IN THE FIRST PART of ‘The language of prescribing’, we looked at the role of the new Area Prescribing Committees in approving drug formularies. These committees are potentially much more influential than the GP practices on which representatives have tended to focus. As well as ensuring that new drugs are safe and effective, the Area Prescribing Committees assess the impact of new drugs on the local health economy. One major cause of failed communication between pharma companies and prescribing advisors is that they measure prescribing indicators in different ways. So how can representatives bridge this language barrier?
The Berlitz Guide to Visiting Foreign Destinations
(such as PCT Prescribing Advisors)
PACT (Prescribing Analysis and Cost) – this is the data that forms the basis of all our prescribing analysis within the PCT. It’s very sensitive and reliable, and provides data down to each GP or nurse and what they prescribe. There are two paper reports (PACT Standard and PACT Catalogue), and now ePACT provides electronic reports that have become essential in today’s fast-paced world of data management.
PACT Standard – this is a paper report issued automatically to all GPs four times per year (each quarter ending March, June, September and December). It contains white pages (quarter prescribing analysis) and blue pages (central pages highlighting a particular aspect of prescribing that is of particular importance, a key focus or issue of significance at the time). These blue pages will take a national theme, show the trends and remind prescribers of their key priorities. The last page of this blue report contains comparative data on how a specific practice’s prescribing compares with that of others within their PCT – and this is done within each therapeutic area.
The PACT Standard is worth remembering: if you want to highlight the fact that your GPs are spending a fortune on competitor Drug X when they could be using your cost-effective Drug A, these ‘quarterly months’ are fairly significant – maybe not dissimilar to your own quarterly figures. They (i.e. GPs, practices and PCTs) abbreviate information, so that their prescribing can be easily compared with that of others – which contains a certain competitive element. Likewise, pharma companies will often compare one brick against another, or one region against another – so while you are all from the same company, you nevertheless become very nosey about where you stand when compared to the others. It’s human nature . . .
PACT Catalogue – this report is not sent out automatically, but at the request of the individual GP. When requested, a full catalogue/inventory of prescriptions issued is provided, and can be made available for any set of consecutive months within the last 24 months. The catalogue can be tailored to individual preparations, BNF categories or a mixture of both. The GP will be told the total number of items and the total net ingredient cost (NIC) of the prescribed products.
The NIC is a very important measuring tool for prescribing advisers. It is the basic price of the drug listed in the Drug Tariff (in the absence of a Tariff price, the manufacturer’s price is used). Remember that the Tariff price is what the NHS is reimbursed with for prescribing the drug, and is based on a ‘national’ price available for obtaining the drug.
Money and medicine
The following list is an example of the monitoring of GP practice prescribing:
Practice Number 1
Formulary ACEI: lisinopril, enalapril and ramipril
Formulary Statin: simvastatin
Practice Number 2
Formulary ACEI: lisinopril, enalapril and ramipril
Formulary Statin: atorvastatin
PACT Report on Statins Expenditure
Practice 1: £250
Practice 2: £1800
These costs in themselves need some adjustment before we jump to conclusions. However, given the Defined Daily Doses or DDDs and Average Daily Quantities or ADQs along with the tariff prices of the statins, we can evaluate the numbers of patients on these drugs. For this practice comparator, I can assure you that the numbers of patients each practice has on a statin is similar. So you can see why a prescribing advisor will be targeting Practice 2 with ‘cost issues’. But what is interesting is the question of effectiveness. Notice that I don’t have a table of ‘events’ or of ‘hospitalisations’ particularly due to cardiovascular disease. So the ‘marketing’ arguments will happen in isolation. They occur around a different table and have now become very contentious.
And what is even more sensitive is the fact that ‘prescribing incentives’ are still very much alive and kicking. There was once a lay belief, particularly within pharma, that when the GMS contract had paid GPs to reach a cholesterol target (or any target for that matter), the prescribing incentives would not really have an impact. This is as far from the truth as can be imagined. Not only are prescribing incentives now paying directly for switching branded products to generic items, but the savings are given back directly to the GPs to keep and spend on what they want (within reason).
This is further enhanced by the fact that the prescribing budget overspend/ savings is now part of the ‘previous out-turn’ budget within practicebased commissioning budgets. When these are ‘linked together’ (as with an accumulator in betting) the rewards are substantial, but the GPs need to hit all the linked items. So, for example, the ‘accumulator’ may be % generics + % antibiotic prescribing reduction + % statin switch to simvastatin + %A2A:ACEI ratio, with each having a set limit that is needed.
Wow! I have got a headache! And so, I expect, does the GP you are about to call on . . .
OMAR ALI is the Formulary Development Pharmacist for Surrey and Sussex Healthcare NHS Trust and is a PCT Formulary Adviser to 2 PCTs. He is a lecturer on the MSc on Pharmacy Practice at Portsmouth University and is also an adviser to three Drugs and Therapeutics Committees in the South of England. Omar is a National Speaker in the UK (cardiovascular, diabetes, mental health) and is an Executive Board Member for the National Obesity Forum. He can be reached directly on email@example.com