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How to... manage a real prescribing budget

A federation of five practices has sliced 10% off its real prescribing budget in just six months. Dr Bill Cotter explains how they did it

A federation of five practices has sliced 10% off its real prescribing budget in just six months. Dr Bill Cotter explains how they did it

For many PBC groups, the chance to have real delegated budgets for prescribing would be high on their wish list. In Bexley, GP members of the Clocktower locality were given that opportunity and are now benefiting from having greater control of their PBC destiny.

In just six months, the locality has saved £375,000 on its £3.75m prescribing budget, freeing up money to be invested in service redesigns that will bring care closer to home, and in recruiting new staff to help deliver them. Of course, with greater control comes risk. But the extra responsibility is worth it, because it allows you to free up resources to develop PBC services that can make a real difference to patient care.

Our area has a federal structure and this has been a key factor in getting us to a point where both commissioners and the PCT were ready to look at real budgets.

Expressing interest

Having a PCT chief executive who backs PBC and is determined to put clinicians in the driving seat has made an enormous difference to the way the approach has progressed in Bexley. Devolving budgets was one of the ways Anthony McKeever wanted to give GPs more responsibility for patient care. He believes that delegating money to the front line allows clinicians to spend it more effectively and results in a more cost-effective use of resources (see box below for more on our PBC vision).

In 2008, Mr McKeever asked practices from the three localities to put in bids for initiatives they hoped to develop. In 2008, five out of the nine practices that make up the Clocktower locality – including the Bellegrove surgery, where I am a senior partner – thought it would be a great idea to take on prescribing budgets. We felt there were opportunities to make savings, which could be reinvested in services that would enhance care for patients.

We were the only locality in Bexley where practices wanted to take on responsibility for prescribing budgets – the other two didn't express an interest. This may be because the Clocktower locality had a good track record for prescribing savings, scoring well in previous prescribing incentive schemes. The five practices interested in bidding for their own prescribing budget were also comfortable with the idea of having their own pot of money to manage. As federation lead, I helped drive the bid to have joint control of prescribing budgets, working with locality manager Neil Jessup to put together a business case.

Making the case

It took two months to put a plan together that would convince the PCT of the value of GPs managing prescribing budgets. Part of our case was that it would allow the trust to test the model of devolving budgets and potentially offer increased savings that would benefit both the trust and the practices involved.

We also proposed an accountability arrangement with the PCT – a set of criteria for practices joining the team, which would require that they had a good track record in prescribing and had come within budget for the previous three years. We hoped this would also reassure the PCT that we were comfortable with handling prescribing funds and any possible overspends.

Our business case took into account the fact that 70% of our actual prescribing budget would be based on ASTRO-PU – the Department of Health mechanism for allocating such funds – and that 30% would be the amount that had historically been allocated to each practice.

We were not entirely confident that the PCT would approve the bid. We knew that from a PBC strategy perspective the chief executive was keen to devolve budgets, but some at the PCT were not so enthusiastic. Another obstacle was the fear of overspend. Some GPs were worried about the risk factor and there were concerns about the amount of money they might be expected to pay back should they go over budget.

It took six months from putting our plan together and presenting our case to the PCT to receiving its approval to set up a two-and-a-half-year pilot in June 2008.

Doing the sums

The five practices' real prescribing budget of £3.75m covered October 2008 to March 2009. We agreed with the PCT that 15% of it would be set aside to cope with overspend or high-cost drugs. If the five practices then went over budget, they would collectively be responsible for 54% of that overspend.

The practices also confirmed with the PCT that 20% of prescribing savings would go directly to the trust, while 80% would

be split three ways. A third would go to individual practices as profit, a third would be put into a general pot of resources, which would be available for projects across the PCT, and the remaining funds the five individual practices would need to bid for to reinvest in patient services.

Making savings

Having been delegated a budget, our main aim was to make prescribing more cost-effective. Much of the hard work to saving on prescribing had already been carried out by the five practices: prior to receiving real budgets, we had focused on big-win areas such as statins and low-cost ACE inhibitors. So to make savings on our real budgets we wanted to maintain spend and find new areas to focus on.

To help achieve this, GP leads from each of the five practices meet on a monthly basis with the prescribing adviser who is employed by the PCT to discuss how to make certain prescribing areas more cost-effective. For example, NICE published guidance on the use of glucose testing strips in stable diabetes patients. The institute recommended a reduction in the amount of testing and therefore the number of test strips prescribed. This was discussed at our monthly meeting as a way to save costs without any adverse effect on patients.

The adviser highlights areas where the practices are prescribing more than the

PCT average and we discuss prescribing patterns that might be more cost-effective. This has helped considerably in terms of maintaining reductions in spend. We also look at how, say, certain asthma and antihypertensive drugs could be directly substituted with cheaper but equally effective alternatives.

