Features

Hampshire medicines management project saves NHS over £1 million

In 2005, the Medicines Manage-ment Programme Board, a body constituted from Eastleigh and Test Valley South (ETVS), New Forest, Southampton City and Mid Hampshire primary care trusts, Southampton and Winchester Hospital Trusts and the West Hampshire Trust, identified five prescribing changes that were capable of saving £1.75m across ETVS and New Forest.

The medicines management teams of these two PCTs took on the challenge of implementing these changes in primary care. Effective implementation required each practice to have dedicated pharmaceutical support and prescribers to be aware of, and in support of, the changes. At no stage were GPs offered financial inducements to participate in the project and we are grateful for their goodwill.

Targets

One of the key objectives of the project was to ensure the cost-effective prescribing of statins. The target was to have the most cost-effective drug, simvastatin, prescribed for 80 per cent of all statin prescriptions.

In the New Forest and parts of ETVS this meant a major change in prescribing habits since, as a result of a previous recommendation to use a different drug (based on costs before generic simvastatin became available at around 10 per cent of the previous price) less than 50 per cent of statin prescriptions were for simvastatin.

Some practices adopted the change early and willingly, while others raised legitimate concerns about the equivalence of effect on cholesterol levels. We generated data from the early adopting practices to prove that simvastatin was as effective at lowering cholesterol and these remaining practices were persuaded. Measurements of, for example, patients’ cholesterol levels and blood pressures revealed that the prescribing changes were not detrimental, and that GP performance (under the quality and outcomes framework) was not adversely affected.

Other practices were concerned about the workload of changing several hundred patients’ prescriptions and worried about handling patients’ concerns. We drafted letters for the practices to use and, in some cases, agreed to have the team telephone number on them so that patients could call. If they did, a member of the team would explain the rationale for the change. In New Forest PCT 78 per cent of statin prescriptions are now for simvastatin and in ETVS the figure is 80 per cent.

Another intervention involved the cost-effective use of antidepressants. It meant persuading prescribers to concentrate on the use of two drugs, fluoxetine and citalopram, as first-line agents, instead of more expensive newer drugs. Though heavily marketed, the newer products have no clear advantages and we often found themselves at odds with the pharmaceutical industry, which tried to persuade us otherwise.

Another commonly used drug, amlodipine, had recently come off patent and become much cheaper. However, the generic product was amlodipine maleate and the GP computer systems tended to offer the original product (besilate) at the top of their menus when the drug was typed in. Detailed work was required to counteract this technical flaw. Unfortunately, this work frequently needed to be repeated when monthly update discs had been run. A combination of educating and persuading practice staff to do this and doing it ourselves was employed.

Communication

The ways in which the medicines management teams got their messages across were varied: GP medicines management groups, practice meetings, individual discussions and prescribing newsletters were all used. In addition, we made community pharmacists aware of what we were planning and when it would happen locally. They, in turn, assisted with giving information to patients about the changes. We also spoke to some of the patient groups attached to surgeries, to explain and discuss our work to improve both the effectiveness and the cost-effectiveness of therapy.

Performance was monitored from Pres-cription Pricing Division data every month. This was shared with all the practices so that everyone knew how they were doing. Figures were regularly discussed at GP medicines management meetings.

Members of our two medicines management teams also met frequently to share learning about the change management that we were driving forward. Clear protocols for making changes were developed and these were adapted for different practices.

Success

Prescribing was monitored using robust data and benchmarking performance against national and Hampshire averages. At the outset, potential savings were carefully calculated so we were able to track progress month by month. Overall prescribing costs have fallen from 2.5 per cent below to 10 per cent below the national average.

Monitoring costs across England had the effect of contextualising what we were doing: we were encouraged, at one stage, when we calculated that if the whole of England had done what we did, savings of several hundred million pounds could have been made.

The work done on this project in 2005/06 resulted in savings of £1,123,000 across the two PCTs. This saving will be repeated in future years as long as the relevant drug costs remain broadly similar. We have also helped GPs to realise that NHS budgets are finite and that savings made in one area may free funds for use elsewhere. This will be helpful for implementing practice-based commissioning.

The freeing of significant resources for our organisations has made a significant contribution to meeting financial targets and to avoiding the draconian measures which would have been imposed on our PCTs had we failed. Such measures would undoubtedly have meant reduction in services for patients.

Patient perpsectives

There were no direct measures of patient satisfaction but in one practice, where over 300 patients had a medicine changed, only 11 rang the medicines management team to discuss it. All patients had received letters explaining the project and only one ultimately refused to agree to a medicine change.

Many of the patients affected had the chance to discuss their medicines and the changes to their therapy with GPs or pharmacists. It was found that, overwhelmingly, patients are happy to agree to things that save money for the NHS as long as they are persuaded that the change is not detrimental to themselves — they are proud, on the whole, to do their bit to help us reduce the NHS spend and hence the burden on taxpayers.

As a result of seeking the co-operation and collaboration of patients, an increased feeling of partnership was evident, which adds to the develop of the partnership agenda between patients and NHS professionals.

Team outcomes

Before this programme the teams had little experience of large scale therapy switches in general practice. As a pharmacist working in a practice, it is relatively simple to carry out tasks that the practice wants. In this project we had to persuade the practices that a major money saving effort was required, even though the two PCTs were doing relatively well in prescribing at the start of the project. The teams have become much more skilled in managing and driving change.

As two PCT teams coming together we have also learnt from each other and matured as an integrated unit. The PCTs have seen clearly what we have been able to achieve through monthly medicines management reports. There is a greater awareness within the organisation of how medicines management is relevant to almost all parts of health service delivery.

In addition, because we have been able to show GPs changes in hospital prescribing practices resulting from other parts of the programme, there is now a genuine feeling that we are all acting together within one health economy.

Finally, our value for money is clear — a group of staff who cost the PCTs around £400,000 per year have achieved savings of almost three times this amount.

Conclusion

As a result of this project, prescribers in both primary and secondary care are more willing to listen to our PCT’s wishes and to collaborate with implementing desired changes. The PCTs now have pharmacists designated to provide support to all practices and good long-term relationships have developed — we are now well-placed to discuss the needs of the PCT and the local health economy and this is beginning to bear fruit in practice-based commissioning locality groups.

Pharmacists in the PCTs are a trusted source of both information and practical assistance. Although this has been built on a history of providing support to clinicians, the ability to make a real financial impact is significant.

Our medicines management programme is ongoing and, it is hoped, will be applied to the whole of Hampshire. The need for interventions is likely to continue as the costs of various drugs change as a result of both patent expiry and the operation of category M in the Drug Tariff. Five further key prescribing interventions are now being finalised.

By increasing the cost-effectiveness of prescribing we free resources for other things, including the uptake of new, expensive and effective therapies in either primary or secondary care.