Prescribing costs in primary care

Prescribig costs i primary care LONDON: The Statioery Office 13.50 Ordered by the House of Commos to be prited o 14 May 2007 REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 454 Sessio 2006-2007 18 May 2007

SuMMARy 1 The Natioal Health Service speds 8 billio a year o prescriptio drugs i primary care i Eglad. Expediture o primary care drugs has icreased by 60 per cet i real terms over the last decade, ad the umber of items dispesed has icreased by 55 per cet. The cotiued developmet of ew drugs for use i the NHS, the idetificatio of ew applicatios for existig drugs, ad Eglad s ageig populatio, mea that further growth ca be expected. 2 There are, however, ways i which the Departmet of Health (the Departmet) ad NHS bodies ca help make growth more affordable without affectig patiet care, ad hece eable more people to be treated or expesive treatmets to be made more widely available. They ca seek to ifluece doctors prescribig decisios, for example where differet drugs have the same cliical effect but differet prices; ad they ca seek to cotrol the prices the NHS pays for drugs. 3 This report examies the first of these approaches: supportig doctors ad other prescribers i their prescribig decisios. We looked at the scope for improvig the efficiecy of prescribig, issues ivolved i assessig prescribig effectiveess, ad the iflueces o prescribig behaviour. We also examied the extet of drugs wastage, due, for example, to patiets ot takig drugs they were prescribed, or beig give repeat prescriptios for medicies of which they already had a sufficiet stock. 4 PRESCRIBING COSTS IN PRIMARy CARE

4 The Departmet s mai mechaism for cotrollig drugs prices is the Pharmaceutical Price Regulatio Scheme, a agreemet egotiated every five years with the pharmaceutical idustry, that aims to esure that the health service ca obtai drugs at fair prices, whilst promotig a strog idustry capable of developig ew ad improved medicies. This scheme has recetly bee the subject of a review by the Office of Fair Tradig, which has made recommedatios for reform of the scheme (summarised i Appedix 1), which the Govermet is curretly cosiderig. 5 The mai strads of our methodology were: a survey of 1,000 geeral practitioers (GPs); a survey of prescribig advisers i Primary Care Trusts (PCTs); case studies of good practice across the coutry; a aalysis of the NHS database of all primary care prescriptios writte for the period August 2005 to July 2006; a i-depth study of practice i two PCTs with differet prescribig outcomes, ivolvig focus groups ad iterviews with GPs ad PCT staff; cosultatio with a expert pael of academics, GPs, pharmacists ad other stakeholders; ad iterviews with represetatives of the idustry, relevat professioal bodies ad other orgaisatios. Appedix 2 sets out our methods i more detail. 6 Although there has bee progress i some areas i recet years, for example a icrease i the proportio of prescriptios writte that allow drugs to be dispesed i cheaper, geeric form, the Departmet ackowledges that there is scope for improvig value for moey i primary care prescribig. I September 2006 the NHS Istitute for Iovatio ad Improvemet lauched its Better Care, Better Value idicator for the prescribig of statis (drugs used to lower blood cholesterol levels ad reduce the risk of heart attacks ad strokes). The Departmet estimated that 85 millio could be saved by more systematic prescribig of lower cost, geeric forms of these drugs. 7 We examied four groups of drugs, icludig statis, that accout for 19 per cet of the total primary care drugs bill ad which are used to treat coditios where there are several suitable drugs available at differig prices. We foud large variatios betwee PCTs i the extet to which local GPs prescribed lower cost drugs for these coditios, meaig that there is scope for most PCTs to icrease efficiecy, without affectig cliical outcomes, by icreasig the proportio of low costs drugs used. We estimated that as a result PCTs could save more tha 200 millio a year, for example, if all PCTs achieved at least the stadard of the most efficiet 25 per cet. We also foud there were variatios i the volume of prescribig which did ot match variatios i idicators of cliical eed, such as local disease prevalece. A uusually low volume of prescribig may idicate umet eed, ad a uusually high volume may idicate excessive prescribig, both of which represet poor value for moey. 8 Practice Based Commissioig, the Departmet s iitiative that gives idividual GP practices more cotrol over their PCTs fiacial resources, allows GPs to reivest a proportio of ay efficiecy savigs they make ito their practices. It therefore could be a lever for improvig value for moey i prescribig, but its potetial has yet to be tested. Oly eight per cet of GPs respodig to our survey said it would ecourage sigificat savigs. GPs will therefore cotiue to eed support from PCTs i maagig their prescribig. 9 GPs have to update their prescribig kowledge cotiuously, but we foud that it was difficult for GPs to assimilate all the iformatio they received o prescribig. Both official NHS prescribig advisers ad the pharmaceutical idustry ifluece GPs prescribig decisios, with the idustry spedig more tha 850 millio aually marketig its products to GPs. Two thirds of the GPs we surveyed said that PCTs prescribig advisers have more ifluece o their prescribig behaviour tha the pharmaceutical idustry, but oe i five GPs idicated they felt that pharmaceutical compaies have more ifluece tha prescribig advisers. 10 Aother ifluece o GPs prescribig is the secodary care sector, as aroud a fifth of primary care prescribig is iitiated i hospital, ad drug choices i geeral practice are ofte guided by local specialists. Hospitals limit cosultats prescribig optios to drugs approved by the hospital s expert drugs ad therapeutics committee as a cost-effective subset of the large rage of medicies available. GP practices are ot subject to such a committee, but GPs should review prescriptios origiatig i secodary care at regular itervals to see if they are still required or should be chaged. However, oly a quarter of respodets to our GP survey metioed that they would routiely review cosultats prescriptios whe asked what arragemets they had i place for maagig prescriptios that origiate i hospital but are dispesed i the primary sector. Prescribig costs i primary care 5

