The NHS Commissioning Board has identified the enforcement of generic prescribing as one of its key priorities for 2013.

A study commissioned by the Board found the NHS could save £200m per year by replacing two branded statins with generic alternatives, and annual savings of up to £1bn could be achieved across all prescribing.

The study recommends that GPs with expensive prescribing habits should be required to explain their decisions to the CCG – thus potentially creating conflicts between CCGs and pharmaceutical companies.

An embargo on branded drugs where generic versions exist could also see deep erosion of the specialised biopharmaceuticals market by biosimilars.

Branded drugs are often more recognisable, easier to swallow and even easier to digest than generic alternatives – but they can cost up to 25 times as much.

Open Health Care UK and data research company Mastodon C analysed the prescribing of two statins across the country. Many GPs were still prescribing branded versions, despite the availability of generics.

The Board’s Medical Director, Sir Bruce Keogh (pictured), said: “Variation in prescribing habits costs the NHS millions of pounds a year. Sharing of information will help clinicians understand whether they are over- or under-prescribing.

“This will focus minds in a way that will not only improve the quality of treatment for patients but also reduce cost and free up money for reinvestment.”

According to experts cited by The Independent, two mechanisms underlie the over-prescribing of brands: GP practices with on-site pharmacies have an incentive to prescribe branded drugs as they generate more profit; and hospitals buy branded drugs in bulk, reducing the cost but creating an ongoing patient expectation.

Open Health Care UK and Mastodon C will develop software to help the new CCGs target local GPs whose prescribing practices are expensive.

New NICE guidance for local formularies requires them to include NICE-approved medicines within 90 days, and not to repeat or challenge NICE appraisals.

CCGs are also required to publish all local formulary information online in a way that is accessible and clear to patients and the public.

This guidance reflects the Government’s commitment to ending the ‘postcode lottery’ and ensuring that local prescribing makes innovative drugs available.

All CCGs are required to publish formularies by 1 April 2013, and the new NICE guidance aims to help them combine three priorities: meeting local needs, reducing variation in prescribing, and enabling rapid uptake of innovative therapies.

Until now there have been no standard guidelines for putting together a local formulary, and this has allowed wide variation in prescribing between locations.

According to the NICE good practice guide, local formularies must follow three rules to ensure they are fit for purpose and compliant with law:

• Medicines with a positive NICE appraisal must be included (where clinically appropriate and relevant to the services provided) within 90 days.

• There must be no local duplication of, or challenge to, a NICE appraisal.

• All relevant local formulary information must be published online in a clear and simple way accessible to patients, the public and stakeholders.

According to Professor Alan Silman, Chair of the Guidance Development Group, the new guidance “allows formularies to continue to respond to local needs and circumstances but also ensures that NICE’s decisions to approve an intervention and other appropriate inputs into formulary production are taken up in a timely and transparent manner.”

ABPI Chief Executive Stephen Whitehead said the guidance was “an important step forward”. However, he added, there needs to be “strong local implementation of this guidance” before the formularies are published.

NHS Chief Executive Sir David Nicholson will require CCGs to state which NICE-approved treatments are available on their formularies.

In a letter to all NHS organisations, Nicholson linked this requirement to the NICE ‘compliance regime’ outlined in the Government’s innovation strategy.

His response follows a public argument between NICE and the NHS Confederation over delays in the availability of NICE-approved drugs.

In an online article, NICE Chairman Sir Michael Rawlins criticised NHS trusts for “trying to pretend” that they were capable of rethinking NICE decisions.

David Stout, Chief Executive of the NHS Confederation, responded that “every NHS organisation has a finite amount of money available” and that the NHS needed to be “open” about the “trade-offs” forced on it by economic pressures.

Nicholson’s letter attempts to bring together both sides of the argument by stating that PCTs and CCGs must make a public, online statement of which drugs on their formularies are NICE-approved.

The letter noted that local formularies should not “duplicate NICE assessments or challenge an appraisal recommendation”, and that addressing variations in compliance with NICE recommendations was important for the NHS.

However, it stopped short of explicitly banning local commissioners from failing to make any NICE-approved drug available. This is already a legal requirement – but NHS rationing is a sensitive issue, given the current strict cost controls.

Local formularies will be required to include “clear, simple and transparent” online lists of their NICE-approved drugs by 1 April 2013.

