Dr Clive Henderson explains how his PBC group approached a pharmaceutical company to improve COPD care
For patients with respiratory disorders, having to be admitted for acute care can be a distressing experience. But as well as being burdensome for patients, these admissions also take their toll on the NHS.
At my practice in Market Weighton in East Yorkshire, the GPs felt that a more intensive approach to patient education, preventive medication, smoking cessation, prompt treatment of exacerbations, and individual self-care plans would help enhance care and reduce costs.
In 2008, East Riding PCT was keen to promote the ideas of PBC, but progress was being thwarted by the lack of start-up capital for projects. Things have changed since then, and now a locality commissioning fund encourages practices to bid for pilot schemes, but back in 2008 my practice had fewer options to get funding for a respiratory care project. We decided to enlist the support of a pharmaceutical firm.
Many pharmaceutical companies are changing their approach to how they work with the health sector. Rather than focusing on the hard sell, or offering doctors incentives to encourage use of their products, they are looking to support the NHS in a more collaborative way that allows clinical freedom for GPs to choose which drugs work best for their patients.
Finding the right company
Like most surgeries, we have a lot of pharmaceutical representatives visiting our practice. We found out which organisations specialised in respiratory products via the BNF's index of manufacturers, and approached them to see if they would give us the financial support to help us improve respiratory care in the community.
We canvassed all the pharmaceutical companies that offered respiratory products, and visited them or invited them to our practice to talk about our proposed scheme. In the end we chose AstraZeneca. The company agreed not only to give us the most money for the venture, it also said it would ensure we were totally independent in our choice of prescribing. There was no pressure at all on us to use AstraZeneca's drugs.
I then met our PBC group to inform them about the scheme. Inevitably some clinicians were dubious about dealing with a pharmaceutical company, but we reassured them this was a hands-off agreement, and also pointed out that without the company's start-up capital we would be unable to set up the scheme. And so the first substantial pharmaceutical industry-sponsored project in our locality was given the go-ahead.
Our practice manager, David Graves, drew up a formal agreement with the pharmaceutical company that we would not prescribe according to any formulary other than our own, which was in line with the British Thoracic Society (BTS) guidelines. The agreement said that regular reviews of the scheme's progress would be made, and after a year or so we would carry out an audit of its effectiveness.
Having got agreement from the PBC group, a neighbouring like-minded practice, Holme on Spalding Moor, decided to team up with us.
We received £70,000 from AstraZeneca, which was enough to pay the salary of a full-time respiratory nurse specialist for two years. The nurse worked more for our practice than for Holme on Spalding Moor. This was partly because we cover a larger population and also because we had initiated the scheme. Both surgeries were happy with this arrangement because GPs saw it as a win-win for patients.
Clinics were set up in both practices and patients were booked in by invitation, chosen from our disease registers. Gaps were left each day to allow time to cope with acute exacerbations or opportunistic assessments.
We also set up a doctor's direct phone line, which is manned by clinicians and operates from 8.30am to 10am. This is a way of triaging those who need immediate care or directing them to the respiratory nurse specialist.
A major part of good respiratory care is about education – making sure that products are being used effectively and appropriately. So a large part of the scheme focuses on giving patients the right product, such as an inhaler, and teaching them how to use it properly.
Care plans were individualised and patients were educated in autonomous dose adjustment. Those at the more severe end of the COPD spectrum were issued with standby antibiotics and steroids. Anyone who had been acutely admitted was seen after discharge, often at home by the nurse. There were also regular home reviews for the worst-affected patients.
In this way we hoped to prevent re-admissions and to ensure the worst sufferers would get the most benefits from the scheme.
Evaluating the scheme
Before we began the project, we enlisted the help of the PCT's data analysts and looked at our historical activity level for respiratory conditions. We used MIDAS, an online data system, to review expenditure and activity. This involved examining not only our own activities but those of other practices. One year on, we evaluated that information again, looking at acute admissions relatedto respiratory conditions.
We found that after the scheme was started there was a reduction of 35% in non-elective admissions, equating to a cost saving of over £59,000. A breakdown of the results showed a 33% reduction in asthma-related admissions and 37% for COPD. Some 58% of the total savings related to COPD. Reductions were seen across the board in both practices and disease areas, representing a 32% overall reduction in one practice (ours) and 39% in our partner practice Holme on Spalding Moor.
