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How CCGs can make savings in their prescription budget

Providing GPs with the right support on prescribing can realistically deliver savings for CCGs in their prescription budgets that could make a significant dent in an annual NHS spend of £8bn a year, says Claire Forde.

Prescribing, although easily described, is almost impossible to define in isolation and nobody is certain of how much opportunity there is for cost savings.

Data from the NHS Information Centre shows that the actual spending on drugs and appliances in England for 2010-11 was nearly £8bn. A National Audit Office report from 2009 suggested savings through productivity gains in four therapeutic areas – statins, proton pump inhibitors, ACE inhibitors/angiotensin receptor blockers and clopidogrel – could be £394m. A separate NAO report suggested that £50m-£100m might be saved through cutting medicines waste.

It is time to raise our expectation of possible savings from within prescribing budgets. If released, these savings will enable clinical commissioning groups to retain and develop services despite the challenging savings targets.

We should not consider 0 per cent or -1 per cent growth of prescribing spend as success. We are only successful if we deliver 7 per cent to 12 per cent savings. This is achievable with sufficient vision and effort.

At NHS Halton and St Helens we decided to compare our prescribing against other primary care trusts using the data from the NHS Information Centre.

We selected 53 PCTs across the country, downloaded their prescribing data, which was broken into 207 categories, and identified the following:

  • lowest average item price per category (we took the average of the two lowest PCTs);
  • national average item price per category.

We calculated the potential saving if each PCT (including our own) achieved the lowest average item price per category and the national average item price per category.

Simple savings

For Halton and St Helens PCT, we would be able to achieve savings of more than £15m (25 per cent) a year on reaching the lowest average item price. Simply achieving the national average item price per category would save the PCT £3.3m (5.4 per cent) annually.

At Halton and St Helens, our top 10 categories for revision alone can release more than £8m for reinvestment in local services (see list).

Halton and St Helens Top 10 for Revision

Number in brackets is NHS Information Centre category number/identifier

  • Lipid-regulating drugs (2.12)
  • Corticosteroids (respiratory) (3.02)
  • Analgesics (4.07)
  • Drugs used in diabetes (6.01)
  • Antiepileptics (4.08)
  • Oral nutrition (9.04)
  • Wound management and other dressings (20.03)
  • Antidepressant drugs (4.03)
  • Drugs for genito-urinary disorders (7.04)
  • Antisecretory drugs and mucosal protectants (1.03)

For England, if all PCTs achieved our sample lowest average item price per category, the annualised savings would reach £1.86bn.

We found the savings available for the 20 highest-spending PCTs in our sample of 53 PCTs (see table, below).The savings would total £132m or £330m a year on achieving the national average and lowest average price per category, respectively.

Interestingly, some of the perceived “healthiest” populations were the most expensive prescribers per category. For example, one London PCT is spending £14.39 per lipid regulating drug item. Meanwhile a south western PCT is spending £7.53 on the same thing.

Should the London PCT achieve the lowest average item price per category, it could save more than £800,000 in this one category alone.

We understand the weaknesses of this analysis as it is purely focused on volume of prescribing and prices paid. However, if only 65 per cent of this opportunity was possible, the NHS could save upwards of £1.2bn a year.

As a prescribing lead for my CCG, I see how this analysis dramatically raises the bar for savings within the prescribing budget. We will be looking at a medicines management service redesign to deliver new and more ambitious savings plans.

Current medicines management services have little evidence to support the delivery of such big savings and we believe innovation can greatly improve the quality of prescribing while releasing these savings back to the local health economy.

The emphasis on quality, innovation, productivity and prevention for prescribing should allow for even more innovation. Today, QIPP focuses on prescribing categories or therapeutic areas. These are 
the same categories that we have been working on for the past 10 years and the problems remain. Ambitious innovation can remove and bring benefits fast.

The challenge is great. For example, some medicines management service providers claim they can release £2,000 of annualised savings per pharmacist per day. If the NHS was able to release the £1.2bn outlined above, this would require a minimum of 600,000 staff days of effort. And, if these staff cost on average £500 per day the cost would be £300m.

