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GPs weigh up pros and cons as switching pressure grows

Cost savings have to be balanced against workload and impact on patient care

For deficit-haunted NHS managers, it must seem almost too good to be true.

A simple switch from one drug to another, no apparent damage to patient care and millions of pounds of potential savings.

But for GPs at the frontline the process is considerably more complex than that, and some have been left frustrated by recent pressures from primary care organisations.

While some PCOs have worked in partnership with GPs and offered incentives for switching, others have taken a heavy-handed, contract-waving approach.

Dr Nigel Watson, chair of Wessex LMCs, says: 'In some areas there have been good relationships. In others it's just "You must do this", with no recognition of the additional work.'

Changes to the drug pricing system have opened up opportunities for drug switching as never before, and some trusts are accelerating their drives to make cost savings.

Cambridgeshire PCT – one of the country's most indebted trusts – saved £1m last year by switching to cheaper alternatives in statins, PPIs, antihistamines, ACE inhibitors and sartans.The trust now has a raft of switching schemes and employs a team of pharmacists who go into practices to identify suitable patients.

The team either switches patients itself with the consent of a GP or passes on the details so the practice can act itself.'

The final and most important stage is to make sure the patients are happy with the switch,' says Sati Ubhi, pharmacist and medicines management lead for the Hunts area in Cambridge PCT.

North East Essex PCT has even more ambitious savings planned: £612,000 on statins alone for the year, £290,000 for switches related to ARBs and £330,000 for switching to generic PPIs.

But in their rush to save cash, not all trusts are sympathetic to the amount of workload involved for GPs.

Dr Jim Kennedy, prescribing spokesman for the RCGP, says: 'There are pros and cons to switching. The pros are that where there are drugs of equal value you're optimising cost-effectiveness. The disadvantage is it takes a lot of time and effort.'

Dr Neal Maskrey, director of evidence-based therapeutics at the National Prescribing Centre, acknowledges switching is no quick fix, but believes the cost savings for the NHS are impossible to ignore.

He says: 'Careful selection of patients and flexibility is clearly required, but even with that essential patient-centred approach it is possible to reduce unnecessary expenditure in some areas of prescribing. Changes in the prices of medicines have affected areas of therapeutics where there are large volumes of prescribing, so the savings are large and the NHS needs those savings.'

Prescribing experts are increasingly pushing for GPs themselves to take the lead on switching – with the potential savings there for practices as well as for the wider NHS.

Last week research by a GP, Professor Mike Kirby, found switching of statins and ARBs at his practice in Letchworth, Hertfordshire, had saved it £26,000 – with no adverse events.

Professor Kirby insists it would even be justified to switch patients back again if drug prices changed. But he cautions that the process is lengthy, involving record searches, preliminary screening by a pharmacist and more detailed screening by a GP.

'It is important to exclude anyone switching medicines that interact with the new drug or those with other contraindications such as chronic renal failure, as well as those who have previously used it and had side-effects or not hit targets. Any clinician performing such switches should also be aware of the small number of patients annoyed at being asked to switch,' he says.

The company ScriptSwitch markets software that prompts GPs to think again if they choose a drug that can be bettered in cost. It believes the software, which is being used in around 70 of the old-PCO areas, could save the average practice £35,000 per year.

This raises the rather attractive prospect of a windfall worth tens of thousands when practices get their practice-based commissioning savings.

Martyn Carroll, a pharmacist and head of medicines management at ScriptSwitch, says: 'In the past PCOs have purchased the software. More recently with commissioning we've had quite a few innovative practices approaching us directly. They wanted to ensure equity in prescribing – that was the initial driver for them. The second end-point is there are cost savings.'

Conflicting evidence has emerged recently on the effect of switching on patient care. An audit published as a letter in The Lancet suggested switching statins might triple mortality. But a second audit found no impact on cholesterol control.

Bhavana Reddy, head of prescribing support at the Northern and Yorkshire regional drug and therapeutics centre, says: 'One PCT in the SHA did find there was no overall change in cholesterol levels.

'PCTs could use it to go to a practice and say: "You have the same CHD prevalence as another practice down the road, and it's achieved its targets with only 50 per cent of the cost, so why can't you?".'

But Dr Watson insists he did find switching statins affected the number hitting cholesterol targets. There is a clear responsibility on GPs not to compromise patient care.

Dr Stephanie Bown, director of education and communication at the Medical Protection Society, warns: 'GPs have a responsibility that there is the best use of finite funds within the NHS. But they have an unassailable responsibility to do the best by their patients.'

Software helped save £14k

Dr Paul Mitchell, a GP at Sutton Manor Surgery in Hull, feels switching systems can ensure good clinical care as well as bringing cost savings.

His practice purchased the ScriptSwitch software. Now when GPs in the practice enter prescriptions the software identifies if there is an appropriate switch, and suggests it.

'Because we have so many doctors it can be difficult to ensure there is consistent prescribing at the practice,' Dr Mitchell said.

'While it's easy for partners to stick to the practice formulary it is not so easy for registrars, who change practice every six months, or for a new F2 doctor who changes every four months. That was the issue we wanted to resolve.'

In four-and-a-half months of using the software the surgery has achieved a 41.3 per cent acceptance rate of switches offered by the system and saved £14,000.

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