The Pharmaceutical Journal
Vol 273 No 7308 p91-91
17 July 2004

This article
Reprint   Photocopy

PDF 50K, Acrobat Reader

UK Drug Utilisation Research Group

Prescribing: pace of change continues

The prescribing agenda has changed beyond all recognition in the past 10 years and the pace is not about to slacken, said Jim Smith, chief pharmaceutical officer for England. “At the end of this year there will be a formal consultation on independent prescribing by pharmacists.” Electronic transmission of prescriptions will start in the community next year, he confirmed, and electronic prescribing in hospitals has recently been brought forward to 2006.

In terms of supplementary prescribers, Dr Smith said that 2,700 nurses and 100 pharmacists had now registered. He agreed that access to patient records is crucial in supplementary prescribing and that for some groups, particularly high-street pharmacies, a lack of access might well be a rate-limiting step to starting prescribing. He did not believe that there is resistance among GPs to allow pharmacists to have access to records. And asked about funding of supplementary prescribing by pharmacists, Dr Smith said that the Department of Health saw this as a decision for PCTs and GP practices. “We won’t dictate a budget for prescribing by pharmacists from the centre,” he said. “It is up to people locally to work out the resources. If supplementary prescribing is not meeting a defined local need then don’t do it.”

Rimal Patel, a community pharmacist in south London, disagreed with Dr Smith that access to records was the rate-limiting factor. “No community pharmacy in London is prescribing at present,” he said. “PCTs have not decided what their policy on supplementary prescribing is.” He pointed out that the prescribing adviser at Southwark PCT has just negotiated funding for these services. “If it has taken this long for a prescribing adviser to negotiate funding how will community pharmacists manage,” he asked. Much of the problem lies with a “broad spectrum of inactivity” regarding supplementary prescribing, he said. It was unclear who would draw up new service specifications for the role, and whether the PCT knew about or wanted to use supplementary prescribers.

However, Mr Patel said that there were many opportunities for supplementary prescribing and other developments for pharmacists. For example, under the new GP contract some surgeries are opting to close on Saturday mornings. “This makes it harder for the local pharmacy to stay open but one solution would be for the pharmacist to offer a minor ailments service and supplementary prescribing on Saturdays,” he suggested. That way patients would get improved access to health services and the pharmacy would be able to remain open. “Again, some surgeries are moving to Local Improvement Finance Trust sites away from local communities. The pharmacy is left in the community but it is where patients live so why don’t pharmacists offer chronic disease management there,” he said.

Mr Patel saw a particular role for pharmacists in POM to P switches. “But for it to work well and safely, an integrated care record has to be put in place,” he said. “Community pharmacy will still be the physical entity but pharmacists will become more service driven, offering pharmaceutical care and collaborating with secondary care. The shared medical record is needed for communication: it is how different professionals know what is happening with a particular patient.”

Changes impact on drug budget

The Prescribing Support Unit was founded in 1996 and provides policy and analytical advice for the Department of Health, explained the unit’s manager Dave Roberts. Functions of the unit include forecasting the drugs bill and looking at policy issues.

The drugs bill has been increasing at a rate of about 10 per cent in recent years. Increases in prescribing rates had been related to national service frameworks and a “massive increase” in prescribing of antiplatelet agents had been seen recently, he commented. Policy initiatives such as shifting the balance of power to a local level, introduction of new prescribers, introduction of repeat dispensing and the new GP contract all had an impact on the prescribing budget.

“ Repeat dispensing is a policy ahead of its time in terms of the IT to support it,” he commented. The initiative started in June 2003 and between then and March 2004, 52,408 items were dispensed by repeat dispensing which was 0.008 per cent of the total items. In April 2004, the figure was 18,049 items or 0.033 per cent of the total. “It will be interesting to see how it takes off when electronic transmission of prescriptions is introduced,” he commented.