Less than 1% of physiotherapists will initially be able to become independent prescribers, according to the Chartered Society of Physiotherapy (CSP).

New regulations enabling physiotherapists to prescribe drugs for a range of conditions have been welcomed by the profession, but the transition will not be rapid.

Only the best-qualified physiotherapists are eligible for the relevant training, so initial take-up will be limited.

Health Minister Lord Howe announced in July that new regulations would enable physiotherapists and podiatrists who gained suitable qualifications to prescribe for their patients.

This change, expected to become law by April 2013, was widely praised as a step towards integrated care of conditions such as chronic pain, asthma, rheumatic disorders, injuries and diabetic foot ulcers.

Dr Helena Johnson, CSP Chair, said that being able to prescribe would “hugely improve” the care therapists could provide, giving patients “a more streamlined and efficient service”.

However, a CSP spokesperson has since noted that only around 200 of its 51,000 members – those already involved in supplementary prescribing – will immediately be in a position to undertake the training necessary for independent prescribing.

A limited further number will be eligible for the training, but will require funding from their employers.

High-profile sports physiotherapist Dave Roberts commented: “It is going to take some time for physiotherapists, GPs and patients alike to get used to the new prescribing landscape.”

There would be concern from patients and from GPs about working together, he said – but “education” of all stakeholders should “counteract any tension”.

A BMA spokesperson said the new prescribing regulations would need to be “explained clearly and thoroughly” to all healthcare professionals.

What does the ‘single operating model’ for primary care commissioning mean for GPs?

The NHS Commissioning Board Authority’s ‘single operating model’ for primary care commissioning represents a major step in defining the relationship between GPs and the new NHS. As such, it is essential reading for anyone with a stake in prescribing behaviours and, more widely, in patient pathways.

A major question posed by the Lansley reforms is: who should commission the commissioners? If GP-led groups are responsible for commissioning secondary care, who can commission primary care? The answer, the NHS Commissioning Board, was greeted with mistrust by many GPs who asked why they needed some Big Brother watching over the job they had always done.

In addition, the passage of the Health and Social Care Act left a lot of broken glass scattered through primary care. The relationship between clinical outcomes and money, the involvement of the private sector in the NHS and the apparent fragmentation of the health service are issues that divided
the GP profession.

So the single operating model has the task not only of outlining new clinical and business relationships, but of building professional bridges. The Board tackles this challenge by saying up front that it seeks to
achieve “the right balance between national consistency and local decision making”.

Unlike earlier documents describing the infrastructure of the new NHS, Securing excellence in commissioning primary care does not list concrete developments to be in place by April 2013. Rather, it outlines a pattern of relationships that will develop from that date, when the new single operating model
for primary care commissioning becomes operative. It represents the parts of the new
NHS working together with a clear goal of outcome improvement.

The commissioning challenge
According to Dame Barbara Hakin, National Director for Commissioning Development, the new system aims to “tackle unwarranted variation and take positive steps towards raising the overall standard of primary care”. The document notes that primary care, while accounting for only 15% of the NHS budget, has a
profound role in making “preventative interventions” and influencing all the care patients receive.

The challenge of replacing “many different systems” for primary care commissioning with “a single national
operating model” without losing “vital local responsiveness”, the Board says, depends on “establishing relationships and arrangements across the new organisations” – including CCGs, whose health strategies
will set the context for primary care.

The NHSCB will be responsible for planning, securing and monitoring primary care services. Its local area teams will manage the performance of GPs and other primary care providers (dentists, community pharmacists and opticians), and will help to support providers in difficulty and deal with major emergencies.

The local area teams will support patient “choice and control in designing services that respond to their needs”, focusing on “the basic service offer” (such as early diagnosis) to reduce variations and health inequalities. Likewise, they will support the development of “local area clinical leadership teams” that draw on the expertise of all types of primary care clinicians. Finally, their focus on patient outcomes means they will look for “improvement strategies” at all times.

All together now
Most primary care commissioning will take place through the Board’s local area teams working with CCGs, local authorities and health and wellbeing boards. The Board as a central authority will “ensure consistency” and provide the framework for performance management and quality assurance. Crucially, this system involves “fewer managerial resources” and “larger geographical footprints” than the previous system. It does not remove local initiative: it just removes the SHA and PCT management layer.

