Management of prescribing in general practice is now a job for a full-time pharmacist. Every day, we are faced with queries around medicines shortages and asking for alternatives. Every week, there are new directives from the commissioners to switch medications to so called ‘cost-effective’ alternatives.
There appears to be no end to the saga of pregabalin and Lyrica in sight. Hospitals have to use different brands to the ones recommended in primary care. There is no consistency in prescribing in areas such as blood glucose monitoring machines and dressings between various interfaces of care. Companies supplying, for example, catheters and stoma products appear to have their own systems with little oversight from those who control our purse strings.
There appear to be no coherent central policies – at best, the situation might be described as organised chaos. This also highlights the fact that a significant chunk of prescribing is not really under our control. And, yet in many areas, prescribing has a significant impact on the practice funding via a variety of schemes.
As usual, we in general practice pick up the pieces. We switch lercanidipine to amlodipine and then back again when patients return with ankle swelling. Yet when the cost effectiveness of a switch is calculated, no consideration appears to have been given to the extra appointments needed at the practice to see a nurse or a GP. I wonder how many of these switches are really ‘cost-effective’ given the input needed from primary care team members including pharmacists attached to the practice, for those fortunate enough to have them.
There are also local directives in many areas of the country to clamp down on over-the-counter prescriptions, but with no real logistic or legal support in case of patient complaints. As Pulse has highlighted, rather than backing up clinicians charged with implementing such schemes, CCGs have said prescribing remains the discretion of clinicians.
There has been no impact assessment of such policies especially in patients from deprived areas or vulnerable families. We do know for a fact that many continue to struggle to pay for their vital prescriptions such as inhalers and antidepressants due to financial constraints. We really have no way to capture any harm resulting from those unable to afford their prescriptions. Similarly, some will be unfairly disadvantaged by a blanket ban on prescribing. While there is no logic in prescribing some very cheap and easily available medications over the counter for those who can afford them, there is a subset of people whose care may be impacted due to such bans. There are also care homes that refuse to allow over-the-counter medication to be used for their residents even if the families are willing to buy it and do not accept the long term homely remedies policy. And yet practices are having to negotiate through these barriers on their own.
It is simply not true that cost effective prescribing will result in cheaper prescribing. A squeeze in one part of the system just results in a bulge somewhere else, be it health or social care. Our commissioning colleagues must move away from this silo thinking and the NHS centrally must provide consistent policies and approaches to all parts of the health system. An organisation as big as the NHS must use its bargaining powers to the benefit of all. We need a coordinated and consistent approach on prescribing to make real headway.
As clinicians, we must also remember that only we are answerable to the regulatory bodies.
Dr Kamal Sidhu is a GP partner and trainer in Blackhall, East Durham