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Published: 27/03/2003, Volume II3, No. 5848 Page 14 15

The primary care drugs bill is still soaring - an£110m shortfall is predicted for this year.But with little fat to be found in prescribing budgets, where can savings be made?

An Audit Commission has some suggestions, as Alison Moore reports Mention prescribing budgets to primary care trust staff and they are likely to reach for the nearest packet of paracetamol. Of all the elements of a PCT's budget, prescribing is among the hardest to control and is causing the most headaches among senior staff.

An Audit Commission report released today, Primary Care Prescribing, highlights the problems that a rise in prescribing costs cause. They have increased by 29 per cent between 1998-99 and 2001-02 and are expected to increase by another 11-13 per cent in this financial year.

At£18m for an average PCT, prescribing now accounts for 16 per cent of their budgets and has left most facing a serious funding gap, according to the report. This has left PCTs needing to cut funds for other services, and the report warns that unless PCTs tackle the huge increase in prescribing costs other services could suffer.

PCTs increased their drugs budget by 10 per cent this year but a likely growth rate of 12 per cent will leave them£110m - or an average of£360,000 per PCT - short. Half of the rise in costs between 2000-01 and 2001-02 is due to just four drug categories - lipid regulating drugs including statins, antihypertensives, and drugs for diabetes and psychoses.

Costs for these rose by 25 per cent while costs for all other drugs rose by just 7 per cent.

The main drivers for the increase in prescriptions for these four categories have been national service frameworks and National Institute for Clinical Excellence guidance. The report acknowledges that much of the increase is 'good' prescribing - effective drugs prescribed for patients who are likely to benefit - and much, but not all, prescribing in growth areas is clinically driven.

The Audit Commission report estimates that potential cost savings of£130m - equivalent to£430,000 per PCT, or 2.3 per cent ofthe drugs bill - could be made by adopting measures such as prescribing cheaper drugs and reducing over-prescribing. 'However, these average figures disguise wide variation in potential savings between PCTs, ' the report says.

The report also acknowledges that these savings could not be realised immediately but it does say that addressing some of the areas could release significant chunks of cash in the short term.

For example, West Norfolk PCT saved£90,000 by prescribing cheaper drugs and reducing dosages, especially in ulcer healing drugs.

Though they are being urged to pare down the prescribing budget, many in primary care argue that little more can be done because such intensive efforts have already been made to cut prescribing and eliminate wastage.

Royal College of GPs spokesman Dr Jim Kennedy says: 'Primary care organisations have had tight working between prescribing advisers and frontline prescribers.

In terms of people getting drugs they do not need, I do not think there is much more to do.'

And NHS Alliance chair Dr Michael Dixon says there is already very little fat in prescribing budgets, though he accepts that more prescribing adviser input may be needed if it is to be found.

The Audit Commission report highlights the need for PCTs to set strategic goals on prescribing, to develop a plan to implement this, to set precise targets, and monitor and report back on them.

Engaging GPs and getting them working towards PCTs' goals is also crucial. Training, developing protocols and ensuring a consistent approach between GPs and hospital consultants can all help, as can having an effective, credible GP prescribing lead. But even this may not be enough to stem the tide of increased prescribing, especially if statins are prescribed to a much wider group of people within the next few years. Research suggests that up to 3 million people could benefit from them, which could cost an extra£800m a year.

Dr Kennedy points out that this sort of investment in preventative drugs may pay dividends years down the line, with fewer people needing hospital treatment because their conditions have been controlled in primary care.

But it is hard to disinvest from hospital services now, and he says that restructuring services to cater for this type of treatment may in itself be expensive during the transition.

Because PCTs have little immediate control over much of their budgets, overspends in prescribing tend to be clawed back in other parts of primary and community care - such as nursing input, where spending is not driven by NICE guidance.

Dr Dixon says that comparisons between extra spending on drugs and greater expenditure in other areas are often not made. 'If it has to be drugs or care, sometimes it is better to have care, ' he says.

However, better prescribing may also impact on the amount of care needed: people taking a number of different drugs - as has become common with major conditions - need greater nurse or GP input as they should be monitored more frequently.

The acceleration of drug costs shows few signs of stopping.

There may even be factors which will cause it to increase - such as the concentration on quality in the proposed GP contract.

Finance directors will need the paracetamol tablets for some time to come.