The seemingly inexorable rise of prescription costs has been substantially slowed in one primary care group by appointing a medicines management pharmacist who also works in hospital. Elizabeth Reid and colleagues report

Writing a prescription is the most common therapeutic intervention, and for the past 20 years it has been common pract ice in NHS hospitals to promote the rational and cost-effective use of medicines through drug and therapeutics committees in the hope of encouraging informed prescribing.

In primary care, medical and pharmaceutical advisers have had the same task, and the two programmes have been virtually independent and lacked co-ordination.

In 1994 the Audit Commission published A Prescription for Improvement, which addressed prescribing in general practice.

It recommended that hospital prescribing should influence that in primary care.

In 1997-98, North West region spent around£750m on medicines - more than 80 per cent in primary care.The region had the highest primary care prescribing rates (20 per cent above the national average) and the highest primary care prescribing costs (14 per cent above the national average) in the country.

Since 1 April 1999 all primary care prescribing budgets have been cash-limited and unified with hospital, community health services and general medical service budgets.So any overspend within the primary care prescribing budget means less money for pressures and developments within the hospital sector.

Medicines management is now within the clinical governance agenda and seeks to promote effective as well as value-for-money prescribing.

The NHS Executive reg ional offices have a monitor ing role w ithin this framework. It therefore makes a lot of sense to address those aspects of prescribing which are common to the two health sectors.

Area prescribing committees went some way to meeting these issues, but the true harmonisation could only work if goals and outcomes could be shared between the two sectors.

In 1998 Manchester health authority appointed a medicines management pharmacist to South Manchester primary care group and South Manchester University Hospitals trust. This appointment developed from a per iod of c lose co -operat ion and shared exper iences from the two sectors.

The aims were:

to carry out an initial survey to ascertain prescribing support needs of GPs;

to focus on specific therapeutic areas;

to set up education programmes.

An initial survey of GPs was carried out to assess opinions and prioritise prescribing issues.The survey was also intended to give GPs a sense of ownership of the project.South Manchester PCG includes 81 GPs in 26 practices covering a population of 146,000.A questionnaire was sent to each GP and a 54 per cent response rate was achieved.

The most important issues were found to be the local disease-management guidelines, education and repeat prescribing.Developing a PCG formulary was not given a priority at that time.The most important therapeutic areas cited were ulcer-healing drugs, lipid-lowering drugs and antidepressants.

Wor k i n g p a r t y Dyspepsia-management guidelines were drafted and then finalised during several meetings of a working party consisting of two consultant gastroenterologists, five GPs and the medicines management pharmacist.

The guidelines were sent out to GPs on 1 February 1999.

This was followed up by practice visits from the medicines management pharmacist to reinforce the message and discuss any problems with the guidelines.Anonymised comparative prescribing data for the PCG was also used.

The response from the practice visits was generally positive.

Proton pump inhibitor (PPI) prescribing was also covered in an education event on gastrointestinal prescribing.A single A4 page of guidance on common problems in PPI prescribing was sent to all prescribers in the trust.This was written by one of the consultant gastroenterologists and attached to the pharmacy information bulletin.

There has been a reduction of 4.9 per cent in the cost of prescribing for the gastrointestinal system in the PCG for the period April-August 1999 compared with April-August 1998.This compares with a reduction of 2.61 per cent for Manchester HA and a national increase of 1.98 per cent for the same periods.

The top five practices for PPI costs were identified using electronic prescribing analysis and cost data - available online from the Prescription Pricing Authority.Two of those five practices were already working with other HAfunded pharmacists on this topic.

The medicines management pharmacist carried out a review of all patients on repeat PPIs in the remaining three practices in order to identify patients suitable for reduction to maintenance, H pylori eradication or further investigation.

These practices have shown a decrease in the cost of PPIs prescribed and the cost of ulcer-healing drugs as a whole (see table 1, below).

The next topic considered was antibiotics.The work on this therapeutic area is closely linked with the national recommendations proposed in the standing medical advisory committee report on antibiotic prescribing.

A working party was set up consisting of two consultant microbiologists, three GPs and two pharmacists. Input was sought from other clinicians where appropriate.Adult and paediatric guidelines were launched in June 1999 at the postgraduate prescribing forum and the medicines management pharmacist again carried out follow-up practice visits.

Patient information leaflets and posters were produced to try to discourage inappropriate antibiotic requests.

Appropriate antibiotic prescribing is also linked to the prescribing incentive scheme for GPs.Since this campaign started, the total cost and volume of antibiotic prescribing in the PCG has fallen below the national average for the first time in at least three years.

Therapeutic forum An ongoing programme of educational events was arranged with the GP postgraduate tutor.These take the form of a therapeutic forum every two months which is fitted into the normal postgraduate education programme.The evening events are three hours long and have postgraduate education allowance approval.

Consultants from the trust are present to provide expert opinion and contribute to the discussions.

