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Possible sources of relevant data were comprehensively investigated during the preliminary stages of the study. The research revealed a lack of accessible data relating to HMRs in Australia. The Health Insurance Commission HIC ; reports on the number of HMRs, as the service is reimbursable under Medicare. However, these figures do not link to other suitable data eg associated expenditure on medications or clinical treatment ; that would enable the cost-effectiveness of the program to be evaluated. Although these investigations did not provide HMR data within the time-frame of this study, the following sources were found to provide potentially valuable material that is likely to benefit future research53. Department of Health and Ageing The Department of Health and Ageing carried out HMR research in 2004 examining medication expenditure under the Pharmaceutical Benefits Scheme PBS ; in the period before and after an HMR. The findings of this research were reported for possible consideration by Cabinet in the 2005 Budget and, for this reason, the data are currently classified as `Cabinet-in-confidence' and have not been available to the study team. The data may, however, be available following the budget cycle and could potentially provide useful information for future HMR studies. Health Insurance Commission A custom data request was made to obtain Medicare and PBS statistics directly from the HIC. The request was rejected because it conflicts with a current regulation that prohibits linking of data items between Medicare and PBS sources. This regulation is currently being reviewed and there is a possibility that it will be relaxed or removed in the future. Department of Veterans' Affairs Research relating to HMRs has previously been carried out for the Department of Veterans' Affairs and, although the data were not found to be in accessible format for this study, there is potentially useful material for future HMR research. The Thunder Bay District Health Unit The Thunder Bay District Health Unit TBDHU ; is dedicated to the principles of public health. It is their mandate to promote health and primary prevention in accordance with specific legislation from the Ministry of Health and Long Term Care for the District of Thunder Bay. As one of 36 health units across the province of Ontario, the TBDHU complies with the Health Protection and Promotion Act 1988 ; and the Ministry of Health's and Public Health Branch `Mandatory Health Programs and Services Guidelines' 1997 ; . The TBDHU carries out three fundamental roles. It is responsible for the delivery of provincial public health programs designed to meet provincial standards in the areas of chronic disease and injuries, family health and infectious disease. It coordinates clinical and specialty services in the areas of dental and sexual health, needle exchange, genetic and speech audiology. The health unit also offers unique resources to the District of Thunder Bay, including access to up-to-date health status information, population health program planning and health communications. The health unit is a non-profit, government agency funded 40% by the municipalities it serves and 60% by the provincial government. It is governed by a Board of Health, which is comprised of 12 municipal representatives and three provincial appointees. The Project Superior Points Harm Reduction Program SPHRP ; is a program supported by the TBDHU and other community agencies such as Shelter House Thunder Bay and Haven House a Salvation Army youth shelter in Thunder Bay ; that provides harm reduction services to a wide range of high-risk individuals including both street-involved and intravenous drug users. Previous statistical and anecdotal information collected by SPHRP, indicated that the number of youth aged 24 years and under living on the streets of Thunder Bay is increasing and that drug use among this population is prevalent. Statistics from SPHRP's Needle Exchange Program indicate that drug use in Thunder Bay has increased Figure 1 ; . From 2003 to 2004, there was a 44% increase in needles collected by the program and a 55% increase in needles given out.
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Principles 2.1 NHS cash for prescribing is part of the wider resource available for the care of patients. 2.2 Professional guidance on standards of practice states that it is the responsibility of every prescriber to make efficient uses of the resources available e.g. GMC Good Medical Practice ; . The GMC advises doctors that they have a responsibility to consider the impact of their actions, such as prescribing, on resources available to other patients; it also states that doctors must not deliberately withhold appropriate treatment. Judgement of excessive or inappropriate prescribing by any health professional will need to reflect the balance between these duties. 2.3 As a guiding principle it is appropriate to prescribe the most cost effective medication for a patient. It follows that switching patients to less expensive drugs usually within a therapeutic class is generally appropriate where there is no contra-indication and where there is evidence of equal or greater care for patients. Patients should be informed of the rationale for these changes, for example via patient information handouts. 2.4 Switching significant numbers of patients' drugs within a therapeutic class e.g. either by changing to brand or by changing the drug ; should only be undertaken where the predicted NHS savings is expected to be sustained and provided there is no clinical disadvantage for the patient. 2.5 There may be occasions where switching patients may be clinically inappropriate e.g. in line with BNF or MHRA guidance certain drugs should be prescribed by brand to ensure continuity with regard to bio-availability. 2.6 It is appropriate that doctors and health professionals have the clinical freedom to switch individual patients to higher priced drugs branded or otherwise ; , or to alternative drugs, for clinical reasons. Due Process 3.1 PCOs are recommended to demonstrate due process e.g. that the development of prescribing incentive or improvement schemes are supported by appropriate processes involving local clinicians, and that the due process of developing and implementing such schemes is evidence based and appropriately documented. Where practices are expected by PCOs to change prescribing practice to improve the quality and or cost effectiveness of prescribing, or to make prescribing budget savings, PCOs are recommended that information about the rationale behind such prescribing changes should usually be available for patients, e.g. from the PCO prescribing advisory group. 3.2 Similarly, prescribers and dispensers should also demonstrate due process e.g. it is reasonable and appropriate for health professionals to exercise wise buying in the purchase of drugs from wholesalers and manufacturers. This acts as a driver for manufacturers and suppliers to reduce prices which in turn reduces the NHS drugs bill via discount claw back systems that apply to dispensing doctors and community pharmacy. 3.3 However, other than as outlined in 3.2, substantial sponsorship or financial deals that could reasonable be perceived to affect the choice of treatment in a way that is financially beneficial to the prescriber but significantly increases NHS costs, other then where there is clear evidence of clinical benefit to patients, should be recorded in a register of "Gifts and Hospitality.
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