The National Audit Office has urged primary care use generic medicines to save money. Oliver Evans hears from the leaders who will be expected to drive the savings in the milieu of restructuring and inform GP prescribing behaviour right down the line

Matching the rising number of NHS prescriptions with the cash to pay for them has kept primary care trusts on their toes in recent years. But major efficiency savings can still be made to ease the financial burden, according to the National Audit Office.

It says PCTs stand to save£200m by prescribing lower-cost drugs in primary care. In particular, the use of cheaper generic drugs could provide as much clinical benefit as their more expensive counterparts.

It also says a further£100m could be saved each year by cutting drug wastage - for example, when drugs are dispensed but not used.

There are 'large variations' between PCTs' use of low-cost medicines, it says, and the lion's share of responsibility lies with managers as the influence of practice-based commissioning on bringing the drugs bill down has 'yet to be tested'.

In its recommendations to PCTs, the NAO report emphasised the need for trusts to evaluate themselves by comparison with one another and to target poorly performing practices with PCT prescribing advisers.

NHS Alliance chief officer Dr Michael Sobanja says: 'PCTs have different priorities. There is no doubt that there is a variation caused by resource levels in medicine management teams. Things haven't been helped by the reorganisation and restructuring of PCTs.'

Need for dialogue

He says: 'Prescribing advisers need to work with local practices and not take a view that says 'all you ever do is this'. The best prescribing advisers, and there are many around the country, do engage in a dialogue and talk about behavioural change.'

The role of advisers is crucial in driving change, says Laraine Tuplin, assistant director of medicines management at Derby City PCT, one of the trusts that the NAO says has the least need to make savings.

She says: 'Doctors are less likely to make the changes because sometimes they don't know what the most cost-effective product is.

'It is no good PCTs sitting in an office sending out bits of paper, because doctors won't read them, and it's no good just popping into the surgery for a chat once a year. It is about having good relationships in your healthcare community.'

Prescription limit

Paul Brown, head of medicines management at Redcar and Cleveland PCT, another top performer according to the NAO, says: 'I think it takes time and some consistency. We have always had a small team and we are not inundated with resources, but they go out and spend a significant amount of time in practices.'

He says a key move in cutting waste was to restrict patients to one prescription every 28 days - an issue highlighted by the NAO as part of its estimated wastage bill of£100m.

Central Lancashire PCT says its 'aggressive' use of atorvastatin to lower cholesterol has made a significant contribution to the PCT being identified by the NAO as one of the trusts that could make the most savings.

But since last year a cheaper type of statin has come on the market, says Malcolm Phillips, the PCT's head of medicines management, and managers now expect to see more cost effective treatments.

Approach with care

He says: 'Statins have been the biggest driver and the number prescribed is going to be even higher, so it is important that we use the most effective agents available to us. At the time this was atorvastatin.'

But he adds: 'That is easy with new patients. The difficulty is when patients are already on the treatment, so the GP will have to approach the situation with care to make the change to the new drug.

'That takes time. You can't tell someone to stop and hope for the best - it has to be done in a managed fashion.'

Leeds PCT professional executive committee co-chair Dr Helen Alpin says the trust is working to make the£4.5m savings set out by the NAO, although last year's PCT reconfigurations had not helped by merging five trusts into one.

She says: 'We haven't yet got in place the necessary management structures to take this forward but we are looking at bringing in an incentive scheme for next year.'

But the figures should not be taken at face value, as they could not be compared with those of other PCTs by showing spending per head of population, she says.

Absolute efficiency?

Dr Alpin adds: 'I think the estimates are optimistic. There is considerable room for improvement in cost-effectiveness but I don't think they will get anywhere near the£300m savings the NAO is talking about.

'That would require absolute efficiency across the system, which is not going to happen at doctor-patient level. You can't assume everyone can have the cheaper generic product.'

The pharmaceutical industry is 'expert in influencing' behaviour, Dr Alpin says, echoing a point made in the NAO's report, based on a survey of more than 1,000 family doctors.

The report said GPs found it difficult to 'assimilate all the information they received on prescribing', and one in five had said the industry had the upper hand in influencing choice.

More than£850m a year was being spent marketing products to GPs, the report said, leading Commons public accounts committee chair Edward Leigh to issue a stern warning. The committee is due to start scrutinising the issue this June.

