Primary Care Pharmacy November 1999 Vol 1 No 1 p12-13

Promoting rational prescribing and budget management

By Jaqueline A. Kinsey, MSc, MRPharmS

An independent function that requires balancing management concerns with professional requirements

Within Wales there are five health authorities (HAs), each with their own pharmaceutical and medical advisors (PAs and MAs) who have traditionally worked together on prescribing issues. Working within the Principality of Wales gives the special benefit of being able to maintain regular communication with all the PAs and MAs. This year has seen some major changes firstly, the re-organisation of the National Health Service has seen the end of fundholding and the advent of the local health groups (the Welsh equivalent of primary care groups) and secondly the formation of the National Assembly for Wales. However we continue to work together at an "All–Wales" level on prescribing matters and we can directly pass any concerns and comments to the Welsh Assembly via the Assembly's pharmaceutical advisor.
The role of the pharmaceutical advisor is diverse, but in the main concentrates on providing prescribing advice and support to general medical practitioners with the promotion of rational prescribing and budget management.

Budget management

Dyfed Powys is the largest of the five health authorities covering over one–third of the landmass of Wales.
There are four local health groups and two pharmaceutical advisors covering 80 practices with a prescribing budget of over £58m. Each advisor has responsibility for two Local Health Groups (LHGs) but it is essential that both work closely together to maintain the same level of service across the HA. Since the devolvement of the PAs to LHGs there have not been any significant changes to the work, although there are now additional roles such as advising the LHG board on prescribing issues and liasing with the pharmacist member of the LHG. Prescribing budgets have also been devolved to LHGs and the management of this budget is seen as a high priority. LHG managers are anxious to see a saving on this budget so that other services can be funded. Conversely, overspends on the prescribing budget will have severe financial consequences and may involve services being cut. Many factors, eg, list size, deprivation, etc, are taken into consideration when setting the prescribing budget. Deprivation varies across LHGs and is not easy to assess.¹ Some areas have high social deprivation with high unemployment and long–term sickness levels, whereas areas such as Powys have high rural deprivation factors.
Setting a budget which practices and LHGs are happy with, or at least will accept, is one of the biggest challenges for the PAs.
Monthly monitoring of the budget occurs with adjustments being made where necessary for changes in list sizes, high cost drugs, etc. Regular scrutiny of the budget can alert the PA to any trends which might have an impact on the budget and these concerns can be fed back to the LHG via the prescribing subcommittees, local clinical governance groups or other appropriate body. However, the PAs are hampered in providing advice by the three–month delay in receiving this data from the prescription pricing bureau.

Prescribing incentive scheme

It has traditionally been a role for the PA to set incentive schemes for practices to encourage them to make savings on their budgets. It is now even more important for the PA to target practices which might not be so keen to address prescribing overspends, as the LHG as a whole must be below budget to trigger the incentive payments. The challenge is to devise a prescribing incentive scheme which is realisable, will reward those practices which have already addressed weaknesses in prescribing and encourage them to the maintenance of good habits and not demotivate those who have a lot of work to do. It should also include some quality indicators so that the level of rational prescribing, ie, that which is safe, effective, appropriate and economic, increases.

Rational prescribing

If the PA is to gain GPs' trust and co-operation it is important that prescribing messages are not seen to be wholly about reducing costs but are messages which are based on evidence based practice. In fact, some messages will significantly increase costs, such as the use of statins in hypercholesteraemia. It has been shown in the past that imposing financial restraints can lead to switches of unrestricted but equally inappropriate alternatives.2,3 Conversely, it is possible to alter prescribing behaviour to improve the quality of prescribing and achieve cost benefits. There is now much evidence on different methods, both passive and active, of disseminating information but no firm conclusions on the most effective.4,5 However, the main accepted model of providing prescribing advice is by "academic detailing" visits.6,7,8 Regular visits are not always possible as, in Powys, some practices can take three hours to reach, so other methods of disseminating information have to be devised. These include:

Evidence based practice should form the basis for prescribing messages

Use of printed material Prescribing newsletters or bulletins have been developed with the help of local drug information services. The aim is to deliver short, sharp messages about prescribing issues that affect GPs locally.
Face to face educational programmes It can be productive to hold joint educational meetings with GPs and pharmacists. The PAs work in close collaboration with Welsh Centre for Pharmacy Postgraduate Education tutors as well as with local medical tutors. This has in the past been a useful forum for community pharmacists to discuss with GPs how they can jointly work together.
Prescribing feedback with discussion in peer groups With the greater emphasis on services at a local level it can be useful to bring GPs together and show them variations in their prescribing behaviour and get them to discuss or even justify their prescribing behaviour to their peers. The discussions around the reasons for variation can be very illuminating.
Feedback from opinion leaders Many pharmacists when discussing prescribing issues with a GP will have heard them say when challenged over the use of a particular drug "I never prescribe that drug - it was started in hospital". If secondary care colleagues are involved in discussions at the primary care level at an early stage, it is possible to address problems that may arise in the future. This is of particular importance with the introduction of new drugs.

Project management

The PA is also a key person in the development of new services. Currently in Dyfed Powys there are various primary care projects which have received money from the former Welsh Office. Currently we are involved in projects looking at the use of community pharmacists providing prescribing advice to local GPs, medicines management in nursing homes, and the use of a supervised consumption methadone scheme. It is essential that this work is continued as better practice can result with cost benefits. The nursing home project has demonstrated better patient care and savings of between 20 and 30 percent.

Conclusion

The role of the PA is varied and interesting and it is only possible to give a small insight into the full role. It is very demanding, you need to be independent and capable of balancing management concerns with your professional position. It is necessary to have good communication and negotiation skills as well as teaching skills. Although the work is challenging and often involves long hours I find it a privilege to be able to speak openly and frankly to so many different professionals.

References

Mrs Kinsey is a pharmaceutical adviser to Dyfed Powys health authority