The Pharmaceutical Journal
Vol 269 No 72xx pxx
13 July 2002

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National Respiratory Training Centre / Keele University

Strategies for best prescribing where no national service frameworks exist

The prescribing community in the United Kingdom, soon to be boosted by many thousands of pharmacists and nurses, faces an uncomfortable dilemma in terms of the priority it should give to chronic illnesses, which are not included in a national service framework (NSF). The NSFs and National Institute for Clinical Excellence (NICE) guidance clearly lay out the standards for prescribing for certain drugs and conditions, but how do we deal with the others? And how would we make transparent to a Commission for Health Improvement (CHI) review what our local priorities are? And what data and information can we use to support those decisions?

This was the background I provided to the first of a series of workshops, "Managing non-NSF priorities: making a case for CHI", attended by nearly 50 pharmaceutical and prescribing advisers, doctors, pharmacists, nurses, clinical development managers and chronic disease managers in the National Health Service.

Asthma was selected as a case study because the burden on the NHS of respiratory disease in general, and asthma in particular, shows no sign of letting up. There are almost four million consultations for asthma in the UK every year and the annual cost of asthma medication has been estimated at £500m.

On one hand, the Government has not overtly prioritised respiratory disease with an NSF. On the other, primary care trusts (PCTs) cannot afford to ignore the impact that asthma has on their prescribing budgets and resource allocation decisions — especially in the context of impending CHI reviews.

Robust strategies required

Dr Robert Queenborough, CHI review team member who also works on behalf of National Prescribing Centre (NPC), argued that, in preparation for the inevitable CHI review, it was vital for PCTs to set up effective medicines management policies. Evidence of the need for such policies was considerable: for example, half of all patients with chronic conditions do not use their medicines as intended, medication problems are implicated in up to 17 per cent of hospital admissions, and medication errors have been estimated to cost the NHS £500m a year in additional days spent in hospital.

He said that the CHI will want to see evidence of robust and defensible systems that work for the benefit of patients. Progress would need to be demonstrated towards NSF targets, but Dr Queenborough emphasised that this should not exclude other health care priorities such as asthma. Throughout the process of establishing medicines management services, the perspective of the patient should be paramount.

He conceded that, in some parts of the UK, effective medicines management services were already in place. However, Dr Queenborough added that resources have not always been used judiciously in the past. Community pharmacists were a case in point, often reduced to mopping up GPs' prescribing anomalies when they should be at the hub of efforts to devise effective prescribing strategies.

Asthma — a prescribing imperative

The case for making asthma a non-NSF priority in preparation for a CHI review is a powerful one. As Dr Queenborough pointed out, the Department of Health has already acknowledged that asthma is one of the major disease burdens of the 21st century. Statistics outlined at the meeting by Monica Fletcher, chief executive of the National Respiratory Training Centre, would seem to bear this out. More than 1,500 people still die prematurely each year as a direct result of having asthma. Approximately 40 per cent of people with moderate-to-severe asthma experience symptoms every day. Asthma in children leads to more than 30,000 hospital admissions a year.

She reported that the quality of asthma care in the UK remains patchy, and that there is a continuing failure by health care professionals to implement evidence-based guidelines. It was in the Government's best interests, she argued, to tackle these inconsistencies head-on, and not let the delivery of adequately funded asthma management slip further down the health care agenda.

However, an NSF for respiratory disease was not necessarily the answer. The more NSFs that were created, she said, the less value they would offer in terms of determining true health care priorities. Neither should asthma simply be regarded as a burden that could be transferred from GPs to pharmacists and nurses. That was not a recipe for constructive change.

There were other ways to influence the prescribing agenda, Ms Fletcher insisted. She urged PCTs, with 75 per cent of the total NHS prescribing budget at their command, to develop better health improvement plans based on real local need, with respiratory disease featuring prominently. PCTs could also be encouraged to set up local respiratory strategy groups, and promote and develop local respiratory care protocols. Such an approach was congruent with the Government's clinical governance agenda and other recent quality initiatives.

