Chris Lancelot: Controlling prescribing costs without interfering

Last week, I discussed what I see as a clumsy attempt by NHS Bedfordshire to reduce the costs of statin prescribing by using Annex 8 to surcharge practices which don't hit its arbitrary 74 per cent simvastatin target.

The GP Record, by Fran Orford www.francartoons.com
The GP Record, by Fran Orford www.francartoons.com

In case you thought this was merely a localised, provincial difficulty, think again. NHS bodies across the UK are likely to try to adopt surcharging in order to deliver the prescribing economies needed in the coming cash-strapped era. This approach risks affecting all of us, wherever we practise.

As it happens, I am fully in favour of prescribing targets - but not implemented like this. Nevertheless, this incident has highlighted the urgent need to develop ways of cutting prescribing costs, using sensitive and sensible methods rather than blunderbuss ones.

But how can NHS organisations keep control of prescribing costs without interfering with clinical freedom? It is quite feasible. The first rule is: never impose a target which, to allow for exceptions, aims on the low side. Instead, impose a high target - perhaps even 98 per cent - but allow extended exception reporting. Reasons include: intolerance to the preferred lower-cost medication; non-availability of that medication; or where different medication has been recommended by a consultant unit.

There should also be an exception 'on clinical grounds', which would need to be spelled out in full in the patient's notes.

This should include 'patient unsuitability' and 'patient insistence'.

Crucially, GPs should also be able to except patients because, in their opinion, either the suggested low-cost medication has deleterious side-effects, or the higher-cost alternative has significant benefits.

Clearly this exception is open to abuse and should be monitored by inspection teams: the requirement should not be to provide a cast-iron argument in an area which is obviously a matter of medical debate, but instead to produce clear evidence that the clinician has thought carefully before prescribing.

A high target with extensive exception reporting would force clinicians both to prescribe thoughtfully, and to toe the line over using cheaper drugs wherever possible: equally, it would accommodate patients with a clear medical need and, crucially, protect GPs' clinical freedom.

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