We asked our expert prescribing panel how GP commissioners could step up to the major challenge of bringing drug costs down without harming patient care.
How did PCTs fair with prescribing?
KL I think they actually made enormous strides. Back in 1998, when I was working for a PCT, generic prescribing was at about 52%. Now we're at 80% nationally.
HM I think PCTs did a great job and concentrated on doing what they felt was necessary. What they tended not to do was look at the broader picture.
How can consortia do better?
HM A major change is that GPs will be accountable for their prescribing decisions. The mix of NHS providers, GPs (prescribing and dispensing) and consultants will bring a broader spectrum of input into prescribing decisions.
KL Under PCTs, there was a bit of an attitude among some GPs of ‘Don't tell me what to do. Don't interfere with my clinical freedom', but the shift to consortia should change all that. Consortia – by being all GPs – can take ownership and make sure all the GP members work together rather than on their own. But what consortia need to deliver now, across the country, is a change in behaviour not only among GPs but also among the public. The scale of the savings needed is such that patients will need to be a lot more involved in shared decision-making about prescribing so that they are on board with the agenda. Another thing that's changed is that there always used to be the idea that no matter how much you spent on medicines, someone on a white charger would come in and sort it out. No one thinks that any more. It's crunch time, and it is focusing minds.
DH In the new world of commissioning consortia, GPs are much more conscious that they're using public funds. The ground has already shifted and moved prescribing onto a much more corporate, accountable basis. I'm seeing a very different reaction from GPs receiving a prescribing letter from their peers than receiving one from the PCT. There used to be a sense of ‘They would say that' when the letter came from a manager or a pharmacist, now it's more ‘That's a good idea'.
Will GPs have to change their prescribing as they move from thinking of the individual to commissioning for the population?
KL They certainly will. I've had the Hippocratic Oath quoted at me in the past. GPs have said that they can only think about the one patient in front of them at the time and thinking on a population level is not for them. But now it's sinking in more widely that if you've spent all the prescribing money on one patient, there won't be enough to go round.
DH It will be a significant step for some. But the culture is already changing and GPs are now realising they have a much broader responsibility. In a way it's an easier step for GPs to make than for hospital consultants because we already have a holistic view of our patients. Consultants have one big disease they focus on, that they're fascinated by and know all about. They focus only on patients with that disease and it will be much more of a challenge for them to take a wider view.
Will the new QOF prescribing indicators assist this process?
KL These are causing a lot of discussion at the moment. They are actually really helpful. They way I read it is that they put a lot more emphasis in GP land on shared ownership of prescribing. The peer review element is also a non-threatening way to get GPs to think together.
DH Agreeing a national target is fine and absolutely the correct thing to do. But it is one size fits all. I hope there will be room for some local flexibility in the way we use it. It will help consortia get practices in line but it still has a bit of a central feel the way it stands at present.
Which are the low-hanging fruit, in terms of getting prescribing costs down? What should commissioners focus on first?
KL This is a tricky one because it will vary from area to area. But widely applicable things include rationalising treatment plans where you can – say to 28 or 56 days – and just making sure to maximise generic prescribing, in particular being prepared for when medicines come off patent.
HM There's a high number of branded products coming off patent in the next four years. Consortia should be looking at these first as the big winners, first off, bringing huge cost savings.
Where are the information voids in terms of cost effective prescribing and how can they be filled?
HM I feel there isn't enough information out there that is specifically about cost-saving measures. I'd like to see greater understanding among all GPs – about prescribing and of cost-effective alternatives.
KL I'm not sure there are any particular voids. There is loads of information available – the National Prescribing Centre's 15 key QIPP recommendations, for example. Practices can also run their own reports on their own data and find out where savings can be made and all have access to medicines management teams.
What are the options available to GP commissioners to get their prescribing bill down?
KL Strategically, commissioners are going to have to be robust about new drugs and whether or not they restrict their practices in using them. PCTs used to make recommendations and it was more or less up to the individual clinician whether or not they took any notice. Consortia may want to manage that more robustly.
One of the really big ones is commissioning from secondary care. Consortia must make sure they haven't got maverick consultants running up unnecessary costs. The way to manage this is via contracting. Making sure there is complete clarity in all parts of the patient pathway so that you know who is paying at each stage so there are no nasty surprises.
Prescribing savings result first of all from asking: ‘Does the patient need any medicine at all?' If yes, go for the lowest-cost option – 30 drugs will probably cover 80% of general practice patients. Then make sure your practice housekeeping system is robust as regards repeat prescription requests. And don't forget to look at secondary care.
When I worked for a PCT, we got a consultant to agree a change to his statin preference by telling him that we'd go halves on the savings with him and that it would pay for him to have a specialist nurse.
DH Consortia will have to get on top of hospital prescribing. And I believe they will be much better at it than PCTs were. Holding the ultimate responsibility for the budget, there's more incentive for them to do so.
Where are the real savings to be made?
KL The real savings are actually to be made where there is poor practice. Geographically, there are parts of the country where more work will be needed. Practices in the north-east are at the top end in terms of QIPP areas but in London and on the south coast, many are not doing so well. It is down to resources. Such areas will have fewer people in the medicines management team, less strategic leadership.
But if real savings are to be made, we have to re-energise the process. We have to go beyond the excuse that ‘We've tried and it didn't work' and try again. There is absolutely no reason why a practice in the north-east should have a generic prescribing rate of 85% while it's 65% on the south coast. We need to establish some momentum so that it becomes common practice.
HM Innovation is key to achieving the real savings, and it is how new processes are identified and implemented that will be the key to real cost savings. At the moment, GPs are encouraged to prescribe medicines that will achieve cost savings – but there are a number of medicines that have new indications that PCTs will currently not fund. GPs should not be bound to this; patients have the right to receive a medicine approved by NICE. Consortia should look at identifying these products and assess whether these new medicines are cost-effective.
DH The big savings are to be made through signing up to efficiencies via prescribing formularies, even in unexpected areas such as dressings. Not many GPs are fully up to speed on these and so can be at the whim of a recommendation. There are big savings to be made in areas like these.
Another example is specials, medicines that have to be specially made up by the pharmacy, sometimes at an enormous cost. Most practices are not aware at all of the cost of these. It's a bit of a hassle to work out and until now there has been no incentive to look at it. But tackling things like these will make a big difference to costs nationally, and even at a federation level, the savings could be massive.
GPs have already focused on cutting their prescribing budgets – are there still sufficient potential savings to be made?
KL I believe there are, but it is becoming more difficult. Patients are becoming more demanding. It's difficult for GPs who might not relish explaining why a patient's medication has changed. But it's worth recommending a team approach. You need to have the practice manager, receptionists, nurses and repeat-prescribing clerk all working towards the same end.
And it's worth restating that a small tweak might make all the difference. One GP saving one pound might not seem like anything, but if all GPs do the same thing, you save £40,000.
DH This is where we need to start looking, alongside the short-term ‘low-hanging fruit' approach. We need to start focusing too on two to three years ahead and thinking more about shifting our prescribing towards preventive medication. That's where savings can continue to be made into the future.
Our expert panel
- Kym Lowder (KL), Pharmaceutical adviser for Primary Care Commissioning
- Heidi McVay (HM), Operations manager, Practice Services UK Ltd
- Dr Donal Hynes (DH), GP in Somerset and a national vice chair of the NHS Alliance
