What if the cascade were abandoned – unintended consequences?

RE: What if the cascade were abandoned – unintended consequences?

J G Wray — Sun, 19 Mar 2017 13:37:46 GMT

[quote user="Richard Carter"]

Sorry Mr Wray but your suggestion belongs in the toilet. It makes a number of presumptions, all incorrect -

the first being that Veterinary Surgeons are not trained in pharmacy and physiology whereas in fact clinicians are quite aware of active ingredients vs trade names and there are extremely good publications to guide one in the choice of drug, expected side effects etc based on long term evidence gathered internationally.

[/quote]

Get away

[quote user="Richard Carter"]second most drugs on our shelves that have been 'cascaded' have already had animal trials to get the human licence[/quote]

No, really?

[quote user="Richard Carter"]third - the UK is not the only country in the world to have a veterinary profession but it is the only one to have a cascade. R&D is international - apoquel is from USA, the trials for ivermectin were done in South Africa, lots of drug trials get done in India[/quote]

Well, I never[quote user="Richard Carter"]

It is an artificial monopoly tying the clinical choice of professionals and keeping a few dubious distributors in a business.

[/quote]

Yes, and......what exactly, beyond stating the bleedin' obvious, in the here and now, moral outrage notwithstanding can you do about it?

[quote user="Richard Carter"]And yes I do remember when phenobarb jumped from affordable to being a small fortune - under the epiphen label, as did KBr, as did metoclopromide, cimetidine, cephalexin.[/quote]

Good oh.

This sense of outrage is is what I was alluding to. It's pointless. It's also faintly hypocritical if you work in a practice where 30-40% of your practice income comes from drug sales, because in practical terms, you can't do without it. If you were to surrender all drug sales because of the iniquity of the cascade then you would cripple your business. You would have the moral high ground, but what else? Why not flush (sic) your business away?

[quote user="Clive Ansell"]

[quote user="J G Wray"]The objection to the Cascade seems largely to revolve around the cost of supply of meds to clients, predicated on an assumption the cost of drugs is THE MAIN REASON why owners don’t seek veterinary care [/quote]

No, not in my case. My main objection is that of curtailment of clinical freedom. As a MRCVS, and a professional in my own right I feel I have the necessary training, skills and experience to make a judgement on a case by case basis of which drugs to use.

[/quote]

Thus the locum vet speaks. I think I dealt with the position of locums in my OP.

You have the option to prescribe any drug in any consultation. If your client cannot afford that drug or your veterinary services then you always have the option to work in the nearly-funded charity sector. Otherwise, it's general private practice with all its moral and ethical frustrations, only some of which are associated with the Cascade.

RE: What if the cascade were abandoned – unintended consequences?

Anthony Todd — Sat, 18 Mar 2017 14:46:37 GMT

[quote user="Clive Ansell"]They routinely use generic amoxicillin, ciprofloxacin, metoclopramide, frusemide, phenobarbitone and don't even stock the licenced ones.[/quote]

Dear oh dear, they must have animals dying like flies from all these illegal, dangerous, drugs, still they've been used for years on children and the elderly so, I suppose, they're reasonably safe?

The other thing is the public [for whom a tenuous argument could be made for "benefit"] are copping the extra cost, but blaming the vets for profiteering!

RE: What if the cascade were abandoned – unintended consequences?

Rob Loxley — Sat, 18 Mar 2017 14:27:23 GMT

[quote user="Clive Ansell"]They routinely use generic amoxicillin, ciprofloxacin, metoclopramide, frusemide, phenobarbitone and don't even stock the licenced ones[/quote][quote user="Clive Ansell"]Enforcement, shall we just say, is very thin on the ground. Again, one is left asking what are our regulatory body is doing about it?[/quote]

RCVS PSS (or if not member then VMD premises) inspection should pick that up. Beyond that, http://www.rcvs.org.uk/advice-and-guidance/code-of-professional-conduct-for-veterinary-surgeons/supporting-guidance/whistle-blowing/ ?

RE: What if the cascade were abandoned – unintended consequences?

Richard Carter — Sat, 18 Mar 2017 10:31:07 GMT

Sorry Mr Wray but your suggestion belongs in the toilet. It makes a number of presumptions, all incorrect -

second most drugs on our shelves that have been 'cascaded' have already had animal trials to get the human licence

third - the UK is not the only country in the world to have a veterinary profession but it is the only one to have a cascade. R&D is international - apoquel is from USA, the trials for ivermectin were done in South Africa, lots of drug trials get done in India

It is an artificial monopoly tying the clinical choice of professionals and keeping a few dubious distributors in a business.

