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Mike Beaman, is a pharmacist from
Littlehampton, West Sussex
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The Broad spectrum feature is
open to any reader. Contributions of around 1,100 words commenting
on topical issues
may be posted to Graeme Smith, managing editor, or
e-mailed to graeme.smith@pharmj.org.uk for consideration
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Back in 1983, when I was appointed a district pharmaceutical officer,
I was asked at the outset by my general manager whether I would pay for
my salary in the first year from savings on the drug budget.
Twenty-five years on, has anything changed? I am sure many pharmacy managers,
both in primary and secondary care, can identify with that.
Recently, I was a guest speaker, alongside a primary care director in
one of the large pharmaceutical companies, at a meeting of the Pharmaceutical
Marketing Society. We spoke on the subject of prescribing influences.
The following is a distillation of our respective presentations and the
discussion that ensued.
We began by reviewing the impact on the NHS of drug expenditure, which
in 2005/06 amounted to 18 per cent of the NHS budget, second only to
the pay bill. This was broken down to 23 per cent in secondary care and
the remainder in primary care. Drug costs in secondary care had risen
faster than in primary care, probably due to the difference in product
mix. When turnaround teams are sent in to make savings on the NHS budget,
prescribing, perhaps unfairly, is always targeted, partly because the
data available are the most accurate and transparent for any aspect of
health care activity.
The pressure on prescribing continues unabated following a series of
NHS changes over the past two years. Strategic health authorities (SHAs)
and primary care trusts have scaled up and this has been accompanied
by the emergence of practice-based commissioning groups, all of which
are focused on managing within finite budgets. SHAs have a performance
management role and prescribing will continue to be monitored against
a series of indicators in the prescribing toolkit. Practice-based commissioning
groups have their toolkit as well, and this could be used to link prescribing
to activity such as utilisation of secondary care services and prevalence
and management of long-term conditions. How many prescribing advisers
have spent inordinate amounts of time with high prescribing practices
when, really, it is their broader activity that should be focused on?
Against this background there has been a series of reviews. The National
Audit Office has examined prescribing cost and quality in primary care
and has recommended improvements to make the communication process with
prescribers more effective. The Office of Fair Trading is currently reviewing
the Pharmaceutical Price Regulation Scheme and considering factoring
in a new element around the cost-effectiveness of drugs. The Government
is currently reviewing prescription charges, no doubt prompted by the
Welsh Assembly’s decision to abolish them. There is scope here
to review the exemptions system, particularly around long-term conditions.
The FP10 has always been an “open cheque book”; why not base
charges on volume rather than number of items?
At a more local level the National Prescribing Centre has been examining
area prescribing committees with a view to making them more effective.
So what support mechanisms are in place for pharmacy managers, particularly
those in primary care, where the bulk of prescribing takes place?
The ever-increasing range of National Institute for Health and Clinical
Excellence guidance on drugs and treatments, ably supported by regional
centres such as MTRAC (Midlands Therapeutic Review and Advisory Committee)
and the London New Drugs Group, provide much needed support in local
decision-making.
The National Prescribing Centre provides a comprehensive range of training,
development and information support. The emergence of new prescribers
and the new pharmacy contract in the community provide alternative routes
to managing prescribing and use of medicines but in both these areas
the impact, as yet, has been less than modest. This is not a criticism
of those health care professions involved; rather, it is a judgement
on the lack of infrastructure to support these changes. For instance,
new prescribers have to hand-write their prescriptions. The number of
pharmacists wishing to become prescribers is limited by a lack of mentor
support. In the case of the new pharmacy contract the All-Party Pharmacy
Group has recently published its review and, hopefully, this will provide
a way forward to make the contract more effective. At times it appears
a bit like being in a swimming pool where there is a lot of activity
going on but mainly in the shallow end.
Are we spending too much on prescribing? Personally I think not, when
one considers the central controls in place around the costs of generic
and branded medicines and the initiatives of senior pharmacy managers
in the area of procurement of medicines and appliances. Coupled with
this are the mounting pressures on prescribing arising from new technologies
in health care, the population changes that are occurring in the UK and
the management of long-term conditions. There will always be savings
to be made on prescribing but the direction of travel should be around
optimisation rather than cuts. It is a perverse situation when savings
that have been achieved on the drug budget are clawed back to offset
deficits elsewhere. But then we now have a government that measures a
part of its performance in the NHS on “financial health”.
What changes would one like to see if one could go back to the drawing
board?
First, budgets should be introduced that cover a care pathway in long-term
conditions rather than operate in “silos”. A new expensive
drug, which might save money elsewhere in the service, might then become
a more attractive proposition.
Secondly, high cost/high technology drugs, particularly those with a
limited evidence base, should be removed from local budgets, which, after
all, are finite. Far better if these could all be managed through specialist
commissioning or at a higher level where further research could ensue
before making them more freely available
Finally, the ethical dimension must be given consideration. The plight
of cancer patients being refused a new drug on the basis that it will
only increase their lifespan by three or four weeks poses a real dilemma
and, as a former prescribing adviser, I never felt comfortable having
to make such decisions. Many PCTs now have mechanisms for prioritising
treatments, including medicines. However, I believe there is a need to
include an ethical perspective to these groups. Furthermore the establishment
of clinical ethics groups could take this a step further by addressing
questions of a broader nature. For instance should we continue to prescribe
statins to patients over 90 years of age?
Clearly a political change of direction in managing the nation’s
drug bill is needed and it will be interesting to see if the forthcoming
NHS review, led by Lord Darzi, will address these issues. Watch this
space!
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