Another forecasting function of the unit was to predict how much of an effect the new GP contract would have on the prescribing bill. The unit identified 24 indicators in the contract that either directly referred to prescribing or could lead to an increase in prescribing. It then estimated current levels of achievement against these indicators for all the practices and then estimated the likely increase in costs if the practices were to meet all the indicators. “If all practices move to the maximum level, it will represent a 5.6 per cent increase in the drugs bill. This is no small amount of money,” Mr Roberts said.

As part of the new GP contract, more data will be collected on GPs’ prescribing. This should help to determine if prescribing is appropriate, rather than just if performance matched a budget, he commented. “At the moment there is no national data linking prescribing and morbidity: this is what is needed,” he said.

NHS is playing catch-up

“While the burden of disease is shifting towards chronic disease, our health care system has not really adjusted yet,” Jim Smith, chief pharmaceutical officer for England, said. “It is still dominated by the acute sector.” He gave an example of a patient admitted to hospital carrying 2,500 paracetamol tablets. “This was a result of not having a medication review for 27 months, and an indicator of the need to address chronic disease management.” New prescribers would play a part in helping to solve the particular challenges that chronic disease presented.

“ Poor compliance is an issue. We need to do a lot around compliance,” he said. Up to 50 per cent of patients do not take their medicines as intended and even Kaiser Permanente found high rates of people not taking their medicines as intended. “Discontinuation rates on statins are amazingly high,” he commented.

Dr Smith stressed that compliance should not be confused with concordance. “Patients cannot be concordant; concordance is about the nature of the patient-professional interaction,” he said.

Too often the NHS suffers from “big ideas syndrome”, imposing something without trying it out first, according to David Lyon, a GP and adviser to the Primary Care Collaborative. The idea behind the PDSA (plan, do, study, act) cycle is that an initiative is tried in one practice for one afternoon then for one day then at two practices and so on until a whole local area is included.

Dr Lyon explained that there are four principles of chronic disease management. First, being systematic about diagnosing disease and drawing up a disease register. Second, being systematic and proactive in monitoring patients. Third, involving patients in their care. And finally, adopting a multiskilled, multiagency approach.

How the industry can contribute and benefit

Pfizer has recognised the importance of improved chronic disease management through a project in Haringey, London, that it is involved in, explained Roy Sutherwood, associate director of corporate affairs at Pfizer.

The idea for “Team Health: Haringey Health Partnership” originated from Pfizer’s involvement in a similar project in Florida, US, and came to fruition in the UK following a meeting between the chairman of Pfizer and the then health secretary Alan Milburn.

The aim of the Haringey project is to pilot a telephone-based disease management intervention, Mr Sutherwood explained. Initially patients with heart failure, coronary heart disease or diabetes are contacted by a case manager who acts as a coach. Treatment goals are set, a care plan is introduced, the patient is routinely monitored, education is provided and referrals are made if appropriate. The care manager provides the patient with information, motivation, support and planning skills. “It is about improving clinical outcomes and promoting greater self-management by patients with chronic disease,” he said. The model involves a collaboration between the PCT, hospitals and Pfizer, and is funded equally by the NHS and Pfizer. It is still in the early stages and results are not expected until the end of next year.

Another approach industry could become involved in is through an outcome guarantee, when the company guarantees that its drug will have a defined effect or it will reimburse the health care provider for wasted resources. This was supported by Mr Sutherwood, who commented: “Outcomes guarantees are an important development. We are very interested in and expanding this.”

One such project for atorvastatin was described by Stephen Chapman, professor of prescribing studies in the department of medicines management at Keele University. All patients titrated to doses set out in the outcomes guarantee reached their target so no money had to be paid out by industry. The study is described in detail in the International Journal of Pharmacy Practice (2003;11[Suppl]: R71) PDF (40K)

Professor Chapman said that the benefits to doctors of such an agreement included help in identifying and monitoring patients, and meeting requirements of national service frameworks and the new GP contract with minimal effort. For PCTs, benefits included maximising health gain for patients, help with audit and monitoring, and minimising financial risk. Patients received a common treatment pathway regardless of their prescriber, help with concordance (through informed consent), close monitoring of treatment and lifestyle advice. “It is a win-win situation,” said Professor Chapman. The industry benefits too from better relationships with practices and an opportunity to work with rather than against PCTs.

