputy Chairperson, who is anxiously waiting, that brings me on to something else. Mr Brogan, in paragraph 3.13, you recognised that the medicines management advisers — for anyone listening, that is the MMAs — play a central part in influencing the prescribing behaviour of the GPs. Given the importance of that role, it is surprising that, proportionally, there are considerably fewer MMAs in post here than in Scotland. Do you accept that the number of MMAs here is too low, with one per 130,000 of the population compared with up to six per 100,000 of the population in Scotland?

What assurances can you offer that the number of MMAs whom we have in place here is appropriate?

Mr Brogan: The report describes how we deploy MMAs. We have roughly 25 practices per MMA, and they go to each general practice on an ongoing basis, provide detailed information, look at the outlying behaviour, identify how we address that and develop action plans. That number came from an Audit Scotland report a number of years ago, and one issue identified was how we enable practices to make changes. In Scottish general practice, GPs have some pharmacist time to help them to make the changes. We are keen to explore with GPs the commissioning of additional prescribing support through pharmacists being embedded in practices. Mark mentioned — it has come up — having a pharmacist in the room with the general practitioner and the patient. It is not quite the same. It is embedded in the practice staff to support and enable the change, deal with the issues of managing patients moving from one drug to another, look at reviews and so on. That is work in progress. I accept the point that has been raised in the Audit Office report. It identifies that we probably need to do more, but that needs to done in a context —

The Chairperson (Ms Boyle): Do you think that more MMAs are needed?

Mr Pengelly: Chair, it is a resounding yes to the substance behind your point. GPs need more support for their prescribing behaviour, but the only slight reservation we have is that we are still not sure — we are doing work on it — whether the right place for that is through MMAs employed in the board who review the performance of GPs or through pharmacists employed directly by GP surgeries. If you speak to the likes of Tom Black from the BMA, he will say that the association is very enthusiastic about the GP federation model, and part of its plans for that, I understand, will be that each federation employs at least one pharmacist to support the GPs in that area. We are doing that, but we absolutely agree with you on the need for more support.

Mr Dallat: Is there a thought that generic drugs have somehow become rebranded and are no longer the tea and the sugar and the tea out of the big container but, in fact, have taken on their own advertising and promotion?

Mr Pengelly: Sorry, I am not sure that I follow your question.

Mr Dallat: I take this seriously, and I brought along this heartburn thing. Omeprazole is £2·27 and is prescribed all over the place at £17. There are different packages for the product. Have you unwittingly got yourselves back into the marketing situation that generic drugs were supposed to take us out of?

Mr Pengelly: No. With the comparison of £17, I think that it is a different drug.

Mr Brogan: It is a different drug.

Mr Dallat: There is a liquid version of this one, which your GPs are prescribing at £10. Does a better class of patient get the £10 one?

Mr Pengelly: As I understand it, stroke victims' capacity to swallow can be severely constrained, so they cannot take tablets, which is why GPs routinely prescribe the liquid form of tablet.

Mr Dallat: If that is the case, I accept that. Are you sure that that is right?

Mr Pengelly: I am advised by clinicians that that is the case.

Mr Brogan: With liquid preparations, the vast majority of medicines available in tablet or capsule form will be swallowed normally. Some individuals will have difficulties in swallowing.

Mr Dallat: I am striving to get to the bottom of why the average amount of money spent on drugs varies so widely from area to area and from health centre to health centre. I will certainly put in a plug for my own and say that you will not get one extra tablet in Kilrea — not for love nor money — if you are not entitled to it, but that clearly does not apply across the board. The report, which I believe that we are supposed to take seriously, is riddled with many questions that have not been answered.

Mr Pengelly: We agree with that, Mr Dallat. In terms of variability, I think that you are referring to the graph on page 43, which shows the average cost per thousand prescribing units. There are a couple of very interesting things about that. This is 2013; if you looked at the same graph for 2010, you would see that, instead of the mean being £41,004, at that stage it was 14% higher. In three years, therefore, we have reduced the mean and significantly reduced the level of variability between practices. However, the graph shows us that there is still differential prescribing. If you take the mean point as the middle of the graph, it is easy to focus all our energy and attention on those practices on the right-hand side of the graph, which have a higher than average cost. I think that we should be equally concerned about those GP practices on the left-hand side, because we need to ask whether their prescribing is clinically effective. It is at a lower cost, but we must always balance cost with clinical effectiveness not only because of the obvious impact that that has on the individuals being treated but because it can lead to some very significant secondary care costs if we do not treat issues properly and appropriately first time in primary care. We need, therefore, to look at both sides, and we continue to work on that.

The paper that we promised to bring to you, Chair, will show that we examine, as a matter of routine, any practice that is more than two standard deviations away from the mean point, so there is a focus on anyone who is not quite close to the mean figure. As I said, we will set out all the other areas that we look at. Variability is an issue that we look at.

Mr Dallat: Chairperson, I am trying to get my head round this. Is Mr Pengelly suggesting that the people who are registered with a practice where the average spend per head is £26,303 are in pain and dying earlier or are in some way more disadvantaged than those who happen to be registered at the practice that is spending £55,501 per head of population?

Mr Pengelly: I hope that I am not suggesting anything, Mr Dallat. I am saying that, if we examine GP prescribing behaviour, we must look at both cost and quality. I am saying that it would be inappropriate just to look at everyone on the right-hand side of the mean point and say that their costs were too high and that they needed to be reduced. When costs are high, they need to be reduced, but we also want to make sure that prescribing is clinically effective. Sometimes that means that the discussion between an MMA and a GP may be, "You have used drug x at a cost of £3, and, in the circumstances, maybe drug y at £15 would have been more clinically appropriate and would have prevented the patient ultimately needing to be referred on to secondary care".

Mr Girvan: Are GPs made aware of the variance of drug costs?

Mr Pengelly: Yes.

Mr Brogan: Every month.

Mr Girvan: In what form do they receive that information?

Mr Brogan: This is the quarterly statement from COMPASS. It is very detailed and has lots of indicators. We provide a monthly statement of the cost. We allocate an indicative budget to every general practitioner. Roughly, we say that an average GP practice will indicatively have £1 million for a prescribing budget. We do not actually give them the cash. We give them the indicative budget, and then we measure their performance monthly on the budget spend. If there are issues of variance at the end of each month, our adviser will be on the phone. Equally, the practice manager will be on the phone to our adviser saying, "What have we done? What can we do right, and how do we move on?"

Mr Girvan: Does that not lead into the point that Trevor made? You go in with a chest problem, for example, and the first prescription that they give you is a certain strength of Amoxil. You finish that course and go back in a week's time to find that your chest problem has not improved. All of a sudden, the GP suggests trying doxycycline, which is fairly strong, as a second prescription, and you end up taking it. That is the cost of two drugs, whereas it should have been knocked on the head the first time with a proper good strong antibiotic. If the doctor sounds your chest and finds that you have a fairly nasty infection that needs to be dealt with, he prescribes amoxycillin. Probably half the infections out there are immune to it, because it has been prescribed so often.

Mr Pengelly: That is fundamentally an issue of the clinical quality of the behaviour of the GP. It is not an issue about how we control the prescribing budget. At the end of the day —

Mr Girvan: That comes back to the manager.

Mr Pengelly: It does, but we dispense the cost of the drugs prescribed by general practitioners based on their experience and clinical judgement.

Mr Girvan: How many GPs read about the cost of the drug to them?

Mr Brogan: Every general practitioner will be expected to read and acknowledge the COMPASS report, because we meet general practitioners annually and go through the COMPASS report in detail.

I will come back to your example, and I cannot help myself. You mentioned Amoxil, but we say that amoxycillin is the generic. That is the one you would go for first if it was clinically appropriate. In Castlederg, for instance — this is not to deride Castlederg — the antibiotic prescribing frequency is somewhat higher. If I were to speak to Brendan O'Hare, I would say, "This is a healthy adult with a chest infection, just leave them alone". The GP gives advice to the patient, and, if they come back and it is clinically significant, then it would be amoxycillin. Then they would be left alone, and then perhaps another one. There is a step-wise progression, and we produce clinical guidelines, offer support and give advice to general practitioners. We give advice on information for patients on looking after themselves and avoiding the need for antibiotics, because antibiotic resistance is a wider issue.

Dr Timoney: There are regional guidelines for antibiotic prescribing, and the report indicates how well that practice is identified. The indicators in that practice have been agreed with the BMA as good or poor prescribing, or necessary volume.

The Chairperson (Ms Boyle): We talked among ourselves about scores on the doors, which councils do for health ratings for takeaways and so on. It would be in GPs' best interests to have that on their doors to show that the practice is highly efficient in what it is prescribing.

Mr Pengelly: Would patients naturally gravitate towards a more expensive GP? I do not know.

The Chairperson (Ms Boyle): I do not know. I am not the expert, but I do not think so.

Mr Pengelly: If we could come up with a score like the council score for catering establishments that combined cost and quality, we would be comfortable with putting that into the public domain.

Mr Brogan: We put all information on prescribing by general practitioners on the Business Services Organisation website. There is a lot of data to work through, but it is important that we put it up there.

The Chairperson (Ms Boyle): Mr Girvan mentioned this — I do not know whether it is myth or fact — but it is in the public domain that GPs maybe have allegiances to some pharmaceutical companies, and that would help to dispel those myths.

Mr Clarke: I am wondering about the trend. I am looking at page 16 again — I am not trying to tramp on anybody's foot — but is part of the problem, Richard, the very fact that we have free prescriptions? There is obviously a cost to free prescriptions. Is the cost the prescription or is it handing in the prescription?

Mr Pengelly: The interesting point is that the number of prescription items per person in Wales is higher than in Northern Ireland. I think that there is a graph that shows that. Since the introduction of free prescriptions in Northern Ireland, our volume has gone up by 5%, but our cost has come down 7%.