To make prescribing more cost effective, one practice decided to invest from its real budget in ScriptSwitch software. The software indicates whether you can prescribe another drug of a similar type and efficacy but at a lower cost. ScriptSwitch will also advise on drug quantities. Using this program means clinicians can influence the prescribing of salaried GPs and nurse prescribers in their practice. ScriptSwitch has since been adopted by the PCT, which felt it would be an effective approach to reducing prescribing costs.

By March 2009, we had met our aim of saving £375,000 – 10% of our £3.75m prescribing budget – to be divided up according to the PCT pilot agreement.

Prescribing savings have enabled my practice, for example, to employ an additional sessional nurse practitioner to improve patient access, which proved particularly useful during the recent swine flu epidemic. Practices involved in the pilot are currently putting in bids to set up schemes to improve care for housebound patients, enhance chronic disease management and to reduce emergency admissions.

As part of the real delegated budgets agreement on how the savings would be split, practices across Bexley also have an additional £100,000 to bid for schemes, providing those funds are used in accordance with PCT plans for healthcare, while £100,000 of prescribing savings has been put in a general pool to support the practices taking part in the pilot. This financial year we're again on target to make substantial savings – £600,000 on a £5m budget.

Reflections

Having a real prescribing budget has allowed us – both as individual practices, and as a group – to develop services using savings that would previously have gone back to the PCT. Having this money also spurs you to make more of an effort to achieve savings, which can then be used to purchase additional services for patients in areas that may need bolstering.

Since establishing the pilot, the care trust has decided to change the formula to a locality-weighted ASTRO-PU for the next financial year. We were also faced with a situation where actual prescribing budgets for the coming year were to be reduced by the PCT by about £1.5m to allow for extra pressures in secondary care and the new pharmacy contract.

Naturally the five practices were concerned, and two decided the risk of overspend was greater than the risk of staying in the pilot, so they opted to give the required month's notice and to leave the delegated prescribing scheme.

A crucial lesson we learned from this experience was that you need to have budget calculations confirmed in advance of any pilot. However, this is not always possible because it is hard to predict how the DH will manage these budgets. Faced with changing circumstances, you need to try to work things through. However, a testament to the fact that we GPs believe in what we're doing is that two new practices joined the scheme because they felt the risk was worth it. And now a second pilot has sprung up in the North Bexley locality, involving four practices.

Those wishing to bid for real prescribing budgets should be aware that PCT finance departments are usually quite wary of delegating schemes where control of practice savings is devolved to clinicians. It is helpful to have a PCT chief executive who wants PBC to progress and allows practices to decide their clinical priorities.

By successfully taking control of prescribing funds, we have proved that it is possible for GPs to manage budgets. Our model is now fairly well established and straightforward to replicate, so could pave the way for primary care clinicians to manage funds in other areas, such as outpatient services. Taking on a delegated budget on your own is a big step. But by joining together, practices can reduce

the risk, as well as being able to share ideas and collaborate to improve services. With budgets becoming tighter, GPs need to look at all possible ways to free up resources – and having your own prescribing budget is a great way to do this.

Dr Bill Cotter is the lead for the prescribing project and federation lead for the Clocktower locality and a GP in Welling, Kent


The federation factorThe federation factor The federation factor

Ever since Anthony McKeever was appointed chief executive of Bexley Care Trust in 2007, GPs in the area have felt empowered to drive PBC forward. Mr McKeever suggested we look at a federal model of working with the aim of developing a common approach to health needs across Bexley in Kent. The PCT met with three local GPs leading on PBC: me, chair of the Clocktower locality; Dr Joanne Medhurst, PBC lead for Frognal; and Dr Tony McCullough, PBC lead for North Bexley, All three localities, which comprise a total of 29 practices covering 220,000 patients, are located close together in the borough of Bexley.
With the locality structure already in place, developing the federal structure was fairly straightforward and we launched it in February 2007. The trust allocated the federation £420,000 from 2007 to 2008, which was used to fund GP time, service redesign work and anything else related to the PBC changes we'd been making. The PEC was looked at afresh to see how it could best support the federal approach. Last year the three locality leads became federation leads and we were invited to sit on the executive team. Each federation lead has a PBC lead, who works at a locality level, and each service area has a clinical lead. There are now 20 across Bexley.
The benefit of this structure is that federation leads meet regularly with the PCT, ensuring its strategy reflects the views of GPs, while locality leads focus on their individual areas and clinical leads concentrate on specific disciplines.
Our PBC vision is about making sure patients get the right care, from the right person at the right time, which influences how we redesign services for the community. Recent redesigns have focused on such areas as anticoagulation, cardiology and rheumatology. Clocktower reduced its rheumatology referrals by more than 70%by developing a rheumatology clinic.

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