Published: 13/06/2002, Volume II2, No.5809 Page 26 27
Primary care trusts have a problem. They are responsible for setting fair and adequate budgets for their constituent practices that will meet patients' needs. These budgets are required to take into account the growth in prescribing expenditure and to show equity of funding and patient care across the PCT. But prescribing expenditure per patient varies considerably between practices. So how can the PCT balance equity and quality?
Prescribing budgets can never be set solely on the numbers of patients in a practice.Many factors contribute towards the rising growth in prescribing costs and, to achieve equity across the PCT, these should be taken into account.
Traditionally, target prescribing budgets have been set using measures that acknowledge the difference demographics make to prescribing need.
Older people, for example, are more likely to require more medication. Patients aged 65 and over are estimated to receive three times'more prescription items than those under 65, and this needs to be considered when looking at a practice population.Women aged 18-30 are more likely to receive medication than men of the same age.
The Prescription Pricing Authority has developed a sophisticated weighting system, ASTRO-PUs, that takes into account age, sex and temporary residents over nine different age bands, giving a more realistic measure of the prescribing needs for practices. A man of 75 will receive more weighting than he did when he was 25. ASTRO-PU is calculated for each practice and the PPA uses it widely to compare prescribing between practices.
As important as adjusting for demography is the adjustment of practice populations for relative need. Social factors make a difference. People living in poor housing with low incomes and poor diets often have greater health needs. But how can deprivation be shown to change the need for more medication and a greater share of the prescribing budget? ASTRO-PU is adjusted using variables shown to have an effect on the cost of prescribing, and is calculated using a national formula.
These variables within a household are:
proportion of adults who cannot work because of long-term sickness or disability;
proportion of dependants (children and people who report long-term illness or are retired/unable to work) and have no nondependant to care for them;
proportion of people of working age in full-time education, regardless of their term-time address.
This variable is negative, reflecting that students tend to come from less needy areas.
percentage of the practice list aged under one year.
Thanet primary care group in Kent covers a population of 132,000 with 66 GPs, of whom 56 work in 15 group practices and 10 work alone. The PCG was concerned to make the allocation of prescribing budgets more sensitive to quality issues.
It added weighting for patients in nursing and residential homes as they have increased prescribing needs - in terms of oral medication but also incontinence products and dressings. Factors are also considered for individual practices, where individuals or groups need more medication than usual. A practice serving a home caring for children with physical and learning disabilities would get more for those patients' extra prescriptions.
But the budget-setting process was not sophisticated enough to take all factors into account, and so a wide variation remained between actual expenditure and practice target budgets, with both over and underspend compared to budget. As prescribing incentive schemes include rewards for expenditure below budget, the budgetsetting process needs to be fair and equitable. If the budget is set too low, how can a practice save money without compromising care quality?
The evidence base is growing rapidly, and patients with chronic disease, in particular, need increasing amounts of medication, as evidence is gathered that shows benefits to health and length of life if a certain drug is given. In addition, national service frameworks and National Institute for Clinical Excellence guidance have pushed forward the quality agenda, recommending prescribing in line with the latest evidence. The overall effect of frameworks and NICE guidance has resulted in an estimated additional 1-2 per cent growth in prescribing in primary care over the 8 per cent general trend of recent years.
1For some time in East Kent, GPs have been encouraged to practise evidence-based care through a premium clinical quality contract in a clinical governance framework. This has resulted in practices producing accurate disease registers in a number of chronic disease areas, and auditing to demonstrate that they are treating patients according to best clinical practice. This also has consequences for the prescribing budget, as more patients with chronic disease are identified and treated appropriately. So how can prescribing budgets, and the process used to set them, reflect the differences in practice populations to fund quality, evidence-based prescribing adequately? It must also show equity across the organisation.
Because much work had been carried out at Thanet PCG to ensure that disease registers are accurate, in 2001-02 it was proposed that the budget-setting process would take into account the costs of treating chronic disease, and provide funding accordingly.
