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The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR62

Systems for managing hospital prescribing policy: have NHS trusts caused any changes?

By Siobhan M. Cotter and Martin McKee

Introduction In the decade prior to the introduction of National Health Service trusts, the management of hospital drug policy appears to have been fairly similar across the NHS. It involved a hospital drugs and therapeutics committee (DTC), a formulary and the ward pharmacy system.
It is unclear how the older, centralised, control system, operated by the pharmacy, consultants and the DTC, has been affected by the implementation of trusts and clinical directorates.1,2 In particular, little information exists on the relationship between the systems that manage prescribing policy and hospital management.
As part of a larger evaluative study on the management of prescribing policy in NHS trusts, we aimed to describe the systems that currently exist for managing prescribing policy and their relationships with hospital management.

Methods Four NHS trusts were specifically selected to represent a spectrum of apparent approaches to the management of prescribing policy in 1997. They included teaching and non-teaching hospitals in and around London, with different characteristics and situational factors (eg, size, staffing, specialism, relationships with purchasers). They had centred their policy management at different administrative levels, with greater or lesser emphasis on clinical directorates taking the lead, and appeared to demonstrate some differences in pharmacy and medical roles in policy management.
This was a comparative case study. Data were collected via document analysis, observation of meetings and staff interactions, and interviews with key staff in the trust and the local health authority (HA). Ethics approval was acquired from the relevant committees. Standard social science methods were used to collect, analyse, validate and combine data.

Focal points

  • The overall system for managing prescribing policy remains similar to that in place prior to trusts although there is evidence of some devolution of responsibility to directorate/specialty levels
  • Trusts have strengthened links between hospital and prescribing policy management systems
  • Greater use is being made of clinical and financial data in managing prescribing policy
  • Managers are more involved in managing aspects of prescribing policy

Results Each trust had a specific trust-wide drug policy body, a DTC. These were usually stand-alone entities at directorate level with representation from pharmacy, nursing, management, the HA, doctors from the major divisions/directorates in the trust, and general medical practitioners, and were chaired by trust physicians. Two trusts had specific new drugs committees with a trust-wide remit. All trusts had temporary or permanent DTC subgroups to address specific areas (eg, antibiotics, nurse prescribing, shared care). DTCs were responsible for the management of drug policy, including prescribing policy, at trust level and reported to the trust executive and board. Their prime responsibility was clinical aspects of policy and especially policy development. A few committees or subcommittees also had active roles in policy dissemination, implementation and review.
Financial aspects of new drugs policy was addressed by the executive at one site and by directorates at the others. The micro management of prescribing policy remained at medical team and specialty/directorate levels and depended heavily on the input of consultants, pharmacists and nurses. Directorates, and sometimes specialties, played the major role in the financial management of policy with varying levels of input by doctors, nurses and pharmacists.

Discussion The systems and processes for developing, disseminating and implementing policy were similar to those in existence in the late 1980s. There was a trust DTC, with varying levels of real responsibility for aspects of preliminary decision-making devolved to directorates/ specialties.
While a large degree of responsibility for financial aspects of decision-making often rested at directorate level, in all cases the final decision, especially on clinical aspects, remained at trust level. However, greater use was now made of financial and clinical management data in decision-making and policy review, particularly at some trusts. Managers, at directorate/specialty and executive levels, had greater input in policy management and the links between the systems for managing prescribing policy and the hospital were being visibly strengthened. Nevertheless, the system still in use to manage prescribing policy appears to be a variation on a single model, one of partially decentralised control.

Health services research unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT

References

1. Cotter SM, McKee M. Models of hospital drug policy in the UK. J Health Serv Res Policy 1997;2:144-53.
2. Leach RH, Leach SJ. Drug and therapeutics committees in the United Kingdom in 1992. Pharm J 1994;253:61-3.