Involving patients and getting away from an approach that still harks back to the 1980s will help GPs tackle the problem of wasted prescription, writes Neil Churchill.
They say culture eats strategy for breakfast. That phrase sprang to mind as I sat in Richmond House listening to various possible definitions of consultation for inclusion in the Health Bill. With respect to the legal wordsmiths involved, culture is going to have a bigger role in giving patients extra clout in the new system than legislation ever will.
There’s no doubt that the government and NHS leadership have both sought to put patients at the heart of things. Ciarán Devane has become a non-executive director at the NHS Commissioning Board and I was one of the patient group leaders invited by chief executive Sir David Nicholson to be involved in recruitment to his top team there. Many of the amendments to the bill were about patient and public involvement. But has the culture started to change?
One place to look is in the way prescribing policies are being implemented. It is perfectly reasonable to ask patients to change to a cheaper, clinically equivalent drug to the one they have been using. Sometimes that might be a generic or a different drug that achieves similar clinical results. However, the patient must be involved in the decision, not least because medicine regimes often fail because patients do not understand their treatment or fail to use drugs as prescribed.
Many parts of the NHS are striving to implement prescribing policies that have previously been treated simply as guidance, but with mixed results. On the one hand, many GPs have told me it is perfectly possible to convince a patient to change their medicine for a cheaper alternative. On the other, I hear of many patients who are being changed without them being involved. In the worst cases, medicines are being changed without either patient or doctor involvement. One patient told me her asthma inhaler was changed without discussion and her dose reduced. “To cut doses of any drug without consulting the patient’s doctor and then not informing the patient is disgraceful,” she wrote. Quite.
Such policies are short-termist and counterproductive. The patient concerned experienced worsening symptoms and required extra drugs and visits to see her GP to get back on track. If she hadn’t asked for help, she might have joined the 70,000 people admitted to hospital for asthma, a number we are all working hard to reduce.
Meanwhile, GPs in London designing a new prescribing policy have argued that giving patients more than one inhaler is an example of waste. To patients, it can often be sensible medicines management to have a reliever inhaler at work or school as well as at home. Waste, to a patient, is more to do with giving people higher strength inhalers than they need, with all the side-effects associated. Shared decisions about stepping down treatments may work better at reducing side-effects and cutting the bill.
Of course, this is one side of the picture. Patients whose medicines are changed through consent are unlikely to contact me to say they were happy with the decision. And patients need to play their part by coming to annual asthma reviews or agreeing a medicine use review in the pharmacy, where their prescriptions can be discussed. Successfully implementing such policies, as in the Isle of Wight or Yorkshire, has seen real gains in productivity and outcomes.
The big question is whether we have the right cultural assumptions about involving patients to deliver these win-wins. I recently heard evidence of how simple “nudge” tactics in communicating with people has dramatically improved results in other areas of public service. For example, using personalised text messages to encourage people to pay court fines before bailiffs are sent in has increased such payments from 5 to 33 per cent. And tax receipts increased by a similar percentage when people were told that nine out of 10 people in their local community paid their tax on time.
Many general practices still deliver a mechanistic and impersonal approach that has changed little from the 1980s.