And yes I do remember when phenobarb jumped from affordable to being a small fortune - under the epiphen label, as did KBr, as did metoclopromide, cimetidine, cephalexin.

Perhaps someone would like to also start a comment on the disparity of prices for the same drug in the UK vs the rest of the EU but when some vets bought a licenced EU drug for the treatment of horses (gentamycin) the full force of the law was brought to bear - why - no risk to the animal being treated?

RE: What if the cascade were abandoned – unintended consequences?

Bob Russell — Sat, 18 Mar 2017 10:20:44 GMT

We tend to follow cascade as a routine. I don't think it is the end of the world but I would take genuine affordability into account.

Steve Dean was extremely aggressive in his attitude to enforcement of the letter of the law but I have found the attitude of the VMD much more sensible once he had departed.

I struggle to justify Clomicalm when the generic costs a few pence. We start them on Clomicalm but I would prescribe the generic once settled should the owners wish but so far nobody has!

The practice using generics should struggle when they have a Practice Standards Scheme or VMD inspection as both would be less than impressed.

If they order the right stuff in for the inspection then they are taking the pi*s and should be reported. It does put them at a distinct financial advantage over other practices. I do not consider this a sound reason for flouting cascade.

Most licenced 'generics' have sufficient competition to mean prices are generally fairer than they were a few years ago. Epiphen was much more expensive than the generic but there is much less difference now.

The NHS is now being screwed by the pharmaceutical industry as they move branded products to uncontrolled price generics with a mighty hike in price!

For example: https://www.epilepsy.org.uk/news/drugwatch/epanutin-capsules

My monthly bill to the NHS was about £30 for Epanutin but now is around £400 for repackaged Epanutin!!

RE: What if the cascade were abandoned – unintended consequences?

Clive Ansell — Sat, 18 Mar 2017 07:53:07 GMT

Another issue with the cascade, is that there are some practices (*) which blatantly break the law and ignore it, thus putting other local practices that stick to the rules at a commercial disadvantage. Enforcement, shall we just say, is very thin on the ground. Again, one is left asking what are our regulatory body is doing about it?

(*) I did a one week locum towards the end of last year in a practice I had never been to before. I had to specifically order in licenced products because I obey the cascade and refuse to break the rules. They routinely use generic amoxicillin, ciprofloxacin, metoclopramide, frusemide, phenobarbitone and don't even stock the licenced ones.

RE: What if the cascade were abandoned – unintended consequences?

grumpyoldman — Fri, 17 Mar 2017 23:23:04 GMT

Pre-cascade we seemed to manage just fine with common sense.

RE: What if the cascade were abandoned – unintended consequences?

Nicola Cole — Fri, 17 Mar 2017 22:58:07 GMT

[quote user="Clive Ansell"]

[quote user="Anthony Todd"]When you have seen the anguish of the devoted owners having to put their two lovely alsatians down because they could no longer afford the POM-V phenobarb which we were required, by law, to prescribe you would get very cross because of the self-serving idiocy of the law![/quote]

POM-V Phenobarbitone, such as Epiphen, is not that expensive so I am left struggling to understand how someone who owns and can feed and look after 2 GSD's would PTS based on the cost (60mg Epiphen = c25p, so say £1/day)

[/quote]

The one that springs to mind for me is cats on felimazole vs neomercazole from a good few years back-large price difference...and no, it wasn't the consultation fee that was the problem (charity clinic, something like a £4 donation for a consult but drugs had to be paid). Admittedly only a small minority of clients in that specific situation...

RE: What if the cascade were abandoned – unintended consequences?

Anthony Todd — Fri, 17 Mar 2017 22:19:44 GMT

[quote user="Clive Ansell"] My main objection is that of curtailment of clinical freedom.[/quote]

Yes, me too. Do the powers that be really think any vet would give a drug, even if unlicensed, [which is a facade in itself], to any animal if any vet thought it could be harmful?

The side effects of most drugs have only become public after wide prescription, not after testing on a dozen beagles.

The vet. drug suppliers of rebranded human generics must be laughing all the way to the bank!!

RE: What if the cascade were abandoned – unintended consequences?

Clive Ansell — Fri, 17 Mar 2017 22:04:33 GMT

I am left wondering whether there is moral or a commercial justification for the cascade at all. Getting a product licence for tried and trusted old favorites that work and are safe such as Metoclopramide or Metronidazole, then putting them in fancy packaging with a silly name (Vomend - FFS), and escalating the price many times over is iniquitous and just reeks of racketeering.

We of course need drug companies to come up with new and exciting drugs, and I can see the need to recover costs of R&D, but where a company produces a new and novel product it is going to sell without needing the cascade regs to prop it up.

RE: What if the cascade were abandoned – unintended consequences?

