This site is intended for health professionals only

At the heart of general practice since 1960

pul jul aug2020 cover 80x101px
Read the latest issue online

Independents' Day

Seven challenges below the prescribing radar

When GPs in West Sussex formed a single area prescribing committee with their hospital colleagues, they realised there were far more challenges than simply controlling costs. Dr Steve Pike explains

http://www.pulsetoday.co.uk/practical-commissioningl

When GPs in West Sussex formed a single area prescribing committee with their hospital colleagues, they realised there were far more challenges than simply controlling costs. Dr Steve Pike explains

Coastal West Sussex Federation is a grouping of five GP commissioning consortia – Chanctonbury, ARCH, Cisbury, Arun and Adur – covering a total of 57 practices and a population of 538,000 patients in south-west Sussex. Our overall GP prescribing budget was £73.5m in 2010/11.

Royal West Sussex and Worthing and Southlands Hospitals NHS Trusts merged a couple of years ago and we took the opportunity then to form a single area prescribing committee, which has enabled us to tackle some of the big prescribing challenges all consortia will have to face.

1. PbR exclusions

The challenge

I don't think most GPs have really grasped that this is coming their way – and it's a very big issue.

Payment by Results (PbR) exclusion drugs are high-cost drugs that are explicitly listed by the Department of Health as not covered by the PbR tariff. There are several reasons for their exclusion. Either the volume of their use is difficult to predict or low, or the relevant Healthcare Resource Group tariff is based on fixed-care pathways that cannot predict use of various treatments – for example, biologic drugs in rheumatoid arthritis – or the high cost of the drug is disproportionate to the tariff for an episode of care.

PbR exclusions can be up to 60% of the cost of all drugs used in a hospital, and are invoiced to PCTs directly by trusts. Clinical commissioners and providers need to have local agreements for monitoring, checking, challenging, and restricting the use of PbR exclusion drugs, requiring a collaboration of medicines management and contracting skills and expertise.

Consortia are going to be on their own with this, dealing with trusts. It's an important issue.

Who manages this at the moment?

This varies considerably between organisations. The high-cost drugs exclusion list only states how trusts should be paid for the drugs, not how the use of those medicines will or should be commissioned locally.

How our federation is handling this

The Coastal West Sussex Federation medicines management team, led by my colleague Sue Carter, collaborates closely with the acute contracting team to review all the monthly claims for clinical, contractual and pharmaceutical appropriateness.

An innovative web-based PbR exclusion management system has been procured from an independent company, and this will be implemented to ensure that all PbR exclusion use meets national and local policy and guidance, that it can be audited, and that we can automatically screen PbR exclusion claims data for contractual or clinical queries.

We're working with the company on a plan for rolling it out and for making sure we have clinical engagement with secondary care.

It has been used in other areas for a couple of years, and should fulfil a number of purposes simultaneously. We'll start with a limited number of clinical areas and expand from there.

Our area prescribing committee is led by clinical commissioners, and they will develop a suite of policies agreed with provider clinicians on the appropriate use of PbR exclusion drugs to ensure clinical effectiveness, better patient outcomes and improved value for money.

2. Robust local decision making

The challenge

Under the NHS Constitution, patients have ‘a right to expect that local decisions on drug funding are made rationally following a proper consideration of the evidence'. Patients can launch a legal challenge if they feel robust systems for local decision-making are not in place.

Who manages this at the moment?

PCTs, delegated to GP consortia.

How we are handling it

We are nicely set up for this because our area prescribing committee and hospital trust drug and therapeutics group both have primary and secondary care membership.

The area prescribing committee has GP prescribing leads from the five consortia that make up the federation. The bimonthly meetings are also attended by a federation board member, the medicines management team, hospital pharmacists and clinicians, nurse practitioners and a patient representative.

The key areas are managed entry of new drugs – including non-NICE drugs, high-cost/low-volume drugs and pharmaceutical ‘orphan' drugs (drugs for rare diseases) – horizon scanning and proactive population decision making, dissemination and implementation of national guidance, the traffic-light system for prescribing in primary and secondary care and effective shared-care agreements. Key commissioning tasks that need to be addressed include priority setting, minimising postcode prescribing and individual funding requests (IFRs).

Most IFRs are for surgical interventions, but where they are for medicines and could apply to a population they may require a new policy development or modification of an existing policy. At the moment, it's not yet clear whether the IFR panel will sit at the local level or at a county-wide or cluster level.