The usual format allows the development of an 'instant formulary' for the chosen therapeutic topic by the end of the evening.The trust base for this project encourages hospital consultant links with the education programme.

Topics covered so far are gastrointestinal prescribing, antibiotics and cardiovascular part 1 (angina, lipidlowering, peripheral vascular disease and stroke).

The medicines management pharmacist has also provided teaching sessions for care assistants on medicines for the elderly in residential/nursing homes as part of a PCG initiative to reduce hospital admissions and GP call-outs over the winter.

Education and manpower planning for the future needs of the service are essential if these programmes are to prosper.The appointment of three clinical pharmacy tutors to Manchester and Salford teaching hospitals now provide an environment for developing knowledge and skills ofmedicines management in pre-registration pharmacy graduates and undergraduate pharmacy students.

The medicines management pharmacist has been involved in setting up the incentive scheme for 1999-00 in conjunction with the HA and PCG prescribing sub-group.

Targets in the scheme include an audit of the prescribing of statins,80 per cent of antibiotic prescribing from a list of eight drugs, and generic prescribing to account for 72 per cent of all prescribing.

Involvement of other hospital staff Two pre-registration pharmacist projects were completed in primary care and the results fed back to the practices concerned as wel l as to relevant hospita l staff.

A junior pharmacist rotation in primary care (half day per week) started in January 1999.This was achieved with a four-week induction period followed by an eight-week project/practical work with feedback to any practices involved.

A pharmacy technician was seconded to the HA for two days a week.They assist the medicines management pharmacist in implementing prescribing changes such as generic switches and PPI reviews.The prescribing support plan for 1999-00 includes the use of seven senior clinical pharmacists from the hospital and one community pharmacist providing one session a week each.A further pharmacist has been seconded from the National Prescribing Centre.These pharmacists have been assigned to practices to implement changes identified from prescribing analysis and cost.

The medicines management pharmacist ensures that these changes are co-ordinated and are in line with PCG/HA policy and also provides any necessary support to the other pharmacists.By assigning pharmacists to a particular practice it is hoped that they will build a good working relationship with that practice and improve communication on prescribing issues across the primary/secondary care interface.

The medicines management pharmacist completes the prescription analysis cost (PACT) data analyses and also undertakes work for the remaining target practices.

Projected savings For the period April-August 1999 compared with AprilAugust 1998, South Manchester PCG had the lowest rate of growth in prescribing costs in the city at 5.07 per cent compared to an HA figure of 6.95 per cent and a national figure of 9.16 per cent (see figure, page 29).

This represents a projected saving for one year of£97,661 in prescribing costs for the PCG.Although the medicines management pharmacist would not claim to have generated the whole saving, the investment in her salary has resulted in savings over three times her costs.

Awareness of interface issues has been improved for both sides by the inclusion of representatives from the PCGs on the trust medicines management committee and the HA prescribing strategy group as well as trust representatives on the PCG prescribing sub-group.

Areas which will be looked at in the near future include prescribing of nutritional supplements, development of a wound-care formulary for both primary and secondary care, 28-day discharge prescriptions with patient packs from the trust and production of a prescribing bulletin for the PCG.Budget setting and incentive schemes for 200001 are ongoing issues.

This programme has resulted from the strategic planning and implementation of a programme of medicines management between primary and secondary care.

The co-operation and collaboration between interested stakeholders are strong features of its success and represent true joined-up management within the NHS.

It offers a template for good practice for local medicines management and could be modified to address other aspects of managed care within a modern NHS setting.

Total proton pump inhibitors: reduction in PPI spend Six months after review in comparison with six months before

Practice % Actual

Practice 1 7.4% reduction£2,074

Practice 2 7.8% reduction£2,587

Practice 3 6.7% reduction£1,254

Key points

A joint hospital, health authority and PCG initiative to improve prescribing has produced significant savings in the PCG involved.

The venture included the appointment of a medicines management pharmacist to work with practices, and a survey to ascertain GPs' prescribing needs.

GPs considered the most important issues to be developing local disease management guidelines, education and repeat prescribing.

Guidelines on dyspepsia management have resulted in a 4.9 per cent reduction in the cost of prescribing gastrointestinal drugs.

Antibiotic prescribing has also fallen.

REFERENCES

1The Audit Commission.A Prescription for Improvement. London: HSMO. 1994.

2Department of Health.A First Class Service: quality in the New NHS .HMSO,1998.

3Standing medical advisory committee report.The Path of Least Resistance . 1998.

4Department of Health. HSC(49)1999.Resistance to antibiotics and other antimicrobial agents.

Elizabeth Reid is medicines management pharmacist, South Manchester PCG/South Manchester University Hospitals trust; Dr Jonathan Cooke is director of pharmacy, South Manchester University Hospitals trust; Dr Roger Johnson is medical director, Manchester health authority; Helen McKnight is project leader, agency for community team support, Manchester.