How to pick a prescription
Prescribing advisers help curb the national drugs spend and GPs value them too. Daloni Carlisle looks at their developing role
When the public accounts committee produced its report on prescribing costs in primary care earlier this year, most publicity focused on the influence of a pharmaceutical industry that spends£850m a year marketing its products to GPs.
But tucked away was a short paragraph about an even more influential group and one that might be regarded, by primary care trusts at least, as a force for good: prescribing advisers.
This specialist band of NHS staff are generally pharmacists who are often, but not always, employed by PCTs. Their role is to support GPs on prescribing issues and to spread best practice. They get their training and guidance from the Department of Health-funded National Prescribing Centre.
Most doctors say they have a good relationship with their prescribing adviser, the committee reported, and feel that the adviser has more influence over their prescribing decisions than do pharmaceutical companies.
They seem to be cost effective, too. The DH quoted the committee's independent research, which suggested they could save at least£2 for every£1 of salary by promoting clinically effective prescribing.
All this was a pat on the back for Clive Jackson, the pharmacist who set up the centre 12 years ago and is still the chief executive. He is not given to hyperbole and says simply: "From our perspective, it was a positive report and we are now waiting for the DH to formulate their response."
He is more excited about the changes set in train last September when the centre began a complete overhaul of the way it works.
This was prompted, he says, by changes taking place in the NHS. The number of PCTs dropped from over 300 to 150 in 2006, and the trusts began to look again at how they employ prescribing advisers. Add the advent of practice-based commissioning and it was clear new forms of working were needed.
"Our horizon scanning shows quite a lot of prescribing advisers are moving to the providers' side. The PCTs do not need large numbers in the commissioning side, but they do need high levels of expertise."
There are currently about 1,500 prescribing advisers in England, although only a few are full time and these are usually working on the commissioning side of PCTs. About a quarter are GP practice based; some of them employed for just a few sessions a week.
"Their role is very varied," says Mr Jackson. "It can range from visiting GPs, setting budgets, medicines management issues, safety, pharmaceutical public health and community pharmacist contract issues. It does depend on how the PCT sees the role."
Their numbers vary enormously from 41 in one PCT to just one in another. NHS North West has 261 prescribing advisers in the region, while South East Coast has just 88.
So last September the prescribing centre replaced its cohort of accredited trainers who were charged with taking national training to their localities with a new system.
Now each strategic health authority area has a regional medicines management facilitator and therapeutics facilitator, both trained by the centre.
Each PCT was then asked to nominate a national prescribing centre associate who would link to the regional facilitators and trickle down the information to their own patch.
"The aim is that every PCT should have high level, high quality support around medicines," says Mr Jackson. So far, all but three of the 150 PCTs have nominated at least one, and sometimes more, associates.
Diane Sander, medicines management facilitator in the North West and lead medicines management officer at Sefton PCT, says it is already making a difference.
She is now working closely with the region's therapeutics facilitator, the two of them building on the collaborative approach developed over the past five years.
"It just feels like we can respond really quickly to local need," she says. For example, they will be designing the programme for a forthcoming networking event for their PCT associates just two weeks in advance of the day, with the programme dictated by what the associates say they want.
"We are not having to work against a pre-determined curriculum," says Diane. "It's us asking, 'What we can do to meet your needs?'."
Sue Smith, the National Prescribing Centre associate at Northamptonshire teaching PCT, where she is also associate director of pharmacy policy and prescribing, is similarly enthusiastic.
"I have been an accredited therapeutics trainer since 2004," she says. "It was very rigorous training for that - the high quality assurance around who can and cannot deliver their training.
"But while we always delivered high quality workshops, the people who came would go back to work and their busy lives and nothing much would change."
The new model has allowed the facilitator and associates to redesign workshops, "so that we go back and do something about it", she says. "The whole focus of the training day is not so much about delivering knowledge, but what to do about it."
The National Prescribing Centre's new NPCi website pages are helping this enormously. This site been completely revamped and now has new resources, downloads and interactive chat rooms.
"For example, last month we did a workshop on diabetes and obesity," says Sue. "We asked participants to download the presentations and look at them before the day.
"On the day, we went through key slides, but then had a chance to look at what we want to do with this information that will change practice and improve patient care and how we can stop what shouldn't be happening."
The group then developed an action plan with a timeline and deliverable objectives attached to it.
So far, the centre is focusing on primary care, but recently Clive Jackson launched a pilot project to see whether a similar model could work in secondary care.
"What we understood from the public accounts committee report is that they want us to do more to support SHAs and others to get good practice out there," he says. "I am quite happy with that."