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Independents' Day

Dr Andrew Green: 'Hospitals blow GPs' prescribing budgets out of the window'

Prescribing budgets may be rising, but primary care has already saved as much as it can from prescribing, argues Dr Andrew Green

GPs are used to balancing two huge responsibilities, that to the individual patient in front of them and that to patients as a whole, and therefore have a duty to prescribe cost effectively. Working with medicines management teams is an important part of this.

However, I believe that the significant gains from medicines’ optimisation have already happened, either because projects have been done in earlier years or because drugs which previously were the target for changes are now off patent. This has led to some changes being suggested that are inappropriate.

Although prescribing budgets are being squeezed, we need to recognise that any change is disruptive for the patient, can reduce concordance, or expose patients who are settled on one medication to a new set of side effects, so changes must be significant in value, be sustainable, be infrequent, and must always be to a drug of similar effectiveness.

Savings should also always consider the total cost to the NHS, not just the drug price, and the cost of pharmacy and increased monitoring also needs to be taken into account.

Changes to the cheapest branded generic applied across the country can rapidly produce supply problems. 

Other initiatives such as recommendations to halve tablets when lower doses are available, to use a number of lower strength tablets instead of one of higher strength, or to change patients to simvastatin, when it is likely that new NICE guidance will no longer recommend this as first line, can also have adverse consequences in the long run. GPs need to be particularly careful to assess each patient for their suitability before making these kinds of changes.

It is also unfortunate that GPs can do a lot of this kind of work with many patients in order to save relatively small amounts of money, then find any saving blown out of the water by a single request from secondary care for a high cost medication that previously would have been prescribed from the hospital directly, with ‘specials’ particularly problematic in this regard.

Many secondary care clinicians appear unaware of the cost of these preparations. Clearly any resource allocation formula needs to be sophisticated enough to allow for this happening, as it would be unethical for a GP to decline to prescribe for a patient a necessary prescription wholly on the basis of cost.

Dr Andrew Green is chair of the GPC’s clinical and prescribing subcommittee and a GP in Hedon, East Yorkshire

Readers' comments (4)

  • Absolutely agree with this, many awful examples; terminal care patient prescribed red-list antifungal by tertiary referral centre at £4000 for the course - red-flag so our regional hospital should have dispensed this; they simply didn't have the drug in stock so our choice was to blow our budget on a single drug or see the patient suffer.
    There is no point saving pennies in GP if the consultants are oblivious to the ever-shifting sands of drug costs.

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  • Piffle - primary care can make equally useless decisions that cost enormous amounts to put right. Just dealt with a completely avoidable case of DKA caused by totally inept insulin prescribing in primary care.

    Stop the blame game - why not ask the drug companies why they charge so much, often billing the nhs thousands more than they charge other countries.

    Secondary care is not the enemy, my poor deluded friends

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  • No secondary care isn't the enemy, but sensible, cost effective prescribing should be every doctor's responsibility, not just the GPs.

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  • There is no joined up thinking between Secondary and Primary care. The degree of hostility between the two is often mind boggling. Always finger pointing and shoulder shrugging from both sides with the patient stuck in the middle.

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