Morbidity mapping

Of course, prescribing should not be considered in isolation when preparing for a CHI review. Knowledge of local morbidity patterns is also a key factor, and one that should be built into disease management plans — particularly when considering a non-NSF priority such as asthma. At Keele University, we have devised a morbidity mapping technique, based on a geographic information system, designed to link primary care prescription records to measures of morbidity for all PCTs across England (see Medicines Management, Issue 2, March/April 2002, p13). Importantly, it highlights those PCTs with relatively high patient need (morbidity) and relatively low service provision (prescribing). It is important to note that although this model can identify apparent disparities between PCOs, because the data are not linked at individual patient level, it does not show cause and effect.

New prescribers

Whether one uses morbidity mapping or other similar tools to influence prescribing, there is no doubt that the imminent introduction of extended and supplementary prescribing will have a profound effect on the future delivery of health care in the UK. Trudy Granby, nurse prescribing support manager at the NPC, was of the opinion that the ability to prescribe will clearly enhance the care that pharmacists and nurses already deliver to patients. However, she warned that this role should not be taken lightly, and urged that steps are taken to ensure that the new prescribers undertake their prescribing responsibilities safely and effectively. Not every pharmacist and nurse would welcome the opportunity to prescribe, she said, adding that those who did take up the challenge should not be tempted to prescribe outside their level of competence and knowledge base.

The success of extended and supplementary prescribing would hinge upon adherence to individual clinical management plans, demonstrating benefit to both the patient and the NHS. Ideally, these would be discussed, agreed and reviewed in conjunction with the patient — in practice, however, this was unlikely to happen. Subject to certain minimum requirements, Ms Granby suggested that there might be components of these plans that were common to groups of patients, and not necessarily individualised to each and every patient. One thing was for certain — pharmacists and nurses would face considerable pressure to prescribe, not only from advertisers, but also from patients and their carers.

Primary care commissioning

Another factor that has already begun to have a significant impact on prescribing patterns in the UK is the commissioning of health care services by PCTs. Harry Ward, director of commissioning for Wolverhampton PCT, advised those with responsibility for prescribing budgets to identify pragmatic prescribing projects that link in with the aims and ideals of the national plan for the NHS. Strategies that acknowledged shared care protocols and pathways across the primary and secondary care divide were more likely to succeed than those that did not, as were schemes that could be justified on the grounds of cost-effectiveness.

Mr Ward commented that there was too much squabbling over new money when there were pockets of money already tied up in the NHS. The secret, he said, was to find ways of unlocking those resources and using them more effectively. There might be additional funding for some projects, but it was likely to have been already earmarked without reference to PCOs, leaving little room for local manoeuvre.

He added that patient expectations in terms of therapeutic choice would continue to increase, and that we had moved from a situation where people were glad to accept what the NHS as a monopoly state provider was prepared to dispense, to one in which informed and enlightened patients were demanding what they regarded as their right to medicines of their choice.

Potential for efficiency savings

Finally, those taking part in this meeting were asked to register their own views, via a keypad voting system, on a number of the issues raised during the meeting. Respiratory disease was clearly regarded as an important priority, with 77 per cent indicating that it was high or very high on their prescribing agenda. However, 71 per cent considered that the management of asthma was only average or below in their locality, and every delegate believed that asthma care was an area where efficiency savings could be made. The majority (63 per cent) were also confident that they could persuade prescribers to make efficiency savings if justified by the appropriate evidence base. On the question of extended prescribing by pharmacists and nurses, 92 per cent said this would improve the quality of prescribing for asthma, although 57 per cent thought it would also increase the cost of that prescribing.

The vast majority (96 per cent) believed they were still largely unprepared for a CHI review of their prescribing practice. However, over half (53 per cent) intimated that a robust, open and transparent process was in place should they be required to submit evidence to the commission.

It was clear that recent Government health care initiatives are having a significant impact on how PCOs manage their prescribing budgets. By far the biggest pressure in this respect was the need to meet NSF targets (56 per cent), compared with patient pressure (19 per cent) and local hospital policies (5 per cent). In terms of specific drug classes that put most pressure on prescribing budgets, lipid-lowering agents emerged as the main culprits (58 per cent), far ahead of ulcer-healing drugs (13 per cent) atypical antipsychotics and inhaled steroids for respiratory disease (only 5 per cent each).

The morbidity mapping concept has now been further developed by 3M Health Care, and incorporated into its Optimising Resource Conflicts in Asthma (ORCA) interactive software program, with the aim of helping PCOs to monitor levels of inhaled corticosteroid prescribing for asthma and to identify potential cost savings by implementing alternative inhaled corticosteroid prescribing strategies.