Medicine jar

Dr Hasan Chowhan
GP Trainer
Vice Chair, North East Essex CCG, Colchester

Within the NHS a significant proportion of the budget is allocated to medicines prescribing. As GPs we often find ourselves on the frontline having to 'gatekeep' this budget. As new clinical commissioning groups (CCGs) take form, we will inherit the same difficulties our predecessors may have had in managing this significant budget appropriately within primary care, especially as increased savings need to be found in this tough economic climate.

As CCGs become more established, there is significant pressure to reduce drugs spending while at the same time improving the quality of patient care. With these unremitting monetary pressures and continual changes to National Institute for Health and Clinical Excellence (NICE) guidelines, medicines management was an obvious Quality, Innovation, Productivity and Prevention (QIPP) workstream within the primary care trust (PCT). Most PCTs will already have plans in place to tackle the primary care prescribing spend, which CCGs will have to continue in an increasingly more demanding world.

Practice prescribing budgets are calculated using a methodology that takes into account both fair shares and historic spend for each individual practice. Within North East Essex, the overall allocated budget for medicines in primary care is approximately £55m. This takes into account both practice and specialist prescribing. Each year, calculations move further away from historic spend and focus on demographics, with a greater emphasis on disease registers, as it is these variables that to a greater extent drive prescribing needs and requirements. For 2011/12, the budget was calculated accounting for a number of variables including deprivation, disease registers and social settings.

One of the biggest issues with allocating a prescribing budget – or indeed any budget to primary care activity – is ownership and accountability. Each individual practice should be made aware of their annual budget, and should have a good idea of how well they have performed historically against this.

As with PCTs before us, CCGs will need to deal with the question that always arises as to what processes need to be put in place for those practices that continually exceed their budget. Currently there is no definite negotiating lever as part of the GP contract. Having to performance-manage a practice that is overspending on any budget is not an easy task.

Typically, if a practice continuously overspends, the PCT is able to approach them and offer advice and assistance (assuming the practice is willing to entertain the prospect). To further fuel the challenge, some practices remain dispensing practices, which can itself prove difficult when negotiating drugs budgets due to the potential conflicts of interest.

What prescribing-management challenges face CCGs?
Following on from the issue of overspending is of course the matter of appropriate prescribing. One of the biggest challenges facing us within the NHS is inappropriate prescribing. A number of issues can affect clinical choices:
Prescribing drugs not required – for example, antibiotics in viral illnesses for demanding patients. This is an issue with the education of medical staff and patients.

Prescribing medicines that are available over-the-counter (OTC) – this is commonly an issue, as patients that don't pay for medicines can obtain them free on prescription. This is an issue for patient education and incredibly difficult to tackle. Perhaps we can learn from Wales' experience with the removal of the prescription charge. There is potential for this to lead to increased demand for prescribing OTC medicines – perhaps an issue for the Department of Health.

Non-compliance – this is a major issue with prescribing that can arise as a result of various scenarios – for example, pharmacies automatically ordering medicines, patients afraid to cancel medicines they are not taking (for fear of upsetting their doctor) or simply stockpiling medicines that leads to their expiration. Such issues highlight the need to educate both the pharmacies and patients.

Of course, this is not an exhaustive list but gives some understanding as to the causes for overspend on drug budgets, which could be addressed through appropriate education of a number of groups. Of course, as new and more expensive medicines are released there will be increased pressure on CCGs to add these to their formulary while continuing to make the savings required.

The impact of this can be quite heavy on prescribing budgets. This is not an easy problem to solve for any PCT or CCG. As mentioned earlier, accountability is an important point here. GPs may be responsible for the drug budgets in primary care, but is it their responsibility to deal with the angry patient demanding paracetamol? The doctor-patient relationship can be very fragile, and introducing financial pressures to the mix may not be an easy topic of debate in a consultation.

Ongoing failure to manage drugs budgets as part of an overall budget will mean deficit elsewhere. This is why it is essential to manage all areas of the budget.

Lithuania?
I was fortunate enough to have the opportunity to look at primary care delivery in Lithuania as part of a Junior International Committee initiative for the Royal College of GPs (RCGP). As part of this I looked into their prescribing methodology and how it differs from that of the UK.

Only a few drugs in Lithuania are completely free. For other drugs issued by a doctor, a percentage of their cost is taken on by the government. For example, a doctor may prescribe a drug and the patient will get a 40% concession. This means the patient will still pay 60% of the cost, giving them the freedom to choose their own brand at the pharmacy.

There are both positive and negative points here, which in itself can open a huge debate. However, this tackles the generic debate in prescribing quite well. Currently, branded medicines can cost more than their generic alternative. By using the above strategy, patients are free to choose their brand. If they choose a more expensive branded drug, they pay a higher price themselves, as well as the health authority.

Prescribing hard budgets in North East Essex
In North East Essex in 2010, the concept of 'hard budgets' was introduced. As part of this, practices were given the chance to own and manage their individual prescribing budget with the aim of tackling the drugs overspend within primary care.
As part of its implementation, we offered access to the PCT medicines management team. This team comprised medicines technicians and pharmacists visiting individual practices and assisting them with CCG-aligned saving ideas within their prescribing budget.

A prescribing incentive scheme was also offered to all practices, which took the strategic health authority's (SHA) 'Better Care, Better Value' prescribing concepts and some other locally agreed principles for safer prescribing.

The benefit of this project to the CCG is that we can give practices ownership of their spend, giving them true experience of budget management. Forty out of the 44 constituent practices took up the opportunity to take a greater responsibility in owning their prescribing budgets. Should practices become fully responsible for their budgets in the future, they would have had two years' experience gained from the work undertaken throughout 2010/11.

One of the biggest challenges to the CCG was agreeing the budgets. A specific 'budget-setting' group was set up for this purpose, headed up by PCT staff, CCG members and the CCG support team to ensure a fair distribution based on fair-share principles.

The scheme is currently working very well, with the prescribing budget only coming in 0.4% overspent in 2010/11 and a forecast underspend in 2011/12 equating to approximately £600,000. The desired outcome is, of course, an overall reduction in prescribing, which we are on target to achieve.

Summary
GPs on the frontline are in the perfect position to manage the primary-care drug spend. As CCGs continue to take form and take on reducing budgets, the responsibility will lie with GPs to take ownership of the budget. Should they fail to take on this task, the consequences will be a deficit elsewhere in the primary care budget. There is, after all, only a certain amount of money in the pot.

CCGs can go about taking on this task in several ways:

Incentivise appropriate prescribing through a variety of initiatives, such as a prescribing incentive scheme or through adopting hard budgets.
The use of medicines management teams to tackle specific tasks and assist primary care in managing their prescribing practices.
Performance-manage those practices persistently overspending through locally negotiated means. This year we also had the addition of the quality premium performance indicators in prescribing, although these will not be carried forward.

Perhaps the next GP contract could incorporate specific levers relating to persistent overspending with practices that will not engage with performance management. This would ensure primary care has to take on increased responsibility for budget management.