Dr. Mark Murphy:

I thank the Chairman and members of the committee for their invitation to the ICGP to discuss prescription pattern monitoring and the audit of usage and effectiveness trends for prescribed medications. We intend to split our five minute opening statement into several sections and I will begin.

To provide some context, there is a rising prevalence of chronic diseases and multi-morbidity in Irish society and while this is not currently reflected in the new GP contract, we hope that it will be soon. This increased prevalence coupled with the fact that we have an ageing population means that we have seen a rise in the number of dispensed items and in the cost of medications in the annual health budget. Our submission outlines in detail the expenditure on pharmaceutical products but in summary, we spend approximately €2 billion on pharmaceutical products per year. That money comes exclusively from the community budget, even if the product is prescribed in a hospital setting. In contrast to our drug budget, Irish general practice is extremely poorly resourced. We spend less than 4.5% of our overall health care budget on general practice. At a time when GP led, community oriented health care should have happened, we have seen a massive retraction in GP funding and in the time we have with each patient. The FEMPI cuts are still imposed on general practice, which limits time for patient care. We work off a 40 year old contract and have severe capacity restraints, with the lowest number of GPs per head of population in Europe. We are also seeing an exodus of our GP graduates.

I will now provide some context for how repeat prescribing works. In the context of acute consultations, it is estimated that two out of every three will result in an acute prescription but GPs manage the repeat prescribing. All of the repeat prescriptions that are issued in pharmacies are delivered by GPs. We might issue a repeat script every three to six months but this can be more frequent if there is a clinical need. While the GP takes the responsibility and assumes the risk for repeat prescribing, the GP may not have been the original prescribing doctor. If a drug is initiated in hospital, the GP transcribes that prescription to a GMS script for a GMS eligible patient.

The ICGP supports evidence based and cost effective treatments in the Irish health care setting, including prescriptions. The ICGP also supports initiatives from the medicines management programme to support effective prescribing. Opportunity costs are evident throughout the health care system, whereby we spend money on low value products with limited benefit and excessive costs which results in other areas of our public health care system being under funded.

Finally, with respect to evidence of trends, from a general perspective raw data from the annual Primary Care Reimbursement Service, PCRS, statistical analysis is very helpful but we must remember that it is raw. I point committee members to the work of the department of general practice staff of the Royal College of Surgeons, where I also work. Professor Tom Fahey and Dr. Frank Moriarty have published research in this area which shows that from 1997 to 2012, there has been a massive increase in prescribing. The prescribing of ten or more drugs for over 65s in 1997 stood at 2% but by 2012 this had increased to 22%. Prescribing has increased massively and we must ask if this is appropriate. The Health Research Board has examined this and found that the odds of what is called "potentially inappropriate" prescribing in 2012 compared to 1997 have reduced by 60%.

GPs and hospitals are prescribing more medications for an ageing, more complex and more multimorbid population but they are doing a better job at it. Our submission also outlines valuable research from other cohort studies, such as the Irish longitudinal study on ageing. That has shown that we can save more than €150 million each year if we introduce a system of reference pricing.

Finally, I will address the prescription of benzodiazepines, anti-depressants, opioids and antibiotics. These are high-profile, topical drugs. We can discuss this in the questions-and-answers session but I will discuss anti-depressants as an example. In 2016, we spent more than €40 million on anti-depressants. To put that in context, we spent only €10 million on counselling in primary care. All evidence suggests that GPs are prescribing very appropriately in the context of a severe capacity shortage in general practice and primary care. Our prescribing of anti-depressants largely reflects a lack of psychological therapies and a lack of social therapies to deal with issues including isolation, fragmented communities and austerity.