Influences on prescribing < Influencers contents | Print this page NHS influencers should be aware that continuing rises in prescribing costs are proving to be a major worry for PCTs. The growing pressures on PCT prescribing budgets are coming from the demands of the national service frameworks (NSFs) plus NICE guidance. The new GP contract too with its focus on chronic disease management, quality outcomes and enhanced services is further adding to these pressures. So the rising cost of the drugs bill is currently the biggest headache for PCTs, soaking up much of the cash PCTs had hoped would be available for service development. Many health communities are in quite serious financial trouble, with underlying deficits that can only be sorted out with cost improvement programmes. PCTs will continue to try and exert continued influence on GP prescribing. But sorting out the reality from the rhetoric can be difficult. Previous Health Secretary Alan Milburn, in his speech at the annual 2003 ABPI dinner said, ‘I said three years ago that more spending on medicines is, in my view, a good thing, not a bad thing… over time I would expect to see the importance of medicines to the NHS continuing to grow… And in all likelihood drugs spending as a proportion of NHS spending will also continue to grow.’ Encouraging comments were also made by ex-minister David Lammy: ‘Increased prescribing of the best drugs saves lives. It is money well spent. Many of the drugs being more widely prescribed are life saving and are having a direct, positive impact on people lives. The government supports their increased use.’ NHS influencers should note this disparity. There is no doubt that the large rise in statin usage — stimulated by the CHD (coronary heart disease) NSF — has added significantly to rates of prescribing inflation. However the hope is that with simvistatin now off patent that prices will begin to fall. Pharmacy medicine (P) simvistatin is now available too. Please note that the All-Wales medicines strategy group (AWMSG) plans to introduce a prescribing indicator of ‘items of simvistatin per 1000 prescribing units compared to total items of statins per 1000 prescribing units expressed as a percentage.’ This relates to the encouragement of generic prescribing by setting relevant targets. Area prescribing committees and PCT formulary committees in England may well do the same here. Prescription Pricing Authority’s annual report The Prescription Pricing Authority (PPA) in its annual 2003 report pointed to NSFs solely as the main driver of prescribing costs and not NICE guidance. The report outlined the factors driving the increasing volume of prescription items. ‘Guidance from NICE is not yet a major driver of prescription volume or cost,’ said the report. If this is the case, the full force of NICE guidance (as it relates to primary care prescribing costs) is yet to impact and a ‘hurricane’ of costs may be on their way. Dr Julian Neal, chair of the BMA’s primary care development sub-committee said that despite new investment with further NSFs, more NICE guidance and the full impact of the new GP contract yet to take effect, prescribing costs will continue to soar and that prescribing overspends will be likely for the foreseeable future. Budgets are increasing by 7 per cent a year whilst prescribing costs are going up by around 13 per cent a year. So if PCT finance directors were hoping for some relief from soaring prescribing costs, they would seem to be set for some disappointment. The PPA’s 2004 annual report is well worth a read (see www.ppa.org.uk). There are useful maps and tables on prescribing patterns across England. In the PPA’s 2003-08 strategy, the organisation says that it wants to enhance the prescribing trend data it provides to the NHS to ‘enable those responsible for managing prescribing to target their efforts on eliminating inappropriate prescribing practice and promoting clinically effective prescribing’. This about the rollout of ePACT to GP practices so that they can then analyse their own prescribing costs and trends. And note particularly: ‘There will be significant changes in the detail of how community pharmacy services are delivered by the NHS. These changes will come through renegotiation of the national contract, the development of LPS (local pharmaceutical services), modernisation of the supply chain for medicines and innovations in medicine management… Innovative ways of delivering pharmaceutical services have the potential to increase the complexity or reimbursement and remuneration.’ The PPA has also launched a NHS primary care drug dictionary. The implementation of NICE guidance and NSFs are not subject to ring-fenced funding, so PCTs have to implement these national initiatives from within their annual allocations. With most PCTs exceeding their prescribing allocations they will be looking at taking money from elsewhere (ie, in clinical areas that are not national priorities). Due to these overspends PCT finance directors have claimed that prescribing costs will be the biggest financial pressure facing PCTs. Uplift factors for 2005/06 are not expected to be nearly enough and drug costs are now seen as one of the major underlying pressures on the NHS. For NHS influencers it would therefore be worth adding PCT finance directors to their PCT account plans. Prescribing issues continue to be covered in the Health Service Journal (HSJ). For this reason and many others, the HSJ is a must-read for NHS influencers. Andrew Curl, deputy director general at the ABPI, had a letter published following comments about NHS growth money ‘disappearing’ into increased drug spending. He said, ‘There is strong evidence that spending on medicines reduces the overall cost of NHS treatments, speeds up the delivery of healthcare and reduces or eliminates the burden in other sectors of state expenditure, particularly social services. More money should indeed ‘disappear’ into increased medicines spending.’ The HSJ continues to feature many articles on prescribing and in one Robert Calvert of North East Yorkshire and North Lincolnshire SHA looked at how the ‘soaring’ drug bill should be tackled. Amongst other things suggested were that PCTs and hospitals needed to establish joint formularies, make more use of independent advisers and that doctors should stop seeing representatives now that there was adequate pharmaceutical adviser support in PCTs. ‘The rate of growth in the cost of medicines is clearly well in excess of general inflation and the rate of increase in NHS funding… As a nation, we have moved from being slightly against taking medicines to pro-prescribing… Concerted and robust action is thus required to constrain the rate of growth… All NHS organisations need to consider their relationships with the pharmaceutical industry and the access the industry has to overworked prescribers… the continuing rising cost of treatment involving medicine is a threat to the implementation of new developments,’ said Mr Calvert. The article also suggests that SHAs should ensure that PCTs have a robust strategy to improve the quality of prescribing and to minimise growth in cost of medicines, while complying with local and national targets. Mr Calvert continued, ‘A staggering 1 per cent of UK gross domestic product now cascades down the nation’s throat each year in the form of medicines purchased by the government. There is every sign that this flow will increase, thanks to an ageing and possibly more demanding population, a creative pharmaceutical industry and the work of NICE… The NHS must do its bit by getting the most out of its medication budget, which means removing drugs of limited value, continuing the drive toward generic prescribing, reducing waste and, crucially cutting errors… In both hospitals and primary care settings, pharmacist involvement can cut costs and improve quality — but there are simply not enough of them…’ NHS influencers need to be acutely aware of this high ‘negativity’ in some quarters towards any increased prescribing. NHS influencers should also be aware of the 2003 publication Prescribing in primary care from the Audit Commission, which covers many of these same areas in great detail. Also in the HSJ Prof Howard McNulty of Strathclyde University suggests that obtaining pharmacy advice at all levels of budget holding from practice, clinic and board level would be a good place to start for those wanting to develop a comprehensive and strategic approach to ‘this universal and ongoing problem.’ Such suggestions that pharmacists should be the people to force down costs will no doubt be of great interest to NHS influencers. Prof Alan Maynard from the University of York has explored the causes in the HSJ of ‘the inappropriate and inefficient prescribing of pharmaceuticals and the cost explosion that is throwing the finances of PCTs into deficit.’ Prof Maynard particularly criticised NICE for being too generous to the ‘drug barons’, flawed industry clinical trials, ‘heavy’ marketing, ‘conference tourism’, finally suggesting more counter-detailing by pharmacists funded from a levy off industry marketing spend as a way of offsetting the ‘mischief of the industry’. But better prescribing in primary care has cut UK mortality rates according to figures released by the British Heart Foundation (BHF). The number of deaths from CHD in the UK fell by more than 2 per cent in 2001compared to the previous year. The BHF attributes this drop in mortality to improved CHD treatment, including increased prescribing of statins and the development of CHD registers. Prescriptions for statins is increasing by about 30 per cent per annum and they now cost the NHS more than any other class of drug. But the statistics appear to show how successful the NSF for CHD has been. ‘The evidence in favour of statins is so strong that we have no option but to prescribe them’, said one GP. Good evidence here for linkage between government objectives and clinical outcomes. Influence of the pharmaceutical industry A survey published in GP in 2003 suggests that one third of all prescriptions written by GPs are based on information provided by the pharmaceutical industry, and that half the GPs asked cited the pharmaceutical industry as their most used information source. But, the article suggests, GPs are driven to this because workload pressure makes it hard for them to access information on new drugs and some GPs did sometimes question the ‘objectivity of the industry’, although most GPs felt that they could separate what was credible from anything misleading. A letter then followed from a GP who was upset over suggestions that single-handed practices are high prescribers and rely on representatives for product information. ‘This would seem to imply a certain degree of innocence at best and stupidity at worst. Perhaps GPs should not be allowed to see reps until they are able to critically appraise a paper and believe the evidence for/against a product and not what they are told’, said the GP. The BMJ has also featured an editorial based on a paper published in Family Practice (2003; 20: 61-8). This is a study looking at the factors that influence GPs when they prescribe a new drug for the first time. According to the results, 92 per cent of the GPs saw representatives and 70 per cent regarded them as expedient means of getting drug data. ‘The significant first stage in the decision-making process is awareness of a new drug. The most important sources were the pharmaceutical industry, in particular the company representative.’ say the authors from the prescribing research group at the Royal Liverpool University Hospital. See ‘Pharmaceutical industry is main influence in GP prescribing’. Also note that one of the GP authors of this study has produced an educational video pack to inform GPs of the methods used by representatives to influence GPs’ prescribing and to ‘enable them to develop ways to counter them.’ ‘We know one important strategy used by drug reps is befriending. But beware — it does come at a cost,’ the GP warned. An interesting letter followed under the title ‘evidence-based general practice’ where a GP suggested seven magical steps for directing GPs towards scientific literature. He included the suggestions that rather than viewing the industry as a ‘carbuncle on the face of evidence-based medicine’ people should learn from how they communicate with GPs and that consultants who whinge about GPs’ prescribing should spend one day in general practice — after this experience they would soon stop whingeing. See ‘Seven steps to evidence based general practice’. NHS views on medical representative activity A series of teaching resources are available on the DrugInfoZone website. The materials on 'Drug promotion — the pharmaceutical representative’ and ‘Making the most of promotional material’ essentially form the basis of a day workshop on the industry and the activities of medical representatives. NHS influencers might find it useful to see what is being taught to their customers. The materials are: Part 1: Presentation Part 2: Evaluation