Mr Clarke: That is good.

Mr Pengelly: We cannot attribute our position to free prescriptions. Even if you look at the trend, England is the only part of the UK that continues with prescription charges. There is no fundamental difference in patterns in trend lines between England, Scotland, Wales and Northern Ireland.

Mr Clarke: I was just curious about the cost and the patterns of prescribing.

The Chairperson (Ms Boyle): We will move on because I am conscious of the time. We have Mr Flanagan next.

Mr Flanagan: I thought that we were still on Trevor. I did not think that he had even started his questions.

Mr Clarke: I filtered mine in.

Mr Flanagan: That is good team work. With reference to paragraph 4.8, when you take account of population factors such as age and social deprivation, the data on prescribing units shows a wide range of variation in the costs of different practices, as we discussed. The Audit Office used your information to estimate the scope for generating savings. At paragraph 4.11, it calculated that £54 million could be saved. Paragraph 4.10 states that the prescribing unit:

Will you outline what NI PUs are and what they can be used for, given that you appear to disagree with their use in this context in your response to the report?

Mr Pengelly: To be clear: I do not disagree with the use of PUs for that important analysis. The bit that I am uncomfortable with is saying that, in any data series in which points run from low to high, if you strike the arithmetical average and if everyone above it constrains themselves to the average, you will save money. To me, that is a statement of mathematics rather than an evidence-based statement about how we effect savings in the prescribing budget. My issue is that, if you do that once, your average moves down, so you continue to do it because everything will then tend to zero. The logical consequence of that argument is that prescribing costs should be zero. We do not disagree with the use of the prescribing unit. I think that it is a very useful piece of analysis. Prescribing units, rather than just going on a pure per capita basis —

Mr Girvan: You believe in logic.

Mr Pengelly: Yes. I am an accountant.

Mr Girvan: Exactly.

Mr Pengelly: It is recognising that different cohorts of the population require differential levels of prescribing — for example, the very young and the very elderly. It is about trying to give a weighted adjustment. We could get a much more sophisticated explanation, but it is about trying to reflect the prescribing needs of the population rather than just being a numbers game.

Mr Brogan: An individual over the age of 65, for example, will be expected to consume considerably more medicines than somebody under 65. So, there is an age/sex curve. As you grow older, you will consume more medicines. The female population uses more medicine in a younger age group than males and then gradually catches up.

Mr Flanagan: What does "younger" mean?

Mr Brogan: There is a 10-year differential. You will see an age/sex curve, and we can provide that to the Committee. As females grow older, once they hit 35 or 40, they start to use more medicines than males.

Mr Flanagan: At that stage of their life, some of them might have been through an awful lot.

The Chairperson (Ms Boyle): I declare that I am not on any medication.

Mr Pengelly: We are absolutely not offering a critique or a validation; we are just saying that the empirical evidence is that that group of the population consumes more medicines —

Mr Brogan: — at a particular age line. You can see the parallels. We try to standardise populations so that, if you have predominantly more younger females or younger males in the population, you can start to compare practices with other practices. So we can flatten out the differences in population up to a point. It is important to remember that it is only up to a point. A needs index is also built into this, which looks at deprivation and other measures of social deprivation. That is really important because of the health outcomes linked to social deprivation.

Mr Flanagan: So you are happy enough to use the prescribing unit data to compare practice with practice, but paragraph 4.11 states that the estimated savings of £54 million is crude. What is the logic behind that?

Mr Pengelly: It is saying that, if you reduce your cost by £54 million, you will save £54 million.

Mr Flanagan: That is a good enough statement for an accountant, is it not?

Mr Pengelly: I cannot argue with its factual accuracy, but I am not sure about the scope to save £54 million, because, if you reduce any number by an amount, you will save that amount. The suggestion clearly is that we should be saving £54 million. We want to look at the evidence of prescribing behaviour in GP surgeries as the basis for saving. If we can drive that saving beyond £54 million, of course we will want to do that, but this is not a statement on what we feel is readily achievable. It is just a statement of mathematics.

Mr Flanagan: You say that you want to look at it. Will you do that?

Mr Pengelly: We have spent some time on it. We look at what GPs do every month, and detailed reports are provided to them. That has been happening for some time.

Mr Flanagan: Paragraph 4.11 states that the estimate does not take into account other factors such as access to other services, the impact of cross-border services, private health care and things like that. You say that you do not accept the figure of £54 million without further robust analysis. So what steps will you take to undertake further analysis to build on that work? What are you doing? You cannot simply say, "We do not accept your figure". You come up with a figure then.

Mr Pengelly: This is a generic analysis based on weighted prescribing units to try to get a like-for-like comparison so that it will red-flag any areas where we feel that prescribing patterns are out of the norm. It will be people who are more than two standard deviations above the mean or areas where there are particular patterns. We do that on an actual basis. This is flagging up statistically where you might want to focus attention. We are focusing attention on every single GP practice in Northern Ireland. We are saying that, for this to be valid, you will need to invest more time and energy. We think that a separate piece of work that we are doing is of more value and gives us a better insight into —

Mr Flanagan: What useful work are you doing to see how much savings can be made?

Mr Pengelly: We are not trying to quantify how much savings can be made. We are trying to drive the cost down to its lowest possible level. We simply do not know. The drug bill will always fluctuate considerably, because people contract illnesses. There is a whole host of reasons, and you will never get stability. However, we need to make sure that we educate and work with our GPs so that, every time that they are faced with a prescribing decision, they make something that is clinically appropriate and financially responsible.

Mr Flanagan: How much are you trying to do on preventative health-care policy? How much of the £100 million that was spent last year on antidepressants could have been sorted out if access to counselling services was far easier, and you did not have to wait nine months to get it?

Mr Brogan: I will give an example of what we have tried to do. We have generated prescribing efficiencies and real cash savings. Last year, we managed to reinvest additional money into Belfast — £1·4 million. It is now investing that into primary care talking therapies and primary care hubs, and it has just initiated that process. We are trying to reduce the amount spent on antidepressants. If you look at the numbers, you will ask why we are investing there. We have to invest in counselling and psychological therapies — absolutely — but we do not have a limitless supply of funding, so we have to reduce on the antidepressant side and reinvest whatever efficiencies we have into those sorts of services.

Mr Flanagan: The expenditure on antidepressants is not going down, because GPs realise that there are lengthy waiting times to see a counsellor. They have no option, therefore, other than to give a patient antidepressants, even though neither the patient nor the doctor wants them.

Mr Brogan: We have yielded out efficiencies and other elements of the prescribing budget to invest in that area. In the Belfast local commissioning group, we expect to see a shift in activity on antidepressants and patients getting the benefit of talking therapies.

Mr Pengelly: Your point is well made, and it is absolutely correct. Again, when it comes to a comparison between Northern Ireland and other regions, particularly in mental health and pain management, there are two areas in which GPs have said that their understanding is that a similar GP in some part of GB has the option to refer a patient to another clinic for some counselling rather than a medical intervention. GPs feel that that option is not open to them here, because the waiting time to access it is so long that they have no choice but to prescribe. That is a component of our higher cost. It is also a simple factor of the financial pressure; we cannot offer every type of clinic and immediate access to those clinics. That is the balancing act that we are trying to drive forward.

Mr Flanagan: If we are serious about tackling the high cost of primary care prescribing, it is not simply talking about generic drugs. We need to sort out the fact that people in the Western Trust area have to wait nearly two years for a hip operation and nine months for basic counselling services. Those things have a knock-on effect on the amount of medication that GPs have to prescribe needlessly, when there is a solution that people should have access to.

Mr Pengelly: Absolutely. The issue of investment goes beyond primary care; it goes well into secondary care. The sort of interventions that you talked about through the Public Health Agency and health promotion can make a very significant contribution to the generality of health. However, the specific point is that quicker access to secondary care can take people off medication more quickly.

Mr Flanagan: Have you done any economic modelling that looks at how investment in counselling services would have a knock-in effect on reduced expenditure on antidepressants?

Mr Brogan: We have. As part of that Belfast LCG model, it has developed a business case to reinvest the funding into the psychological —

Mr Flanagan: I think that you said that you had expended £1·4 million on counselling services and things like that. How much will that save on antidepressant prescribing?

Mr Brogan: I could not give you the figure. I would have to get the business case.

Mr Flanagan: There is a figure, but you do not have it.

Mr Brogan: There is an estimate about the impact, and that takes four or five years to run through. However, we can certainly get that information for you.

Mr Flanagan: Mark, do you agree that the Health and Social Care Board and the BSO need to undertake further work to compare and investigate the reasons for variations in prescribing units between GP practices to get to the bottom of this?

Dr Timoney: I think that they have gone a long way in getting to that analysis through the COMPASS reports that we discussed. There are absolutely clear comparisons between neighbouring GP practices in areas on a regional basis and at a high level on the range of prescribing indicators agreed with the BMA that we discussed — the levels of overprescribing, the examples of good prescribing and examples when prescribing is less than desirable. A lot of work has been done. It is about ensuring that appropriate clinical choices are made to make sure that patients' issues are addressed about the current prescription and how they can get the best treatment available to them cost-effectively on the basis of that analysis for an individual practice and its population.

Mr Flanagan: We are here to make sure that public money is spent wisely. Are you confident that there are no GPs compromised by their links with some pharmaceutical companies, or are you still fearful that that exists?

Dr Timoney: There are rules of engagement. The industry has come a long way in its responsible promotion of its material. I do not think that the risk is as high now as it was 10 years ago. The industry does deploy a lot of its resource in marketing, and that is bound to have an influence. Our medicines management advisers tell us that that influence is there. However, with our formulary, NICE guidance and various other guidance, there is ample evidence to counterbalance erroneous influence.

