More than 150 primary care group prescribing support advisers attended a conference organised by the National Prescribing Centre in London on November 16. Pamela Mason reports
In her introduction, Ms Annie Copell (assistant director, National Prescribing Centre) said the main aim of the conference was to help primary care group pharmacists to enhance their role in prescribing support. Sharing ideas on management of the prescribing agenda in primary care groups, including how to monitor of the quality of prescribing would help to achieve this aim, she said.
Setting the scene, Mr Stephen Davies (lead pharmacist, Doncaster Central PCG) said that PCGs were now top-slicing the prescribing budget and therefore wanted pharmacists to be working in practices and not just act on a sessional basis once or twice a year.
However, several issues had impinged on the prescribing budget during the past year. The biggest single problem had been Category D generics, which accounted for 3 to 4 per cent of the drug spend in Doncaster. But other issues, such as discount clawback, drug shortages and the introduction of new drugs (eg, Relenza), had made it difficult to stick to the budget.
Unfortunately, some PCGs did not see the difficulties and, with acute time constraints, PCG support advisers would have to be well organised to solve the problems. The cost agenda had now overtaken the quality agenda, although, as a profession, prescribing advisers would be judged on the quality agenda. To make the best use of time and resources, a clear strategy was needed.
Professional isolation was a problem for prescribing support advisers. Often the only pharmacy voice in a multidisciplinary environment, prescribing advisers were viewed with suspicion from both outside and inside the pharmacy profession. Although networks were now being established, the presence of two primary care pharmacist groups had encouraged polarisation within the prescribing adviser network.
Access to appropriate information was improving but was not as good as it could be. Prescribing analysis and cost (PACT) data were retrospective, and drug information centres were less experienced in responding to queries from primary care, which were often different from those generated by secondary care. In the context of unified budgets, if the quality of prescribing was improved, money could be saved on both hospital admissions and social care, but there was no guarantee that any part of the savings would flow to prescribing advisers, Mr Davies concluded.
Mr David Roberts (head of the prescribing support unit, Leeds) emphasised the importance of using prescribing and clinical databases effectively at PCG level. The main source of prescribing data was the Prescription Pricing Authority (PPA), and although its data were universal, comprehensive and accurate, they were limited in several ways.
First, these data were based on cost. Secondly, although data identified the number of items prescribed and hence gave an indication of frequency of prescribing, they did not identify item size, which was an important issue, particularly in repeat prescribing. Thirdly, the cost included on PACT data was the net ingredient cost (NIC); this was the Drug Tariff price and it did not include dispensing fees, container cost, VAT, etc. Fourthly, PACT data provided no individual patient data, although various prescribing measures weighted to registered populations were included in PPA reports.
The first of these prescribing measures to be developed was the prescribing unit (PU) which took account of age and the number of temporary residents. Developed after the PU, the ASTRO-PU took account of age in more detail and also sex differences. The STAR-PU was still more specific and in addition to age and sex, took account of different therapeutic areas, showing for example that prescribing of endocrine drugs was highest in middle aged women.
Both an art as well as a science, setting a PCG prescribing budget represented a huge challenge. However, there were various tools for budget setting, including historical patterns of expenditure, which, although late, gave extremely accurate forecasts at health authority and national level.
In addition, there were various other sources of prescribing data, which in order of ease of use were EPACT, epact.net, community.net and the prescribing toolkit. The prescribing toolkit was particularly easy to use and was a stand alone information system which currently contained information on potential savings from generic substitution, a specialist drugs catalogue and various prescribing indicators.
Prescribing data sources differed in quality and ease of data extraction. Thus, PACT data were easy to access, but did not provide detailed quality information. Weighted measures such as average daily quantities (the English versions of defined daily doses), STAR-PUs and GP clinical systems data (eg, MIQUEST) provided more detailed information but required more resources to access. Individual patient records provided the most detailed data, but took a lot of time to access. It was, therefore, a question of financial management versus clinical governance, and there was a need to decide where to put resources.
One of the challenges facing PCGs was hospital prescribing, according to Mr Joe Asghar (pharmaceutical adviser, Northumberland health authority). Historically, working relationships between primary and secondary care had been patchy. Primary care had prescribing data while secondary care had almost none and fundholding had left a legacy of cost shifting. Whether the issue in a locality was actually about cost shifting or shared care depended on factors such as the local culture, historical prescribing behaviour and joint formulary committees. Introduction of new drugs was a particular difficulty and GPs were often concerned about having responsibility for unfamiliar treatments.
