Professor Colum Dunne:

I thank the Oireachtas Joint Committee on Health and Children for providing this opportunity to make a contribution to the discussion regarding the price of prescription drugs in Ireland. I am currently the director of research at the graduate entry medical school, and founding director of the centre for interventions in infection, inflammation, and immunity at the University of Limerick. I am also a member of the university's governing authority. My contribution to this committee is based on work completed, especially by Dr. Suzanne Dunne, and by a broader team comprised of researchers who have extensive experience of health care studies. The work has led to the completion of a PhD and, for the most part, has been published in high quality peer-reviewed international journals.

This morning as I sat in the Visitors Gallery I heard discussions on reference pricing and pharmacoeconomics. My focus here today will be on people who are at the coalface regarding generic medicines and especially the knowledge, attitudes and awareness of those people which are the influences of their behaviour. Prior to implementation of the Act in 2013, we initiated a programme of work that allowed us to investigate the perceptions and attitudes of patients, community pharmacists and GPs towards generic medicines. As Senator Crown will know, the relationship between hospital consultants and hospital-based pharmacists is quite different so we did not engage in any survey of those people.

Our work was designed to explore the topic by generating insights using interviews that were initially recorded, then transcribed and analysedusing well recognised methods. This research is different to survey-based research where we know there can be confusion or even an overestimation of the understanding of generic medicines, for example, a misunderstanding of genetic versus generic in terms of the medicine.

We believed that the outcomes from this work would complement research done elsewhere, for example, in the National Centre for Pharmacoeconomics. Also, that the data would be evaluated in the context of there being previous international reports and published papers but relatively little directly focused on the Irish setting.We were unable to find published investigations, that had been completed, on the consumer or pharmacist cohorts in Ireland. We found only one study on the GP cohort which was published in 1997.

Our work has been peer-reviewed. Our review of the differences between generic drugs and their originator counterparts, using Ireland as a case study, has been especially well received as a comprehensive exploration of this topic. It has been accessed more then 20,000 times online which places it in the top 5% of publications, as measured by level of attention, which is indicative of importance of this work and the generalisation of it in an international context.

We further believed that the outcomes would be unique in allowing us an accurate picture of the situation in Ireland prior to the Act and, as such, it would position us well to revisit and compare these attitudes and perceptions following the introduction of the Act. In other words, it would allow for an evaluation of the impact of the Act.

I shall summarise some of the take home messages generated by this work. There is a hierarchy of understanding and acceptance of generic medicines in Ireland. Let us bear in mind that my explanation here involves generalisations. While health care professionals tend to have a positive view of generic products we found that pharmacists had the greatest understanding and acceptance, followed by GPs and, to a much lesser extent, the patient-consumer group.

Notably, the GPs had less confidence in generics than pharmacists. In fact, 15% of GPs involved in our studies, though a small number, would prefer not to use a generic medicine in preference to the originator. That said, since 1997, there has been a general and significant shift in favour of generic medicines. Nonetheless, this disparity is problematic. While pharmacists believed that although they are spending an increasing amount of time with their customers explaining aspects of generic medicines, patients are placing greater credence and trust in the opinions of their GPs.

In contrast with reports from other countries where foreign produced products were believed to be superior, Irish prescribers did not lack confidence in products that are produced in Ireland. In fact, they recognised the employment and impact that manufacturers contribute to the Irish economy.

Pharmacists believed that their jobs were becoming more complex due to the stock control requirements related to the sale of branded generics. Patients expressed the lowest level of confidence. Almost a quarter stated a preference for the branded medication in addition to a belief that generics were of poorer quality than originator medicines. However, 25% of pharmacists and over 20% of GPs reported situations where patients complained that an originator medication did not work as well as a generic. The implication of this is that its the change of medicine per se, rather than the introduction or use of a generic product, that is at the root of their disquiet.

A consistent message emerged from each of the cohorts that we worked with. It was that the provision of information and relevant education is required on this topic. In response, and in addition to assessing GPs, patients and pharmacists, we recognised that the information available on the Internet may influence the understanding of generic medicines. Therefore, we evaluated the quality and understandability of relevant information available internationally and to those in Ireland. Very similar to other jurisdictions, in Ireland none of the websites most likely to be seen by a searcher demonstrated the desired combination of providing high quality information in a readily understandable fashion. To provide a potential approach to enhancing the provision of understandable health care information we developed a new tool. We subsequently validated it using generic medicine information available in the UK, North America, Canada and Australia.

In conclusion, this research addressed a knowledge gap. It also represents a baseline for the future study of these views post-implementation of the changes. In the context of modern information provision, clear deficiencies in quality of information and accessibility of text were observed. A health care and medical information website tool is now available for use in the development of something for the Irish market.

I wish to add some practical recommendations, insights and some points of note. Approximately 88% of GPs prescribe generic medicines actively. However, 94% of GPs and over 88% of pharmacists report receiving complaints from patients about generics. Only 26% of GPs and 21% of pharmacists stated that they actually attempt to educate their patients or customers.

In regard to the "mockya medicines" comment - I wish to state that I am from Cork - we noted that over 30% of GPs and 64% of pharmacists expressed the opinion that at least some of the negative experiences reported by patients are due to the nocebo effect which is the opposite of the placebo effect. In other words, if somebody believes they are getting a cheaper product then they do not have confidence in it and, therefore, do not perceive a benefit. Some 77% of the pharmacists surveyed and nearly 90% of GPs stated they would accede to their patient's preference for a branded product. In other words, because of the pressures of work, the need to deal with a large number of patients and customers, and the complexities of their jobs, these professionals are unable to spend time trying to persuade patients to take a generic product.

Finally, patients exhibited a high level of trust in their physicians and 90% of patients stated they would be happy to take a generic medicine if it is prescribed by their GP.