Medicines management (the processes and behaviours that determines how medicines are used by the NHS and patients) 1 is integral to many commissioned services and issues relating to medicines must be considered in most commissioning decisions.
Whatever becomes of the NHS reforms better use of medicines will remain important for improved care. Most CCGs have identified prescribing as an initial area of delegated budgets in which they can affect change. Spend on medicines accounts for about 12 per cent of the overall NHS budget.
In 2010, the annual drugs bill in primary care was around £8.5 billion, increasing at 4% per annum and in secondary care around £4 billion and is increasing at nearly 8% per year. A large proportion of the hospital spend on medicines is excluded from PbR which means a greater level of financial risk for commissioners and complexity of commissioning. Prescribing leads will need to have a good understanding of how to make the most of medicines becoming generic and how high cost drugs are procured from secondary care.
Quality of medicines use in the UK is not ideal. A recent systematic review found a prescribing error rate of around 7.5% and that 6.5% of unplanned hospital admissions are medication related. 2 A recent study in UK care homes showed that 70% had one or more medication errors as a result of prescribing, monitoring, dispensing and administration errors. 3 In addition adherence to medicine taking and waste remains a priority for most PCTs.
To capture other important issues about how medicines are used, such as placing patients at the centre of decisions, adherence and providing safer care the phrase ‘medicines optimisation’ is now sneaking into Department of Health speak. 4 The overall agenda however remains the same… to continuously improve the quality i.e. clinical effectiveness, safety and patient experience, 5 it is just that in future there will be a greater emphasis on elements other than cost effectiveness such as achieving better outcomes from optimising medicines use, and enhanced public and professional engagement.
The Quality, Innovation, Productivity and Prevention (QIPP)agenda is the driving force for improving medicines management.6 Much of the activity for medicines management QIPP is at the general practice level and individual GPs and their practices remain instrumental in shaping improvements in medicines management quality and productivity.
How can GPs further improve prescribing?
The National Audit Office (NAO) highlighted five key ways to help GPs improve their prescribing:7
- Communication from trusted sources and local opinion leaders
- Financial incentives
- Provision of tailored comparative information to GP practices
- Provision of practical support such as pharmacist time to GP practices
- A co-ordinated approach to prescribing across the primary and secondary care sectors
1. Communication from trusted sources and local opinion leaders
Whilst NICE guidelines and the NICE Quality Standards are the basis on which prescribing should be based there is usually a need to produce local agreement on the choice of particular medicines as well on areas not yet considered by NICE. The NAO found that there is often a need to produce summaries for local consumption that areless technical and clearer to follow. This process involves prioritising some options and removing others. Whilst this might be based on the clinical needs of the local population, there are sometimes suspicions that this might be motivated by budgetary constraints of the PCT. GP prescribing leads will be taking on this function and need to involve all stake holders in producing local guidance.
Like all health care professionals GPs have different learning styles.7 When learning from others, the NAO report that GPs found colleagues and prescribing advisers to be the most useful source of information. CCGs need therefore to identify local clinical leaders to promote messages about better prescribing.
The method of changing behaviour is also important to consider. Newsletters and written information are useful to educate people but may not necessarily change behaviour. Small group sessions or one to one “academic detailing” from a pharmaceutical adviser can be helpful. In the future CCGs may lose this method of communicating prescribing issues if they don’t continue to employer a pharmaceutical adviser.
The most effective evidence based strategies for implementing prescribing guidelines require a combination of interventions. All of these interventions are resource intensive.Some CCGs have gone down the route of creating practice clusters that meet on a monthly basis. In many CCG board meetings medicines management is discussed as a key issue. This forum provides the benefit for peer review and discussion.
In 2005, Kingston PCT disinvested from its medicines management team. In 12 months prescribing costs rose exponentially and the PCT went into turnaround. The medicines management team and lead were reappointed; this had a significant impact upon returning the PCT to financial balance.
2. Financial incentives
Financial based incentive scheme are very powerful in motivating organisations and individuals to change.7 Prescribing incentive schemes can improve prescribing cost-effectiveness, quality and safety.
For those CCGs that have inherited a prescribing incentive scheme they will need to consider how they can retain the scheme whilst also being the commissioners funding them. The benefit of CCGs have is their ability to develop schemes which are more reflective of the opportunities to make change/needs of practices. The medicines management part of QOF (meeting with the prescribing adviser at least annually – Meds 6 and Meds 10) although a small number of points, are achieved by most practices in England.7 This is because GPs have a good track record of co-operation.
3. Provision of tailored comparative information to GP practices
A key challenge for CCGs will be how do we deal with practices that are failing to meet clinical standards. Comparative data will be essential to identify practices that are outliers in performance.
Provision of tailored information, or benchmarking, on prescribing, is something that pharmaceutical advisers have been able to produce for practices since the mid 1990’s. Prescribing costs and volumes data can be accessed easily through ePACT (electronic prescribing analysis and cost) data produced by the NHS Business Services Authority Prescription Pricing Division. Prescribing data and data relating prescribing to diagnosis and outcomes will be essential for CCGs. Production of this data requires skills and resource and it seems sensible that a Central Support Organisation (CSO) produce these for CCGs. Whilst this type of centralisation goes against the ethos of local decision making CCGs can maintain control by having service level agreements with CSOs and maintaining the responsibility for decision making at CCG level.