Anthony Todd — Fri, 17 Mar 2017 21:59:28 GMT

I seem to recall it was going to be £48 a month and they were young....

I think it was costing, with good control, about £4 a month using generics in 1000 packs, but it was back in the day.

It sent waves around the practice.....

RE: What if the cascade were abandoned – unintended consequences?

Clive Ansell — Fri, 17 Mar 2017 21:35:42 GMT

RE: What if the cascade were abandoned – unintended consequences?

Anthony Todd — Fri, 17 Mar 2017 15:09:08 GMT

[quote user="David Mills"]Have you considered that lower drugs prices might, just might, bring more people through the door? [/quote]

When you have seen the anguish of the devoted owners having to put their two lovely alsatians down because they could no longer afford the POM-V phenobarb which we were required, by law, to prescribe you would get very cross because of the self-serving idiocy of the law!

[and the smug smile of the supplier of the same drug, and probably the same actual tablet, now the only source]

RE: What if the cascade were abandoned – unintended consequences?

vs0u — Fri, 17 Mar 2017 13:55:39 GMT

The R and D argument doesn't stand up. If anything, cascade discourages genuine R and D by giving drug companies an easy option of rebranding something that's already proven to be safe and effective.

In the absence of cascade, if a company develops a new drug which is novel and useful it will sell.They will still be entitled to the exclusive period of however many years before generics can be manufactured, same as now, to allow them to recoup their investment. If they rebrand something that's already in use it won't sell as we will all carry on using the generic which is cheaper. The big new innovations like convenia, cerenia, apoquel, the once a week treatment for otitis whatever it's called, would still sell anyway.

I think the cascade should be in place only for food producing animals and for antibiotics/antivirals/anthelmintics, where use may cause human health problems.

RE: What if the cascade were abandoned – unintended consequences?

Braden Collins — Fri, 17 Mar 2017 13:28:34 GMT

Whenever I see JG Wray has started a post, I know it's going to be worth reading, but I also know I've only got a 50/50 chance of understanding it.

Coming from a country without a cascade, I see the good and the bad. We're several years behind the UK with many drugs - for example, Apoquel only became available here at the end of last year. We also have the freedom to use generic drugs, which might save the client some money.

Having worked in the UK, my dislike for the cascade came from drug companies doing one of two things:

registering a drug such as cimetidine when a human version had been used for many years
advertising things like "the only formulation of X registered for use in cats", when we had been using the competitors cheaper X for many years in cats without an issue.

Those sort of behaviours give the impression that profit, not R and D were the motivating factors for their behaviour. It felt as though the cascade was cornering us into using their products without bringing something new to the table in many cases.

I don't feel that loss of the cascade would affect profit with appropriate pricing strategies. Using a simple percentage mark-up would lead to less profit from drug sales. If we start using a cheaper version of a drug, we will look at the mark-up in terms of dollars and cents on the older version, and use that to set the price for the new drug. It means that the client gets the drugs at a lower price while we maintain our profit margin.

for many drugs, would a cheaper generic version lead to happier clients? I don't believe so. When we look at our bigger bills, the bulk of the bill comes from our professional services. Our overall income is similar to JG's with 72:28 fees to drug sales. It would have to be a massive reduction in drug price to reach a point where cost no longer became an issue for most clients.

If our drug sales disappeared tomorrow, what would we do? We couldn't handle our current work load with fewer staff, so we would need to increase prices elsewhere to compensate. So the client would potentially end up paying more as we would need to protect our profit margin as well as someone else needing to make a profit. Maybe we should be aiming to get rid of the internet rather than the cascade to save our clients money and further animal welfare?

We have been very protected from the internet and corporate practices here, but we can see them coming. It is going to be a challenge to fight it out in a world if you compete on price when the internet can supply cheaper drugs and the corporates can supply cheaper services.

I think competing on quality service, charging appropriately for it, but above all else showing the value of what we do is going to be the only way to win in the end.

RE: What if the cascade were abandoned – unintended consequences?

David Mills — Fri, 17 Mar 2017 13:20:49 GMT

The whole world's a stage and we are but players on it.

Do you know how much big pharma spends on r and D in percentage terms? Compared, to say, marketing. (<5% and >30% respectively). The cascade has been brought in my lobbying from these companies. Nothing to do with animal welfare. Most drugs come from the human market and have gone through animal testing. Where do you stand on back-patenting of drugs e.g. mdz, meth, metoclop....??

Basingstoke has a higher than median average wage. Other areas ain't so lucky.

Have you considered that lower drugs prices might, just might, bring more people through the door? Why not, say, for the next month, flog advocate for £10 a box and see what happens?