11 Our aalysis showed that several mechaisms are effective i improvig value for moey i prescribig, ad ca be adopted by PCTs. These iclude persoalised commuicatio with GPs from local experts, providig fiacial ad practical icetives, ad ivolvig the whole prescribig commuity, across primary ad secodary care, i decisios o local drugs policies. Curretly PCTs curretly vary cosiderably i their approaches to medicies maagemet, ad the extet to which they are employig these strategies. 12 We foud that drugs wastage is a sigificat cost for the NHS: at least 100 millio a year, ad perhaps cosiderably more tha this, although the lack of robust data, ad the wide rage of reasos for waste, makes quatificatio difficult. There are local examples of atiwastage practices i place, such as limitig the iitial time period of ew prescriptios, or of the legth of time betwee repeat prescriptios, ad iformatio campaigs to raise public awareess about the cost of medicies to the NHS. The Departmet recogises that wastage is a serious problem, ad has itroduced medicies use reviews for patiets with log term coditios, ad repeat dispesig schemes that allow patiets to collect repeat prescriptios directly from pharmacists, who ca check whether they are still takig their medicies or experiecig difficulties with them, i a attempt to tackle some of the causes of waste. 13 Uptake of these iitiatives, however, has bee low sice their itroductio i 2005. I the year to September 2006 less tha 0.5 per cet of dispesig was doe by repeat dispesig. By December 2006 about 500,000 medicies use reviews had bee coducted i total. Academic research suggests that may PCTs remai to be coviced of the value of medicies use reviews, ad that further actio is eeded to support ad embed the medicies use review service. It will be importat to evaluate the effectiveess of these iitiatives after the electroic prescriptio service comes fully olie. Coclusio o value for moey 14 There is scope to improve the efficiecy of prescribig i primary care. Improvig efficiecy frees up moey, without affectig cliical outcomes, which ca the be used to pay for treatmets for other patiets. We foud over 200 millio of potetial efficiecy savigs by lookig at just 19 per cet of the primary care drugs bill. The areas we examied offer the most sigificat savigs opportuities, but further savigs may be possible i other areas of primary care drugs expediture. 15 Wastage of drugs, uder-prescribig, ad overprescribig, wheever they occur, represet poor value for moey. The Departmet of Health does ot curretly moitor levels of drugs wastage, so it is difficult to form a view o whether its curret ati-wastage measures are proportioate. Assessig whether local prescribig volumes are cosistet with cliical eed is complex. However, combiig prescriptio data with local prevalece data ca provide bechmark iformatio for PCTs ad GP practices to help idetify opportuities for improvig the value for moey they get from their prescribig. Recommedatios 16 We make the followig recommedatios o the basis of this examiatio. The Departmet of Health should a b c d e Build o the Better Care, Better Value stati prescribig idicator to develop further metrics, across a larger proportio of the primary care drugs bill, that PCTs ca use to quatify achievable improvemets i areas of high prescribig volume ad agaist which they ca assess themselves. Commissio the NHS Busiess Services Authority ad the Iformatio Cetre (Prescribig Support Uit) to collaborate i developig prescribig bechmarkig tools for PCTs that improve o the curretly available electroic prescribig aalysis ad cost data by icorporatig local prevalece iformatio. Actively promote their prescribig bechmarkig tool to PCTs ad seek PCTs feedback to improve its accessibility ad fuctioality for producig reports that prescribig advisers ca use directly with GP practices. Evaluate the effectiveess of medicies use reviews ad repeat dispesig schemes after the electroic prescriptio service comes fully olie. Update the 1996 survey of residual medicies to come up with a more robust estimate of the scale of medicies wastage i Eglad, ad better iformatio o why patiets do t take their drugs. Strategic Health Authorities should f Esure that PCTs itegrate approaches to prescribig across primary ad secodary care, so that patiets discharged ito primary care have their medicies reviewed regularly, that drugs are ot cotiued for loger tha ecessary, ad that there is cosistecy betwee GPs ad cosultats choices of drugs. 6 Prescribig costs i primary care

All Primary Care Trusts should g h i j k Assess the value for moey they are gettig from prescribig by bechmarkig themselves agaist other PCTs, ad idetify areas where improvemet is ecessary. Make more active use of the medicies maagemet idicators i the Quality ad Outcomes Framework to promote more efficiet prescribig, where this is a issue of importace as part of the local prescribig strategy, with appropriate performace maagemet by Strategic Health Authorities. Use GP practice-level iformatio about prescribig i the areas idetified for improvemet to idetify practices whose prescribig behaviour is sigificatly differet from that of their peers. Esure that prescribig advisers maximise their face-to-face cotact time with these practices, ad gai commitmet to improvemets i prescribig, develop practice-level actio plas, ad moitor ad follow up performace. Support prescribig advisers i seekig to ifluece GPs prescribig behaviour i targeted areas by: keepig messages clear ad simple, focused oly o a small umber of key prescribig priorities; emphasisig that value for moey i prescribig icludes quality of outcome as well as ecoomy, ad that there remais scope for practices to use more expesive drugs whe that is cliically appropriate; ad backig up key messages with edorsemet from seior maagemet ad local cliical opiio leaders. Idetify the costs associated with possible PCTwide ways of improvig prescribig such as additioal fiacial icetives or practice-based pharmaceutical support for GPs, ad the potetial retur o ivestmet i terms of prescribig cost savigs; ad implemet such programmes whe they would be cost effective. Prescribig costs i primary care 7