The drive to control NHS costs has led many PCTs to 'blacklist' drugs recommended by NICE, a GP investigation has found.
GPs do not see blanket bans as an appropriate way of cutting costs. But as drug spending rises, clinical commissioners will face the same challenge PCTs have in limiting prescribing costs (see graph: Drug spending - the savings challenge facing commissioning).
Under current PCT rules, GPs can face financial penalties or heavy scrutiny if they fail to follow PCT prescribing advice.
GPC prescribing subcommittee chairman Dr Bill Beeby says that while prescribers need to be 'mindful' of costs, individual clinicians must be allowed to make decisions based on each patient's circumstances. 'PCTs are not treating patients,' he says. 'The only reason PCTs will do this is for cost containment.'
Manchester GP Dr Anita Sharma, who represents her LMC on Oldham's medicines management committee, says decisions on which drugs should be available 'are difficult and can be controversial'.
But she believes the NHS will only be able to achieve its required £20 billion in productivity savings by containing prescribing costs.
'We face a period of increasing financial pressures and we should work together and focus on improving the quality of prescribing, appropriately and cost effectively,' she says.
GP prescribing: CCGs will face the same challenge as PCTs in limiting the cost of prescriptions (Photograph: J Varney)
PCTs have been introducing traffic light classifications of drugs that are deemed suitable for prescribing in different settings since 2005.
But over the past two years, there has been a sharp rise in the number of items included on blacklists. Some PCTs now list more than 100 drugs that doctors should not prescribe.
There is little agreement among PCTs about which drugs should be included on these lists, but one common policy is that all newly licensed drugs are added to blacklists until they have been appraised by NICE.
West London GP and British Cardiology Society member Dr Sarah Jarvis believes there is 'no excuse' for such blanket decisions. She says PCTs should be working with local networks to make decisions on whether new drugs that have not yet been assessed by NICE should be made available.
PCTs say they have decided to restrict some drugs because other products in the same class are cheaper or have more data to support their use. But Dr Jarvis says: 'They should be having discussions with GPs and introducing prescribing targets.'
Dr Beeby points out that PCTs' blanket bans on the use of particular treatments have no legal status. 'There are no regulations that allow PCTs to do this,' he says. 'If a drug has a licence, it is legal for someone to prescribe it. If a drug has a licence and is recommended as a third-line treatment by NICE, we have to accept it is going to be used and we have to check it's being used appropriately.'
Dr Beeby also says that the existence of a PCT 'blanket ban' would not protect doctors against negligence claims if they did not prescribe a treatment deemed appropriate for particular patients.
Even though blacklists have no legal status, GPs wanting to prescribe a drug on a blacklist have to go through a lengthy appeal process to do so.
Many PCTs also monitor prescribing to check for GPs writing prescriptions for blacklisted drugs and challenge prescribing of these items.
Some PCTs publish league tables of compliance with blacklists and some formularies are linked to incentive schemes, so GPs lose income if they prescribe drugs that are blacklisted by the PCT.
Dr Krishna Korlipara, who helped develop the Bolton Collaborative Consortium, a GP commissioning group in Greater Manchester, says GPs should not be forced to balance the welfare of individual patients against costs. But he is optimistic that commissioning groups will resist making such decisions and not be 'overridden' by those pushing for restrictions.
'In the brave new world with GPs being the people making decisions, if people all have patient welfare in mind, patients should be able to access these drugs,' he says.