If PCT Directors of Finance were hoping for some relief from rapidly rising prescribing costs in the new financial year, they are surely set for a major disappointment. More and more NSFs and NICE guidance appear to be fuelling rampant prescribing inflation and NHS folk are now complaining that the prescribing pot is almost dry! In fact prescribing costs will likely to be the bane of PCT Finance Directors this year and, along with their Prescribing Advisers, they will be actively looking at ways to try and control this surge in costs. So folk might want to examine the recent Audit Commission report Primary Care Prescribing, which highlights the problems that the fast rising prescribing costs are causing and what PCTs might do about this.

Audit Commission Report

The report presents findings on prescribing management from some 120 PCTs in England and warns that unless PCTs 'tackle' the increase in prescribing costs, other services will suffer. Key recommendations include that good management of prescribing requires 'mechanisms to influence prescribers', 'appropriate direction of the efforts of the prescribing team' and 'closer working with other PCTs and secondary care.' Like their earlier report Prescription for Improvement, it estimates that cost savings are still possible by prescribing cheaper drugs and reducing both over-prescribing and 'unnecessary' prescribing. The report further highlights the need for PCTs to set much more strategic goals on prescribing. Several case studies show the apparent benefits of developing a better understanding of the 'impact of good prescribing support' with such support including the development of practice formularies across all practices within a PCT patch. In the report there is significant emphasis on how to build better prescribing strategies which companies need to take careful note of. There are also recommendations around the need for (more) effective GP Prescribing Leads. The Commission would like to see both Prescribing Leads and Prescribing Advisers out more in GP practices, face-to-face, eyeball-to-eyeball with prescribers and not in PCT offices! They strongly suggest that the efforts of the prescribing team need to be better 'directed towards those actions that demonstrably lead to change.' There are recommendations too about PCTs working more closely in large metropolitan areas to avoid duplicating effort in local health economies. Area Prescribing Committees (APCs) are also mentioned, as is the need for PCTs to get more of a handle on Acute Trust prescribing. So all this leads us quite nicely I think into the area of primary care driven formularies.....

Primary Care Formularies

Formularies do definitely seem to be back in town and back on the front burner. Formularies are of course not new and have been around for a long, long time. What does seem to be new are PCT-based formularies and possible plans for national formularies. The industry is very much against any development of national formularies across the UK and sees them as threatening the use of new and innovative products in clinical practice. Although the ABPI has always supported the concept of responsible and rational prescribing, it questions the benefits of developing national formularies which they say would be costly to produce and maintain, not to mention the fact that they unlikely to bring benefits to doctors and their patients. Indeed evidence does suggest that such large imposed formularies do cost more to administer than they save and restrict patient access to new treatments.

But despite these objections, and bearing in mind the comments made above, formularies are very likely to be increasingly used as a way of trying to keep drug inflation down. With the growing cost pressures on their drug budgets, most PCTs will be looking at how to best use formularies. So this is yet another area for local NHS Industry Teams to track and folk might want to find out what kinds of formularies are being set up. Also what formulary designs are effective and work? Why do formularies often fail to meet their objectives? When/why are formularies successful? Where is formulary development going?

The local NHS itself will be looking more closely at the effect of hospital formularies on primary care; more joint formularies (prescribing guidelines across primary and secondary care) and policing and implementation (what to do when they are not working and GPs and hospital doctors continue to go their own way), etc. A major tool in successful formulary development and maintenance will be effective formulary management systems to initiate, monitor, manage and review the formulary. This will involve formulary pharmacists co-ordinating activities and encouraging formulary adherence. There will also be a need for a system which provides information on drug usage for audit and feedback to prescribers. The role of primary care pharmacists and clinical pharmacists in formulary implementation thus cannot be understated. Formularies are also likely to increasingly come under Medicine Management Services within PCTs.

Area Prescribing Committees

APCs were mentioned in the Audit Commission report above and folk might want to check these out again. APCs evolved prior to creation of PCTs being founded nearly 10 years ago when health authorities were asked then to take a broader and more strategic approach to prescribing..... There are thus already mechanisms in place for significant formulary development. There would be no reason, for instance, why an APC, or whatever they are called, could not service a number of PCTs within a strategic health authority area. Have a look at Area Prescribing Committees - Maintaining effectiveness in the Modern NHS. A Guide to Good Practice published by National Prescribing Centre (NPC). See www.npc.co.uk.

At a national level, the All Wales Medicines Strategy Group and the Scottish Medicines Consortium (SMC) are new groups picking up on formularies. But despite this, there will always be situations in which regional, area or local drug and therapeutic committees will want to critically appraise the evidence about a new product. Thus local formulary groups are never going to go away. They can, and frequently do, make up their own rules and seem to actively put into place barriers or employ delaying tactics in order to prevent new products being prescribed in their area. Please see the accompanying box, although this list is by no means exhaustive! Such barriers to formulary inclusion, whether in acute or primary care settings, will likely continue.

Local primary care formularies will thus increasingly be yet one more hoop for the pharmaceutical companies to jump over. Following the Audit Commission report, expect activity at PCT level regarding formularies to grow with PCTs continuing to develop their approaches to formularies, whether fully 'comprehensive' or targeted at specific therapeutic groups. Expect more pharmacists to have responsibility for development of primary care formularies. So are we beginning to see a different and more strategic approach to use of formularies? They certainly will not go away......

This article was first published in the Pharma Times: August 2003

About the author

Alan Jones is an independent health policy analyst and adviser. He writes and presents widely on the New NHS. Alan spent some 20 years in the Pharmaceutical Industry in a variety of sales, marketing and business development roles including some 10 years at Glaxo Wellcome UK where he was responsible for relationship building between Glaxo Wellcome and the Department of Health, and in developing a corporate understanding of current NHS policy initiatives and their likely implications and impact on the business.

Alan is also managing consultant at ajc healthcare, which specialises in NHS policy issues for both the Pharmaceutical Industry and the NHS and aiming to support organisations in steering the right strategic course through a rapidly changing NHS environment.

Alan has a Masters in Business Administration and is a fully qualified teacher - before joining the Pharmaceutical Industry, he spent a decade teaching and lecturing in colleges, schools and universities in the UK, the United States and West Africa. He is also a reviewer with the NHS National Co-ordinating Centre for Health Technology Assessment (NCCHTA) and was a member of the UK Local Organising Committee for the International Society for Technology Assessment in Health Care (ISTAHC) held in Edinburgh in June 1999.

Click here to contact Alan Jones

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