The Pharmaceutical Journal Vol 267 No 7177 p828-829
8 December 2001

Prescribing Advisers:
The challenge of tackling a complex agenda in a changing NHS

The structures for most primary care trusts (PCTs) would be in place by April 2002, explained Dr DAVID COLIN-THOME, national director for primary care service, Department of Health, and certainly by October 2002 the 480 primary care groups (PCGs) would be no more.

The key to progression and development of the PCTs would be their size. PCT populations would range from 80,000 to more than 380,000, and Dr Colin-Thome went on to describe how "smaller PCGs will need to demonstrate a connectiveness to national organisations, whereas the larger ones will need to demonstrate localness".

With the merging of current health authorities subsequently forming 28 strategic health authorities in England, the nature of pharmaceutical service provision was set to change yet again, he suggested.

Dr Colin-Thome said that, with the continuing surge in consumerism, "a patient want is a patient need". It meant the emergence of agendas in the areas of patient self-care and patient values.

A further issue was that financial direction of National Health Service monies would be from primary care trusts. They would have 75 per cent of the national health care budget and 100 per cent of the local budget.

The impact on secondary care services was far from understood. It appeared that PCTs would manage the whole of patient care up to the point of becoming a hospital inpatient. Primary care would be completely redesigned.

Guideline overload

Dr MARTIN DUERDEN, consultant in medicines policy and use, and honorary senior lecturer, University College London Hospitals, launched into the topic of what prescribing advisers actually did. He spent some time on the intricate role of the National Institute for Clinical Excellence. In a time of "guideline overload" there was a need to consider what the objectives of NICE have been. One clear and consistent message that was well supported was the belief that NICE would illuminate where certain drugs would fit into current regimens over and above the requirements required for obtaining a licence. Whether or not NICE has achieved this was controversial.

One thing that was certain was that the Government had added new hurdles for the pharmaceutical industry to clear. This could be seen as limiting the dissemination of new clinical entities on to the market and certainly creates "extra hoops for the manufacturer’s to jump through to prove their drug market worthy".

Dr Duerden went on to explain that, although postcode prescribing was seen in a negative context, NICE has done nothing to reduce it.

It was notable that the Medicines Control Agency required something in the region of £40m for the granting of marketing authorisations and preparation of summaries of product information. The task that NICE had to achieve represented a far bigger agenda, and yet its budget did not approach anywhere near this value. However, there was a general agreement that, although it was not consistent, some useful guidance had been produced by NICE and it had led to real changes in patient care. Whether these changes are measurable was doubtful but it was apparent that NICE’s authority was not directive nor was it tight enough.

Questions were also raised about NICE’s sensitivity and its influence on the pharmaceutical industry. This further negated its impact and raised doubts over the authenticity of its decision-making process.

Importance of NSF targets

Dr BRIAN CURWAIN, chief pharmacist, New Forest Primary Care Trust, emphasised the importance of national service framework (NSF) targets and how prescribing activity — and essentially pharmacists’ activity — would be judged. Pharmacists needed to be managers of change, he said, adding: "If the budget does not add up, you will be out of a job."

Facilitating change was a theme explored in a varied and interactive workshop covering the NSF for Older People. "Communicating with practice managers, general practitioners, nurses and financial advisers will be crucial", said Dr Curwain, as would the increasing trend toward integrating social services at the front line of health care.

Dr Curwain had positive ideas on making use of the news media to deliver pharmacy messages to the public. Given that the NHS was the biggest employer in Europe, the profession needed to ensure that its voice was heard at the right times in the right directions, he said.

Evolution of pharmacy input

On the topic of future mergers and the prescribing advisers, PAULA HEAD (principal pharmaceutical adviser, Kingston and Richmond Health Authority, and chief pharmacist, Kingston PCT) delivered an elaborate display of how the evolution of pharmacy input and advice has increased steadily in her locality. In the new PCT structures, 15 per cent of the unified budget would be allocated to two or three pharmacy advisers, with the remaining 85 per cent distributed among some 120 members. Hence the power and influence of these individuals was highlighted.

In a positive approach to change and visionary ideas for the future of prescribing advisers in the new NHS, Ms Head went on to stress the importance of identifying deliverable health care for the local population, within budgetary constraints. With individual patients at the heart of change in health care, the NHS required quality support staff. There were also issues surrounding corporate governance and statute responsibility to service level agreement.

She went on to say that exciting new roles were emerging within new structures. Public health, health improvement plans, pharmaceutical needs assessment and health promotion all required a pharmacy input and could be crucial to the active role the profession played in the near future.

Managing interface problems

Professor TOM WALLEY (department of pharmacology and therapeutics, Liverpool) concentrated on managing problems at the interface between primary and secondary care. The essence of the task at hand was not to maximising the interface but to remove it. The problems appeared to remain the same, Professor Walley said, identifying communication and cost shifting as long term and arguably difficult issues that still had to be faced. Because PCTs would control 100 per cent of the local budget, they could and would dictate secondary care activities.

Also of interest was the impression that budgets in secondary care had always been overspent, and the hospitals had always been bailed out. It was significant that, for the first time, secondary care would be entering an era in which there would be no bail-out funds available. Furthermore, issues needed to be proactively managed. For instance, horizon scanning groups, set up to plan for future budgetary pressures, would be required to allow for planning and active resource management.

To what extent hospitals would directly and indirectly influence primary care prescribing remained to be seen, Professor Walley said. What seemed certain was that a clash of cultures between secondary and primary care would now be experienced. The two sectors did not appreciate each other’s culture. Secondary care, which was often research driven and was seen as "expert", might well be ignorant of primary care issues, drug budgets and even the notion and implications of a unified budget. There was a danger that secondary care would just continue doing what it had always done.

Professor Walley said that poor internal and external communication and rapid turnover, particularly of junior staff with limited induction training, had played a significant role in creating the problems associated with discharge letters and continuity of care. In the new NHS, the patient’s experience had become a real agenda — and even a political tool, it could be argued. Clinical governance was linked to patient user surveys, which were already being carried out in "league table" fashion.

Looking to the future of prescribing, Professor Walley said that issues included 28-day discharge prescriptions, consultants prescribing groups of drugs rather than individual drugs, and the use and abuse of FP10(HP) prescription forms.

Professor Walley foresaw restraints on new drugs to stop them leaking out into general practice and hospitals moving into the role of specialist service centres. This raised the question of where accident and emergency services would be placed and what would be the future of the current district general hospital.

Targets and budgets

OMAR ALI (formulary development pharmacist, Surrey and Sussex NHS Trust, and prescribing consultant, primary care) looked at the problems of meeting NSF targets within budgetary restraints. To meet the NSF targets on cholesterol reduction required something in the region of £750,000 per annum, he said. The Government has given £50,000 towards this, and expected the NHS to find the rest. This represents a zero-sum game for health care, where targets were set, budgets were calculated but funding was not released.

Mr Ali also explored various facets of the value of prescribing advisers. Traditionally, prescribing advisers had carried out roles as clinical advisers, budgetary controllers and risk managers. The future lay in where society decided to place this value.

The health authority was no longer in authority, Mr Ali said. The agenda would be that of the PCT, and so pharmacists would be buying into a whole new set of values unless they stood up for the ones they had strongly believed in.

Mr Ali also highlighted the issue of clinical governance, particularly with reference to performance management. Explaining the paradox that had arisen, he said: "If we meet our NSF targets for cholesterol management we will be over budget; if we remain within our budget, we cannot have met the targets." Either way, it seemed, a no-win scenario had developed, and future success would depend on how pharmacists chose to tackle this.