How can the NHS enhance value in primary care prescribing?

The NHS often thinks in terms of containing costs around primary care prescribing but focusing on getting the best value out of the money spent may offer a way to build engagement with GPs.

While GPs want to do the best for their patients, choosing a cheaper option which delivers the same quality and reducing waste enables them to do that while also reducing costs – and could free up money to deliver other things they value.

Whether integrated care boards are able to make a difference will depend on how they can influence thousands of daily decisions made in the consulting room. An HSJ  roundtable, in association with Spirit Health, looked at some of the challenges and how different areas are tackling them.

Disconnected budgets and supply issues challenge GPs and impact engagement and savings in primary care.

A massive issue is that ICB-level prescribing budgets often mean little to individual GPs and practices. Hitesh Patel, pharmaceutical adviser for Dudley Integrated Care Trust and a lead pharmacist for a PCN, described them as becoming a “nominal figure”, leading people to lose interest in trying to meet them.

But the NHS has also been hit by pricing changes and massive issues with supply, he said: “There are so many sorts of variables that are outside of our control that it becomes difficult to manage a budget and deliver those sorts of savings that we’re talking about.”

The position can be complicated by data on primary care prescribing spend which can sometimes be less than helpful. Data on an area’s spend may not be comparable with others, both because of different demographics and whether prescribing was initiated in secondary care and then passed down to primary care. Peter Cope, head of medicines optimisation, Dorset ICB, said the data sent by NHS England suggested some areas were spending 50 per cent more than others per patient, which was hard to believe.

“Some ICBs are on the back foot before they even start,” he said. The formula used for NHS allocations was meant to reflect aspects such as rurality, deprivation and social care costs but could just perpetuate inequalities in prescribing and drive reductions in prescribing quality to meet what the allocation was.

He said that when he was a GP – before he took up his present role – “I didn’t give a monkey’s about this stuff. I’ve got the patient in front of me and actually all I’m interested in doing is the best thing for the patient.”

Head of service delivery – medicines optimisation at Spirit Health, Duncan Richardson, pointed to a sense of disconnect between the integrated care systems and practices which seemed to have developed over the last year or so. This was not universal, he insisted, but it added to the challenge. He raised the question of whether understanding where the savings would go would help motivate people because the money saved could support the work GPs are trying to do.

Engaging with GP practices and primary care networks is crucial to delivering the best value from prescribing spend.

The first challenge may be making GPs care about getting better value out of the money spent. Many GPs will be concentrating on doing the best for the patient in front of them and ICB priorities will feel very distant. Dr Cope said Dorset had recently run an engagement event where they put all their PCN prescribers in a room, and just listened to what they said about how the NHS felt from their perspective, and then talked about how it felt from the ICB’s position to create some sort of shared understanding. Creating a better voice for PCN chief pharmacists was also part of the plan, he said.

But Dorset had also prioritised certain groups of patients rather than pursuing multiple priorities. Within its population, there were those at risk of fractures and falls who were often on multiple medications. It had devised a directed enhanced service covering this group and had told GPs this was all which could be addressed in the first year because that was all there was capacity for.

Shared understanding and transparency can help, he added. Part of that may be understanding the opportunities to do other things if prescribing spend can be contained. “In Dorset, prescribing is taking a larger and larger slice of the cake, so there are things that we want to do in our system around prevention and we are gradually gearing up that space year after year with primary care prescribing,” he said.

The arrival of ICBs has also meant some changes to medicines optimisation teams whom GPs may have been used to working with. Zak McMurray, medical director (Sheffield), South Yorkshire ICB, praised the value of a named medicines optimisation lead and said his area had had a very effective team, which had driven down costs and improved the quality of prescribing – for example, around antibiotics – but now that team was spread across South Yorkshire. 

Empowering those on the ground to make changes rather than making changes top-down also drives engagement. “Top-down imposition doesn’t allow you to maximise the opportunities because actually, if you just work with your colleagues in a specific area, bearing in mind all the populations are different, then actually you could make it much more effective. So that’s part of the frustration that I think then disengages people from it,” he said.

Incentives for practices to make changes may help, said Dr McMurray, but a shift of money from secondary care into primary and community care was ultimately necessary

Several panellists said successful engagement comes down to relationships and trust, and building this takes time. “It does feel to me over the last five or six years that actually clinicians are disengaging from management. The management [is] seen as the enemy again by a lot of clinicians [who are] working on the coal face,” said Dr McMurray. “We need to work on engaging people again, but they also need a bit of time to engage and it does feel flat out at the moment.”

While priorities in different areas can differ, they can also offer a chance to engage with GPs on the issues they see daily in their surgeries. Dr Cope said in some parts of Dorset, people did not live long enough for polypharmacy to be an issue, and cardiovascular disease prevention was a better way to engage with clinicians rather than a top-down approach.

Incentives for practices to make changes may help, said Dr McMurray, but a shift of money from secondary care into primary and community care was ultimately necessary. “I think that is going to be a massive issue around engagement because why would GPs engage if all the money that’s saved is going to go the wrong way. We’ve got to be upfront about it. You’ve got to create some sort of shift of resource either through incentive or through an adult conversation that says we’re going to shift X per cent of overall funding into the community part of the system.”

But any change should not add to GPs’ workloads. Mr Patel said, as a pharmacist, he often had practices concerned about who handles the queries if someone’s blood glucose monitor is changed and the patient is struggling with it, for example.

