Round Table 2 Lecture 1: Influencing prescribing in primary care in the NHS

Janice Steele. Acting Chief Pharmacist. Croydon Primary Care Trust

Background
Very historically in the United Kingdom, clinical pharmacists tended to be only based in hospitals where they were shown to have a large influence on how drugs are used. No equivalent expertise was made available to support general practitioners prescribing in primary care. However for the last 15 years pharmacists have been employed by the NHS to work with general practitioners to improve the safety and cost-effectiveness of their prescribing in the same way as clinical pharmacists work with doctors in hospitals. Over that time the expertise of primary care based prescribing advisors has increased and now these pharmacists focus on the following areas to maximise their impact:

Areas of activity for a prescribing advisor

*Data analysis: Designing a range of prescribing indicators and competencies which can be used to identify outliers and areas for improvement. There is also work underway to enable commissioners to link drug expenditure to clinical outcomes.
*Horizon scanning: Work to identify new cost pressures (e.g. new drugs coming to market) and then work with clinicians to manage those pressures. Also work with clinicians to maximise saving as drug become generic (come off patient).
Design annual Work plan to prioritise areas of activity for each general practice.
*Working at the interface: To manage the entry of new drugs into the NHS by agreeing place in therapy, where the drug will be prescribed and how it will be monitored (shared care). Also agree what drugs will be in a joint primary/secondary care formulary. And improve communication between hospitals and general practice by agreeing what information about medicines will be communicated when a patients is admitted and discharged from hospital.
*Communication of Information Pharmacists work to improve the quality of information available to prescribers using :
- newsletters
- internet sites
- practice visits sharing good practice
- links with medical education
- computer software to give messages at the point of prescribing
- use of incentive schemes
*Creating and maintaining a Trained workforce: - needs a clinically trained workforce to maintain credibility
- requires good communication skills
- requires an understanding of primary care (compared with hospital)
- needs support with evidence based messages e.g. statin packs to support therapeutic switching.
- Needs close liaison with medicines information service and clinical networks.

The future
In 2008, the NHS spent £11 billion on medicines which accounts for about 18% of the total money spent on the NHS and 70% of the drugs budget is accounted for by medicines prescribed in primary care. The NHS now employs over 1000 pharmacists working in Primary Care Trusts to help manage the risk associated with that budget and through the mechanisms described they have reduced the increase in drug spend from over 10% a year to less than 3% a year in primary care despite a large increase in the amount of drugs prescribed (especially for prevention of cardiovascular disease). In addition to ensuring drugs have been used cost effectively a number of drug safety issues have also been addressed successfully. New areas of activity now also include reducing drug related hospital admissions and reducing waste with medicines through poor compliance.