Mr Flanagan: How compliant are those in the primary-care sector now with the formulary list?

Dr Timoney: Compliance is at 83%.

Mr Flanagan: How does that compare with previous years? Is it increasing?

Dr Timoney: When we set the formulary we said that it would contain a list of drugs that were suitable for initiating and maintaining patients for 70% of the population. That allows a measure of clinical freedom for those patients who do not respond to first- and second-line choices. The doctor is then free clinically to decide to take another drug in place.

We felt that 70% would afford a margin of clinical freedom. However, when we analyse the implementation of the strategy, it tells us that 83% are compliant with those first- and second-line choices.

Mr Flanagan: Have you any idea how that compares with secondary-care prescribing?

Dr Timoney: Secondary-care patients are of a different nature. They probably find themselves in secondary care because the first and second choices afforded to manage their condition may, in some cases, not have worked. Although the same formulary and list of drugs apply, compliance may be somewhat less. We address the formulary with secondary-care clinicians and ensure that they take it into account.

Mr Flanagan: Is the figure lower, or do you not know?

Dr Timoney: I have not seen an analysis of the secondary-care figures.

Mr Flanagan: Richard, I want to draw your attention to the PEDU review in December 2011. You will be well aware of it. It critically assessed the plans of the Department of Health to deliver savings, drawing on the findings of the McKinsey and Appleby reviews, as well as the application of best practice from Britain.

The review acknowledged the McKinsey calculation on prescription and prescribing savings. Michaela calculated that there is about a 40% gap in costs between here and England. My understanding is that the PEDU review concluded that there may need to be a monetary approach to prescribing protocols and generic prescribing if the overall cost with England does not narrow.

Now that you are in this role compared with your previous one, what steps do you intend to take to meet the expectations set by PEDU?

Mr Pengelly: The PEDU report reviewed the McKinsey work. McKinsey, I think, identified potential savings in primary-care prescribing of between £148 million and £177 million if Northern Ireland was able to move to the top-of-class English performance. That was a valid approach for the McKinsey review, which was trying to set an aspirational target to save money in Northern Ireland.

We need to recognise that top-of-class performance in England terms is never practically achievable across Northern Ireland; prescribing patterns in the affluent south-east of England will never be achievable. That said, they set a figure of £148 million to £177 million. Since 2010, we have delivered savings of £132 million. Allowing for the differential of not achieving top-of-class performance, the Department has delivered well against a very aspirational target.

In moving forward with things like mandatory formulae, those discussions have, coincidentally, started in the Department since my arrival, as Mark reminds me, so it is an issue that we want to pursue. The point is that I have not left behind that exposure to some of these issues that I encountered when in PEDU.

Mr Flanagan: Has the overall cost gap with England narrowed significantly since this review?

Mr Pengelly: It has narrowed. As for "significantly", the table at the front still shows quite a significant gap.

Dr Timoney: Cost per head is at a 5% reduction rate in Northern Ireland and 3·5% in England, whereas cost per item is reducing in Northern Ireland at 10% and the English rate is reducing at about 8·5%. We are, as I said, moving faster.

Mr Pengelly: However, not as fast as we want.

Mr Flanagan: So, are we looking at cost per item or cost per head?

Dr Timoney: It was to offer two measures of performance.

Mr Flanagan: When we are talking about the potential introduction of a mandatory approach to protocols and generic prescribing, are we talking about cost per item or cost per head?

Mr Pengelly: It would influence both. They are two subtly different measures of the same broad performance.

Dr Timoney: We use two measures. One is cost and one is volume. You try to attract the volume on one hand and you try to get the best safety nets, given other quality and safety factors.

Mr Flanagan: Can you tell us what progress has been made on the initiatives outlined in the McKinsey review?

Mr Pengelly: The McKinsey review largely set an envelope for what could be achieved if we moved towards performance in England. The £132 million that has been saved has been through prescribing, particularly since 2010, the responsibility transferred to Joe's area in the board. There is a huge amount of detail in the initiatives. Joe, do you have a couple of headline points on that?

Mr Brogan: I am trying to recall. I was trying to dig into the McKinsey review. It highlighted some therapeutic areas, and we have made some progress, albeit we accept that we have more progress to make. McKinsey also talks about procurement efficiencies. We have attempted to do more procurement in primary and secondary care, and efficiencies have come out of that. The general point is that we have done some things; we have yielded efficiencies of £132 million. We have more to do and we accept that.

Part 1 of the Audit Office report talks about English hospital prescribing, which came up earlier. It is important to look at the entire system. If you add English hospital prescribing to English primary-care prescribing and then compare with Northern Ireland, there is not a lot of difference when you add in the two elements of our care. So, it is important to consider all that in the round but accept that there is more to do to get the efficiencies that we need.

Dr Timoney: McKinsey pointed out that, in 2010-11, there had been significant work done in Northern Ireland to achieve those efficiencies. As a result, the Department's response to McKinsey was to drive the 2010-11 targets higher. In fact, we tried to achieve in the comprehensive spending review period in one year what we set out to achieve for the whole three-year period. That was at the point when the work transferred to the board, and that formed the basis of the board's efficiency plan. Those efficiencies have been achieved to the extent that Mr Pengelly has pointed out, which is in the region of £132 million over those three years.

Mr Brogan: I am sorry, can I come back to you, Mr Flanagan? I have just pulled up the McKinsey report so that I can refresh my memory. We set a prescribing efficiency target annually, and we manage that through a prescribing multidisciplinary efficiency review team of accountants, who are very important to us, doctors and pharmacists. We review 25 projects in all different types of therapeutic areas.

Mr Flanagan: What about the patients? Do you talk to them at all?

Mr Brogan: We do. If we identify that there is a potential for efficiency, we engage with patient groups to understand —

Mr Flanagan: So, patients are an afterthought?

Mr Brogan: No. First, we have to scope out what is potential and, as we develop our plans, we will engage with patients to understand whether it is a reasonable thing to do and how would we manage that, fully aware of the changes that we would be expecting to make with patients.

Mr Flanagan: Mark, my final question is for you, and it relates to the drive for value for money and efficiency through the prescribing of generic medication. I am concerned that one of the results of that is that when people are regularly prescribed antidepressant medication, they go to the doctor for a repeat prescription, and every time they go to the chemist to pick up the medication, they are given a different brand of generic medication. The side effects change every time, which means that somebody with mental-health problems or suicidal ideations is being given a different type of medication with a different coating on it, which causes different side effects every time they get a new prescription. As part of the drive to save money, what are you doing to ensure that patients are not being negatively impacted because of the change in their medication?

Dr Timoney: We recognise that medicines optimisation is key to our work over the next numbers of years; that is why we are launching a medicines optimisation quality framework at the start of the new year to look at the patient experience through their medicines review and to address quality, safety and the patient experience. We want to make more use of our pharmacists' clinical skills and the time that they take when dispensing to reassure patients that the drug is equivalent so that, when the patient experiences a problem with the drugs, they can discuss the side effects with them to ensure that there is no detrimental effect.

Mr Flanagan: If a doctor is prescribing medication that is the exact same as the branded product, why does the same pharmacy give out a different brand of unbranded medication every time?

Dr Timoney: Because that is how they procure medicine. They are free to procure medicines from whatever source —

Mr Flanagan: Does it make sense?

Mr Pengelly: The alternative is that we only prescribe branded medicine and quadruple our cost.

Mr Flanagan: The alternative is that a pharmacy has an agreement that it keeps the same brand of non-branded medication, particularly for antidepressants and for people who have suicidal ideations.

Mr Pengelly: The concept behind the move from branded to generic — the point was made earlier by one or two members — is that branded and generic drugs are chemically identical. We acknowledge that, in some very limited cases, there can be a limited therapeutic index that can cause difficulties, but the concept is that they are the same. So, let the market deliver generic drugs at the cheapest possible price so that the chemical compound is delivered in an effective but financially responsible way. We could turn that on its head — that is doable — but it would drive significant cost growth with, I suspect, pretty limited clinical effectiveness. There are issues about making sure that people put their hand up. One of the reasons that we will give separate money to pharmacists is that people should acknowledge that their pharmacist is an expert source of advice.

Mr Flanagan: In some of the stories that I have read, Richard, it is too late for people to put their hands up because they are dead because their antidepressant has been changed repeatedly every month and they have gone through the side effects every month and cannot cope and kill themselves. That is what is going on. I do not know whether you are aware of it or not, but that is happening with generic antidepressants because people's medication is being changed every month.

Mr Pengelly: We obviously do not know the detail of individual cases. However, I have heard from professionals that the instances where different types of a generic formulation would have a meaningful impact are exceptionally limited.

Mr Brogan: If there are instances, we would certainly be interested to follow up on them. The generality is that community pharmacies will stick with whatever is available through their named wholesaler. There is a commercial arrangement on what generic medicines they will buy in at any given time. Largely, they will try to stay to the same one, but we have no control because that is a market issue. So, inevitably there will be changes. If there are changes, particularly where individuals have particular needs, we have asked pharmacists to talk to the patient from a professional perspective about the change so that they manage that. If that has not occurred, I will be interested to find out and understand what has happened because, ultimately, we want to make sure that patients get the right medicines and consume them appropriately. If we do not achieve that, it does not really matter whether we are prescribing branded or generic. We need to keep patients well.

Mr Flanagan: I am happy to follow that up with you if you are happy to hear that. Thanks.

