 The NHS in England and Wales is required to provide funding and resources
for medicines and treatments recommended by the National Institute for
Clinical Excellence through its technology appraisals. This is no mean
feat considering the frequency at which such guidance is published.
One health community in the south west of England — comprising
Bristol, North Somerset and South Gloucestershire — has responded
to the challenge by developing a strategy that ensures NICE guidance
is implemented effectively and consistently across the region. Specifically,
it has set up what it calls a NICE College to bring together all parties
involved in commissioning and delivery of services.
Alaster Rutherford, head of medicines management for Bristol North Primary
Care Trust, explains that college members meet once a month and include
chief pharmacists from all the acute and primary care trusts, as well
as representatives from finance, commissioning and public health.
The college examines guidance from a local perspective and requires each
health organisation expected to be affected by it to prepare an implementation
plan. Each plan includes:
· Action needed to implement guidance
· Anticipated patient numbers
· Impact on waiting lists
· Changes in referral patterns
· Estimates of resources required over and above delivery of the existing
service
· Savings in other areas
Using estimates given within each piece of NICE guidance, PCTs agree
with their acute trust the expected level of activity for any given technology.
Only technologies with a significant financial impact — over £3,000
per patient per year — are monitored on an individual patient level.
Other health communities within the NHS may decide to fund the implementation
of NICE guidance on a cost per case basis. “The problem with this
approach is that trusts have to bill and PCTs have to pay for individual
interventions,” Mr Rutherford says. This, he adds, is unnecessary
and overly bureaucratic.
Local initiatives
Mr Rutherford explains that Bristol North PCT has a number of local
initiatives designed to improve implementation of guidance. These include
an incentive
scheme to encourage GPs to attend educational sessions timed to link
in with the launch of NICE recommendations. For example, the January
meeting covered management of depression and followed a clinical guideline
on this topic published in December 2004.
Practice pharmacists provide prescribing advice to each GP practice
in the PCT. They are briefed about NICE recommendations and meet GPs
to
agree outcome targets for guidance implementation. “In the future,
I see practice pharmacists as being change agents around NICE guidance.
They are the catalyst within each practice,” says Mr Rutherford.
Another intervention within general practice is the inclusion of “pop-up” boxes
on GP prescribing systems, to remind GPs of relevant NICE advice.
Bristol North PCT has also developed an innovative scheme within community
pharmacy to enhance awareness and implementation of NICE guidance. The
PCT has made £20,000 available annually as a competitive funding
pool to its 42 community pharmacies. To receive part of the funds, pharmacies
sign up to one of three service levels, each level guaranteeing funding
of £150. The remainder is divided up at each service level and
distributed to participating pharmacies.
At the first level pharmacies must have copies of relevant NICE guidance
or guidelines. Those aiming to provide the third level must conduct an
audit around a piece of guidance. One area in which the PCT was keen
for an audit to be completed was around use of cyclo-oxygenase-2 (COX-2)
inhibitors. Community pharmacists reviewed NICE guidance relating to
use of these drugs and identified patients presenting with prescriptions
for COX-2 inhibitors plus aspirin and contacted patients’ GPs.
In addition to these initiatives, Mr Rutherford also ensures that awareness
of NICE guidance is raised among pharmacists through continuing education
workshops. In his role as a tutor for the Centre for Pharmacy Postgraduate
Education he links workshops with guidance. “We are trying subtly
to get everyone up to speed on the most important clinical guidelines,
including those for chronic obstructive pulmonary disease and heart failure.”
The effects of these initiatives, as a whole, can be significant. Mr
Rutherford points out that local prescribing of COX-2 inhibitors has
been half that of the national average. “The initiatives are about
promoting an escalator of excellence,” he says. Changes afoot
The introduction of “Payment by results” in April (when set
tariffs for treatment will free PCTs from price negotiations) will change
the focus of the NICE College, explains Mr Rutherford. “Up until
now, the focus of the college has been driven by the allocation of resources.”
Payment by results will see an increase in the amount of money available
to fund treatments covered by new NICE guidance. This means the college
will be able to concentrate on quality and clinical governance — making
sure patients are receiving the treatments they need — rather than
on whether there is funding available.
In addition to this move, Mr Rutherford believes there needs to be a
brutal analysis of how illnesses are managed. “We have newer treatments
available for patients with worsened conditions. Do we necessarily still
need the infrastructure that has been in place for dealing with that
condition? Therapeutic advances may shift patient care away from hospital
beds and into communities. Has the overall team approach changed to accommodate
this,” he asks.
He also believes that implementation of NICE clinical guidelines presents
a challenge. There is no statutory obligation to fund the guidelines
but their implementation is included as a developmental standard within
the Department of Health’s “Standards for better health” document
published last year. “Health communities should be planning how
they are going to tackle this,” says Mr Rutherford, warning: “The
thing about developmental standards is that they tend to become obligatory.”
The initiatives introduced by this health community mean that stronger
working relationships now exist between organisations and duplication
of work across PCTs has been reduced. And there are now robust, long-term
processes in place for implementing NICE guidance. |
The
Pharmaceutical Journal