Medicines Management
Issue no 2, pp20-21
March/April 2002
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Medicines Management |
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Features |
What you need to do to establish and benefit from a joint formulary
Primary care organisations are developing joint formularies with their local acute trusts to help rationalise prescribing at the primary and secondary care interface as well as to lower costs. But the process largely depends on coterminosity with areas served by the local acute trusts, and is often more advanced in urban areas with fairly well defined patterns of referral. For example, Hodge Hill PCG, Birmingham, was able to develop its joint formulary with Birmingham Heartlands and Solihull NHS Trust, after the two local district general hospitals became a single trust. Peter Clewes, prescribing adviser at Hodge Hill PCG, says that having input from North and South Solihull PCGs, with support also from the Birmingham PCGs, helped the formulary development process. Before the PCG existed, there was a GP user committee that dealt with interface prescribing issues. But this had not been successful in tackling the trust's prescribing committee about the costs of drugs in primary care as a result of their prescribing of discharge medication and outpatient prescribing. First steps Once the PCG was launched, the hospital trust agreed to help form an interface prescribing group (IPG), which was a joint hospital and primary care prescribing committee. The group first met in April 1999. At its first meeting, the group decided that developing a joint formulary would be its main aim. Mr Clewes says that the group used the British National Formulary as the basis, and each prescribing lead from the five PCGs was asked to lead the development of two or three chapters during the following year. Draft chapters were circulated to PCG GPs and interested hospital clinicians for comment and then approved, following a final review, by the IPG. The next stage was to develop a formulary editorial committee, comprising two PCG prescribing leads, two trust pharmacists and three PCG prescribing advisers. In February 2000, the finished formulary was sent to all GPs in an A5 ring binder format, which allows for updates. A paper version was produced for the acute trust, and an electronic version has also been developed for the hospital intranet. The formulary covers most prescribing in primary care, and Mr Clewes says it is the first step towards developing a mandatory hospital formulary, which the hospital prescribing committee is currently debating. First and second choice drugs are set out for primary and secondary care, followed by a special consideration choice, and medicines for trust or GP specialist prescription. The IPG continues to revise the formulary, adding in summaries of guidance from NICE and the national service frameworks as they are published. There is also a form for GPs and specialists to suggest additions, and managing these new medicine requests has become quite a task for the group. Mr Clewes says that the PCT is committed to making the most of local community pharmacists' skills, and adds that Pharmacy in the Future provides an exciting opportunity to extend team working, and further develop the joint formulary work at the interface. "Community pharmacists are involved in some of the formulary development work as we take comments from local practice-based pharmacists. These pharmacists, mostly community pharmacists, regularly engage with GPs and invite comment and opinion during the formulary consultation processes," he says. Individual implementation strategies When the formulary was launched, each PCG was left to decide its own strategy for implementation. "We thought it was important the formulary was owned by the PCGs and trust, and not dictated by the IPG," says Mr Clewes. He adds that the closer working relationship with the hospital trust has led to many positive spin-offs. "We have various working groups around guideline development including ones for statins, hypertension, antibiotics and oral sip feeds, and we have held several educational evenings for GPs," says Mr Clewes. The formulary development has also led to the appointment of a full-time interface pharmacist to examine other prescribing issues, and the department of pharmacy practice at Aston University is evaluating the impact of the formulary on prescribing habits. The formulary has already had an impact on the drug selection process, which has led to evidence-based and cost-conscious prescribing decisions in primary and secondary care. "As the IPG moves on to develop guidance and policy, with the same principles, alongside the formulary, NICE guidance and NSFs, prescribing is likely to become more manageable," says Mr Clewes. He adds that the IPG is a useful forum for discussing the development of prescribing and medicines management issues across the interface and allows a co-ordinated approach. "However, much will depend on the long-term stability of the IPG against the background of the current organisational change," he says. Development work around local pharmaceutical services will start shortly, and Mr Clewes adds that issues like clinical governance in the community pharmacy agenda are being tackled as part of a city-wide approach. "Pharmacist supply of medicines through patient group directions already takes place and supports our medicines management agenda," adds Mr Clewes. Joint formulary to tackle costs North Peterborough PCT began work on a joint formulary with its local hospital trust in early 1999 when the chief executives from the PCT and hospital decided they wanted to tackle cost pressures at the primary and secondary care interface. Deirdre Tunney, prescribing manager at North Peterborough PCT, says: "Patients were often discharged on medicines from the hospital formulary that were not necessarily on individual practice formularies, leading to changes in medication." She adds: "Each hospital had its formulary previously, as did individual practices — it was just a matter of bringing the two together so that patients did not have their medication changed on discharge." To achieve this, the PCT and hospital trust established a core group with representation from primary and secondary care, involving prescribing leads from local PCGs (as they were at that time), management from hospital pharmacy and also primary care pharmacists. Each chapter of the formulary was developed individually, using specialists in each therapeutic area, alongside pharmacists from primary and secondary care. Chapters were then added to the formulary based around the BNF. A community pharmacist active in the locality was involved in the core team that developed the formulary. "It was useful to have those views being fed in on some of the practical aspects of prescribing," says Ms Tunney. Since publication of the formulary, each community pharmacist has been sent a copy. "We're now talking about evaluating the effect of the formulary, and possibly looking to begin work extending the quantities that can be prescribed on discharge or at outpatient clinics," says Ms Tunney. She adds that the joint formulary has also helped avoid the practice of consultants writing to GPs to avoid formulary restrictions. "We want to make sure that any drugs being prescribed are being used right across the spectrum," she adds. Most of the formulary gives generic choices, but there are references to proprietary drugs where the core team felt they were relevant and should be used. But Ms Tunney does not think that the formulary will have much of an impact on local community medicines management schemes, apart from helping them rationalise practical aspects like stock control. "The sort of medicines management initiatives we are doing are mostly around medication reviews, and particularly on people who are taking several medicines," she says. In the meantime, the formulary is kept alive and updated by a joint formulary committee, which meets every six weeks to consider new additions and recommendations. Ms Tunney says: "The committee has given us a much better forum for liaising with secondary care, and has meant that we can pursue issues like the expansion of 28-day prescribing on discharge, and align that with primary care." Joint formularies not always answer Not all PCTs are using joint formularies to rationalise prescribing choices and lower costs at the interface. In rural areas, such as that covered by Fenland PCT, prescribing advisers say that it is just not possible to develop a joint formulary as they refer patients to too many different hospital trusts. Ron Smith, prescribing adviser at Fenland PCT, says: "The problem we have compared with North Peterborough PCT is that we refer to three or four different acute trusts, because of the geography of the area. There is just no point in going down this route for us." Other PCTs such as Hillingdon are taking a disease management approach to rationalising medicines use, by drawing up specific management guidelines in each therapeutic area. Prescribing adviser for Uxbridge and & West Drayton locality, part of Hillingdon PCT, Vasundra Tailor says: "We decided in Hillingdon that we weren't going to go down the route of developing a formulary but would work towards disease management and integrated care pathway that covered the medication angle." She adds that the process has involved getting local clinicians from primary and secondary care together to discuss the range of first and second line drugs that are appropriate in each disease area. From this, a disease management guideline is drawn up, with recommendations for medicines alongside a detailed care pathway, providing management guidance to GPs about when they should refer patients to the acute trust, for example. The guidelines are not only sent out to primary and secondary care clinicians, but also to local community pharmacists who are beginning to become much more involved in medicines management issues through medication reviews. |
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