The Conservative MP says: 'Some small changes to how GPs prescribe could free up a lot of money for our struggling NHS.

'But, for this to happen, GPs will need to be less influenced by the blandishments of the drugs industry and more focused on getting value for money in their prescribing.'

Companies defended

Association of the British Pharmaceutical Industry spokesman Richard Ley however strongly defends the track record of the companies that benefit from the annual NHS drug bill of£8bn.

He says: 'They are trained professionals and are in a position to analyse any information that is put before them. Far from being apologetic about providing information to doctors, I would say it is an essential part of their education. I would call that informing doctors, not influencing them.'

Unsurprisingly, the ABPI also welcomes the report's assertion that prescribing advisers should consider the 'quality of outcome as well as economy' and says there should remain 'scope for practices to use more expensive drugs when that is clinically appropriate'.

Patients first

ABPI commercial director David Fisher says: 'The needs of patients must not be sidelined in the search to save money.

'While cheaper versions of some medicines may well be appropriate for many patients, they are not always so - and doctors must be supported in looking at the true value an individual medicine can bring, and not simply its cost.'

He says doctors should also not be 'constrained' from prescribing medicines that have not been approved by the National Institute for Health and Clinical Excellence.

NHS Confederation chief executive Dr Gill Morgan says NICE could begin to play an integral role in how drugs are dispensed in a cost-effective way.

She says: 'There are issues for NICE to consider, as one of the implications could be that the cost of the treatment should be part of their assessment when more than one similarly effective therapy is available.

'This is important morally and ethically, as every pound that is spent on a more expensive drug, where there is a cheaper alternative, is a pound that cannot be spent to the benefit of other patients.'

The prospect of NICE advising doctors on which drug brand to choose was given a cautious welcome by its chair, Sir Michael Rawlins, at the Commons health select committee's first session looking at the organisation this May.

NICE's central role

In February, in its report The Pharmaceutical Price Regulation Scheme, the Office of Fair Trading said NICE could play 'a central role in any value-based pricing scheme'.

Sir Michael says: 'Of course, it's possible for that to be done if that's what the government wants, but we would not wish in any way to change our standards or robustness or anything like that, and certainly I don't think it's possible to do it suddenly.'

Not only would there be a dearth of health economists to do the work, he warns, but it would also require a 'massive workload' for NICE.

Until then, financial incentives are touted as a strong way of making GPs look at the alternatives available to them.

Dr Morgan says: 'PCTs need to challenge GP practices, and design the right incentives in the system to help this happen.'

Suffolk PCT was ranked third by the NAO among trusts that could make the most cost savings, in this case£4.5m.

Right to prescribe

Christine Bower, the trust's head of pharmacy and medicine management, says: 'Some will embrace incentive schemes and do everything, and others are quite reluctant and require a little more help and support. Some just won't do it.'

Dr Brian Dunn, a member of the British Medical Association's clinical and prescribing subcommittee, says a light touch is needed in dealing with GP prescribing.

He says: 'Some PCTs have almost tried to force GPs to stick to certain formularies and I think that is not the way to go, because, if you do that, I think GPs will always cite their right to prescribe for the patient as they see fit.

'Education and facilitation is the way to go. When PCTs have done that, I think they have seen better results.'

But the burden does not just fall on PCTs. The report urges the Department of Health to develop metrics 'across a large proportion of the primary care drugs bill'.

This should reflect the DoH's Better Care, Better Value statin indicator, which the department said would save£85m a year, according to the report.

This has helped Surrey PCT save£2m, says head of medicine management Kevin Solomons. It was ranked as the trust with the greatest capacity to make savings, a tidy£6.8m.

Software help for GPs

He adds: 'The PCT has targeted key areas to ensure that cost-effective generic drugs are used where possible, and has installed software at GP practices to help GPs identify and prescribe generic drugs for patients.

'This initiative is currently saving the PCT around£25,000 every week, which equates to£1.3m each year.'

In response to the NAO's recommendation, health minister Lord Hunt states: 'Further indicators are being developed to help drive more efficient prescribing for other conditions.'

And progress is being made on using cheaper generic drugs, he adds: 'About 84 per cent of prescription items are now written generically, compared with just 60 per cent in 1996-97.

'This is the highest generic prescribing rate in Europe and means that the NHS gets maximum value from reductions in generics' prices.'