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How to use prescribing incentives to make a £2m saving

Dr Raj Bajwa, Dr Stephen Murphy and Jeremy Newton describe how their collaborative launched a highly successful prescribing incentive.

Dr Raj Bajwa, Dr Stephen Murphy and Jeremy Newton describe how their collaborative launched a highly successful prescribing incentive.

Practices in Buckinghamshire had always regarded themselves as good cost-effective prescribers.

41203083Their PACT data always compared favourably with the national averages and the spread of performance by practices in Buckinghamshire Primary Care Collaborative had the typical spread from significant underspend to overspend on budget.

The method of budget calculation had been modified gradually over the preceding three years so that historical performance was no longer taken into account when calculating budgets. By 2007/8 we were given budgets based on 100% weighted capitation.

This was a welcome move as it did not reward overspending or penalise underspending practices.

But then our PCT found itself in a challenging financial position and prescribing was identified as a key target area, especially when SHA data showed that Buckinghamshire practices had some of the highest prescribing costs in South Central SHA.

This came as a surprise to many who had been used to national PACT benchmarking in which we had compared very favourably.

It further noted that, based on May outturn data, the PCT was heading for a £3m (5%) overspend on its prescribing budget alone.

Because Buckinghamshire has relatively low deprivation, its central funding is substantially lower than other parts of the country. So although we might spend less than elsewhere (as seen on the PACT data), we would still be overspent on our allocated budget as a local health economy.

Forming an action plan

The PCT convened a meeting, which included:

• PCT directors

• the medicines management team

• PEC GPs

• the three collaborative prescribing leads in Buckinghamshire.

The question we considered was: ‘What would it take to save £1.5m in prescribing across Buckinghamshire in nine months?'

The collaborative produced a paper it had prepared, outlining two possible incentive schemes and favouring one in particular. This was received positively by the PCT and was launched in September 2007.

This was our first big task as a collaborative and we realised this would be a test of our ability to deliver.

How the scheme worked

The scheme commenced on 1 September 2007, using June outturn data as a baseline from which to assess performance.

Practices were promised:

• 10% of any savings made below June outturn prediction

• 15% of any savings made below the practice prescribing budget.

41203082This provided an incentive to all practices to reduce their prescribing spend regardless of their starting position and also gave a greater incentive and significance to coming in under budget.

Buckinghamshire collaborative was allocated a risk pot of £75,000 that it could invest at its discretion in practices or processes to help with prescribing.

Individual practices could request funding by submitting a brief business statement (template provided). The collaborative reviewed each request and agreed a specific amount for the practice that could be used for an agreed purpose. Once requests were authorised by the collaborative they were forwarded to the PCT to release funds as appropriate.

Any money from the risk pot that was not spent by the collaborative could be used at its discretion.

Data would be provided by the PCT at practice level in a timely accurate manner using comparative data including not only financial performance but also performance against the top 10 formulary targets. This would be done by a dedicated PCT project manager who was newly appointed to take on sole responsibility for the prescribing scheme.

Payments would be made to the practices when March 2008 prescribing data was available from the PPA to assess achievement of targets. All incentive payments would have to be reinvested in patient care and would be held by the PCT until investments were identified by practices.

The collaborative leads, in conjunction with the PCT medicines management team, identified 10 high-impact areas in which practices may wish to focus their efforts. Comparative data was provided to help practices target their efforts most effectively. Formulary choices were evidence-based.

The high-impact areas identified were:

• statins

• ACE inhibitors

• angiotensin 2 blockers

• calcium channel blockers

• proton pump inhibitors

• antiplatelet agents

• inhaled steroids

• nasal steroids

• SSRI antidepressants

• a-blockers.

Treatments of limited clinical effectiveness were publicised to improve awareness and a system for centrally procuring dressings was set up.

Making it happen

Buckinghamshire collaborative worked hard to ensure that practices knew from an early stage that an incentive scheme was imminent so they could start working towards it even before it was launched.

This was done via email, locality prescribing forums and most importantly at the council meetings. This ensured the scheme was publicised and supported well before its official launch.

The most overspent practices were identified and offered help even before the scheme went live.

All practices were given the offer of a visit by the prescribing lead GP and this offer was accepted by some, including the top 10 practices, although it was not mandatory.

Practices were encouraged to develop their own solutions. We were able to fund all viable schemes proposed by practices and hence the entire risk pot was spent.

The pot included money for ScriptSwitch software, which compares the prices of different drug options at the point of prescribing. This was offered to all practices and actively sought by 17 out of 34.

Other reasons for the success of the scheme were:

• we worked closely with the PCT medicines management team as a joint resource for visits, advice and support

• all formulary advice was evidence-based and did not compromise patient care

• the data provision was excellent

• the timing of category M price reductions was perfect and rewarded our high level of generic prescribing

• momentum developed at an early stage, which helped to stimulate further efforts by practices

• the impact of simple data graphs comparing practices was significant as

a stimulus for change

• most importantly, the groundswell of energy and goodwill from each practice, without which none of this would have been possible.

What did we achieve?

The collaborative itself managed to reduce its prescribing outturn by £2m (5.22%) in nine months. Each of the 34 practices in the collaborative showed considerable progress in reducing prescribing expenditure and promoting greater compliance with formulary prescribing.

More than £371,000 was paid out to collaborative practices in incentives for reinvestment in patient care.

If current trends persist, every practice in the collaborative is on course for an underspend on its prescribing budget in 2008/9. They will then benefit from an even more rewarding incentive scheme this year.

The scheme has definitely instilled PCT confidence in the collaborative and we have greater autonomy with our operational plan for 2008/9. Member practices now have a great sense that we can enable change from the ground up as opposed to the PCT compelling change from the top down.

Dr Raj Bajwa is prescribing lead for Buckinghamshire Primary Care Collaborative and for Buckinghamshire PCT

Dr Stephen Murphy is communications lead and Jeremy Newton is operations director for Buckinghamshire Primary Care Collaborative

Prescriptions Bucks PCT fact file 60-second summary

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