England will have a single national formulary (SNF) for prescribing within the next two years under proposals outlined in the NHS 10-Year Plan.
Backed by NICE, the SNF will reduce duplication and the ‘postcode lottery’ that has arisen out of locally derived formularies, the Government said.
A new formulary oversight board will be set up and given responsibility for sequencing products included in the formulary on the basis of clinical and cost effectiveness.
GPs and other prescribers will be ‘encouraged’ to use products ranked highly in the SNF.
But they will ‘retain clinical autonomy’ as long as they prescribe in line with NICE guidance, the plan states.
‘The system for getting new medications to patients is needlessly complicated.
‘The process by which each local area decides which drugs are available is bureaucratic and creates a postcode lottery.
‘These local formularies do not make sense in a universal service that should provide a core standard of high-quality care to everyone,’ the plan continues.
Implementing the SNF will drive ‘rapid and equitable adoption of the most clinically and cost-effective innovations’, it adds.
‘We will work with industry throughout the implementation of these policies to make sure we realise these objectives together.’
Under the new Government plan for the NHS, NICE will also be tasked with deciding what treatments are no longer providing value for money.
One analysis had suggested 30% of the costs of treatment were no longer good value for money and in some areas such as heart failure lives could be saved by treating people earlier in the pathway, the plan said
‘To create more space for the myriad of innovations of the future, we will need to improve the outcomes and value we are delivering from innovations already in use.’
NICE will be asked to re-evaluate priority clinical pathways ‘on a rolling basis’, identifying where existing innovation should be retired, as well as instances when one technology should be sequenced after another to improve value.
‘We will link NHS compliance with these decisions to core clinical standards, best practice tariffs and incentives,’ the plan noted.
NICE’s technology appraisal process will be expanded to cover some devices, diagnostics and digital products. It will focus on those that meet the NHS’ most urgent needs and support financial sustainability, such as digital behavioural therapy for adolescents on mental health waiting lists, the Government said.
Dr Sam Roberts, chief executive of NICE, said: ‘The plan gives NICE the power to get medicines to patients faster, reduces the postcode lottery for high impact health technology, and maximises the value for money of existing innovations used in the NHS.’
Professor Azeem Majeed, professor of public health and primary care at Imperial College London, said expanding NICE’s remit to identify treatments and technologies that should be ‘retired’ was sensible.
‘Some medical interventions provide little or no clinical value, so a systematic mechanism for identifying them could free up resources.
‘However, withdrawing long-established therapies is never purely technical. Some drugs deemed low value for most patients may remain helpful for specific sub-groups, so any retirement list will need transparent criteria and an appropriate appeals process,’ he said.
For patients who have taken a medicine safely for years this will need to be carefully managed as abrupt messages that a treatment is obsolete can undermine trust, he said.
‘GPs will need time and support to explain the evidence, discuss alternatives and, where necessary, manage dose adjustments or monitoring.
‘All of this will generate extra workload – such as updating clinical systems, recalling patients and documenting shared decisions – so the policy must be matched with practical resources such as embedded decision-support prompts, template letters and clinical-pharmacist time.’
The move to an SNF could eliminate postcode variation and and reduce duplication of work as well as reducing unwarranted variation in prescribing, Professor Majeed added.
‘But it is essential these changes are introduced in a way that does not shift more work into primary care without the necessary shift in NHS resources,’ he said.
Dr Steve Taylor, a GP spokesperson for Doctors’ Association UK, said script switching has been an increasing issue for patients and GPs as the NHS looks to cut costs, but it comes with a lot of issues.
Medicines shortages can also hamper GPs being able to prescribe the exact medicine they have been advised to.
‘At times the medication becomes unavailable, sometimes it confuses patients resulting in a failure to take medication appropriately, there are instances where the switch is more expensive.
‘Having a SNF seems like a good idea until you factor in shortages, compliance, and choice of prescriber and patient.
‘If it is automated, with the option for pharmacists to switch when availability is a problem, then it might work. It is important that this is in place first.
‘The UK already has some of the cheapest costs in terms of medication and it would be important to see the cost benefit analysis, including time wasted for clinicians, patients and pharmacists,’ he added.
However Dr Sam Finnikin, GP in Sutton Coldfield, welcomed the news of an SNF.
He said: ‘It makes no sense for every ICB to be reviewing formularies for the same medications based on the same evidence. I don’t think this will restrict prescribing, Afterall we have local formularies at the moment, but it should make the system more efficient and reduce unwarrented variation.
‘I think it should reduce the effects of pharma prescribing pressures on localities and individual prescribers as well. GPs shouldn’t be free to prescribe badly – those that do prescribe badly (expensive and or ineffective treatments) will hopefully benefit from clear and consistent advice.
‘The problem with shortages may be compounded though – this is a good point and would need to be address. Also, I would hope it wouldn’t require mass switching as this is not a popular move for anyone and is seldom effective in the long run.’
And he added: ‘Regarding NICE reviewing medications that aren’t cost effective any more. This is long overdue. Stopping doing things that are no longer cost effective, or where better options exist, is wasteful and doesn’t serve anyone well – but it requires time and effort to review the evidence base and make these recommendations.
‘NICE are the right people to be doing this, but this expanded remit needs to be met with expanded funding. Clinicians can get stuck in there therapeutic ruts – and this move would help get them out of them.’
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The issue for GPs is not the formulary, or what GPs “could” prescribe, it is what expectations come with the formulary that GPs “should” prescribe – once any drug locally is moved to green status form red or amber, there is an expectations GPs will initiate, titrate and monitor – with no resource transfer, this oculd have massive cost implication – inclisiran is a good recent example, Area Prescribing Committees were instructed to make it green, (without evidence) NICE even agreed – but no funding for the 2 nursing appointments a year to administer, anf the phlebotomy test to monitor. This is likely coming next with ADHD meds – all of these dumping workload and risk into GP with no reward.
What utter rubbish!
Firstly we already have a BNF, as well as the rather larger range of the British Pharmacopoeia.
Secondly, we clearly need a range of local formularies because antibiotic sensitivity and resistance patterns vary on a regional basis (although I am still not sure how this come about other than as a result of local GPs sticking to the recommendations from their local microbiology Lab).
I tend to follow the first/second line choices of whichever of 3 nearby LHBs I feel the patient may have had largest recent association with. EG if a resident of north wales has been in a shropshire hospital, I follow SATH microbiology guidance, but if they have been in Carmarthen/Llanelli I use that of HDHB, obviously. They ARE different.
People in Dover will have more contact with French and Syrian patterns of antibiotic resistance, rather than isolated rural Welsh or Irish ones.