Mr Beggs: Thanks for the information to date. I hope to draw some more information out so that we can improve our system. I would like to focus on the drug Pregabalin, which I understand, based on the cumulative amount, is the most expensive drug prescribed by GPs and cost some £17 million in 2013. Hopefully, in looking at how you have managed it and looking at the record, we can see how effective the process has been. Figure 25 in the Audit Office report shows a steep rise in the volume of Pregabalin prescribed in Northern Ireland, from about 140,000 items to 250,000 items in a four-year period. It did not quite double in quantity. Can you explain the dramatic increase in the prescribing of that drug?

Mr Brogan: There are three licence indications for Pregabalin. One is neuropathic pain, and that is largely the volume that we are related to here. Neuropathic pain is a specific type of pain. Diabetic patients who have had an amputation get neuropathic pain. You have a particular nerve pain. It is also licensed in two other indications — epilepsy and generalised anxiety disorder. Largely, the rise is to do with pain and dealing with intractable pain issues. In 2010, NICE issued clinical guidelines saying that Pregabalin is a very good, clinically effective, useful intervention. There are other drugs, including Amitriptyline, which is unlicensed. It is an old — I use that word advisedly — antidepressant, but it has been used for that kind of pain disorder.

In the past, GPs would have used Amitriptyline as their default drug, but it is unlicensed; it also has a negative effect, particularly on older people who have cardiac problems. Therefore, GPs have tended to use a mixture; they will still use Amitriptyline, but they have used Pregabalin more so . With neuropathic and intractable pain, they will also seek advice from specialist pain clinicians. Indeed, we have seen that much of the rise is due to the fact that pain specialists in secondary care have used that drug and welcome it. There are another couple of drugs that are used as well: Gabapentin and Duloxetine. Those are the four main drugs used in that field.

We are quite happy that the Audit Office identified that particular area. We do think that we are probably using too much of that particular drug, but we also know that the other drugs that are used in that condition area — Amitriptyline and Gabapentin — are not used to the same level as other parts of the UK. Therefore, there is a bit of an issue —

Mr Beggs: Are they used to a higher or lower level?

Mr Brogan: Scotland, for example, will use maybe two or three times as much Gabapentin as Northern Ireland. Therefore, there is something about the mix and the clinical decision-making around whether you use Pregabalin, Gabapentin, Amitriptyline or Duloxetine. Having said all that, and looking at the numbers and the potential for efficiencies, I think that we probably use too much. With regard to the interventions that we have tried to develop to deal with that, the issue that we are talking about is intractable pain, so we have to develop services and alternatives to manage that, such as Mr Flanagan talked about earlier — psychosocial support in managing chronic intractable pain. We have developed a toolkit in conjunction with pain specialists, particularly in the South Eastern Trust, that is really helpful for patients. We are trying to advise that, yes, they may need medicine, but that there are other means of trying to manage intractable neuropathic pain.

Mr Beggs: Richard, have you looked at the cost of all that medication as opposed to the cost of providing additional methods of treatment and avoiding medication? Have you looked at the cost savings that could be made by providing appropriate services to counselling and support in different mechanisms?

Mr Pengelly: That will be looked at in the board as part of its commissioning role. GPs regularly say that one of the reasons why they are accused of over-prescribing — to use that phrase — is because of the lack of availability of some pain clinics. Earlier this year, the Patient Client Council produced a report, 'The Painful Truth', where it interviewed patients who were suffering chronic pain. One of its findings was that the view of patients was that sometimes GPs were too quick to prescribe rather than explore alternative interventions. There is a combination of factors, but those costs are explored by the board and evaluated as part of the commissioning decision.

Mr Beggs: I am getting confused. Joe said that the pain clinics were prescribing this and that that was the cause of the rise. Can we have clarity: is it the GPs or is it the pain clinics that are prescribing specialist drugs? In one sense, we have the permanent secretary saying that GPs indicate that they are prescribing them due to the lack of pain clinics to provide alternatives, and then we have a representative of the board telling us that they are being prescribed by the pain clinics. Can you clarify what is going on?

Mr Pengelly: Sorry, we are both saying exactly the same thing. The point that Joe was making goes back the point about the influence of secondary care on primary care prescribing. The patient suffering chronic pain in a secondary-care environment will tend to be prescribed this very expensive drug. That influences primary-care behaviour.

Pain clinics are part of secondary care; they not part of the primary-care prescribing issue that we are looking at in this narrow context.

Mr Brogan: I will give you a little more detail, Mr Beggs, if you bear with me. We do audits in primary care and in hospital land looking at the primary prescriber of Pregabalin. That was done in the South Eastern Health and Social Care Trust are. That showed a 60:40 split, so 40% of initiations were GP land and 60% in secondary care. That has changed over the years as GPs have got more used to that drug.

It is a bit of both and, coming back to your point, it is important to look at whether there are alternatives. We have had some success in providing alternatives to patients. Having said that, there will always be a need for medicines to deal with some of these issues.

Mr Beggs: Again looking at this almost doubling in four years, during that period NICE originally recommended Pregabalin at a first-line treatment. It then withdrew the early guidance and advised that it was one of three drugs for treatment, so it almost doubled despite the removal of the NICE guidance and a clear indication that there were three drugs. Has the new guidance got down to the coalface?

Mr Brogan: What we do with NICE guidance, where it is appropriate to do so, is develop an implementation tool. Following the first NICE guidance in 2010, there was NICE guidance in 2006 or 2007 for diabetes because that dealt with the neuropathic pain. That guidance mentioned Pregabalin. One could argue that our GPs and specialists used the first NICE guidance some years before that and started to use Pregabalin earlier.

In 2010, the key guidance came out. We looked at it and started to inform GPs that there were alternatives and to use Pregabalin judiciously. When the new guidance came out, we redeveloped our guidance to GPs working with secondary and primary care so that, alongside our formulary, they were singing off the same hymn sheet, as it were, so that we are completely clear about the right treatment modalities, what we would expect a GP to do in particular situations, and then how we refer on to secondary care.

Mr Beggs: Have the alternatives also doubled during this period?

Mr Brogan: No.

Mr Beggs: Essentially, they are not listening to what you are telling them.

Mr Brogan: The doubling of Pregabalin is in the number of prescriptions. The cost per head moved from £8·20 or so to £9·43. The number of prescriptions may have gone up because we asked GPs to reduce the number of items on them. Instead of prescribing 56 days, move to 28 days. That will increase the number of prescriptions, and that might be because they want to see the patient more frequently.

Mr Beggs: The cumulative cost at figure 26 shows that the equivalent of £9·43 for every person in Northern Ireland has been spent on this drug. That is almost £10 per head of population, yet in England, Scotland and Wales it is less than half that. Does that not sound alarm bells?

We were told earlier about monthly reports with any movement off standard deviation and that there is analysis. We are way off the mark compared to other parts of the United Kingdom. What is happening? What are they doing wrong or what are we doing wrong?

Mr Pengelly: There is a sense that we are doing something wrong; the issue is about the extent of it. This is a perfect illustration of the debate that we had earlier with Mr Girvan. We get the detailed reports, which are subject to dialogue between MMAs and GPs. The reality is that, in many cases, prescription of this drug at primary care is the appropriate clinical intervention. The difficulty is, as part of that dialogue, finding out those cases where it is not the appropriate intervention, and there are cases. However, that is a constant process of dialogue.

You mentioned a specific focus on the number of times that this is prescribed, so it is part of that debate with each of the practices where this is happening. I share the Committee's frustration that we cannot make more rapid progress in bringing the cost down, but it has to be driven by that dialogue.

Mr Beggs: Given its higher cost per person and greater use here, is there any particular underlying health issue with epilepsy, general anxiety or neuropathic pain in Northern Ireland compared to other parts? Is there a medical issue with the population that is more common and has resulted in the increased prescribing of the drug?

Mr Brogan: There is a general need. I cannot not give you any evidence around what the difference is in Northern Ireland. Essentially, you are asking whether there is a difference in need with this specific issue across the four countries. I cannot give you that comparison.

Mr Pengelly: The general articulation of needs differences between Northern Ireland and the UK would not explain the differential. There are accepted higher levels of need. I think that Appleby talked about 9%; the National Audit Office report, which used Deloitte, talked about it being as high as 26%. That would not explain the degree of variability with other parts of the UK.

Mr Beggs: When I look at figure 10, that is my impression. Your quality outcomes framework (QOF) figures indicate in the areas mentioned that we are only very slightly out of kilter with other parts of the United Kingdom for levels of epilepsy and, perhaps, depression. Would it be about 0·3% of a difference as opposed to 100% of a difference?

Mr Pengelly: This issue has shown the specific disease prevalence, but it is like anything: the devil is in the detail. This high-level summary masks that.

Mr Brogan: This is QOF data. QOF is developed, essentially, as a payment tool for GPs. There are a number of disease registers that we contract GPs to maintain. They are listed, and that is fine; it shows the overall incidence. The Audit Office report has taken the Northern Ireland numbers and compared them with the other UK countries. That is not necessarily the way to compare disease prevalence. We need to investigate it in a different way and to seek other data sources.

Mr Beggs: One of my colleagues will perhaps pursue the issue of QOF data later, so I will not delve into it. It has been estimated that if we had reduced our prescribing of that drug to UK levels, about £9·7 million could have been saved in 2013. Given that that drug costs our GPs the most to prescribe —£17 million — what actions have you taken to bring improvement in that area?

Mr Pengelly: The detail of the reports that we will send the Committee indicate that that is a key metric of GP behaviour. It is part of the dialogue. That will come to the Committee. Your time —

Mr Beggs: OK. I look forward to receiving them. What action do you take when a GP ignores all the data and information that you provide them?

Mr Brogan: The contract gives us a vehicle whereby a GP or practice is deemed to be excessively prescribing, and we agreed with the BMA a definition of excessive prescribing. We have agreed seven indicators that demonstrate where there is excessiveness beyond the average. Again, it comes down to the control charts —

Mr Beggs: Will you provide us with those indicators?