Various executive letters (ELs) had attempted to address these issues, and EL(95)5 had helped by providing a rational basis for budgeting and resource allocation between primary and secondary care, so avoiding the conflict of who should pay. However, primary care would find it difficult not to accept some clinical responsibility for new treatments and could not hide behind ELs and health authority budgets.
There was a need to redefine shared care and transfer of prescribing issues, and the transfer of prescribing responsibility between hospital and GPs should be supported by information, communication and education. This had to be appropriate to the needs of the prescriber, specific to the circumstances of the patient, relevant to the drug and condition and supported by shared care arrangements if appropriate.
In Northumberland, a solution to GP concerns had been developed in the form of a virement scheme in which the primary care prescribing allocation for specific drugs - growth hormone being used as an experiment - was vired to the trust. This meant that the trust provided growth hormone for all patients in the local health authorities and there was no more primary care prescribing of this drug. The apparent success of the scheme had led to planned expansion of the scheme to other health authorities.
The future for managing hospital prescribing depended on the availability of high quality prescribing data from hospitals, development of the prescribing agenda in hospitals, the impact of the National Institute for Clinical Excellence (NIC
Ms Sue Noyce (chief officer, St Helens North PCG) discussed the knowledge, skills and training required for prescribing support advisers. These indivduals needed a sound clinical basis and an understanding of primary care systems, costs and the hospital interface. An ability to evaluate published evidence and health economic data and a perspective on public health and the pharmaceutical industry was also important. In addition, excellent interpersonal skills, an ability to communicate with both professionals and patients, expertise in the management of change and skills in information technology and marketing were essential. Moreover, prescribing advisers needed to be authoritative and pragmatic, have a sense of humour and a commitment to continuing professional development and be multidisciplinary team players. Prescribing advisers would need to conduct their own training needs analysis and develop their own training plan. Training needs could be met by experiental learning (eg, a learning log), distance learning, project work, mentoring and studying books, journals and tapes, as well as attending conferences and taking sabbaticals.
Mr Clive Jackson (director, National Prescribing Centre) described prescribing support as one of the fastest growing professional specialisms in the new National Health Service. This support was often extra to the professional input provided by health authorities, but models were different across England and evolving rapidly, he said. Moreover, with the advent of primary care trusts (PCTs), there would be further significant changes in the way prescribing advice was delivered.
An NPC survey in summer, 1999, had found that 344 PCGs covering 91 health authorities currently had prescribing support. Some PCGs had more than one individual carrying out this task with the result that there were now over 440 professionals - almost all pharmacists —working in this field. Over 150 of these individuals were working full time for the PCG, and more than 90 were working half time or more. Many of the 137 PCGs who, at the time of the survey, did not have prescribing support, were actively recruiting during the autumn.
Prescribing advisers in primary care had the potential to be a powerful force in helping to shape the future direction of health care and the delivery of pharmaceutical care. Moreover, this input needed to be effectively demonstrated not only at local level, but also at national and regional levels, influencing thinking and policy. To achieve this required a strong, co-ordinated professional network, which would help prevent isolation and provide an effective two-way communication channel for sharing ideas and information.
There were already two groups in existence - the Primary Care Pharmacists' Association (PCPA) and the Prescribing Support Pharmacists' Group (PSGP) - and the National Prescribing Centre in collaboration with the Department of Health had developed a national initiative which aimed to define core roles and competencies for this group of professionals. A resource document would be produced and it was hoped that it would be disseminated by April, 2000. Ultimately, competencies would have to be linked to professional standards and accountability. The next logical step, therefore, was to develop standards for practice and link this to CPD requirements.
The NPC would be providing significant levels of support to primary care prescribing advisers at HA, PCG and practice levels. This would include personal mailings (eg, Connect newsletter, advertisements for events, ad hoc information) and conference or workshop training both nationally and locally. PCGs would receive corporate mailings (Merec Bulletins, briefings, new drugs monographs, etc) and would have access to the NPC website database.
To promote professional credibility, there could now be a need for a faculty of pharmaceutical prescribing science and management, Mr Jackson suggested. Comparable to one of the Royal Colleges in medicine, such a faculty could provide a professional focus for national activities, work on maintaining competencies, accredit training and education, identify gaps in training provision and could provide a unified national view to input into policy development.
In conclusion, prescribing advisers needed to develop a strong identity as a new professional group and promote a co-ordinated network. Professional standards, accountability and delivery of high quality services were key issues and urgent thought needed to be given to a new approach to professional evolution, Mr Jackson said.