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Healthy balance

GPs must weigh up more than cost when prescribing for better patient outcomes

Expendable pharmaceuticals are usually the first target when budgets are reduced, and with an increased focus on wastage of NHS monies on unnecessary prescriptions, physicians are under pressure to improve quality and efficiency in their prescribing habits.

Quality and efficient prescribing is central to the effective functioning of a health system, but the question is, should these concepts consider more than just the cost-saving measures to allow for better patient outcomes and longer-term benefits?

The notion of good quality prescribing is a highly subjective one. We know that prescribing decisions are influenced by many parties, each with their own prescribing preferences. Factors including NICE guidance, treatment protocols, PCT plans, the pharmaceutical industry, education on new drugs and patient pressure all have a role to play in deciding what the GP prescribes to the patient. Furthermore, as the number of influencers within the NHS grows, it is rapidly changing the dynamic of the payerñprescriber relationship. Compounding this is the protectiveness around ring-fenced budgets and, where benefits of prescribing policies might emerge in other budgets, it is difficult to convince purse holders of the bigger picture when it comes to both patient and financial outcomes.

A recent study by the Stockholm Network showed that healthcare decisions in the UK are increasingly made on the basis of cost rather than in the best interest of individual patients. The report showed that patients are not always getting the life-saving treatments they need because typical health technology assessments ñ as used by NICE in the UK ñ are too rough a tool and are unable to cater for the real needs of patients. Incidentally, it is worth noting that the Quality Adjusted Life Year (QALY) measurement (£30,000 per QALY) remains the gold standard, despite criticisms.

A recent House of Commons Health Select Committee report raised concerns about the arbitrary nature of this threshold, above which drugs are deemed too expensive.

Proponents of appropriate prescribing argue that prescribing should be the outcome of a decision-making process that maximises net health gains within available resources, inherently giving more importance to the outcome than the process of rationality involved in prescribing.

Measurements and tools of appropriate prescribing allow for the combination of evidence-based medicine and professional opinion, and have evolved to help allocate scarce resources both cost-effectively and equitably. Limitations associated with the use of efficacy and cost-effectiveness as stand-alone concepts are overcome in this way.

In the UK, the emphasis is now on targeting spending to the patients who will benefit. This may encompass treatment changes following regular reviews or, where reasonable, switching from a treatment to a maintenance dose in order to reduce costs.

We must also bear in mind the positive consequences of sometimes not treating with medication. An example of this is seen in a recent initiative by the Department of Health (DoH), which reminds the public and physicians that using antibiotics is not effective on many common ailments. The campaign highlights that inappropriate use of antibiotics can increase the emergence of antibiotic-resistant strains of infections and that prudent prescribing is required.

Unnecessary prescribing is being targeted across the spectrum of prescription medicines. Proton pump inhibitors (PPIs) were recently exposed as net spending on this class of medicines reached £425m in England. However, in over 70 per cent of cases there was no indication for the prescription.

It is estimated that almost £100m of NHS money is being wasted on prescription medicines each year when equally effective over-the-counter medicines could be used. With reports like these serving as fodder for public scrutiny, is it any wonder that drug budgets are the first to suffer?

The DoH should do away with rhetoric and replace it with flexibility for prescribing practices, even if it means taking a hit for the team...

Unnecessary over-prescribing can run drug budgets down rapidly; that much is evident. Initiatives such as introducing a pharmaceutical adviser, although somewhat draconian, get the message across that lazy prescribing will be noted and dealt with. On the demand side, user charges have shown to reduce unnecessary over-consumption. They may, however, have an overly regressive approach and be deterring those working people who cannot afford to pay for their medicines, but for whom they are most necessary.

The combined force of the Quality and Outcomes Framework (QOF) and practice-based commissioning (PbC) has made drug spend an integral part of the overall budget where structured savings have to be made in order to afford other patient services. As the government has only just begun to commission formal evaluation of PbC, there are limited sources of information available about what impact PbC is having on the NHS. However, the aggressive pursuit of world class commissioning and a statement in the Our NHS, Our Future interim report, that says the most effective treatment is often the most efficient treatment may be evidence that, behind closed doors, PbC is showing promising results.

With less money floating the economy, policy makers will become hyper-aware of the places where spending can be trimmed and wastage curbed. This should be construed as a positive opportunity for clinicians to take individual patient needs into consideration and exercise clinical flexibility in their treatment, using the latest high-quality medicines where necessary. It should not be used as a short-term cost-saving exercise by governments to earn political kudos.

Ultimately, there will be long-term cost benefits where recovery times are shorter and patients are back to work sooner, requiring less convalescent care and associated social services. If they are to put their money where their mouths are, and truly improve patient outcomes, the DoH should do away with rhetoric and replace it with flexibility for prescribing practices, even if this means taking a hit for the team and delivering savings to other purses.

The Author
Lisa Mehigan is a consultant, healthcare public affairs, at Fleishman Hillard

4th March 2008


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