Mr Brogan: We will provide you with all that. There is an accountability mechanism for the outliers.

Needless to say, it is outliers, so it is at the two to three standard deviations and beyond. We are talking about the minority of practices that we identify as potentially excessive. Our requirement is for them to move towards the mean, where there is a little bit of variation.

Mr Beggs: I see that you have given yourself a target of reducing costs by £1 million as opposed to the £9·7 million. Is that challenging enough?

Mr Brogan: I accept that. We will produce the history of the past four years and our attempts to try to develop and get efficiencies out of this area. Unfortunately, the current programme shows that we are not necessarily going to achieve that £1 million target, but we will continue to progress against that towards the end of the year.

Mr Beggs: My local minor injuries unit has closed down over hundreds of thousands of pounds, yet this area could save millions of pounds. If you are not even going to hit your £1 million target, does that not tell you that there is something wrong with our system and that we need to do something more fundamental?

Mr Pengelly: I think it is telling us that it is not merely a case of wishing our problems away on this. We have identified by this high-level analysis, potentially, the scope for making savings. You only effect those savings by making individual changes at the point of prescription. That is fundamentally about education. Moving to the point where we pre-approve every prescription is not realistic, so we have to continually highlight prescribing patterns that are outwith the norm and educate GPs about alternative interventions, alternative drugs and what options might be available to them to squeeze this down. We work continually with them to do that. We want to make more rapid progress. I accept that the pace that we are moving at is frustrating, but we cannot just flick a switch and capture these savings.

Mr Beggs: You are certain that we have all the tools that health authorities have in other parts of the United Kingdom? Is it just that we are not getting the message across?

Mr Pengelly: No. We acknowledged earlier, and the Chair raised with me, the need for additional pharmacy support for GPs. The issue is about whether that would be in the form of additional MMAs or additional pharmacists embedded within GPs. We need to do that, but that in itself brings a resourcing problem. That is an issue that we are looking at going forward into the 2015-16 financial year.

Mr Beggs: Is it a cost-effective resourcing problem that saves money?

Mr Pengelly: It is, but there is an issue. There are two tiers of challenge facing the health service —

Mr Beggs: Sorry, does this save money by investing —

Mr Pengelly: There are two tiers of challenge facing the health service: one is meeting statutory obligations about which we have no discretion, and the other is with discretionary funding and making it available on a prioritised basis. This would be a priority intervention. If we were able to secure unlimited funding from the Executive, this would unquestionably be a priority intervention. However, it is a discretionary spend, and, at the moment, we are facing a significant challenge to continue to meet our statutory obligations.

Mr Beggs: I think one of my colleagues will delve further into that.

The Chairperson (Ms Boyle): Following on from that, there are no sanctions for doctors who overprescribe, obviously. So, in reality, what can be done beyond the work that the MMAs do in educating GPs? Do you intend to look at what any other jurisdictions are doing?

Mr Brogan: We do look at the other jurisdictions, and we try to identify best practice and implement that in Northern Ireland. There is a sanction within the GMS contract. We can invoke the contract for that excessive prescribing element. Where there is no justification for that excessiveness, we can invoke the contract and, ultimately, we can remove the contract from the general practitioner.

Mr Beggs: How often have you invoked it?

Mr Brogan: It has been done very infrequently, but it has been done.

Mr Beggs: How often?

Mr Brogan: It has been done at least once in the past three years.

Mr Rogers: Gentlemen, you are welcome —

Mr Girvan: Sorry, before you move on, from 2000 to 2013 there was an increase in the prescribing of drugs by 70%.

Mr Pengelly: Yes, but since 2010 there has been an increase in prescription numbers by 5% but a decrease in cost by 7%, so there is a generality of better prescribing behaviour. The reality is that we have a growing population.

Mr Girvan: I am not talking about 7%; I am talking about a 70% increase in the number of prescriptions issued from 2000 to 2013.

Mr Pengelly: There are a number of factors there. We have a growing population.

Mr Girvan: We have not grown that much. We have gone from 1·68 million to 1·8 million.

Mr Pengelly: The point that Joe made is that, in many cases, to encourage better prescribing behaviour, GPs are being advised to prescribe shorter courses of treatment. That will have an influence. If I prescribe you a year's worth of drugs, that is one item on a prescription. If I break that down into 52 instalments so that you come back to me on a regular basis —

Mr Girvan: That is 52 prescriptions for the one.

Mr Pengelly: That is an extreme example.

Mr Girvan: I understand. What interrogation goes on into repeat prescriptions for somebody who ends up in hospital, and when the pharmacist in the hospital — you maybe have some experience of this — goes to check on the drug regime that the patient is on, he finds that they are on 24 tablets a day and does not know why they are on that? They might ask, "How long have you been on that?", and the patient might reply, "I have been on that for seven years on a repeat prescription". The pharmacist might say, "You should have only been on one course of that for a maximum of three months", yet they are in with a kidney problem caused by the medication that they have been on and are still on because they had been on it for seven years on a repeat prescription.

Dr Timoney: We have attempted to put a service in place over the years to look at and track that. We have integrated medicines management pharmacists, as they are described, who are picking up those patients coming out of hospitals, reconciling those medicines for their appropriateness when they arrive in the hospital, and ensuring that, during the patient's stay, medicines are changed and that those 24 medicines are reduced to an appropriate number —

Mr Girvan: Four, and the person said that they had never felt better in all their life.

Dr Timoney: Then, in advance of them being discharged from hospital, that information is communicated back to primary care so that, when the patient goes home, it stays with them. When that was tested and researched, it showed that there was a reduced length of stay in hospital and reduced readmission rates, that the medicine's appropriateness improved, and that every £1 invested in that service —

Mr Girvan: If they had not appeared in through A&E, they would still have been receiving 24 tablets a day and would have been sitting like a zombie in their living room, unable to function in their daily life, while their GP was quite happy to dish that out to them.

Mr Brogan: Absolutely. We see cases all the time of patients being on medicines, and, when it comes to review, they did not actually need them or we could have optimised that. We want to learn from those experiences, and we have just commissioned pharmacist support in GP practices to undertake the medication review. Another element of that is particularly around care homes. Patients in a care home setting, who are usually old and have lots of medicines, need to have ongoing reviews. As part of our commissioning arrangements with GPs, we will ask the pharmacists to go into care homes to undertake the medication review, reduce the medicines that they do not need and optimise to make sure that they do not get the side effects but get the right treatment outcomes.

The Chairperson (Ms Boyle): In my area, my own GP practice has changed its methodology in how you access repeat prescriptions. You can no longer just phone in and get your repeat prescription; you have to either go online or walk in and order your prescription. The facility to just phone up for a repeat prescription no longer exists. Is that across the board, or is it just down to the discretion of the GP practices? Is that maybe a way of trying to make savings, or is it a way of making sure that the quality and safety of things is done right? Has that been done by the board right across?

Mr Pengelly: There are two issues, Chair, and I will let Joe speak to the second one. The first issue is how you access a request for a repeat prescription; at the moment, that is particular to individual GP practices. One of the separate issues that I want to drive forward is that, across Northern Ireland, we can get that automated so that everyone has the ability to go online and order. That will reduce administrative costs in the GP practice and make it easier for people, because it can sometimes be difficult to get through to your practice when people are trying to access appointments. That is separate from the point about review and whether you can continue to call on a repeat prescription, which is the clinical point.

Mr Brogan: It is up the individual GP practice how it manages that repeat request line. Some have a telephone request, and it will be a number of hours. As you say, some will have the online facility, where it is appropriate to do so. For certain individuals it is great, but for others it may not necessarily be so. We advise GP practices that they have to listen to their patients in terms of what the needs are, but there ultimately needs to be scrutiny of the requirement. An individual may literally be on 20 different medicines. When a request comes in, we ask the practice — particularly the practice staff, who we do a lot of work with — to scrutinise the request. It is not simply saying, "I need all my repeat prescriptions"; it is, "Do I need medicine 1, 2, 3 and 4? Do I need that paracetamol? It's just when required. Do I need this particular tablet? I only use it now and again." That scrutiny is really important. We try to make sure that the practice staff are well trained and ask the right questions of the patients. Ultimately, it is to get the right amount of medicine supplied in good time for patients.

The Chairperson (Ms Boyle): It may work in towns and urban areas, but it would not work in some of the areas I represent, such as Aughabrack or Aghyaran. We have broadband issues.

Mr Rogers: I am very interested, Richard, in your statistics and what people say about statistics and so on. You talked about figure 14 and the mean etc. There is an over-reliance on statistics. You talk about the mean and two standard deviations from the mean. That is fine if the mean is not skewed. However, if you take something like the drug that Trevor mentioned earlier, the generic alternative is roughly £2·20, and the other one is £17. Look at Northern Ireland in figure 17: they used a large percentage of the £17 drug. My reading of figure 14 is that the mean is really skewed. It would be very interesting to look at the mean across England, Scotland, Wales and Northern Ireland to see where it lies.

Mr Pengelly: The point we are making is that these are of some use in terms of giving you a limited sense of relative performance across a large population sample. The reality is that, whilst the use of prescribing units is a good way of standardising, it is entirely possible to get two practices side by side that have such a fundamental difference in the makeup of their population that even that attribution would give you a skewed result. It is giving the generality of performance. Sorry for repeating myself, but all paths point to the actual prescribing behaviour. All this material does is throw up a series of red flags where we want to pay particular attention. There is a whole range of areas — as I said, we will put this in the pack that we will forward to the Committee — that we examine in detail for each practice. Issues like this, where there is a massive differential between broadly similar therapies, are areas of particular focus.

Mr Rogers: We are looking only at that mean and saying that there are a few above and a few below it, but that mean does not truly reflect where we should be in terms of costs. Are those targets reasonable?

