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A prescription for change in statin prescribing

A major overhaul of statin prescribing has freed up resources for new services in an east London PCT. Kiran Shah explains how teamwork was key to the scheme’s success

A major overhaul of statin prescribing has freed up resources for new services in an east London PCT. Kiran Shah explains how teamwork was key to the scheme's success.

In April 2006, Redbridge PCT in east London was ranked among the bottom 10 performers in the country by the Department of Health for cost-effective statin prescribing – sitting 297th out of 303 trusts.

However, in the space of eight months Redbridge climbed to 74th – the largest single improvement by a primary care trust, with a 25% increase in cost-effective prescriptions.

The low ranking had come as a shock and the PCT responded by agreeing to meet the national average (60%) by the end of December 2006.

A statins programme was set up to provide support to practices to encourage patients to change from high- to low-cost statins, where clinically appropriate.

A practice support pack, patient information leaflet and clinical evidence supported the change but the success of the programme lay with securing the backing of the borough's 50 GP practices, which are represented by three PBC clusters.

Each practice had received their own PBC budget for services commissioned for their patients. Notional prescribing budgets were also devolved to each practice as part of their overall PBC budget.

41181094The PCT had agreed that a percentage of any savings made could be reinvested in the redesign of services to benefit local patients. Agreement was reached with the PBC cluster leadership teams that improving the low-cost statin prescribing rate would be a PBC target, to release savings that could then be reinvested.

Each PBC cluster nominated a GP prescribing lead who would work closely with the PCT's medicines management team (MMT) to implement this target by liaising with GPs and clinicians at two local hospitals (Whipps Cross and Barking, Havering and Redbridge) to promote cost-effective statin prescriptions.

Visits were arranged to all those practices that had an average low-cost statin prescribing rate of less than 60% (42 practices in all) to support them in implementing this change.

41181093At the beginning, practices questioned whether their ability to meet QOF cholesterol-lowering targets would be affected by our plans. By working first with keener practices, and proving that there was no impact, we were able to share this information and reassure other practices.

The MMT helped practices with administrative support, including sending letters to patients and copying patient leaflets and also ran clinical searches to identify suitable patients for switching.

We then agreed to:

• monitor and obtain regular updates on the numbers of patients who had been switched

• provide additional support to practices that required it

• maintain support to those practices that were already implementing the statin programme.

A series of multidisciplinary educational meetings were held with patient literature produced and additional clinics organised for patients to attend to answer any queries.

A resource pack was developed in consultation with the prescribing leads that included the following information:

• practice support pack

• two template sample letters for patients

• two patient information leaflets, one on cholesterol and statins and the other about repeat prescriptions

• desktop reminder about statins for each GP.

A regular newsletter was also produced detailing progress in achieving targets across the PCT. It was distributed to nurses, community pharmacists and all prescribers.

GPs and prescribing advisers reviewed patients' notes and identified those suitable for a change in prescription, and the acute care trust's drug and therapeutics committee agreed acute clinicians would also amend their prescribing choices.

In addition, an audit of cardiology referrals was undertaken by a cardiologist with results fed back directly to the clusters. Some practices also held pharmacist-led sessions with patients, advising them on their existing medication.

Most patients were given blood tests and their cholesterol levels reassessed, allowing their treatment to be reviewed.

Patients were encouraged to raise concerns they had with their GP or community pharmacist with the PCT's support.

The rise in dosage that accompanied the switch to simvastatin was carefully explained and patients were reassured that it didn't mean that their condition was worsening.

Start-up costs for the scheme totalled £50,000 but the savings have been substantial.

The annual cost of treating a patient with atorvastatin (10mg) was £216.36 compared with £42.84 for a course of generic simvastatin (40mg) – a saving of £173.52 per patient.

To date, these changes have led to an estimated saving of nearly £1m, some of which has been reinvested in primary care. This includes the financing of a community heart failure service, initially staffed by GPSIs supported by a secondary care consultant, and in the future, heart failure nurses, to provide a higher standard of diagnosis and treatment.

Redbridge PCT recorded the highest increase change of low-cost statin prescribing in the country between October and December 2006 and currently has a 73.49 rate for cost-effective prescribing.

The uptake of generic statins is still increasing month on month, showing that multidisciplinary collaborative working can influence prescribing patterns.

Redbridge PCT continues to work to promote cost-effective prescribing by producing regular newsletters, educational meetings, practices' prescribing information and visits to practices.

A steady supply of clear, concise information about the promotion of low-cost statins to both patients and clinicians, and setting a clear goal within a specific timeframe, were essential to the success of the project.

The result is a more cost-effective, efficient service delivering the same standard of care and savings generated reinvested in improved primary care services for our patients.

By working first with keener practices and proving targets were unaffected, we were able to reassure others

‘Heated discussions': a GP's view of the project ‘Heated discussions': a GP's view of the project

Dr Ramzan Mughal, a GP in Ilford, Essex, and a prescribing lead for one of Redbridge's PBC clusters, told Practical Commissioning he believed the project had been a success – once it had overcome a number of GP concerns...

"We have managed to save quite a lot on the prescribing budget. It is something that has been done after careful consideration, consultation with practices, after reviewing each patient, and in line with national recommendations – not something that has been done as a blanket policy.

When we went out to talk to practices, initially there were very heated discussions about this, and very constructive comments came back to us."

The main GP concerns were:
• potential interactions with other medications
• increased side-effects in patients on simvastatin compared with other statins
• feeling they were being pressurised into switching purely because of the low cost of simvastatin
• general patient intolerance
• the careful monitoring involved that might lead to increased workload
• specific precautions such as interaction with grapefruit juice.

We took up all these concerns, discussed each of them and addressed them at local educational meetings.

Ultimately the decision to switch rested with the GP, based on the specific needs of a particular patient.

We've had patients who've been resistant – and in some cases we've had to change them back or put them on a different statin.

My overarching message for other areas would be to ensure the motives for the change are explained to GPs and careful consideration is given to guidelines and what best practice should be.

statins protocol Statins

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