Practices will need to deliver major prescribing savings for consortia. Pharmaceutical adviser Kym Lowder provides a guide to cutting bills
A National Audit Office report estimated at least £200m could be saved from primary care prescribing. Practices must therefore be prepared to deliver major savings for the new GP consortia.
1. Look at whether a prescription is required
The first step is to ensure a prescription medicine is required at all. Information, self-help solutions and over-the-counter remedies all have their place and can give patients more autonomy and control over their own care. Consider commissioning or extending minor-ailment schemes that allow patients to consult community pharmacists for conditions such as allergies, thrush, conjunctivitis and constipation. This could cover advice and supply of medicines at NHS expense for those exempt from charges.
2. Review repeat prescriptions
Around 80% of all prescribed items are repeats. How often do you review your patients' medicines in a structured format at a dedicated time? What about patients in care homes, many of whom are on eight medicines or more? Medication review is part of the QOF and has 15 points associated with it. Review is expected to be at level 2 as a minimum (compliance and concordance), as defined by the National Prescribing Centre.
Consider using community pharmacists who can offer medicines use reviews. Despite some negative press around MURs, if you know what you want from them, practices and patients can find them helpful.
The QOF process delivers huge amounts of data, most of which will have a medicine involved. Instead of doing extra work, use QOF reports to work on key prescribing initiatives. For example, review the patients on your diabetes register and ensure, where appropriate, blood glucose monitoring strips are taken off the repeat medication list, with patients given information and guidance about the pros and cons of self-testing.
3. Focus on areas of prescribing waste
The majority of drugs new to market are me-too drugs, another pril, sartan or cox-2 inhibitor. Unless there are proven advantages in terms of patient outcomes or cost, the best advice is to stick to what you know.
Areas with potential for improving quality and value include newer oral agents for diabetes, long-acting insulin analogues, low-dose atypical antipsychotics (in dementia), high-dose inhaled steroids and combination inhalers, wound-care products and ‘specials'. Often greatest gains can be achieved through good housekeeping and engaging with patients at all stages of care.
4. Use formularies to promote low-cost drugs
The key is getting it right at initiation of therapy. Most medicines can be prescribed generically and prescribers should make the most of their ‘G for generic' button on their practice computers. Evolving GP consortia provide an ideal opportunity to consider the development of a consortium formulary. This doesn't have to be difficult, particularly if the focus is on the top 20 therapeutic areas accounting for most of the prescribing spend. Generally, 20% of medicines account for 80% of expenditure.
A formulary will also help GPs counter the pressures from the pharmaceutical industry to prescribe their latest product.
National organisations like the National Prescribing Centre,1 NICE,2 SIGN3 and MTRAC4 provide timely and evidence-based commentaries on new drugs and their place in therapy. Prescribing decision-support software such as ScriptSwitch5 can help support implementation of prescribing decisions, but will only be effective if practices commit to making changes.
5. Tweak your prescribing systems
Implement changes to your prescribing systems to drive down costs:
• Prescribe multiple medicines over equal periods, such as 28 days – ensuring patients renew all their repeat prescriptions at the same time should reduce waste, unnecessary ordering, trips to the surgery and surgery admin. There is a nationally commissioned service aimed at achieving this – the repeat dispensing service. It just needs the will to make it happen.
• Minimise ad hoc items on the repeat form – discourage ordering for ‘the cupboard' or ‘just in case', or in some cases every month because it is easier to tick all the boxes. Examples include antihistamines, skin preps, testing strips and seasonal items.
• Rationalise doses – 2 x 5mg = 1 x 10mg. When titrating doses, it is easy to forget to rationalise strengths or frequencies once the final regime has been achieved.
• Double-check ongoing need for liquids and specials – swallowing difficulties do not have to mean an automatic conversion to liquid form. Firstly consider the ongoing need for the medicine, and then consider a switch to a product that already exists in liquid or soluble form. Remember that although crushing tablets is considered as invalidating the product license, all ‘specials' are also unlicensed products.
• Consider 14-day scripts when initiating new medicines – many patients cash in their prescription and then decide not continue taking the medicine, either from choice, health belief or because of side-effects. Limiting initial quantities can allow further GP-patient discussion about their therapy and address any concerns before deciding to issue another prescription.
• Put stop dates on medicines for limited periods – an increasing number of medicines require review at specific times. With clopidogrel, for example, this could be four weeks, 12 months or indefinitely.
6. Communicate with patients
Effective communication between prescriber and patient is essential at all stages, whether at diagnosis and initiation or several years on. With around 50% of patients not taking their medicines as the prescriber intended, more attention needs to be paid to supporting patients in this area. Whatever a GP prescribes will be irrelevant unless the patient complies and is concordant with the treatment. That is what makes a medicine value for money.
7. Take the challenge forward as consortia
Consortia will manage the challenge in various ways – perhaps by appointing a prescribing lead GP, conducting peer review or taking a topic-based approach to examine the issues one at a time.
Many GPs currently have access to PCT-employed pharmacists to support practices, as well as the back-up of the wider medicines-management teams. The remit of these teams is much broader than just the prescribing budget, and in building new organisational structures it will be important to ensure key elements of medicines management are not lost.
Kym Lowder is a pharmaceutical adviser to Primary Care Commissioning
Seven steps to driving down prescribing costs