In contrast, during that same period there was a 21% increase in respiratory-related admissions across the whole of the East Riding of Yorkshire, which equated to nearly £800,000 in increased costs.
Outpatient appointments fell by 22% for our two practices (£7,000 in savings) while across the East Riding as a whole these appointments dropped by 2%.
A closer look
These outcomes were greatly encouraging and represented a vast improvement in patient care. I sent out a rather triumphant email to the PBC group. However, we then looked at how much primary care costs had increased to achieve this.
We found that in terms of bronchodilators, we had prescribed 12% more items, at a cost increase of 9% (£7,461). For steroids, including combinations with long-acting agonists, there were 24% more items at a 35% cost increase (£55,232). Other products, mainly leukotriene antagonists, had increased by 77%, resulting in a cost increase of £5,276. This meant there was an overall increase of 18% in issued items and a 27% growth in expenditure: a total cost increase of £67,969.
During the same time, locality prescribing costs and the number of items issued had also risen, but only by 10% (£130,000) yet secondary care costs had increased by 21% (£800,000).
From a clinical perspective the pilot has been a remarkable success. Patients have told us they feel valued, that they appreciate the enhanced care and that they feel better informed and more in control of their conditions.
Some have said they can now walk to the shops when they couldn't before, are sleeping better, not coughing as much, finding their inhalers are more effective and having fewer side-effects such as sore throats. GPs have valued having a skilled nurse practitioner to work with, and their support has also helped to reduce the practices' workloads.
The increased expenditure on medication almost exactly matched the secondary care savings. If the respiratory nurse specialist's salary had not been externally sponsored, the enhanced care would have cost £35,000 overall. However, without this project, presumably we would have matched the regional trend of 21% increased secondary care costs (£35,400) and a rise in prescribing (£25,174), so even allowing for the nurse salary made a saving of £27,500.
We were issuing medication according to BTS guidelines and our prescribing costs were high. By doing such a study, we now realise there is a great unmet need.
Ironically, had we used more of the pharmaceutical sponsor's products our prescribing costs would have been cheaper. Our increase in costs may also reflect the benefits of patients having one-to-one support, and education from a nurse specialist that was not available to the same degree in the locality as a whole.
One year on and the respiratory nurse specialist has gone on to work in acute care, so we are recruiting a replacement as the funding we received was for two years.
As part of the PCT prescribing incentive scheme we are allowed to reinvest £40,000 in other projects for the following year. However, we do not get access to any hospital savings unless the entirety of our secondary care budget saves more than the target. These savings also have to be planned, rather than fortuitous. So unfortunately, despite the savings from reducing admissions, we have not received any freed-up resources.
As to where we go from here, our financial model needs tweaking. We may have to move away from prescribing independently from our sponsor and towards using cheaper products.
To address costs we are hoping to enlist the support of the PCT's general prescribing committee to find the most cost-effective prescriptions, concentrating on the more severe respiratory care cases, which could potentially make greater savings.
A question still remains over the effect on next year's outcomes. Will the education and prescribing changes have knock-on benefits, even if there is no nurse in post? There are also likely to be increased prescribing costs in subsequent years.
However, none of this detracts from our appreciation of the sponsorship we received. In such stringent financial times, I would encourage any practice to go for pharmaceutical financial backing, providing there are no strings attached.
Any agreement with a pharmaceutical firm should be run past the PBC group and the PCT before you take the project forward. From the outset, it's vital that you present a strong business case and that the contract prohibits directed prescribing. While we have had a positive experience, I suspect the current recession may reduce opportunities for sponsorship.
We owe it to the NHS to be innovative. We're supposed to be thinking laterally about how to invest money. Whether it's working with charities, patient groups or drug companies, it's all about how best to invest money to achieve the best in patient care. Sponsorship should be part of the work we're doing with our PCTs.
Dr Clive Henderson is a GP in Market Weighton, East Yorkshire, and PBC lead of Howden, Goole and West Wolds locality commissioning group email clive.henderson@gp-b8100
Dr Clive Henderson Dr Clive Henderson