Medicines Management
Issue no 1, pp15-16
January/February 2002

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Features

Working with GPs: the "prescribing efficiency scheme" pilot in Devon

I am a community pharmacist working for Moss Pharmacy in Cullompton, a small town within Mid-Devon Primary Care Trust (PCT). The town has two GP practices and two pharmacies (both owned by Moss).

I was keen to improve patient services and to build closer working relationships with the local surgeries, so I contacted the PCT prescribing adviser to see if there were any local initiatives that would assist in achieving these aims.

It was proposed that Cullompton could be a pilot site for a 'prescribing efficiency scheme' (PES). All four PCTs in North and East Devon Health Authority have piloted similar schemes which are tailored to reflect local needs.

My starting point was to think about how we could optimise the use of medication as it is one of the major challenges facing general practice and PCTs, with an increasing need to demonstrate that prescribing is evidence based and cost-effective.

Nationally, repeat prescribing accounts for between 66 per cent and 75 per cent of prescriptions and about 80 per cent of drug costs in primary care1.Good control of repeat prescribing will deliver a better quality of patient care to those on long-term medication while minimising the risk of inappropriate prescribing and polypharmacy. It will also increase cost-effectiveness through a reduction in the drug wastage frequently generated by inefficient repeat prescribing systems. Ideally, repeat prescriptions should be reviewed regularly. In practice however, it may be difficult to review fine prescription details due to shortage of time.

The PES offered assistance in the process of review of both repeat prescriptions and for prescriptions for acute conditions. Community pharmacists are well placed to offer prescribing support to practices, particularly with respect to cost-effective prescribing, as they continually manage issues of cost, formulation, pack size and availability of prescribed medicines.

Purpose of the PES pilot

The purpose of the PES pilot was to study and evaluate a collaborative working initiative between community pharmacists and general practices, which would assess and review prescribed medication at the point of dispensing and initiate interventions that would result in clinical and/or financial benefit. The two panels (below) indicate the benefits we expected GPs and pharmacists to experience.

Probably most importantly, we also expected that there would be improved overall patient care through integrated pharmaceutical care.

Establishing the pilot

A pilot scheme undertaken by Cotswold PCG between January and April 2000 was used as a basis for the Mid Devon pilot. Initial meetings were held with representatives from the two practices, myself and the PCT prescribing adviser to decide what interventions would be studied. All interventions would involve discussion with the patient concerned.

Approved interventions

A list of approved interventions were agreed as follows:

• Change from branded products to generic equivalents (except those drug formulations listed in the BNF where prescribing should be by brand name)

• Change from generic products to branded products where appropriate to ensure consistent supply eg, lithium, theophylline

• Dose/strength optimisation

• Identification of repeat medication that had been discontinued

• Identification of excessive quantities of dressings

• Ensuring appropriate use of soluble dosage forms

• Review the use of modified-release painkillers and topical NSAIDs

• Review the use of enteric coated aspirin

• Review the use of frequently requested 'prn' drugs eg, 5HT antagonists for migraine, nitrates, inhaled beta2-agonists, stimulant laxatives

Agreed protocol

The agreed protocol consisted of two options. Either I would contact the GP responsible for the prescription immediately to recommend a clinical amendment and dispense it as instructed and then return it to the surgery for amendment; or I would dispense the repeat prescription as written and contact the prescriber to recommend a change for future repeat prescriptions.

My role in this process was as follows:

• To assess all prescriptions received for dispensing from participating GPs for possible interventions

• To record the intervention on a pro-forma, noting any potential clinical benefit and/or cost saving

• To send completed pro-formas to practices each week for review

Both practices had a nominated member of staff who was responsible for handling the returned prescriptions who had to:

• Ensure returned prescriptions were reviewed and amended

• Ensure amended prescriptions were returned promptly to the pharmacy

• Ensure patients' computer records were amended

• Receive weekly pro-formas and return those reviewed to the pharmacy complete with GP initials

The pilot was conducted over a six-week period during February and March 2001. Practices were paid a participation fee to cover the cost of staff time involved. Community pharmacists were paid a participation fee and a fee of £1.50 for each intervention made.

Evaluation and results

The pro-formas were used to ascertain the proportion of clinical interventions that were implemented and the cost savings to each practice.

Feedback from practices, community pharmacists and patients was also noted.

During the six-week period, a total of 204 interventions were made saving £718. Interventions mostly involved the rationalisation of dosing regimens and ensuring the continuity of branded supplies of certain drugs.

One hurdle I had to overcome initially was the fact that one of the participating pharmacies had no permanent pharmacist. This was unfortunate, but the protocols were explained to the locums working there who were able to action interventions involving prescriptions for acute conditions, while I studied all the repeat prescriptions outside normal working hours to identify common themes for intervention.

I found it interesting as to which interventions the practices were particularly keen to monitor.

Both practices agreed to establish a protocol for the pharmacist to discuss with the patient the use of simple rubefacients instead of topical NSAIDs. This was in line with the PCT prescribing strategy.

Interestingly, discussing the switch from topical NSAIDs to simple rubefacients was a daily occurrence and I was successful in 50 per cent of cases. Some patients were sceptical but I found talking to them about their medication rewarding and believe it went a long way in building the patient-pharmacist relationship.

By far the most common intervention was for dose/strength optimisation. Optimising the doses of ACE-inhibitors (eg, changing from two 2mg perindopril tablets daily to one 4mg tablet once daily) and statins generated the most cost savings.

Patients were unaware of the different strengths available and, when changed from two tablets a day to one, were often grateful to be taking fewer tablets.

I found that brand names were most frequently used when prescriptions were handwritten. Lithium carbonate was the most common generically written drug that was recommended for brand prescribing.

Benefits to pharmacy

I believe that the full participation of the local GP practices in this pilot gave patients a positive image of pharmacy. It definitely increased the number of daily requests that pharmacists received from patients wanting to know more about their medicines.

The pilot was also valuable in terms of improving my working relationship with the GPs and the practice staff.

I firmly believe that by using a team approach to patient care, the pharmacist can, and should, have a central role in helping patients get the best from their medicines. The community pharmacist is in an excellent position to improve patients' understanding of their medication and help practices manage repeat prescribing.

I look forward to actively participating in future initiatives to manage repeat prescribing in the PCT.