The Pharmaceutical Journal
Vol 270 No 7241 p409
22 March 2003

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Area prescribing committees — what is their role in the new NHS?

By Peter Burrill, MRPharmS

In this article the author discusses how one area prescribing committee is adapting to the changing National Health Service

Back in 1994, in a different National Health Service, the Department of Health issued EL(94)72, "Purchasing and prescribing". This executive letter asked purchasers to address issues on prescribing and required district health authorities, family health services authorities and health commissions (two reorganisations ago) to ensure that appropriate action was taken on hospital-led prescribing and new drugs.

This action required us to:

• Develop and agree strategies for improving the cost-effectiveness of prescribing across the primary/secondary care interface

• Ensure the appropriateness of hospital-led prescribing

• Ensure that hospitals, when establishing their policies on prescribing, took account of the total costs of drugs to the NHS

• Develop an authority-wide policy for the managed entry of new drugs into the NHS

• Establish effective channels for agreeing joint strategies on prescribing and drug use within a wider health care context

• Develop a local strategy and rolling action plan for tackling prescribing issues in 1995–96 and subsequent years

It also required us to ensure that:

• The organisations had appropriate access to expert advice on prescribing and medicine usage issues

• Joint decision-making mechanisms were in place which fully reflected the interests of hospital and general practitioners

• Satisfactory arrangements were in place for implementing and monitoring changes

Health authorities (as they soon became) reacted to this by forming area prescribing committees (APCs). Typically an APC would be led by the HA pharmaceutical or medical adviser (or both) and would include clinicians and pharmacists from the local acute trust, some local GPs and possibly a public health doctor and someone from commissioning or finance.

Most, if not all APCs set up traffic light systems for prescribing responsibility with red indicating hospital only, amber meaning suitable for shared care, and green meaning any competent GP should be able to prescribe. However, different APCs would put the same drug into different categories, leading to cross-border problems.

For six years, 99 APCs managed as best they could, but in September 2000, the National Prescribing Centre published "Area prescribing committees — maintaining effectiveness in the modern NHS. A guide to good practice". For the first time, APCs were able to compare themselves to a "standard" and change if necessary.

The guide advised: "In principle, APCs should aim to take a strategic and advisory approach to medicines management issues, which informs rather than governs local policy. The central principles of rational prescribing and medicines use, namely clinical and cost-effectiveness, appropriateness (including convenience) and safety, should guide the thinking and outputs of the committee."

Primary care trusts took over local running of primary care from HAs last year. PCTs have the power of local decision making but also the responsibility of providing health care for the local community while staying within budget — no easy task.

Are APCs still necessary?

APCs are now even more necessary. With 99 HAs it was possible to have 99 different decisions about something. With over 300 PCTs the possibilities are tripled. Pressures on the drug budget continue to grow — national service frameworks, National Institute for Clinical Excellence guidance, new expensive drugs, landmark trials and the concept of medicines management to name a few. A strong, effective APC is essential.

Before the demise of the HA we reviewed the role and functions of our APC and reconstituted it as the priorities and clinical effectiveness forum (PACEF). It involves three PCTs, an acute trust and a mental health trust. It has a spectrum of activities and functions ranging from strategic decisions to practical implementation. These include:

• Deciding values and ethical issues

• Dealing with individual cases

• Reviewing cost-effectiveness

• Reviewing effectiveness

• Making commissioning decisions

• Implementing national guidelines and guidance

• Producing local guidelines

Its membership has been strengthened and comprises:

• Each PCT prescribing adviser

• The professional executive committee chairman and one other GP from each PCT

• A director of public health, director of finance, and senior commissioning manager (one from each PCT)

• A medical director, chief pharmacist, drug and therapeutics committee chairman, and a consultant from the acute trust

• A consultant from the mental health trust

• The specialist in pharmaceutical public health and a non-medical public health specialist from the public health network

• A nurse prescriber

• An ethics adviser

• A social services representative

• A lay member

An effective chairman is essential but the forum member who is the key to making it all work is the evaluation pharmacist. He or she may have a different title depending on where they work and in North Derbyshire it is me. I prepare most of the agenda items, such as new drug evaluations, appraisal of trials, reviews of NICE guidance, draft guidelines and so on. I lead on many of the discussions and report PACEF decisions via the monthly newsletter.

To date, PACEF is working well and there appears to be a desire for it to be successful. The new APCs are driving forward rational, cost-effective prescribing (and related matters) in the new NHS. This is the pinnacle of the pyramid from which prescribing policy decisions are made and cascaded.

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