ࡱ> ?A>q bjbjt+t+ ,AA] y2NNNNNNNN[]]];l@$JdNNNNNdNNNNFNN[N[d. h[N:ucO6K LMC Statement on Prescribing Support for General Practice 1.0 Summary The LMC considers that there is an urgent need for action across the Somerset Health Economy to address primary care prescribing costs. 2.0 Background The growth in the cost of prescribing has for years exceeded its annual budget allocation. With PCTs holding unified budgets this risk now has to managed at a local level. The LMC is concerned that not enough is being done to help GPs control prescribing costs whilst ensuring that patients are receiving all appropriate and affordable treatments. 3.0 Current Position Although there is disparity between practices in their prescribing spend per PU, this variation has been tending to decrease whilst total spend is rising at about 4% more than the budget allocation. We do not know what the optimum spend is, or whether high prescribing practices in Somerset have better health outcomes. 4.0 Prescribing Pressures 4.1 Prescribing costs rise for a number of reasons. Notably these include: Underfunding of national initiatives (NSFs, NICE) Health technology developments Better quality of both primary and secondary care Target driven performance measures Better informed GPs and patients Rising expectations for lifestyle drugs Defensive medical practice Effective pharmaceutical company marketing 4.2 Furthermore, practice notional budgets are increasingly under strain due to the transfer of prescribing responsibility for chronic disease management from secondary care to general practice. The impact of wider prescribing by nurses and pharmacists may add to the burden. 5.0 Consequences of Prescribing Overspend Given that PCTs and Trusts have a first responsibility to balance budgets their only response to an overspend is to make savings elsewhere - presently almost exclusively I other primary care budgets - which will involve reductions in other services. These may lead to yet more prescribing (for example, if counselling services are reduced more anxiolytics and antidepressants may be used). It is arguable that since under the present system it will never be possible to balance the prescribing budget this means that if development money is not topsliced, few if any service developments can take place. 6.0 Likely GP Response 6.1 There are further efficiency savings that can be made within practice budgets, but these are becoming progressively harder to implement and less cost effective both in terms of prescription drug savings and other non-drug costs. 6.2 GPs are becoming less willing to make changes in prescribing that only have a marginal impact on the total overspend and which do not lead to an increase in primary care development. 6.3 The default position that the doctor takes under these circumstances, and the only one that the individual practitioner can ethically make, is to provide the most appropriate prescription for the patient, rather than that which is most cost effective for the health economy. 7.0 Need for an Integrated Prescribing Support Response Sooner or later a Government will have to introduce a national formulary of drugs prescribable under the NHS. We accept that there is no prospect that the current one will do so. Nonetheless, prescribing risk has to be managed at a much higher level that the individual GP. We suggest that this should involve a number of interventions. 7.1 Practice Prescribing Support Practices should have protected time to work with a pharmacist and the PCT prescribing lead to identify internal prescribing trends and to develop strategies for analysing the cost effectiveness of internally initiated prescriptions. Prescribing Incentive schemes should be quality and not cost based. 7.2 Better Local Information Information from pharmaceutical advisers does influence prescribing activity and is valued by GPs. A regular joint information sheet shared across PCTs that addresses local problems in a structured way would be valuable 7.3 PCT Endorsement 7.3.1There is an increasing willingness by GPs to accept clear directives from the PCT or HA not to use certain products for example, clopidogrel. Obviously positive recommendations are useful as well. 7.3.2 Some prescribing is generated by fear of complaint or litigation. Although antibiotics are not indicated for minor respiratory tract infection, a patient who develops pneumonia after being appropriately denied a prescription is likely to complain. PCTs should endorse the practice prescribing plan, and be prepared to formally accept responsibility for dealing with problems that arise from the doctors compliance with it. 7.4 Drug Appraisal The entry of new product and formulations into general use (or the use of established agents for new indications) needs to be carefully controlled. The LMC has been working with the PCT Pharmaceutical Advisers on a rapid assessment process that gives GPs a provisional view on new developments. However, this needs to be backed up by system that provides an authoritative view at a county or HA level. A body like the County Prescribing Group needs to be reconvened as a matter of urgency, and provided with resources to both review the evidence in support of claimed therapeutic advances and also prioritise them. 7.5 Engagement with Secondary Care 7.5.1 The most important single cost pressure on GP prescribing is consultant recommendation. This is sometimes derived from national guidance, but is often a matter of opinion or evidence of effectiveness in specialist circumstances. The value of the recommendation is never considered in relation to other priorities. For example, methylphenidate for the treatment of Attention Deficit Hyperactivity Disorder is now available in a single daily dose form which improves compliance but would cost 72, 000 if adopted across the county. It is now being started or advised by consultants on the assumption that GPs will take on the prescribing responsibility. Is this a good use of resources? 7.5.2 Hospital doctors must be engaged with the wider needs of the population by ensuring that Trust Drug and Therapeutic Committees do not endorse new products until they have been properly assessed and their relative value decided. 8.0 Roles in Prescribing Support 8.1 Clearly no individual can manage this whole range of tasks within a PCT. Some can sensibly be shared between PCTs. There will need to be enough people to deliver timely and effective support if the process is to be worthwhile 8.2 However, once a product has become established as a primary care prescription it is almost impossible to withdraw it. In the LMC view any delay in establishing a robust process will mean further loss of control over prescribing costs. 9.0 Conclusion Prescribing data lags behind actual activity by 2-3 months. Action taken now will take a further 2-3 months to have any real impact. This delay carries significant cost risks. 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