Pharmacy spending pressures demand efficiency, digital tools and collaborative pathways to manage costs and improve patient outcomes.

Despite these issues and all of the factors pushing up pharmacy spend, some areas have faced large efficiency targets around prescribing. For Kent and Medway, the target is 9 per cent, said Priscilla Kankam, deputy director for medicines optimisation at Kent and Medway ICB. “We’ve done all sorts of things, incentive schemes, we’ve implemented all sorts of digital software to help, but we know it can only do so much,” she said.

Chief pharmacist at South East London ICB Vanessa Burgess agreed making savings can be challenging after many years when the NHS has tried to reduce costs through medicines management and optimisation, warning sometimes a focus on saving pennies could miss the pounds.

Tase Oputu, chair, English Pharmacy Board, Royal Pharmaceutical Society and associate director of medicines optimisation for high-cost drugs at Kent and Medway ICB, said the development of care pathways had been crucial to getting to grips with the costs of and value delivered by prescribing. “Making sure that we have pathways of care which follow the patient no matter where they are, and not seeing the hospital as being one particular place and primary care as a separate place [is important], but the patient just doesn’t see that,” she added.

Electronic prescribing systems could also help as could pharmacists having access to patient records and being able to write into them, she said.

In Dudley, there had been some progress towards getting away from silos through PCNs commissioning some pharmacy services from the integrated trust which had helped to address high spend areas such as wound care. This meant it was not just the products which were being purchased which were being looked at but the overall impact on the patient – for example, did the changes implemented mean wounds were healing more quickly, said Mr Patel. A similar approach was going to be tried in continence services.

“Now we’ve got one integrated care partnership where we’ve harmonised formularies. Hospitals have been involved in that process as well. So we’re all singing from the same hymn sheet now,” he said.

But there may be an issue for ICBs in how quickly some of the potential savings and improvements in value are delivered. Mr Richardson said redesigning end-to-end pathways could bring benefits but they often were not delivered for several years. Investing for the longer term was key, he added.

Ms Burgess added: “It’s very, very difficult to do that kind of work because you may be releasing money somewhere in the system, but you know it may be a long time down the line in terms of avoiding a renal transplant or it may, if you’re lucky, be in year for something like heart failure.”

At the same time, the NHS is facing pressure from increased demand in some areas such as chronic kidney disease, metabolic and obesity care and migraine drugs, she said, with the possibility of new Alzheimer’s drugs looming as well, although some drugs coming off patent might help to contain costs. Spend on medicine needed to be seen as an investment in good outcomes, she said.

Can the NHS and hard-pressed practices manage to contain costs and improve value alone? There are many constraints, including workforce

Reducing medicines waste was also part of the value approach, which included a patient-centric approach which worked with them on shared decision-making and overprescribing. Sometimes national contracts and priorities did not help – Mr Patel mentioned seeing an 89-year-old patient who had been referred to him to initiate statin prescribing.

But secondary care prescribing often happens in a silo, pointed out Dr McMurray, with a single chronic condition being focused on rather than the holistic approach GPs would have. Half of GP prescribing spend was initiated in secondary care, he added, while high spend in hospitals also had the potential to affect spend on areas such as preventive work.

Ms Kankum pointed out there were sometimes perverse incentives around areas such as oral nutritional supplements where cheaper rates were charged to hospitals which then passed the prescribing onto primary care, which had to pay much more.

Can the NHS and hard-pressed practices manage to contain costs and improve value alone? There are many constraints, including workforce. Mr Patel said working with partners could help on some of the projects to improve value in areas such as diabetes where there was national advice around low-cost blood glucose monitors and pen needles. “It does not have to be practice teams doing that,” he added.

Balancing cost-saving and patient wellbeing in healthcare requires value-driven strategies, collaboration, and transparent communication across systems.

Having spent years working with healthcare systems on their medicines optimisation workplans, it was good to discuss value for money in simple terms across primary care. We all know cost-saving is a priority, but it can’t come at the expense of patient wellbeing.

One key area getting significant airtime is “end-to-end treatment pathways”. While they might not deliver immediate savings, the long-term health benefits are undeniable. The challenge, of course, is the current focus on quick fixes, but with proactive planning, we think you can achieve both, whilst considering the specific needs of each population.

Another hidden cost culprit: secondary care prescribing that gets passed on to primary care. Negotiating better deals across the entire healthcare system would prevent cost inflation in primary care.

It’s important to remember that optimisation isn’t just about cutting costs here and there. We’re aiming for value. This means finding the most cost-effective options that deliver quality patient care, potentially even reducing overall medication use.

Community pharmacies are fundamental partners. A top-level conversation is still needed to find more ways for them to benefit from cost-saving measures, ensuring their financial viability and ability to serve patients effectively.

Sometimes, the simplest things have the biggest impact. Reducing multiple priorities for GPs and focusing on single key areas collaboratively across the system could lead to significant long-term improvements. Transparency, of course, is key – everyone needs to know where the savings are going.

The bottom line? Rebuilding trust and open communication with GPs is paramount. By all working together – whether that be with Spirit Health or internally – and focusing on value-driven optimisation, we can achieve better health outcomes for patients while making the most of medication budgets in primary care.

As an independent service provider to the NHS for more than 15 years, Spirit Health has a number of tools and services we provide to medicines optimisation teams. Whether that’s implementing change to improve patient care, delivering long-term value from your prescribing or everything in between, we are here to make health easy.

Duncan Richardson, managing director, active implementation, Spirit Health