Report of the accounts commission for Scotland

The Accounts Commission is a statutory independent body responsible for external audit of NHS services in Scotland. Building on the work already developed by the Audit Commission in England and Wales, the team has worked with health board medical and pharmaceutical prescribing advisers over the past year to provide new information on patterns of prescribing, and to identify areas of practice where there is scope for improvement in quality and cost-effectiveness

While the report of the Accounts Commission is a Scottish document the issues are the same throughout the United Kingdom and the important areas for change are applicable.
A series of prescribing indicators designed to assess good clinical practice and cost effectiveness has been designed. Comparisons between practices and health boards are valid because the data has been adjusted using a weighting system (SCOTR PU) based on Scottish data which takes age, sex and temporary resident numbers into consideration. Daily defined doses have been used to standardise quantities of drugs prescribed. The adjustments cannot take morbidity into account, nor the effects of very expensive drugs prescribed for small numbers of patients. However the data produced does provide useful information and prescribing advisers will benefit by receiving individual practice analysis of the quality and cost indicators used in the report, information that has previously been unavailable.
The report highlights that variation between practices cannot be explained by the differences in patient population alone and suggests that there is still considerable potential to improve quality and cut costs. It also concludes that this is likely to be achieved only if general medical practitioners, pharmacists and trust and health board managers work together, and if GPs are given support to identify the most appropriate treatment for patients and to explain the reasons for change to their patients.

"There is still considerable potential to improve quality and cut costs"

Priority areas

The following priority areas are set out:

Ensuring the most effective drug treatments for asthma, hypertension and bacterial infection

Development and use of drug formularies to improve quality and safety of prescribing

Reduction in use of drugs classed by the BNF to be "less suitable for prescribing"

Increasing generic prescribing

Substitution of drugs from the same therapeutic class in appropriate patients

Avoiding unnecessary use of special formulations, eg, sustained release preparations, where standard preparations are suitable

Reduction in prescribing of drugs where the BNF considers efficacy not to have been established or relief to patients is minimal

Reduction in use of over-prescribed drugs, eg, newer antibiotics

Improved management of repeat prescribing to avoid unnecessary treatment and minimise side effects

It is estimated that implementation of these recommendations would improve patient benefit while saving in the region of £26m a year to reinvest in new patient services and effective new treatments. The report endorses the support of pharmacists as facilitators in assisting GPs to achieve high quality cost-effective prescribing, not only at prescribing adviser level to identify areas where prescribing could be improved and to offer advice on how to achieve it, but also at practice level, working within the primary health care team. It accepts that projects involving pharmacists and GPs working together have indicated benefits to the practices involved, and identifies the main constraints to further development as availability of pharmacists and finance. The most appropriate support level depends on a number of key questions listed below. It also recognises the need for additional training and the practical problems facing community pharmacists.

What areas could be improved?

What is the most appropriate way to achieve the improvement?

What are the objectives of providing support?

What type of service is to be provided?

What would each individual type of support provide?

For how long will each type of support be required?

Are GP practices in agreement with the Primary Care Trust about type of support which would be most beneficial?

Has similar support been provided in the past to other practices within the PCT? By other PCTs? What were the outcomes? Why?

Will the proposed support achieve the objectives in the most cost-effective manner?

Is the proposed support equitable?

Is the proposed total package of support achievable in terms of total resources available?

How will the proposed support be evaluated?

There are three important recommendations for pharmacy:

Primary care trusts should consider how to implement the Clinical Resource & Audit Group (CRAG) document "Clinical pharmacy practice in primary care".²

In each PCT, prescribing advisers, GPs, community pharmacists and practice pharmacists should agree a strategy for working together to meet the needs of individual practices and realise PCT-wide initiatives

PCTs should encourage GPs and community pharmacists to consider medication review either at the GP practice or in the pharmacy

This document provides pharmacists with scope for further opportunities to become involved with the practice based primary health care team to improve quality of prescribing for patients.

References:

1. Accounts Commission Supporting prescribing in general practice. Accounts Commission, September, 1999.

2. Clinical pharmacy practice in primary care. Clinical Resource & Audit Group, February, 1999.

Primary Care Pharmacy November 1999 Vol 1 No 1 p30-31

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