Data will in the future be available from a number of sources such as the pharmaceutical industry and private organisations. They key issues that prescribing leads need to address is the ability to:
- triangulate disease management information across primary and secondary care and relate this to prescribing. For example in diabetes how does prescribing costs relate to practices performance on the diabetes QOF and hospital admissions and referrals for diabetes?
- develop systems that support the real time collection of some data from GP systems as PACT data can be 2 months behind
GRASP-AF risk assessment tool is a web-based downloadable tool compatible with General Practice IT systems to enable all AF read coded patients on the register to be identified as not currently prescribed warfarin and risk assessed for Stroke using the CHADS2 scoring system. Warfarin is therapy with proven safety and efficacy in stroke prevention in AF but for various reasons is under prescribed. NICE recognises this and estimates that this represents 166,000 patients across the UK in AF, at high risk of stroke and not on warfarin. Treating these additional patients would potentially prevent 6000 strokes annually and save 4000 lives nationally.
4. Provision of practical support such as pharmacist time to GP practices
Practical support to GP practices is effective in reducing unnecessary growth in the drugs bill.7 Over recent years PCTs who have developed a robust medicines management infrastructure, have been able to deliver significant savings on GP prescribing spend, and have lower prescribing costs per head.As well as managing costs practice pharmacy support can help with improving the safety of prescribing by reviewing high-risk medicines, monitoring of high-risk medicines and implementation of safety alerts. They can also help patients get more involved with their medicines through medication reviews.
NHS Bradford and Airedale commissioned a medication review service for care home residents to help improve the cost effectiveness and quality of prescribing and monitoring of medicines.
From April 2011 to January 2012 the provider reported £332,000 of annualised savings on prescribing (net savings £152,000) from 2239 reviews of residents (£148/resident gross and £68/resident net). These reported savings were mostly made from stopping unnecessary prescribing. In total 3325 medicine interventions were implemented (mean 1.5/resident) with 711 monitoring tests (mean 0.3 /resident).
An example of quality improvement was the effect on antipsychotics in dementia. The pharmacists working with GPs were able to either reduce the dose or stop antipsychotics for dementia in 34% of residents.
5. A co-ordinated approach to prescribing across the primary and secondary care sectors
Secondary care has a large influence on primary care prescribing. The Audit Commission, in 1994, estimated that 16–20 % of primary care prescribing was initiated in hospital and a further 40 % could also be strongly influenced by hospitals prescribers. 8
Given that primary and secondary care prescribing are so closely linked and that £20 billion of efficiency savings must be found by 2014,9 secondary care physicians must be involved in transforming prescribing. CCG may want to look at how medicines fit into pathways of care or if there are ways of procuring medicines that are most cost effective for the NHS and more convenient for patients.
Out of hospital care is driving the development of new clinical models in primary care. The impact on medicines management needs to be modelled in any change as part of whole system assessment. What is the true drug acquisition cost in secondary care? Is the drug within or out of current PbR tariffs, what are the implications for primary care based administration (safety, costs etc.)?
In addition the Kings Fund recommends the following techniques to improve medicines management.10
- Medication reviews in general practice
- Practice based audits of prescribing practice and outcomes with peer review
- Use of IT for decision-support
- Improved systems for safe transfer of information on patient’s medicines on admission and discharge
- Pharmacist and nurse led interventions to provide educational information and outreach services aimed at reducing prescribing and monitoring errors.
None of what has been mentioned is particular new but it has not routinely or universally been applied in practice.
As the Kings Fund point out ‘it is relatively straight forward to impart knowledge about what to change; it is much harder to create the culture and enthusiasm required to deliver change’.10 However affecting change in medicine management is considered to be both high impact and low difficulty in terms of health outcomes; patient experience; savings and ease.
Much of how to improve the quality of prescribing is already known. Driving improvements in the safety and cost effectiveness of medicines require considerable resource and strong leadership. CCGs and prescribing leads will need take hold of the agenda and make it their own and use the current workforce in medicine management teams to achieve their objectives.
Dr Duncan Petty is lead pharmacist and Director at Prescribing Support Services. Dr Richard Dawson is a GP in Bradford, and the CCG’s prescribing lead
- NPC, 2001. Modernising Medicines Management.
- Garfield S, Barber N, Walley P, Willson A, Eliasson L. Quality of medication use in primary care–mapping the problem, working to a solution: a systematic review of the literature. BMC Medicine 2009;7:50.
- Barber ND, Alldred DP, Raynor DK, et al. Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. Quality and Safety in Health Care 2009;18;341-346.
- Colquhoun A. Will optimization help save the NHS? Pharmaceutical Journal 2012;288:143.
- DH. High quality care for all: NHS Next Stage Review final report. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825
- Quality, Innovation, Productivity and Prevention (QIPP) https://www.evidence.nhs.uk/qipp
- National Audit Office, 2007. Prescribing Costs in Primary Care.
- Audit Commission, 1994. A Prescription for Improvement. Towards more rational prescribing in general practice.
- DH. Quality and Productivity. http://www.dh.gov.uk/en/Healthcare/Qualityandproductivity/index.htm
- Kings Fund, 2011. Transforming our healthcare system. Ten priorities for commissioners http://www.kingsfund.org.uk/publications/articles/transforming_our.html