Health Service Journal
Budgetary impact of expensive drugs needs to be anticipated locally
Financial consequences of paying for high-cost drugs and implementing
guidelines issued by the National Institute for Health and Clinical Excellence
need to be anticipated in local plans, according to Stephen Brown, director
of pharmacy at United Bristol Healthcare NHS Trust and pharmaceutical
adviser to NHS South West.
However, there is nothing new about this, Mr Brown emphasised. Primary
care organisations used to do these kinds of assessments at a local level
and NICE has not completely replaced the need for that work, he said.
Trusts would not have to start this process from scratch, he stressed,
since a wide variety of resources and information is available for them
to use. The process would, however, require sharing of information across
broader geographical areas to increase the consistency of views, he said.
Tools produced for horizon scanning and cost analysis can be used for
setting budgets before guidelines are issued. Implementation plans can
then be produced, explaining the cost impact, the payment-by-results
classification of the treatment and whether any service redesign will
be necessary, he said. Guidelines can then be implemented by carrying
out a line-by-line assessment of their content, assessing the costs for
individual patients and monitoring the costs of implementation.
However, consideration of the wider impact, on funding new high cost
medicines, of payment by results and NICE guidelines needs to take into
account challenges arising from medicines that have not been assessed
by NICE, those for which NICE assessments have not yet been undertaken
and those that fall outside NICE’s remit, he said.
There are a number of possible solutions to the issues raised by these
medicines, Mr Brown said, such as establishing clear commissioning principles,
on, for instance, substitution of drugs not included in NICE guidelines
for drugs that are included.
Other solutions should involve, he said, setting up clearly defined processes
and drug policy forums for assessing the drugs, and developing networks
across and between strategic health authorities.
Alongside guidance for medicines for which no NICE guidelines are in
place, Mr Brown also spoke about the need to develop local commissioning
processes for drugs excluded from payment by results, since, Mr Brown
stressed, exclusion of a drug from payment by results does not mean that
it will automatically be funded by commissioners.
Mr Brown went on to lay out his recommendations for how the commissioning
process for high-cost medicines, including ones which would be excluded
from payment by results, should work. Prospective budgeting should be
undertaken for high-cost drugs, he said. A process similar to the process
NICE carries out should be applied to all exclusions from payment by
results to establish criteria for use.
A reimbursement mechanism then needs to be agreed, he added. Spending
on payment-by-results exclusions needs to be monitored and compared with
the allocated budget. In addition, the commissioning process needs to
be linked up to the prescribing committee process, Mr Brown stressed.
Prescribing standards should be task-based and multidisciplinary
Multidisciplinary standards for prescribers are needed, Bruce Warner,
senior pharmacist at the National Patient Safety Agency, believes.
He said that, to prescribe competently, prescribers need to know what skills
they require and they must be able to demonstrate their mastery of those
skills and their ability to apply them to practice.
However, the skills needed to perform prescribing tasks varies across tasks,
not across professions, he said, and so skill sets for prescribers should
be task-based and not centred around particular professional groups.
Establishing multidisciplinary standards would, he argued, help to avoid
the blurring of responsibilities across professional boundaries and thereby
reduce clinical mistakes.
National action needed on waste
Those involved in schemes seeking to reduce medicines wastage need to
begin working together at a national level, said John McIvor, chief executive
of Lincolnshire Teaching Primary Care Trust.
He believes there is a lot of worthwhile activity was being wasted, because
it was not being conducted in a concerted, continuous or joined-up fashion.
“Where is the collective action nationally,” he asked. “We
need to stop being precious about our own ideas and start working
together.”
Mr McIvor described a recent scheme he had worked on in South Yorkshire
tackling medicines wastage. A campaign was run across nine South Yorkshire
PCTs and South Yorkshire Strategic Health Authority. The principal aim
of the scheme was to encourage patients and carers to think carefully before
requesting repeat prescriptions for medicines they no longer need and the
main groups targeted by the campaign were patients and carers, but doctors
and pharmacists also needed to be aware of the campaign, he explained.
“A campaign of this kind cannot work in isolation without the full
support of health care professionals, such as GPs and pharmacists and,
of course,
practice, hospital and pharmacy staff who interact on a daily basis with
our main
audience,” he said.
It incorporated two key messages — “only order what you need” and “bring
back medicines for safe disposal” — across a variety of marketing
materials, including posters and leaflets, advertisements on buses and
trams and inserts in prescription bags.
As a result of the campaign, 65 per cent of patients questioned said they
had discussed their medicines with either their GP or their pharmacist.
In addition, 68 per cent of patients said that they had returned their
own unused medicines to the pharmacy. In 50 per cent of cases this was
because the medicine had been stopped or changed.
“What would have happened if we hadn't run the campaign,” Mr
McIvor asked. “Patients would have been ordering the same medicines,
perhaps taking them themselves or just putting them in the cupboard, using
them
in the same way. It seems to me that that is negligent on the part of those
prescribing, that we should have such a startlingly high figure.” |
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Pharmaceutical Journal