Accessing P class medicines from general practitioners or community pharmacists: investigating user choice, substitution and relative costs between the two routes

Abstract

BACKGROUND - Self-medication using P class medicines has been promoted in recent years. Policy makers believe that this will help to contain NHS costs, as users substitute the purchase of these medicines, over-the-counter from community pharmacies, in place of prescriptions obtained from general practitioners. It is assumed that this will simultaneously secure savings on the NHS medicines bill, dampen demand for general practice consultations and promote more efficient use of scarce primary care resources. These assumptions were, however, unfounded in evidenceAIM: To assess the extent to which increased availability of P class medicines facilitates substitution between general practice and community pharmacy and the costs accruing to stakeholders as a result.OBJECTIVES: profile users accessing P medicines, investigating patterns of use among different demographic and socio-economic groups; map the access routes adopted by users; assess the extent of substitution between general practice and community pharmacy services; develop a model to predict users choice of access route; and investigate the changing distribution of costs.STUDY DESIGN: Cross-sectional descriptive study, with prospective follow-up of users. Semi-structured interviews elicited users' routes to access P medicines and the time and resource costs incurred by stakeholders. Costing analyses estimated total, mean and ranges of costs associated with different access routes. Consumers' surplus analysis calculated the net consumption benefits accruing to users facing different time and money costs. Cost minimisation analysis examined the relative costs and efficiency of the alternate access routesPARTICIPANTS: 1185 users recruited in 15 community pharmacies in Lothian while obtaining a P medicine, either on prescription or over-the-counter.RESULTS: Substitution: the majority of users buying P medicines from a community pharmacy successfully substituted this in place of obtaining them on prescription from a general practitioner. However, a fifth of these users subsequently visited a general practitioner also. User Profiles: Healthy, more affluent users were significantly more and less affluent, iller users significantly less likely to attempt to substitute. Costs: Substitution generated savings for society overall, with all stakeholders benefiting, on average. Resource savings swing heavily towards the health sector. Users were only marginally better off, on average. Time and resource costs were significantly higher among those in less favourable economic circumstances, who perceived themselves not to be in good health, or who were frequent users of primary care. Cost minimisation analysis indicates promoting increased self-medication using P medicines accessed from community pharmacies, as opposed to from general practitioners, enhances technical and allocative efficiency within the primary care sector.CONCLUSION: Policies increasing availability of P medicines have improved access for many users and are consonant with encouraging enhanced, graduated access to first-contact services. However, they promote differential access that is systematically related to the socio-economic status of users. Already disadvantaged people are further disadvantaged. Consequently, inverse care is emergent. The challenge facing policy makers is to improve the efficiency of the policy, simultaneously maximising the substitution potential while avoiding the emergence of inequities in access. Making P medicines available free, over-the-counter at community pharmacies to prescription exempt users could potentially realise both objectives. Longitudinal, whole-systems analysis, developing broader socio-economic theories of consumption, are required to inform how best to tailor future policy initiatives in this important health policy area.