The use of medicines in the NHS is attracting an unparalleled amount of interest. Policy-makers, practitioners and patients have increasingly been drawn into debates about the cost of and access to medicines. Much of this debate has focused on new medicines - particularly those for conditions previously thought untreatable, such as multiple sclerosis and Alzheimer's disease - and the robustness of clinical and economic evidence justifying their use in a cash-limited environment.
These issues have also brought into sharp focus the clinical, financial and organisational tensions that can play across the interface between primary and secondary care. The use of older, more established medicines can also be a cause for dispute.
Chesterfield and North Derbyshire Royal Hospital trust and North Derbyshire health authority have piloted a scheme that could help shape models for the management of cost-effective prescribing across the primary secondary care interface, which will assume even greater importance with the advent of primary care groups and trusts and a cash-limited, unified budget.
For a number of years reports of tensions had been surfacing between prescribers in primary and secondary care settings. These had come through the HA prescribing group and the trust's drug and therapeutics committee. As has been described elsewhere, much of this relates to four areas:
use of drugs that are 'loss-led' into hospitals by manufacturers, but which attract premium pricing in the community;
the introduction of new and more expensive agents as first-line treatments in place of older and more cost effective products, particularly in managing and preventing peptic ulcer, oesophageal reflux disease and angina;
the failure of acute trusts to manage effectively medicines brought into hospital by patients, which often results in increased primary care prescribing;
the absence of efficient communication systems to inform GPs of changes to patients' drug therapy after an acute admission.
Addressing the problem The rationale behind our approach was that a patient started by the hospital on an expensive treatment tends to stay on it by v ir tue of the nature of repeat prescribing .
But the difficulty in addressing this problem was that reports of its occurrence were often anecdotal and could not be directly linked to a substantive trust policy or practice. A proposal was developed to use audit methodology to investigate GPs' principal concerns. An Executive Letter on prescribing expenditure gave HAs the opportunity to use 'a small element' of their prescribing allocations to fund schemes that focused on rationalising repeat prescribing.
2Following discussions at the HA prescribing committee, we approached the regional prescribing adviser with a proposal to fund non-recurrently an audit pharmacist to work in the trust to address repeat prescribing at 'source'.
With the approval of the local GP advisory committee and trust drug and therapeutics committee, a post was funded for a year, at a salary of£22,000, 'top sliced' from the GP prescribing budget.
The project agenda for the audit pharmacist was based on specific issues identified by GPs as causing particular problems, and which were causing tension across the primary-secondary interface. The pharmacist and the project workload was managed jointly by the HA prescribing adviser and the trust head of pharmacy.
Projects identified as having highest priority were:
to review the use of 'loss-led' modified-release oral nitrates (isosorbide mononitrate) by the trust in the prevention of angina and to consider options for switching to non-modified release formulations;
to review the use of proton pump inhibitors and consider the appropriateness of such prescribing for the treatment and prophylaxis of gastrointestinal diseases;
to seek the views of all referring GPs on trust prescribing practices through a postal questionnaire;
to review arrangements for the prescribing of oxygen to patients during an inpatient stay and how such arrangements translated into primary care;
to review the appropriateness of the prescribing of laxatives to patients at discharge.
The results of these projects are shown in the panel below.
Conclusions The audit pharmacist initiative resulted in significant improvements in the cost-effectiveness of prescribing in specific areas, although the resulting savings in primary care are difficult to quantify within the project's timescale.
Each area will be revisited in a year's time to see if further work is needed.
The dialogue generated between prescribers and pharmacists at trust, HA and GP level has had a lasting impact on the medicines management to the benefit of both patients and practitioners.
1 Lyon R. Working with GPs on prescribing issues. The Hospital Pharmacist 1999; 6: 53-55.
2 EL(96) 107. Prescribing Expenditure: guidance on allocations and budget setting for 1997-98 .
Four what it's worth: the results of the audit pharmacist's projects
Oral nitrates 'Modified release' preparations of oral nitrates given once a day have traditionally been 'loss-led' into hospitals by manufacturers, resulting in a 40-fold difference in the price paid by the hospital compared to that paid by GPs .
Treatment initiated by hospital prescribers which appeared cheap to them generated significantly greater costs in primary care. The impact of such practice on GP prescribing budgets was a frequent criticism of hospital prescribers.
The audit revealed that no clinical justification existed for much of this prescribing. So a programme of prescriber education was launched in the trust to promote the use of cheaper, but equally effective generic nitrates. The result was a significant reduction in the use of loss-led nitrates (see graph).
We estimate that this will bring savings of£1,200 a year in primary care for every 10 patients switched from a loss-led to a generic nitrate, set against an HA spend on nitrates of£50,000 a month.
Proton pump inhibitors The audit showed that most hospital-initiated prescribing of the newer and more expensive proton pump inhibitors was clinically appropriate.
This tended to conflict with the anecdotal reports of GPs.
But the robust audit evidence allowed an informed debate and put to rest an issue which had generated controversy and tension for some time.
The audit also allowed for an alignment of prescribing practice in primary and secondary care by establishing a single proton pump inhibitor, which at the time offered optimal clinical economy, as the drug of first choice in both environments.
We estimate that savings of£1,500 a year can be achieved for every 10 patients switched to the most economic product, used at the most appropriate dose, compared with more expensive models.
Total HA spending on proton pump inhibitors is around£170,000 per month.
GP audit The questionnaire was sent out to 155 GPs, of whom 63 per cent responded. GPs indicated a number of concerns, relating mainly to the timeliness, legibility and accuracy of prescribing information sent to the GP after patient discharge.
All parties acknowledged that electronic interchange of prescribing information offered the most effective way to resolve such problems.
But because this is still some years away, several aspects of the process have been reviewed, which should improve accuracy and detail in the prescribing information provided to GPs by the hospital.
GPs also expressed concern at the waste and consequent costs of patients' medicines being thrown away or lost on admission to hospital. Many were unaware of the introduction of schemes by the trust promoting the use of patients' own medicines during admission.
The local GP advisory committee was used as a forum to raise awareness of such developments.
Oxygen The audit revealed a number of weaknesses, both clinical and logistical, in the prescribing of oxygen in both the hospital and the community.
For example, not all patients prescribed oxygen stood to benefit, and GPs sometimes found that oxygen was hard to get hold of because only limited numbers of retail pharmacists are contracted to supply oxygen cylinders.
This has led to a wider review of the process between HA representatives and local respiratory physicians, resulting in a new document being drawn up to improve the flow of information between primary and secondary care.
Laxatives The audit confirmed that 85 per cent of laxative prescribing at discharge was appropriate.
The results of this have been fed into a wider review of laxative use across the trust, with the aim of producing guidelines for the drug treatment of constipation.
Key points Tensions exist across the primary-secondary care interface between GPs and hospital prescribing services.
Repeat prescribing arrangements are a good focus for audit, as a patient started by the hospital on a treatment will tend to stay on it after discharge, with knock-on costs for primary care.
Cost-effectiveness improvements in prescribing practice have included a significant reduction in hospital prescribing of 'loss-led' oral nitrates in favour of generic equivalents and the adoption as standard of the most cost-effective of the new proton pump inhibitors.