Monday, July 06, 2015

Labelling NHS Prescriptions: Preliminary Thoughts

Disclaimer: These are preliminary thoughts on a policy issue. They are intended to stimulate some discussion of an interesting policy that has not yet had much public debate or more detailed analysis. The views, as with all posts on this blog, do not represent any official institutional position.

Labelling Prescription Medication in the UK

The UK government is proposing to add a label to prescription medications valued twenty pounds or more stating how much they cost along with the words "funded by the UK taxpayer" (see BBC and Guardian articles for details). The stated rationale (extract from the Minister's speech below) behind this is to make salient to patients, in the context of a mostly free-at-point-of-use healthcare system, that the medications they are using are valuable and are funded from tax money. This may then discourage misuse or waste of the medication. It may also presumably bring cost considerations into the discussion between the patient and doctor. I haven't seen this stated but I also presume the rationale is to make the cost of different types of medication more salient in general public debate particularly in the context of negotiations with pharmaceutical companies.
But there is a role for patients here too. There is no such thing as a free health service: everything we are proud of in the NHS is funded by taxpayers and every penny we waste costs patients more through higher taxes or reduced services. Yet estimates suggest that missed GP appointments cost the NHS £162 million each year and missed hospital appointments as much as £750 million a year. That is nearly £1 billion that could be used for more treatments or the latest drugs. On top of which we spend £300 million a year on wasted medicines. People who use our services need to know that in the end they pay the price for this waste.
So today I can announce that we intend to publish the indicative medicine costs to the NHS on the packs of all medicines costing more than £20, which will also be marked ‘funded by the UK taxpayer’. This will not just reduce waste by reminding people of the cost of medicine, but also improve patient care by boosting adherence to drug regimes. I will start the processes to make this happen this year, with an aim to implement it next year.
The purpose of this post is to discuss some potential issues with this policy.  I have nothing to do with this policy and no special information other than what is available publicly as to how it was constructed and for what purpose and am posting purely to raise discussion about a policy issue of clear relevance to the public more generally and also the readers of this blog who are interested in the application of behavioural science in policy.

The first question to be raised is how can this policy be tested. If it is rolled out universally and without any time staggering then there are limits to what can be done as any changes could be due to anything else changing during the time period. Perhaps with precise timing it will be possible to see whether usage of medication changes consequent on the policy being rolled out. 

The potential for unintended negative consequences arising is worth discussing across a number of different facets. Firstly, it is possible that providing cost information will make people sensitive to it in ways other than wanting to reduce cost and waste of medication or being receptive to doctor's reluctance to prescribe very expensive medication. For example, cost may act as a signal of quality and make patients more likely to want to have expensive medications. It may even act as a signal that the medications are valuable and potentially can be resold. This may seem unlikely in a free-at-use system but given internet trade and the potential for non-medical uses of a number of prescription drugs it is certainly possible that reminding people for the first time that the medications they are using are potentially worth hundreds of pounds may make this more salient to them. I have absolutely no idea how to estimate the extent this will happen in advance and raise it as a possibility worth thinking about and discussing rather than something for which there is concrete evidence to believe it will happen. 

Furthermore, there is potential heterogeneity in how this label would affect people. It is possible that some patients will interpret the signal as a statement that they are being a burden. Will there be groups of particularly dutiful people who will feel guilty about taking medication they are legitimately entitled to due to this stark message being salient everytime they take their medication from the box? You could argue that it is also making salient the fact that taxpayers are paying for it. So one benign outcome would be people internalising the cost information but also internalising the fact that they as "taxpayers" have paid for it. But there is clearly a potential for certain groups to perceive themselves as being a burden and it is worth some research or at least the impression of doctors and pharmacists on the extent this is happening. There is arguably a particular duty of care not to stigmatize people who are marginalised due to poor physical and mental health. 

More generally, there is now a wide literature on the perverse effects of disclosure that should be thought through when making policies like this. Simply put, there is a strong element of interaction between a message, who delivers the message and the recipient of the message in disclosure contexts. The potential unintended consequences listed above are only a subset of the types of effects these interactions might produce. While I do not have a strong a-priori sense of the relative magnitudes of the different effects it is certainly worth testing them particularly if this is likely to be a long-run policy and potentially applicable to other areas. 

It also raises a question as to why prescription medications are a particular focus. Should labelling be introduced for a wide range of public services e.g. pointing out the full economic cost of a college place, a BBC drama or a session of the Commons? It would be worth a lot more discussion as to the principles underlying when such communications are deployed. If only a random subset of public services are subject to this labelling then it may make cost issues more salient in those domains than in others. 

There is also the potential for such messaging to be used not for the purpose of promoting efficient allocation but rather to convey broader political messages. The word "taxpayer" in this context has the potential to convey a wide range of messages. In essence pretty much everyone in the UK is a taxpayer. If you purchase a pack of biscuits you pay tax on the transaction. But it is surely possible that the connotation of the word may suggest to some that there is a difference between those in formal employment and those outside the formal labour market. The potential for the message to convey a view that those not working for reasons of illness are somehow not "taxpayers" is certainly worth thinking about. Also the potential for the continuous priming of this message to promote negative sentiment among those in the formal labour market to those not in formal employment is also worth thinking about. The counterargument is that "taxpayer" may genuinely be used to convey "all of our taxes pay for this" and is thus intended to tap into norms of community and reciprocity. Again, I think this is debatable and probably testable. 