Mr Pengelly: The use of the mean is really to highlight areas for specific attention. Attention is paid every month to looking at the prescribing pattern of the GP practice in the context of its actual population. The use of the mean and the prescribing units is only useful in trying to get a sense of how practices compare with each other. Where we effect change is what happens within a practice, where we use actual data and population numbers.

Mr Brogan: We have 350-odd practices. I mentioned earlier that each practice is allocated a budget of roughly £1 million. The performance of the individual practice is a much better way of understanding whether it is prescribing cost-effectively for that population. We then look at the overspending practices. We expect to work out what the variables are along a whole range of indicator sets, and we will then have a discussion about what the individual practice need is and what its access to other services is. We will then try to attempt to reduce prescribing back towards where we think the budget ought to be in terms of its spend.

Mr Pengelly: The real value of figure 14 from our perspective is much more about monitoring trends, as opposed to a particular point in time. That is one of the issues and, to be frank, one of our frustrations with our colleagues in the Audit Office: it would have been very helpful, to understand this, to put in the positions as at 2010 and 2013, because it would have showed a reduction in both the variability and the mean cost. That is where that information is particularly important, because it shows you the direction of travel you are making, the movements in variability and the movements in average cost, as opposed to using it as a vehicle to actually understand what is happening in any individual practice.

Mr Brogan: In terms of the variability, we have moved from over five practices beyond three standard deviations to just two. So the variability is starting to flatten, and the mean has actually come down over the past number of years.

Mr Pengelly: By 14% in three years.

Mr Rogers: I take your point. It would also be useful to see the trends in Scotland and England and so on.

On a similar point in terms of statins, on page 48 the report states:

So, the HSC Board is taking a bit of credit. However, when you look at the graph in figure 18, the number of prescriptions for statins has gone from 1·65 million to 1·95 million. There are 300,000 more prescriptions. Surely, if you buy more drugs you will get them cheaper, so the unit cost will be cheaper anyway.

Mr Pengelly: No. The total cost is £14·64 million. Again, the upward trajectory of the number goes to the prescribing habits; there are more scripts containing fewer days of treatment.

Mr Brogan: Perhaps, and the other side of it is that in terms of cardiovascular need, this drug is for cholesterol lowering, so the drive from a therapeutic perspective is to reduce cholesterol as low as possible. We have seen more and more patients going on to therapy, so I would expect the number of prescriptions to go up because that is where the need is going and that is where the evidence points to as being the right thing to do. We have tried to reduce the amount of cost that it takes to manage that demand, and we have succeeded.

On your point about buying more reducing the unit price, unfortunately we are part of a worldwide market and the price is fixed for the branded medicines. In generic medicines, there is market competition, and we will follow the market price. However, for the brands, the price is set at a UK level; we have no ability to manage that.

Mr Rogers: Similarly to what everybody else has been asking, and still on the issue of statins, the Audit Office illustrates that GPs in Northern Ireland continue to prescribe a higher proportion of a more expensive brand of statins, whilst NICE guidelines recommend the use of generic alternatives. The NICE recommendations were published in 2006, and Scotland moved in 2011, as did Wales. However, on page 51, the report states:

Mr Brogan: I accept that point. We did not have a body to assess how clinically effective and cost-effective the medicines that were coming into the market were and make that judgement. We have that body now, which will help us. I accept that.

Mr Rogers: Why did it take until 2014 to get there, when across the Irish Sea it was happening in 2011?

Mr Brogan: We have been following NICE clinical guidance throughout. It does say "in 2006", and we have been following that. It also mentions two other elements: the Scottish Medicines Consortium and the All Wales Medicines Strategy Group. We simply did not have those bodies in place in Northern Ireland. It took us a number of years to get there, but we put that in place from 1 April 2014.

Mr Rogers: Who took their eye off the ball?

Mr Brogan: It is not necessarily a case of taking your eye off the ball; it is a case of looking at what is right for the population in Northern Ireland, what the other systems are in other parts of the UK, interrogating those systems and understanding whether they are correct for Northern Ireland, alongside NICE clinical guidelines. From our perspective, we have to follow NICE. We then developed a framework where we have NICE but we also have an additional element, which is aligned with the Scottish Medicines Consortium.

Mr Rogers: Why did this not happen?

Mr Brogan: We already had NICE guidance, so this was adding to NICE. England does not have an SMC or the All Wales Medicines Strategy Group. They just have NICE. We have added to that and said, "Right, we have NICE plus this other body." We recognised that more could be done and we put in a system where we can have that, without necessarily any challenge from other parties, to make sure that we have a good framework for making clinically effective and cost-effective medicines available.

Mr Rogers: Was it in April 2014 when you recognised that more needed to be done, or was it back in 2011?

Mr Brogan: No, it has taken just over 18 months or two years for us to be able to put that framework in place by 1 April and to get that arrangement developed.

Mr Pengelly: Whilst there were those additional arrangements in Scotland and Wales, they were not in place in England, and England is still performing much better than us on a cost basis. The work that we are dong to help our performance is, to some extent, aided by this, but I would not want to point this out as being a panacea for all our issues if it is not there in England and they are achieving better performance.

Mr Rogers: OK, I accept your point. Joe, you said that costs were not paramount in the decision-making in terms of GPs. We understand that the patient comes first and whatever else, but where were costs and value for money on the list? You said that there have been improvements since April this year, and I acknowledge that, but what is being done here proactively to ensure that we have value for money?

Mr Brogan: Proactively, we address this issue on a monthly basis with individual GPs and practice staff. Value for money is absolutely there, alongside the other elements of safety and quality. I would not say that one is necessarily more important than any other in the round. They all have to be taken together, and it comes down to the interaction with the patient. It is a question of what is best for the patient who is in front of the GP but also what is best for the wider health service as well.

We remind and educate GPs. We provide them with tools and support for their staff in terms of the changes. We provide advice right across primary care, community pharmacy, GPs, health visitors and district nurses in terms of what is the right thing to do for individual patients and the wider HSC.

Mr Rogers: What if they do not take that advice?

Mr Brogan: We have already mentioned that we have the GMS contract, which gives us an element of leverage. Ultimately, there is a professional sanction where, if there are examples of excessiveness or issues, we will take professional sanction as well as contractual sanction.

Mr Rogers: Without going into detail, have there been any cases of professional sanction?

Mr Brogan: We have certainly raised issues from a professional perspective where those issues have caused us concern.

Mr Dallat: I have this heard this story from both sides. I have had local pharmacists complaining to me that they were reimbursed at less than the cost price. Is that true?

Mr Pengelly: I think that can be the case in some cases.

Mr Dallat: Can you explain that?

Mr Pengelly: It is a fairly complex model.

Mr Brogan: We pay community pharmacies for the drugs that they dispense. There is a range of drugs; there are the branded medicines and the generic medicines. We know that on the generic medicines side they earn additional profit. They may buy a drug from the wholesaler for £10, but the reimbursement drug tariff price may be £11, so they are getting a 10% profit. We apply a clawback, which equalises the amount of profit earned on the branded and the generic. Typically, on the branded medicine side, they do not earn that level of profit. So what we have attempted to do is to modulate it across the piece. With branded medicines they may appear not to necessarily be getting the full reimbursement price, but that is equalised because the generic medicines are actually getting additional profit. When you balance it out, there will be additional profit, and there is a profit margin that we have factored into the remuneration, the target being £16·5 million on an annual basis.

Mr Dallat: Just for our report, can you give us a breakdown of the percentage of the £460 million which was received by the small independent pharmacists, for whom I have a lot of time, the Northern Ireland-based pharmacy chains, the UK-based chains and the global chains.

Mr Brogan: Yes, we will provide that.

Mr Dallat: OK. I suppose that the question I really should have asked is: why have your Department and the pharmaceutical contractors failed to agree on the arrangements for reimbursing the cost of the most frequently prescribed and dispensed generic drugs? Are the contractors too powerful? Why is there no agreement?

Mr Pengelly: This goes right back to the basic contract that started in 2006. The key point at the moment, to be fair to both sides, is that the 2010 judicial review clarified the statutory duty on us to provide "fair and reasonable" remuneration to pharmacists. So, the devil is in the detail about what is fair and reasonable remuneration. You can understand that their view and ours may be somewhat at odds. At the moment, we are starting work on a cost-of-service inquiry, which will try to clarify what is the actual cost of providing a community pharmacy service in Northern Ireland. Aligned to that, there will be an assessment and a margins survey about the state of the market, the price at which they are accessing largely generic drugs from the wholesale market and what is a reasonable level of retained profit. That will allow both sides to engage in detailed discussion about what is a reasonable level of remuneration and underpin what will, hopefully, be an agreed contractual position.

Mr Dallat: Tell me, Richard: why have the community pharmacy contractors in Northern Ireland refused to participate in the UK-wide study to establish profit margins for pharmacists on generic drugs?

Mr Pengelly: I suppose that the short answer would be that that is a question that we would like them to answer in detail.

Mr Dallat: You are funding them.

Mr Pengelly: We need a community pharmacy service and, to be fair, we have our differences with community pharmacists on this aspect, but I do not want that to detract from the fact that they are a fundamentally important piece of health and social care provision in Northern Ireland.

Mr Dallat: Absolutely. I could not agree more. All the more reason why I should ask you the question: why have you no power to compel them?

Mr Brogan: Maybe, Mr Dallat, I could come back on that. Was the question around the margins survey and why they were not participating in that?

Mr Dallat: Yes.

Mr Brogan: They are participating in the margins survey. They are collaborating very well in identifying what level of profit margin —

Mr Pengelly: They did not participate in the costing survey previously, way back, which predated the first judicial review.

Mr Brogan: Are we talking about the current position or a historic one?