Asked if the outcomes guarantee project could be replicated for other drugs, Professor Chapman said it could providing certain conditions were met. A clear health need in the local population, a strong evidence base for the drug, and a clear and objective way to measure outcome (such as a cholesterol level) were all necessary.

Comparison of drug costs across Europe

Pharmaceutical policy has to find a balance between health needs and the needs of industry, explained Elias Mossialos, professor of health policy at the London School of Economics. “Those countries with strong industry — Germany, the UK and France —have less stringent price controls.”

Different approaches have been taken to the regulation of prices in the EU. These include direct price controls, international price comparisons, profit control and reference pricing. The UK is the only country to use profit control through the Pharmaceutical Price Regulation Scheme (PPRS). “PPRS is here to stay,” said Professor Mossialos. “It is the only way the UK government has to retain pharmaceutical industry R&D investment in the UK so it doesn’t shift to other countries.”

The PPRS agreement is currently being reviewed. Radical changes are unlikely, according to Mike Sedgley, of the London School of Economics. “The latest PPRS agreement is due out in the next few months. There is little evidence that stricter regulation will be contemplated by the Government.” He commented that, although neither side “quite liked” PPRS, both realised that other options were not possible.

Professor Mossialos went on to say that more and more countries are trying strategies to improve prescribing and save costs. These included encouraging generic prescribing, prescribing budgets, pay agreements linked to prescribing, prescribing guidelines and monitoring of prescribing. Dispensing incentives through generic substitution were used in a number of countries. And patients were also being targeted: such as by asking them to pay a percentage of the product price or limiting the reimbursement they get.

A comparison of prices of pharmaceuticals showed that UK prices are only slightly higher than those in many countries in Europe, and well below those in the US. “They are not as expensive in the UK as many people think,” he said. Generic consumption also varied, being highest in the UK, Denmark and the Netherlands.

Issues in research and development

Altogether, 26 per cent of the total R&D expenditure in Europe is in the UK. But the pharmaceutical market share for products launched in the previous five years was much lower in the UK than in the majority of countries in Europe and the US. “Does this reflect therapeutic conservatism on the part of doctors in the UK,” asked Elias Mossialos, professor of health policy at the London School of Economics. Certainly there is no delay from pricing or reimbursement application to reimbursement of new products in the UK whereas delays of over 180 days are common throughout Europe, he said.

Jim Smith, chief pharmaceutical officer for England, commented that because practitioners in the UK are basically free to prescribe anything they believe is in the interests of patients, they exercise this privilege with caution. “Perhaps this is why the uptake of new drugs is slower in the UK,” he suggested.

Roy Sutherwood, associate director of corporate affairs at Pfizer, pointed out: “There has been a drastic reduction in European R&D over the past 20 years.” He said that governments’ investment in health R&D had been reduced. Figures in 2003 showed that that the US government spent 0.23 per cent of the country’s gross domestic product on health R&D compared with 0.1 per cent in the UK, 0.06 per cent in France and 0.03 per cent in Germany. “The lack of government incentives has led to scientists voting with their feet and moving to the US,” he said.

Research and practice must be integrated

Better integration of research and practice from the outset make implementing research in practice much easier and ensures it is relevant, explained Catherine Duggan, director of the academic department of pharmacy, Barts and the London NHS Trust.

Therefore, she advocated research that involved practitioners and patients at every stage. An example was a trial in Barking and Havering. Altogether, 37 pharmacists in the area are involved in the trial which is examining care plans. Patients are given a voice: they have a choice of where they would like a medication review to take place. More than 70 per cent had chosen the pharmacy over the GP surgery or at home, she reported.