Prescribing the cost-effective way

GPs must learn the skill of balancing cost and clinical effectiveness in prescribing, says Dr Sara Whitburn

Prescribing is an important and complex part of our daily health provision role. As GP registrars, we are often trying to focus on our clinical skills, diagnosing and matching medication appropriately with the condition we are seeing, but for good prescribing there are other factors that need be considered.

The GMC’s ‘Good Medical Practice’ outlines that for good practice in prescribing you should be aiming for evidence-based, cost-effective and safe prescribing with a fully-counselled patient. What does cost-effective prescribing mean?

What is cost-effective prescribing?
Cost-effective prescribing is prescribing medication that is both clinically and economically appropriate for a condition. The finance to pay for medications is a limited resource. An expensive drug may improve health for one patient, but means that there is less money to pay for other, possibly cheaper, resources to benefit a wider population of patients.

At present, NICE generally only approves new drugs if they cost less than around £30,000 per quality-adjusted life year (QALY). To assess what is economically appropriate we must ask how well the medicine or treatment works in relation to how much it costs the NHS — does it represent value for money?

In 2005/6, 663 million items were prescribed, costing £7.6 billion and accounting for 14 per cent of the entire NHS budget. Not every consultation ends with a prescription, but most do. In 1998 69 per cent of patients consulting a GP received a prescription.

Who pays for medication?
Medication is paid for by the patient and the health service. Patients make a contribution by paying prescription charges. The average cost per prescription for 2005/6 was £11.48 compared with £8.67 in 1995/6. Some prescriptions are exempt from charges for medical, maternity and social reasons or on the grounds of age. In 2003, 86 per cent of all prescriptions issued were exempt from charges. The bulk of payment for medication is via the health service.

Prescribing budgets make up a significant amount of primary care organisation spend in primary care. As prescribing costs are now within an overall cash limit, this means that if for example a primary care organisation (PCO) overspends on its prescribing budget, it will have to make savings in other parts. Likewise, if a PCO were to underspend on its prescribing budget, there would be more money available to spend on other areas.

Increases in generic prescribing, reviews of repeat prescriptions and a greater willingness not to prescribe are all ways GPs can increase the cost-effectiveness of prescribing individually every day.

Information services
Knowledge and recommendations of appropriate OTC medications can decrease the cost of medications to patients and PCO  budgets.

A number of policy initiatives have also been introduced that attempt to contain prescribing costs. These include provision

of prescribing analysis and cost (PACT) data. The equivalent of PACT in Scotland is the Scottish Prescribing Agency (SPA) and in Northern Ireland it is Northern Ireland Prescribing Prices Information (NIPPI).

PACT data are issued every three months by the Prescription Pricing Authority, which processes all dispensed NHS prescriptions. It provides summaries of GPs’ individual and practice prescribing. This information can be used to audit prescribing practices.

Another mechanism to try and decrease the medication bill is the Pharmaceutical Price Regulation Scheme. This is a voluntary, non-statutory scheme that indirectly controls the prices of branded licensed medicines to the NHS in the UK by regulating the profits that companies can make on these sales.

Scripswitch is a computer program that runs within EMIS to suggest a cost-effective version of the drug you prescribe.

Other resources
Resources can help provide information about the cost-effectiveness of medication and treatment to support decision-making while prescribing. There are technical guidelines such as those produced by NICE in England and Wales, the Department of Health, Social Services and Public Safety in Northern Ireland and the Scottish Medicines Consortium and NHS Quality Improvement Scotland in Scotland. Other resources provide evidence-based advice such as the Drugs and Therapeutic Bulletin and the National Prescribing Centre through its online resources and the MeReC Bulletin.

Dr Whitburn is a GP registrar in Dursley, Gloucestershire

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