Both the scale of the opportunity and the cost of a potential solution are dramatically beyond those discussed here. However, any leading business would easily invest £300m to recoup £1.2bn worth of annualised benefit, especially if the payments were tied to results and performance.

Support from PCTs

It is unrealistic to think that GPs can provide the 600,000 days of effort required. Equally, we cannot rely on community pharmacy to deliver results that conflict with the remuneration structure of volume dispensing.

GPs will need to be supported and informed about where these savings are and the level of intervention required will be more granular and clinically focused than before.

The vast teams of clinicians inside PCT medicines management teams should realign their services and focus primarily on patient level interventions, using their knowledge and skills to radically transform a practice’s prescribing efficiency.

That effort should initially focus on the practices that need it most. The days of sharing expensive resources across a wide range of practices with differing levels of opportunity should be over. The resources should be targeted at the areas where most benefit can be realised and then moved on to the next most useful location.

Rigorous implementation of guidelines for prescribing will be needed across every practice. Continuous and regular compliance support will also be required to ensure savings released are retained.

The radical upheaval in the NHS has, from a prescribing perspective, enabled a fundamental realignment of GP effort and priorities, as GPs now control and benefit from efficiencies delivered within the prescribing budget.

We see this as an important and exciting development that will allow GPs to demonstrate significant benefits from engagement with the CCG priorities.

To date, savings made in prescribing by committed GPs were often siphoned away to plug overspends by other GPs within a PCT. This was a difficult and demoralising reality that faced GPs annually. These restrictions should no longer cloud our ambitions and achievements.

See savings table, attached middle column (top of page).

Readers' comments (1)

  • NHS Pharmer

    I note that Dr Forde is the founding director of a Medicines Management Service, selling services to the NHS. HSJ - These types of conflicts of interests should be made more clear to readers, as these articles, while in this case making some valid, contructive, generalisable points, could be seen as advertorials.

    While it is interesting to note some of the benchmarking in the article, some of which is inexplicable and indefensible clinically, it does not allow for differences in populations (acknowledged by the author), SOME of which could be relevant; not least deprivation, prevalence of long term conditions and historic disease management in both primary and secondary care.

    The currently agreed priorities of Medicines Management teams and indeed their support from GP practices - which can be variable and in some (thankfully less frequent now) cases obstructive - is essential to high impact changes sticking. A result we all work towards. CCGs can obtain support purely for the purpose of producing cost savings in the primary care dugs budget, but this would devalue the wider professional input of doctors, pharmacists, nurses and technicians into prescribing decision making across health and social care economies.

    Medicines Management teams also work in a wide variety of the areas where medicines are used, including: service redesign, secondary care contract monitoring and management, policy development and implementation, managed introduction (and exit) of drugs and therapies across the health economy to ensure patient orientated outcomes are at the heart of high quality, safe, effective and cost effective care.

    We also look at areas which may not be fully appreciated by emergent CCGs, such as the accountable officer for controlled drugs, practitioner poor performance, community pharmacy development and contract management, Local authority medicines policies and managing and developing primary care enhanced services for all professions, to name a few.

    CCGs must realise that cost savings are one very important part of Medicines Management, but as we move into the brave new world of Medicines Optimisation, an investment in prescribing could and should lead to better management of patients' conditions and consequent quality improvement and safety gains. These will undoubtedly lead to better long term conditions management, reduced exacerbations and so admissions to hospitals, thus savings of a greater magnitude may come from other budgets in addition to prescribing efficiency.

    Current NHS employed Medicines Management teams are very efficient compared to the prices quoted by Dr Forde at £500 per day (equivalent to a salary of £115K). By using a full skill mix of GP leads, Pharmacists, technicians and in some areas dieticians and nurses, the cost of providing a full service is on average, in Greater Manchester, £191 per day (range £170 - £230). This cost includes the full NHS employment costs and modest travelling and other expenses.

    When CCGs are deciding whether to employ, buy from a CSO or an external supplier they should consider the outcomes they require for their patients, and the value they attach to that, not just the windfall savings they can make in a prescribing budget.

    Andrew White
    Head of Medicines Management, NHS Bolton
    Medicines Management Project lead, NHS Greater Manchester.

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