The PCG required practices to submit figures for patients with ischaemic heart disease, diabetes and hypertension as part of the clinical governance framework, and it was proposed that these would be used in the budget-setting process to take into account the cost of prescribing in these areas of chronic disease. The aim was for the budget to be adjusted to fund statins for patients with ischaemic heart disease, and hypoglycaemic medication for diabetic patients.
For 2001-02, hypertension was not included in the budget-setting process because disease registers in this area were not as accurate. In addition, practices used different criteria in determining whether or not a patient should be included in the hypertension register. Treating hypertension adds to the cost of prescribing, and the PCG expressed a wish to include these patients in the future. Using prescribing data from the PPA, it was possible to calculate the cost of funding prescribing for statins for ischaemic heart disease and hypoglycaemic medication for people with diabetes and hence a cost per patient. The number of ASTRO-PUs allocated to each practice were adjusted accordingly and used to set the target prescribing budget.
Target budgets were calculated using the new weighted ASTRO-PU. The target share of the prescribing budget using clinical governance figures was compared to the target share that practices would have been given using the old system of budget setting. The difference in adding in a factor for chronic disease was between a 10.5 per cent increase and a 12.5 per cent decrease in target share.An initial analysis showed that practices which received an increased budget under the new system were more likely to be those who had shown an overspend in the previous financial year.
So it could be argued that patients with chronic disease did contribute to the difference in prescribing expenditure between practices.
Practice target budgets and expenditure were compared for 2000-01 (before the use of clinical governance data) and for 2001-02 (with clinical governance data included).
Thirteen practices had expenditure greater than the target budget for 2000-01. For 12 of these practices, including a factor for chronic disease brought them closer to target for 2001-02. For the remaining 12, which had expenditure less than the target budget for 2000-01, only two were closer to target for 2001-02.The rest had expenditure further below target than for 2000-01.
The next question was whether the practices whose expenditure was dropping were spending the increased allocation to fund chronic disease.Data from the PPA was used to measure expenditure on statins and hypoglycaemic medication for all practices. In general, those practices that had moved further below target spent less on statins per patient with ischaemic heart disease than those who were closer to target.GPs welcomed the use of disease registers in this way.At Thanet PCG, the East Kent medical audit advisory group had worked hard in all practices to ensure that disease registers were accurate, so practices were confident the data was correct.Consequently, the GPs considered that including this data in budget setting recognised the cost of prescribing for their chronic disease patients and was a fairer way to set budgets.
In April 2002, Thanet PCG joined with Channel PCG to become East Kent Coastal PCT. Because the use of clinical governance figures appear to give a fairer budget reflecting the cost of chronic disease treatment, the new PCT has again set prescribing budgets in this way across the whole PCT.
Hypertension has been included for 2002-03 following work in practices to improve the accuracy and consistency of disease registers.
In addition, audits are to be carried out in practices that spend less than the average amount on statins to ensure that all patients are receiving the best evidence-based care. In this way, prescribing budgets have been linked to the quality agenda and the PCT's clinical governance framework. Further links are made, in that the prescribing incentive scheme is only awarded to practices that have submitted a clinical governance plan. In 2001-02, all practices were happy to submit such a plan as the importance of clinical governance had been recognised.
Prescribing will always differ between individual practitioners, and a mechanistic formula will never be able to take into account all the factors that influence its cost. Nevertheless, East Kent Coastal PCT believes that using figures obtained via the clinical governance process to set budgets is a positive step forward. l Alison Issott is prescribing adviser, East Kent Coastal PCT.
A primary care group has weighted the formula for allocating prescribing budgets to take account of chronic disease.
The new system is sensitive to local factors such as the siting of a home for children with physical and learning difficulties.
Monitoring of the system suggests that some practices are underprescribing.
Successful use of the formula is partially dependent on practices having accurate disease registers.
1Department of Health.
PCG/PCT prescribing and budget-setting 2002-03.