No one knows what effect primary care groups will have on prescribing costs. But Frances Wilson explains how one health authority reversed a drugs overspend

What will happen to prescribing costs in primary care groups? Will control of unified budgets result in drug costs eroding the money available for other treatments, or will PCGs be able to use economies on medicines to increase patient access to other services? Health authorities have strategies to manage the use of medicines, containing or reducing the drugs bill while improving the quality and cost-effectiveness of prescribing in primary care. It is hard to see how these will be transferred to PCGs.

GP responsibility for budgets may result in better control, but fragmentation of current medicines management systems, with their in-built economies of scale, could still destabilise the overall effect. Managing medicines involves not only the prescribing decision, but other considerations, including relationships with patients, patient attitudes and the settings in which medicines are supplied. Nurse prescribing will add a new dimension to the strategies.

How do HAs address prescribing issues? What must PCGs do to achieve similar success individually? And how will HAs continue to support and monitor this? The most important areas of future work will be:

avoiding waste;

introducing new drugs;

evaluating evidence;

incentives to prescribers to address


role of pharmacists in developing new services;

addressing medicines issues in new settings.

West Hertfordshire HA was formed in 1996. A prescribing and medicines management team was created. Prescribing in Hertfordshire had been reduced from a 5 per cent overspend, equivalent to£3m, in 1992, to a 0.5 per cent underspend at March 1996. Since then, it has made many more successful changes in both cost and quality.

Initiatives undertaken include monitoring indicators of good quality prescribing, such as the ratio of corticosteroids to bronchodilators in asthma, and ACE inhibitors for heart failure patients. Indicators of poor quality prescribing include appetite suppressants and high prescribing of minocycline.

Monitoring changes in prescribing

Prescribing of 'statin' drugs to lower cholesterol has almost doubled in two years. But is it being targeted at the right people? These are questions the HA is addressing in conjunction with GPs and local consultants. By contrast, the use of minocycline has fallen following a concerted campaign to promote oxytetracycline as a first-line drug in view of the serious side-effects reported with minocycline.

Prescribing of drugs to promote weight loss has - from national data - been reduced to the lowest in the UK - evidence shows them to be ineffective long-term.

Managing the entry of new drugs has been addressed through the formation of a committee consisting of the two Hertfordshire HAs, GPs, trust representatives and pharmacists. Protocols have been developed with key trusts for beta interferon and growth hormone. The introduction of donepezil for Alzheimer's has been addressed, as has the launch of new drugs for stroke prevention, the wight-loss drug orlistat (Xenical) and the male impotency treatment sildenafil (Viagra).

The financial position continues to improve - at the end of March, the out-turn was a 1.1 per cent overall underspend. The position of non-fundholders and fundholders was not substantially different. Most non-fundholders were underspent - 1 per cent overall.

Contrary to popular belief, expensive medicines are not the problem. Key cost drivers are commonly prescribed drugs - for example, for asthma, diabetes and lowering cholesterol. Costs in cholesterol-lowering therapy have more than doubled in the past two years. PCGs will need policies on the increased use of resources in these areas as new evidence of benefits becomes available. Costs will need to be weighed against benefits, and patients prioritised in line with health improvement programme priorities. The value of new medicines, such as oral drugs for asthma, will need to be carefully assessed.

HA roles are likely to recede to monitoring,development and evaluation of evidence at a broad level. PCGs may provide the opportunity for innovation. In medicines use, issues include:

use of patients' own drugs in hospital;

repeat prescribing, which makes up over 75 per cent of all prescribing;

care of elderly people, who consume almost half of all medicines prescribed;

hospital supply for outpatients and discharge medication for inpatients.

HAs will keep a key role in performance monitoring , but GPs will be responsible for managing drug costs within existing resources.

Local priorities will still have to be determined within a cash-limited and unified budget of which drugs will account for approximately 15 per cent. HAs will have a key role in seeing PCGs through the learning curve and adopting the role of a critical friend thereafter.