There is no question that the UK government has been leading in attempts to use non-price forms of intervention in policy. But there is also a potential for such communication-based forms of intervention to be used to make political points, with the case of the "immigration vans" in 2013 being one prominent example. In this particular case, there needs to be more discussion about why this messaging is being used as opposed to other forms and the particular outcomes intended and extent to which the above consequences have been thought-through.


1. The BIT document "Applying behavioural insights to reduce fraud, error and debt" contains a number of principles on how communications of this nature might be used. The document is very interesting and highlighted on this blog before. Though it is still well worth debating the connection between the broader principles and the specific case above.

2. The 2012 "Action Plan For Improving The Use Of Medicines And Reducing Waste" document contains a number of suggestions for doing this. It also includes the following paragraph which is interesting in the context of the current plan. It clearly needs to be reconciled why this policy was not considered suitable for this reason three years ago but has now been announced as going ahead.

"We have considered the suggestion of disclosing the cost of NHS medicines to patients, perhaps by including information on packs or labels, to raise awareness of their value to the NHS and reduce wastage. It was agreed not to pursue this. We have noted independent research commissioned by the Department of Health, which suggests that some patients, for example older people in need of effective treatment could be deterred from taking the medicines they need because they are worried about the impact on the public purse. However, we see no reason why national or local information campaigns could not highlight the total cost of medicines used in the NHS."

3. The previous research I can find on this topic in the UK context is below. It is based on the views of service providers and tends to reflect the concerns outlined above. It is difficult to conclude though that this is direct evidence to suggest the policy would not work. However, if people directly involved in this area share these concerns it puts more importance on a more worked-out rationale for why these concerns will not materialise.

Trueman et al (2010) Evaluation of the scale, causes and costs of waste medicines. Report of DH funded national project. York Health Economics Consortium and The School of Pharmacy, University of London.: York and London.

"Some sources have advocated putting the supply price on every NHS medicine pack in order to raise awareness of costs, and so perhaps to reduce wastage and/or increase consumption. This research sought to understand the views of respondents on this suggested way of reducing the cost and volume of residual medicines supplied by the NHS. It found rather less immediate support for this proposal than there was spontaneous advocacy in favour of increased direct charging. Some interviewees said it would ‘make patients realise the cost of medicines’. But in rather more cases, service user respondents and others felt that pack pricing might cause some patients in need of effective treatment to become worried about its cost to the public purse. It might also, it was suggested, in some instances encourage the ‘selling on’ of some medicines and/or deliberate requests for more costly treatments. One GP said that the people who he most wanted to target probably would not care about the price of their medicines. Messages that appeal to a sense of responsibility are by definition unlikely to affect the genuinely irresponsible. Interviewees also mentioned the problems that could emerge in situations where (as is the case with approaching a half of the items used in the community) a medicine’s ingredient price is lower than the prescription charge: In conclusion, the interpretation offered here is that even it were possible within the European setting to implement such an idea, relatively few people are on consideration likely to judge the option of printing UK prices on all NHS medicine packs advisable. Most may be more inclined to think that it would cause more problems than it would solve"

1 comment:

koenfucius said...

You raise some very pertinent questions around this policy, both with respect to the potential outcomes (whether intended or unintended), and with respect to the evaluation of these outcomes.

Maybe the only real purpose is political: no intent to change anyone's behaviour, but simply aimed at raising the salience of the cost to the taxpayer. This would then serve to strengthen the argument for keeping the NHS budget down.

However, if the purpose is to influence behaviour, presumably attempting to reduce consumption of medication, one needs to ask the question what the meaning is to the intended recipients. The primary influence is that of the prescribing practitioner: patients generally don't determine what drugs they need and in what quantity. Are practitioners unaware of the true cost to the NHS of a drug? Probably more so than patients, although they may of course not be up to date with the cost of every drug. So at least mentioning this cost verifies or clarifies the cost. But to what extent does a prescriber have alternatives? The NHS already seeks to use generic drugs (£1_3bn_from_generic_drugs.aspx), so most physicians presumably opt for here rather than branded substances. But perhaps there are situations where two different drugs could be used with similar patient outcomes, of which one is considerably cheaper than the other. Such situations might benefit from increased salience — at the time of prescribing. Imprinting the cost on the package is neither helpful (the prescriber does not see the package when creating the prescription) nor necessary if this is the purpose of the policy. It would suffice for the software used when prescribing a drug to list the true cost to the prescriber only, without revealing it to the patient.

So what effect does listing the cost have on the patient? What does that amount actually *mean* to the patient (or indeed to non-patient taxpayers)? This depends very much on the reference point of the recipient of the message — and here we have a problem. Most members of the public don't have a sensible point of reference for the cost of a drug to treat a condition. They are not typically in a position to make a meaningful comparison. Is a drug that costs £20 per dose expensive? What about £50 or £200 a pop? How does that compare with the cost to the taxpayer of a visit to a GP, of a hip replacement operation, of an MRI scan, of emergency surgery to fix a broken skull after a traffic accident, or of a course of physiotherapy after a stroke? How can it be balanced with the outcome to the patient?

Most people would not have a clue. They will use points of reference they know: the cost of a pint of milk, of filling up he tank of their car, of a family meal or a cinema ticket etc. such comparisons are of course mostly spurious. They cannot and should not be used to influence decisions. But unfortunately such spurious references will be used as a benchmark - without being any more relevant than he last two digits of your national insurance number (as in one of Dan Ariely's famous experiments on anchoring -–-the-truth-about-relativity/).

Even if the intended behavioural change for te patient was clear (which it doesn't seem to be), it is unlikely that given the absence of a meaningful anchor, that change will be as intended.