exercise Part 3: Quiz Part 4: Example
guide for representatives Part 5: Quiz answers Part 6: Critique
of a number of drug adverts Part 7: Lecture/workshop materials Part 8: Evaluation exercise suggested answers Single-handed versus group practices A government-funded GP-led study has reported that single-handed GPs are more likely to have higher prescribing costs than those in group practices. These same GPs also see industry representatives more frequently and prescribe newly available drugs more readily. ‘GPs are not aware how much their prescribing habits were influenced by seeing drug company representatives. The results suggest that drug reps may fulfil a pastoral need in these GPs, says the study leader. See Quality and safety in health care (2003,12, 29-34). Prescribing remains a very sensitive area for PCTs. NHS influencers should be aware that these comments about the effect of representatives on GPs are bound to be picked up by PCT managers. New approaches required for the management of medicines expenditure Prescribing/pharmaceutical issues seem to constantly feature in health service publications, and as we have seen, fairly polarised views seem to be being taken with PCT spokesmen remaining focussed on costs alone. This exclusive headline focus on the cost of medicines with no mention of the resulting outcomes and health gain is a tired old argument. What is really needed is a much more strategic approach to medicines management, particularly now that PCTs are the main commissioners. Perhaps what is needed is for the following messages to be given to NHS decision-makers by NHS influencers: Reappraise the role and value that medicines will play in the 21st century. The NHS currently spends around 15 per cent of its budget on medicines. But is this the ‘right’ amount to spend? What would be appropriate? The constant focus on input costs needs to be re-evaluated with a move to more focus on the outputs of using medicines and the resultant health gain. Longer-term planning and commissioning using medicines needs to be factored into the implementation of both the NSFs and NICE guidance, with a real focus on health outcomes. Enhance understanding and skills associated with health economics. All present evidence suggests that healthcare decision-makers have a poor understanding around the economic evaluations of new technologies. As this new area enters mainstream NHS thinking as a result of NICE appraisals, both competencies and capabilities will have to be increased. Health economic tools should be used honestly to allow virement across budgets and this may well be into the prescribing pot. Clarify the use of nomenclature. More clarity is needed around the words being used within the prescribing arena. Eg, what does cost effective and cost ineffective actually mean? Is it clinical-effectiveness or cost? Is absence of evidence the same as evidence of absence? What are the differences between efficacy and effectiveness; equity and equality? With the ongoing debate around the SSRIs (selective serotonin re-uptake inhibitors), and Cox 2s, NHS influencers should expect published evidence on drug safety to increasingly come under more scrutiny and become more relevant. In fact almost two thirds of PCTs now have a prescribing formulary, according to some market research done by Pharmacy Management. The survey of 220 PCTs found that some 64 per cent were working with a formulary or an approved list of drugs in primary care and that almost half (47 per cent) shared a formulary of ‘some description’ with their local hospitals. Cardiovascular and gastrointestinal drugs featured most heavily in PCT-approved drug lists. The same research also showed that 96 per cent of PCTs had a prescribing group in place. Pharmaceutical/prescribing advisers Pharmaceutical/prescribing advisers were the creation of the previous government when family practitioner committees became Family Health Services Authorities in the early 1990s. Today in England there are now well over 1,000 of these key customers in post. Many PCTs now have policies for seeing industry representatives (these need to be obtained) and often direct any approaches made by companies to their senior managers towards their pharmaceutical advisers. But it is not guaranteed that they will want to make an appointment with an NHS influencer. Advisers require a different approach and probably require additional skills and competencies from industry staff. For instance, these customers will be keen on a more evidence-based approach and data presented on pharmaceuticals to include clinical and cost-effectiveness. They may also want independent systematic reviews, number needed to treat (NNT), quality of life (QoL) studies and/or more pragmatic studies. NHS influencers therefore need to be comfortable with health economic principles. Competencies
for pharmacists working in primary care NHS influencers
should also be familiar with the way in which NICE appraises new
medicines, as pharmaceutical advisers will most certainly be familiar
with the new evidence requirements required by the institute. New
guidance to companies and new internal processes were launched by
NICE in 2004. See www.nice.org.uk.
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