At the heart of the model are the common operating procedures for local area teams, of which the most important is “to standardise the performance management frameworks and processes at practice, provider and individual levels”. Managing variability and the healthcare market are also key priorities.

Commissioning support services may also assist local area teams: emphasis is placed on the value of
business intelligence in providing “a single flow of standardised information”, and the potential for CCGs to share support for primary care development and redesign with local area teams.

Micro commissioning
CCGs themselves will work closely with the NHSCB to review the “micro commissioning decisions” made by
GPs in “each referral and prescription”. The Board says that its work with CCGs has shown they can progress effectively together towards “quality improvement” through benchmarking, data sharing and peer review. It notes further that CCGs will be able to commission integrated “wrap-around” community-based services in which GP practices can participate, with care taken to manage conflicts of interest.

The local area teams will establish relationships with a range of partners, including CCGs, Local Healthwatch, health and wellbeing boards, local authorities, Public Health England local units and the CQC. Clinical networks will feed into the primary care system “with a particular focus on early diagnosis and timely treatment”. Public health commissioners will advise local area teams on priorities for the local
population, and work with them to develop health improvement initiatives that may include primary care.

The Board concludes: “During the next three to six months, we will fully explore all the interdependent relationships critical for the operating model and take any action necessary to ensure that they will work effectively.” It encourages discussion of the model within PCT clusters and feedback on
potential improvements.

A business network
The single operating model for primary care commissioning is not so much a ‘one size fits all’ as an ‘all things to all people’. It shows the old hierarchical NHS giving way to something much closer to a business network, with shared rules and goals but different cultures. The imprecision of the arrangements described displays the will to promote clinical innovation and business
development.

The emerging structure is designed to give GPs more confidence that they will be neither isolated nor controlled. Those who need guidance and support will receive it, while others will have the freedom to change treatment pathways and business models. This will help to defuse opposition to reform in the
profession, while setting the stage for further changes.

For pharma, the new model points to the development of a complex and flexible customer network with many points of contact. Key account managers are much concerned with how primary care operates and the factors influencing it. This model shows primary care in a dynamic field of NHS and other stakeholders, responding to ideas from all sides: an exciting prospect for suppliers.

The number of prescription items dispensed annually to treat alcohol dependency has risen by 63% in the last eight years.

The total cost to the NHS of drugs for alcoholism increased by 45% between 2003 (£1.72m) and 2011 (£2.49m), including 3% in the last year.

These figures in the report Statistics on Alcohol: England, 2012 reflect increases both in the prevalence of alcoholism and in NHS investment in drugs to treat it.

The report also showed a 40% increase since 2003 in hospital admissions where alcohol abuse was the primary diagnosis, reaching 198,900 in 2011.

Hospital admissions where alcohol abuse was either the primary or a secondary diagnosis reached 1,168,300 in 2011, an increase of 11% on the previous year and of 130% on 2003.

The north-west had the highest number of prescription items for alcoholism at 517 per 100,000 people, while London had the lowest at 138 per 100,000.

Tim Straughan, Chief Executive of HSCIC, commented: “This report shows how drinking in England has impacted upon admissions to our hospitals and prescriptions dispensed in our communities.”

Diabetes care in England is in a “state of crisis” with fewer than half of patients receiving adequate care, a new report has said.

According to Diabetes UK’s State of the Nation 2012 report, failure to provide diagnostic services is leading to an epidemic of preventable complications.

Despite the range and quality of diabetes medications available, their impact is blunted by inadequate prescription and dosage control.

The existing National Service Framework for diabetes is far from being realised, according to the report, and 40% of patients (including 85% of children and young adults) are not well-controlled.

Under 50% of people with diabetes are receiving the tests recommended by NICE – and as a result, receiving the correct types and levels of medication.

Diabetes care costs 10% of the NHS budget, and 80% of that is spent on treating complications that correct medication could prevent.

The report calls for an urgent strategy of early diagnosis and risk assessment to match treatment to patient needs, combined with better patient education.

Barbara Young, Chief Executive of Diabetes UK, said: “The wide variation in standards of care shows the need for a national plan to be put in place. By taking the longer-term approach of investing in making sure people get the basic checks and services, we could save money by reducing the number of complications.”