Examples of decisions we have had to make locally about medicines include ones on orphan drugs such as amifampridine, the positioning of drugs such as denosumab in the prescribing traffic-light system, and the commissioning of non-NICE drugs such as betamethasone and calcipotriol scalp gel.

We need to be able to defend our decisions and to be able to show the process behind them – and that's where we see the benefits of the federated model. Individual consortia making these decisions may not have the expertise to defend a legal challenge at that level.

3. Implementation of medicines management QIPP

The challenge

To meet the requirements of the QIPP medicines use and procurement workstream.

Who manages this at the moment?

PCT, delegated to GP consortia.

How we are handling it

QIPP is central to our commissioning strategy. Locally, following discussions with Surrey and Sussex LMC, NHS West Sussex and the five consortia, we have combined QIPP priorities with the new QOF indicators QP1-5 by recommending that practices choose three of the QIPP therapeutic topics, using data from the QIPP prescribing comparators available on the Prescription Pricing Division (PPD) toolkit and benchmarking graphs. It seems that the toolkit comparators are currently the only national benchmarking data available to use in QP3-5.

Addressing the QOF indicators in isolation could be complex, but this approach seemed much more effective and efficient. It made complete sense to focus our efforts on keeping life as simple as possible and at the same time getting practices to review their prescribing in key therapeutic areas identified in the medicines management QIPP.

We have used a similar structure and documentation to QP1-5 for three of the other QIPP topics under a local prescribing incentive scheme so that practices are able to choose three of the recommended six for QP1-5 and the remaining three for the prescribing incentive scheme. We are encouraging practices to look at three other QIPP indicators for QOF MM 6 and 10.

In summary, we think we will cover most of our QIPP priorities through QOF and the prescribing incentive scheme. This is quite important because approximately two-thirds of PCTs have abandoned their prescribing incentive schemes. Our prescribing incentive scheme also covers attendance of a GP representative from each practice to our popular quarterly locality prescribing meetings.

4. Getting secondary and primary care on same page

The challenge

How consortia can achieve effective collaborative working over prescribing with secondary care.

Who manages this at the moment?

PCT, delegated to GP consortia.

How we are handling it

We have the advantage locally of having a single hospital trust – Western Sussex Hospitals NHS Trust – one GP federation and one area prescribing committee all covering the same patient population.

Via the area prescribing committee and hospital drug and therapeutics group – both of which have GP membership – we are able to develop effective shared-care agreements. These enable us to make savings across the health economy by transferring the prescribing responsibility to primary care, where it is safe and convenient for patients and better value for commissioners. And it has the benefit of everyone knowing what the shared-care arrangement is.

5. Ensuring medicines management expertise input into commissioning decisions

The challenge

Referral management is an important part of commissioning, and the review and development of clinical pathways often requires a significant medicines management component.

Who manages this at the moment?

PCT, delegated to GP consortia.

How we are handling it

Locally, we involve our medicines management team in all clinical pathway development. For example, in the diabetes task and finish groups, in consortium and federation board meetings, and also in the development and review of local enhanced services. It's important this involvement happens at an early stage, otherwise key prescribing issues could be omitted.

6. Horizon Scanning

The challenge

Working out commissioning implications of new drugs, both in service provision and cost, and planned new drug entry.

Who manages this at the moment?

PCT, delegated to GP consortia.

How we are handling it

Horizon scanning occurs at our area prescribing committee meetings. It's much more appropriate to do this within a larger model, using the economies of scale rather than having everyone do their separate thing. Also, you ensure that small consortia work together with their neighbours in terms of forward planning.

7. National Guidance Dissemination and Implementation

The challenge

Working out the commissioning implications, including service provision and cost of national guidance implementation – for example from NICE, the Care Quality Commission and the National Patient Safety Agency (NPSA). NPSA alerts have a time deadline for implementation.

Who manages this at the moment?

PCT, delegated to GP consortia.

How we are handling it

We discuss the implementation of national guidance at both the area prescribing committee and drug and therapeutics group meetings, and disseminate it through the consortia prescribing groups back to GP practices and individual GPs.

Dr Steve Pike is a GP at the Selden Medical Centre in Worthing, and coastal West Sussex GP prescribing lead

Further information

-

Resources

PBR exclusions - www.dh.gov.uk/

QIPP prescribing toolkit - www.ic.nhs.uk/services/

QOF quality and productivity indicators - www.nhsemployers.org/

National Prescribing Centre advice on PbR - www.npc.co.uk/

Related images

  • Dr Steve Pike

Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say