News analysis: What the squeeze on GP prescribing means for the NHS

As the NHS struggles with a burdensome efficiency drive, GPs are increasingly concerned about how the squeeze on prescribing will affect patients, clinical freedom and workload.

GPs are facing increasing scrutiny as pressure to reduce prescribing costs continues to grow (Photograph: JH Lancy)
GPs are facing increasing scrutiny as pressure to reduce prescribing costs continues to grow (Photograph: JH Lancy)

The latest advice from the NICE-run National Prescribing Centre (NPC) is a case in point. Working with the NHS Information Centre and NHS Prescription Services, it has launched a set of comparators to track prescribing variation in 10 key areas.

These will inform the Quality, Innovation, Productivity and Prevention (QIPP) scheme, and although the DH begs to differ, the comparators look a lot like performance targets.

Signal to GPs
GP revealed last year that PCTs were 'blacklisting' drugs approved by NICE - barring GPs from prescribing them - to cut costs.

The NPC's latest advice, tailored to work with these targets, gets tough on prescribing, from antidepressants, to antibiotics, to dressings (see box below).

Latest prescribing advice for GPs

Laxatives - Use only short-term treatment for constipation where other measures have failed.

Antidepressants - Reserve drugs for more severe illness, or where non-drug approaches have failed; generic SSRI should be the first choice for depression, sertraline for generalised anxiety disorder.

Trimethoprim - Limit prescribing for uncomplicated UTI in non-pregnant women to a three-day course.

Minocycline - Avoid as first-line acne treatment in light of high costs and adverse effects.

Wound care products - Use the cheapest dressings, do not routinely use antimicrobial products.

Statins - Revise use of ezetimibe and high-cost statins in line with NICE guidance.

Type 2 diabetes - Consider risks and benefits of intensive glycaemic control and use of hypoglycaemic agents; revise prescribing of long-acting insulin analogues and use of self-monitoring of blood glucose.

For example, it warns that only generic SSRIs should be the first-choice treatment for depression in adults. Yet the NPC points out that other drugs still make up at least half of all antidepressants prescribed - a clear signal to GPs.

Similarly, the NPC wants clinicians to avoid prescribing minocycline as the first-line acne treatment - and says £2.2m could be saved in doing so.

The NPC stresses that revisions must be implemented only after careful review and switches made only where appropriate. Nevertheless, there is growing pressure on the profession to change prescribing behaviour to suit budgets.

This is reflected in PCTs stepping up efforts to switch patients from atorvastatin to cheaper, generic statins in recent years.

However, when atorvastatin comes off patent in the UK in May, it will surely signal an about-turn from most PCTs and CCGs. Patients will be switched back to a drug which, months before, their GP was asked to take them off.

Short-term focus
For Dr Bill Beeby, GPC prescribing lead, the situation is intolerable. 'What we've got at the moment is an extremely short-term focus on what is perceived to be a solution to this year's budget,' he says. 'This year, atorvastatin is expensive, so people are changed over. Next year, if, as presumed, the price drops, they will say: "Why didn't we always use this?".'

Dr Beeby doubts the planned savings from such schemes ever materialise. 'The predictions don't take into account the hidden costs,' he says. These include consultation time - where several appointments may be needed to discuss the switch and check a drug is well tolerated - and extra checks such as blood tests.

GP workload also takes a hit. Dr Beeby says: 'We don't have to do this for many patients to wipe out a week's work.'

Dr Beeby: What we’ve got at the moment is an extremely short term focus on what is perceived to be a solution

Moreover, not every patient will agree to switch, further limiting savings. 'If we do it and the patient is not on board, they will complain,' he says.

He adds: 'The process of changing drugs can be fraught. It's right to choose the correct drugs first time. But switching needs to be given very careful thought.'

Berkshire GP Dr George Kassianos says: 'The availability of excellent drugs but at much lower price is an important milestone in GP prescribing.'

But the effect on patients appears to be overlooked in some cases. He says: 'An example here is the patient who is well controlled on a particular drug for depression - with no side-effects, good compliance and feeling absolutely fine and happy. I am asked to stop the current medication and start this patient on an SSRI because they are good and cheap.'

Challenge to practices
The rollout of yet more GP prescribing targets is a real challenge for general practice. Revising prescribing may be warranted in the light of fresh evidence. But, Dr Beeby argues, patients' trust in their doctor may be damaged if they are regularly switched between drugs for the sake of savings.

'Patients risk losing confidence in us if we swap from one to another and back again,' he says. 'There's obviously a risk that people might not be so compliant, although it is a theoretical issue.'

He adds: 'When two treatments have equal value and benefits, it's our duty to pick the most cost-effective one. But we have to consider the patient's viewpoint.'

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