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New PCTs to tighten general practice prescribing controls

Published on 12/09/06 at 12:10pm

Moves to rein in the prescribing freedom of GPs and give prescribing advisors more power are gaining ground in the NHS, despite considerable resistance from the frontline.

Freedom to prescribe whatever products they see fit has been enshrined in GPs' contracts since the formation of the NHS, and is included in the new GMS contract. But this freedom continues to be a source of tension between GPs and their paymasters in primary care trusts, who have struggled to enforce formularies on doctors.

PCTs and their predecessors have used a number of methods to control GP prescribing, but even the use of prescribing advisors and prescribing incentive schemes have proved largely ineffective until now.

But observers in the NHS and pharmaceutical industry say the balance of power is set to shift, as the health service is restructured once again with the creation of larger PCTs in England from 1 October.

PCTs were previously in charge of commissioning services, but much of this power has been handed to GPs through practice-based commissioning (PBC), where general practices have control over how budgets are spent. This means performance management will be a large part of the new remit for PCTs, with a number of commentators expecting them to quickly focus on costs in general practice prescribing.

Noel Staunton, an independent pharmaceutical consultant says: "Within the next 12 months or so, PCTs will try to save every penny they can on drugs - it will be bad times for the pharmaceutical industry. The forces of 'let's spend less on drugs' will triumph over the forces of 'let's spend more'."

The Department of Health is widely acknowledged to have miscalculated how much the new GMS contract would cost the health service, with most GPs easily reaching and exceeding payment-related targets.  Earlier this year, the government admitted it is spending 300 million pounds more on GPs than originally intended, but the Conservatives claimed the figure was, in reality, as high as 1.5 billion pounds.

A breakdown of where last year's 3.6 billion pound increase in NHS spending went also reveals that drugs and NICE recommendation costs accounted for about 20% of this figure, the second largest cost after increased pay.

This is balanced against the fact that a 7% reduction in branded medicines prices was enforced last year, through the new PPRS price agreement and uptake of new medicines remains slow.

Noel Staunton says these competing viewpoints about the prescribing budget and other GP costs are being championed by different groups within the Department of Health.

"My reading is that there is a debate occurring at the highest level as to exactly how hard prescribing costs should be restrained in the UK. On the one hand, the Department of Health's commercial directorate seems very keen to save every penny it can on prescribing costs - but it seems there is another directorate concerned with commercial pressures within the drug industry."

The use of prescribing incentive schemes to influence GP prescribing is widespread across England, and has long been used by PCTs to control costs and stop doctors prescribing drugs considered not clinically or cost-effective.

Chris Doyle, managing director of Brand New Concepts, a marketing and commercial services company serving the NHS and industry, said: "Come next April, there are going to be big changes in the approach to prescribing habits. The reconstituted PCTs will be able to add to or re-negotiate their contracts with GP practices and you can be assured that the first thing on their agenda will be the introduction of cost-effective quality points."

He added: "I think the new PCTs will wait until April when they will be in a position to try to re-negotiate parts of the GP contracts and come down hard on prescribing habits. It will be pay back time."

Meanwhile, prescribing advisors are watching the situation with great interest. Norman Evans, a former prescribing advisor and now a consultant in pharmaceutical public health for Wandsworth PCT, said: "The days of GPs hiding behind clinical freedom must be numbered. They must be made more accountable."

He added that prescriber advisors did not wield much power. "At the moment, there aren't any new incentives for them to change their prescribing habits. We have an army of prescriber advisors out there  but where is the evidence to say things have changed? We can only persuade GPs to adopt better prescribing habits through education and through presentation  but we have nothing to say we are being effective."

This view was echoed by John Anthistle, NHS strategy manager for Servier Laboratories, who agreed that the credibility of prescriber advisors was not high.

He said: "The job of prescribing advisors is to ensure GPs prescribe the cheapest drug possible to reduce costs  but they are toothless watchdogs at the moment, as GPs haven't got much incentive to change. If they are criticised over prescribing, they usually view it as just a slap on the wrist."

Ironically, while practice-based commissioning will give them more power, it will also make them more answerable for costs.

"This will be a rude awakening - they will have to be far more accountable for services, including drugs commissioned and the role of the prescriber advisor will really come into its own," said Anthistle.

Joanna Clason, a spokesperson for NHS Confederation said she agreed with views that the management of prescribing habits by PCTs was currently inconsistent across the country, but refuted claims that prescribing advisors were "toothless watchdogs".

"They have always been important in helping GPs to prescribe appropriate drugs. They have a lot of influence. In the future, they will be even more important."

She added: "A lot of PCTs have been focusing on GP prescribing habits and have been working pro-actively with them to achieve the most cost-effective prescribing habits."

She stressed that cheaper did not always mean better. "What PCTs are trying to achieve is the habit of prescribing an alternative drug that has the same effect, or better  and may be cheaper.

"PCTs and GP practices are genuinely trying to work together on this."

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