Mr Dallat: We are talking about the UK-wide study to establish profit margins. Maybe, if there is confusion, I can ask the Comptroller and Auditor General to clarify that.

Mr Kieran Donnelly (Northern Ireland Audit Office): Chair, I think we are talking about the previous arrangements, where there was a lack of participation at the earlier stage.

Mr Pengelly: This predated the judicial review.

Mr Dallat: How do they manage this in other jurisdictions? Did you find out why they were successful and you were not?

Mr Brogan: In 2004-05, the Department initiated investigations on a collaborative basis alongside community pharmacy. There are two big elements to that: the cost of service investigation and undertaking the margins survey. Equally, in the other countries, that was the course of travel. I cannot get into the detail of why the wheels came off in Northern Ireland, because I was not party, necessarily, to those discussions. Needless to say, with the judicial review, we ended up in a place where none of us wanted to get to. We were compelled to provide fair and reasonable remuneration, which is absolutely right, and now we need to learn from those mistakes and do the investigations, one of which is the cost of service investigation. It should be noted that the margins survey is on track, and we are collaborating really well with community pharmacy colleagues to understand the level of margin.

That gives us the clarity around the profit that is earned in respect of generics and proprietary. Once we have the cost investigation complete — it comes back to Mr Pengelly's point — we will be in a better place to have the negotiation associated with the contract.

Mr Dallat: Surely there must be some blame somewhere for bringing about a situation where there were two judicial reviews, costing £550,000, because you insisted on applying the Scottish drug tariff without any agreement whatsoever. Was that your darkest time in the whole thing?

Mr Pengelly: The application of the new tariff in 2006 was a consequence of the Department of Health in England having material concerns, which were underpinned by an evidence base, that there were significant figures of retained profit within the community pharmaceutical sector. As a consequence of the new tariff that was implemented then — I think that the latest figures were up to 2008 or 2009 — over £3 billion was saved from the drugs bill in England. Given that we were following that tariff, if we apply a pro rata approach, it has saved over £100 million in Northern Ireland.

The problem was that, in England, it was implemented in line with a new contract, which allowed for some of the savings generated by the new category M element of the tariff to be recycled to pharmacists for providing additional services in the community, but because we could not agree the contract with the pharmacists here, there was no mechanism to recycle those savings. So, in the first year, as the report acknowledges in respect of 2006-07, there was a £6 million payment to recognise the fact that those savings were not being recycled. That payment was not made automatically by us. That was part of a negotiated process. For as long as we made that payment without it being formally underpinned by additional services, the pharmacists would not have any incentive to enter into contract negotiations, so we did not make the payment in order that we could secure the traction to try to get a contract dialogue going.

Mr Dallat: Have you reached agreement with the contractors now?

Mr Pengelly: No, we have not, because the work of the cost of service inquiry is ongoing. To be fair to both sides, neither side will enter into material contract negotiations until we understand the cost of service. We are due to finish that work, hopefully, by the end of this financial year. That will form the basis of what we hope will be a meaningful and positive dialogue for getting to a new contract.

Mr Dallat: Is that not a very depressing situation that we are in?

Mr Pengelly: It is frustrating that we do not have a contract, but it takes two to tango.

Mr Dallat: Millions and millions of pounds are dispensed every year, and you have no contract.

Mr Pengelly: It is dispensed in line with a tariff that is based on firm empirical evidence. The intention is that the new contract will not fundamentally alter the price. The major component of primary care prescribing costs is the ingredient cost of the drugs dispensed. This is not to go to that. It is fundamentally looking at how savings from future changes to drug prices can be recycled and how we can incentivise community pharmacists to do that bit of work that they do tremendously well when the public go to them. We need to incentivise the public to make better use of pharmacists too, so that that is their first port of call for advice on minor injuries and ailments.

Mr Dallat: I am asking this question as much in defence of the local pharmacists as of the taxpayer. The local pharmacist is the heart of many small communities. It is important for me to understand. When the crisis happened in 2006, I knew nothing about it, and it took a lifetime to find out what was going on. It would have been nice had those issues perhaps been channelled through the Assembly and the Committees. Then at least we might have known what was going on. Perhaps that is a good example of how the Department should not embark on doing something on its own without some kind of consultation.

The pharmaceutical side, of course, is extremely powerful. There was some reference at the beginning of the meeting to pens: I have an SDLP one here. I do not think that it would influence anybody. In terms of sponsorship, are there conflicts of interest, and is there a code of conduct to ensure that those giant organisations are not influencing what happens?

Mr Pengelly: There is a code of conduct in place. Mark touched on that earlier.

Dr Timoney: That is right. The industry has taken responsibility to ensure that the code of conduct has been developed by a consortium of all the representative members of the industry, and it has broadly promoted it to its members and to health care professionals who engage with the Department. The rules of engagement are clear: let us have the patient first and the interests of Health and Social Care second, and let us protect the intelligent property. Very good positions for agreement have been established through those mechanisms.

Mr Dallat: So, Dr Timoney, you would not be terrible happy if a new health clinic official opening was sponsored by a drug company.

Dr Timoney: Provided that the rules of engagement were upheld and it is in patients' interests, I think —

Mr Dallat: I think that we have both made the point that there needs to be some kind of code of conduct. We are handling millions and millions of pounds of public money, and there are all sorts of ways of influencing how that money is spent. The questions that have been asked today bear out the need for a great deal more work to be done before the taxpayer, the patient and the local pharmacy can be absolutely sure that the tail is not wagging the dog.

Mr Pengelly: That is a fair comment, Mr Dallat. We have a code of conduct, but the difficulty is in policing it and making sure that it is applied day and daily and within the spirit in which it is intended. That will be a challenge for us, and we need to continue to monitor it.

Mr Dallat: Sometimes the Committee is accused of not being fair. As you have, we should recognise the health clinics and doctors who are applying the thing across the board and to the fairness of everyone. The Audit Office report obviously suggests that a great deal more work needs to be done. Hopefully, when our report is completed, there will be a clearer understanding of where we are and where we are going.

Mr Girvan: I want to come back on a point about the pharmacies. It could probably work both ways, but a doctor could, instead of writing a prescription for a generic drug, write it for a branded drug. The patient then would go to the pharmacy, hand in their prescription, and the pharmacist could say that the chain does not carry that drug but that he has another one that is exactly the same medication and give that to the patient. It is a generic drug and is exactly the same as the one that was prescribed, only the doctor prescribed the branded medication. The branded drug may be £17, and the pharmacist handed out the £2·53 drug. On occasions, it might work the other way round.

Mr Dallat: Yes, it does at times.

Mr Girvan: I use the example of a very large pharmacy that has a very large chain, not only here but in the rest of the UK. Tracing where it purchases its drugs, as a private company, is virtually impossible; and, to be honest, it does not have to furnish you with that information. They could well have dispensed the generic drug, and you were paying out on a prescription for a branded drug. They could have dispensed a drug that is up to seven times the price of the generic one plus the profit.

Mr Brogan: If it is prescribed in the generic form and a generic is available, they can only claim for the generic. They cannot claim for the branded drug. If they do so —

Mr Girvan: You have said that if branded drugs are prescribed by doctors, there may be a very good case for why it has to be that branded drug. They do not have to make that case. They just have to say that the doctor prescribed it.

Mr Brogan: If a doctor has prescribed a brand, the pharmacist must follow the brand. They cannot deviate from that and substitute a generic. If they have done that, I would be interested in understanding that example, because —

Mr Girvan: I am sure that it happens.

Mr Brogan: — that is a breach in their terms, and I would be interested in that.

Mr Girvan: I am using an example.

Mr Pengelly: To put it in lay terms: a branded prescription must be dispensed in branded form and will be remunerated on that basis. A generic prescription can be dispensed in either generic or branded form depending on availability but will be remunerated in generic form only.

Mr Girvan: I am sure that, of those in the room who have received prescriptions, a number have gone to a pharmacy that did not have the variety of drug on the prescription. I am one in particular, because I get a repeat prescription. Levothroxine is quite a common medicine, but there is another generic form of the same medication, and they will give you that. If they do not have the variety that you are on, they will dish out the other one. I do not care. I am happy. I have got my medication, and I am away and will take it in my usual form.

Mr Pengelly: But you will go back to your GP and ask him to dispense your medication in generic form in future rather than in branded form.

Mr Girvan: Of course I do, but what I am saying — where I am coming from — and you have to understand —

Mr Pengelly: The point that Joe made was that if the GP writes the prescription in branded form —

Mr Girvan: Which he does.

Mr Pengelly: — the community pharmacist should either dispense it in branded form or should not dispense it. It is his or her job to secure the branded form, and he or she should not — that is an issue of compliance for us that we need —

Mr Girvan: It is about policing that. How do you police it? There is no mechanism to police it.

Mr Pengelly: We need members of the public to put their hand up and advise us. We can only reasonably expect them to do that if we better educate the public that that should not happen. I suspect that your point is about which members of the public would understand that a pharmacist should not dispense generic —

Mr Girvan: Most people will have got their medication and be away.

Dr Timoney: There are a small number of medicines that should always be prescribed by brand. It is because their toxic levels are very close to the therapeutic levels or where there is a risk that not taking enough of the drug could offset the patient's condition. Northern Ireland has been applauded for putting together a list of those medicines. You mentioned thyroxine, and it could be that a challenge has arisen in relation to those medicines. Just bear in mind that —

Mr Girvan: I understand that.

Dr Timoney: — there are certain clinical conditions for which generic medicines are not always appropriate. However, in the majority of cases —

Mr Girvan: There have been occasions — I am sure that it happens on many occasions — when somebody goes in with a generic prescription and the pharmacy does not have that drug but might have the branded drug.

Mr Pengelly: They will only be recouped at the generic cost.

Mr Girvan: I understand that, and that they might do that at a cost to themselves. But I have seen it the other way. I have experienced it myself, and I am sure that many around the table have experienced the same. It goes on, even if you are stating that it is a breach. Pharmacists tell patients that it is exactly the same medication and that they can have confidence that they are taking something that will not cause them any more difficultly. When they do their paperwork at the end of the month or whenever, they will not remember that they prescribed a statin to a particular lady.

Mr Brogan: One of the questions you asked was about the assurance. We have assurance mechanisms in the payment agency, which will pick up on missed codes. We ask community pharmacists to code what they have dispensed. If it is a generic on the prescription, we expect them to code for that generic, and if they code for a branded medication, that will be challenged. On the other side, we run checking clinics to check whether generic medicines have been dispensed when branded medicines have been prescribed. We invite members of the public to come along with their medicines, and we look at the prescriptions and at what has been dispensed. Of course —

Mr Girvan: How often does that happen?

Mr Brogan: That happens every month.

Mr Girvan: How many would take up that opportunity?

Mr Brogan: It is a very small population base. We dispense 38 million or 39 million prescription items, and we only sample across the region. On occasion, we have identified where there appear to be issues and have gone back to the community pharmacy to address those issues. If there are individual issues and patients are receiving a generic when a brand has been prescribed, we would certainly wish to hear about those and to follow them up.

The Chairperson (Ms Boyle): Thank you, gentlemen. To wrap up, I have one or two questions. I want to go back to the QOF data. It is generally accepted that we have a health need here that is higher than in other regions — England, Scotland and Wales.

That, of course, is acknowledged in paragraph 3.22. However, it gives rise to concern that, in paragraph 3.25, data on disease prevalence produced in QOF do not generally support that perception. In fact, according to QOF figures, we have a lower prevalence of many of the main diseases here than in other parts of the UK. Paragraph 3.24 highlights your concerns about using the QOF data in that way. However, in paragraph 3.23, we read that the HSC Board does not share those concerns. How can the Department and the HSC Board hold such divergent views on that?

Mr Pengelly: The key issue here is that the Department and the board do not hold divergent views. The board feels that its views are not properly reflected in this, and it agrees with the Department's view. In fact, the board led the dialogue to say that the use of the QOF data in that way was inappropriate.

The Chairperson (Ms Boyle): Following on from that, you have explained your objections to the use of data from QOF and various other sources. What work have you done to quantify health-care needs here relative to those elsewhere in the UK? What specific piece of work has been done?

Mr Pengelly: The most recent piece of work was the Appleby review, which gave a figure of 9% and pointed out that some areas could range up to 17%. After that, there was the 2012 work by the National Audit Office that utilised Deloitte, which had it ranging up to 26%.

The concept of health need is important in understanding some of the different costs between Northern Ireland and other places. The issue about providing health care does not require an absolute articulation of the number attached. The reality is that health need will be different across a whole range of disciplines, both horizontally and vertically. Different speciality areas will have different levels of need, as will the primary care sector against the secondary care sector. It tends to be a number that is most used in the debate between this Department and the Finance Department. We tend to use it as a way of saying that our costs are being driven by a higher level of need. It is not of particular relevance for planning the delivery of care in Northern Ireland. We tend to work on a trend basis in Northern Ireland.

I want to be clear that it is not that the QOF material is not important and valuable in its own right; our point is that we feel, as do our professional statistical colleagues and the health and social care information centre in England that produce QOF data, that it is not appropriate to be used to understand the drivers of primary care prescribing costs. That is the subtlety. It is used as a measure of activity and to drive clinical activity in primary care. It is not complete in terms of all disease spectrums, and, typically, it is completely silent on social and economic factors and the big issue of co-morbidity, which is a very significant factor in prescribing costs.

The Chairperson (Ms Boyle): Finally, figure 11 on page 38 seems to dispel another myth that here has a relatively smaller share of older people than GB, and that that trend is likely to continue until at least 2030. Do you accept that health-care needs may be greater in areas with a larger number of older people?

Mr Pengelly: I absolutely accept that a greater proportion of elderly people is a significant driver of cost, but it is only one driver. There is a whole range of other issues like, as I have just mentioned, co-morbidity and social and economic factors. I accept that the graph is absolutely correct in what it portrays, but the issue for us is that our proportion of the elderly population is increasing at a faster rate than other places in the UK. So, from this point on, as we do year-on-year comparisons, that will make it difficult for us to match year-on-year changes in England, Scotland and Wales. It is a significant component, but only one component of driving overall need and cost.

The Chairperson (Ms Boyle): Whilst we as a Committee acknowledge the efforts of the Health and Social Care Board that have generated the savings, it seems that much more can be done, and we remain of the view that some form of comparison must be possible on the basis of the report and what we have heard today. Further analysis needs to be done — you have accepted that — on the primary care prescribing budget, and that has to be done in the most cost-effective manner. Obviously, what is coming out of here today is that you must set challenging savings targets for the future, so that valuable resources can be released back into our health-care sector. It ain't rocket science. Mr Girvan and I sit on the Finance and Personnel Committee, and we heard this morning about how our innovation labs can assist with solutions.

Mr Pengelly: The Finance Minister is with our Minister at the South Eastern Trust's innovation lab this afternoon seeing the good work that is happening within health and social care.

Mr Girvan: We will not tell you what I said.

The Chairperson (Ms Boyle): It is in Hansard.

Mr Girvan: I hope that it is not another talking shop for them to have another series of meetings and deal with stuff. It has to have results that are customer-led, and there has to be definite evidence of that. Progress has to be made. There is plenty of opportunity, because we are always holding carrots out, but I have yet to see some mechanism for a stick to be used. I come from the private sector, and the stick would work very well here. I would like to see some form of sanction being taken against those who refuse to go down that route, so that we had some way of dealing with it. I appreciate that those doctors might well feel that they have their own contract. What we have from the BMA, negotiated as a national contract, is sacrosanct and cannot be touched, but, because we are commissioning them to deliver a service, there has to be some way of ensuring that they do it effectively and efficiently.

Mr Pengelly: On your point about real innovation as opposed to talking about innovation, I note that Northern Ireland is one of a very limited number of regions across the EU that has been awarded three-star reference site status because of some of the innovative work that we have been doing in medicines management. We actually chair a cross-EU reference site collaborative network, with other regions looking to the work that we are doing here. That is some external recognition of the progress that we have made.

Mr Beggs: I want to push a little bit more on medicine management advisers. What is the break-even point? How long does it take for them to recoup the money by bringing in the savings through good practice by GPs? You are reticent to employ more of them because of the limited budget, but how soon would they actually save the money in the medicines budget and therefore pay for themselves?

Mr Pengelly: That is the key question.

Mr Beggs: Do you not have an answer to that?

Mr Pengelly: I am trying to explain the answer to it. We are doing a business case at the moment. The point of it is to identify the cost of more MMAs, what the potential saving would be from each of those MMAs and what time period we would secure that in. The issue is whether we need to go to the Scottish position or beyond that. Where does the law of diminishing returns kick in? There is also the point that I mentioned earlier — that we absolutely need more pharmacy support for GPs, but the question is whether it should be MMAs or pharmacies in the GP practice. The advantage there is that MMAs will spend a lot of time talking to GPs. Pharmacies are part of that care package. They are there, based in the pharmacy every day.

The business case that Joe and colleagues in the Health and Social Care Board are preparing at the moment deals with all the points you mention; it is looking at the cost, the associated savings and the payback time. That will come to us to make decisions. I personally think — I think that this is the point you are getting to, Mr Beggs — that it is not beyond us to assume that the cost of an additional MMA will be recouped in the year that the cost is incurred. I think that there is that possibility. So, it is not the traditional invest-to-save, where the concern is that you spend a lot of money this year to save money next year. I think that it can be neutral year-on-year. We are very positive about where we go with it.

Mr Brogan: I can give you a real example, Mr Beggs. We embarked on a project this year looking not just at pharmacists but at dieticians. We invested £350,000 in a range of dieticians, who went into GP practices, did assessments of dietetic requirements and improved the clinical care. The upshot of that was that we returned £1·1 million of efficiencies. So, that is a one-in-three efficiency saving for that investment. That project won an award at the Northern Ireland Allied Health Professions conference last month. Those are the kinds of examples we want to explore as part of this business case, because it is a mix. Certainly, our MMAs have done a brilliant job, and we pay tribute to them, but we need to think about what is the mix in effecting the change within general practice.

Mr Beggs: Given the millions of pounds that can be saved, I urge you to come to a decision and allow those savings to be made.

The Chairperson (Ms Boyle): OK, members, we have all had the opportunity to ask questions of our witnesses, so I believe that there are no final issues that could be arising from today's session. Mr Brogan, I am certainly not looking forward to getting older and the cost that I will be to the health service. I am not looking forward to taking all those drugs.

Mr Layberry, do you have anything to add or are you content?

Mr Jack Layberry (Department of Finance and Personnel): No, thank you.

The Chairperson (Ms Boyle): OK. Mr Donnelly, is there anything you want to add?

Mr Donnelly: Just a comment on a point that Mr Pengelly made about figure 14, which looks at the variation in GP practices. Our objective with that graph was simple, which was to demonstrate that, at a point in time — 2013 — there was a substantial degree of variation. I think that Richard said that he would have liked to see another graph going back to 2010. Fair enough. That would have shown even more variability. So in a sense there is less variability now, but there is still enormous variability, and that needs to be looked at.

The Chairperson (Ms Boyle): OK, thank you, Mr Donnelly. I am content with that.

I thank you all for your attendance before the Committee. It has been extremely useful. As we develop our report, we will certainly take on board the information that you provided.

Mr Pengelly: Thank you, Chair.