A warning shot has been fired across the bows of practices that persist in "substandard" prescribing and dispensing.
At a conference in September, Peter Rowe, the government's National QIPP (Quality, Innovation, Productivity and Prevention) Lead for Medicines Use and Procurement, warned doctors of a "general political exasperation about poor practice" and asked why there is still "unwarranted variation in prescribing and dispensing." Failure to address this issue would lead to difficult questions about sustainability, said Rowe.
At the conference, held by GP service provider PSUK, Rowe told delegates that unwarranted variations in prescribing and dispensing (ie, those not justified by local population needs) had astonished ministers, who now demanded collective action from GPs. NHS finances just cannot support the status quo, said Rowe.
The financial picture
In his 2008/2009 annual report, NHS Chief Executive Sir David Nicholson said the NHS should be "prepared for a range of scenarios", including the possibility of an investment freeze.(1)
Three years on, the environment for NHS service delivery has become more, not less, demanding. In an article published in May 2011, John Appleby, Chief Economist of The King's Fund, warned that the NHS across England should prepare for budget cuts in real terms of around 8% by 2013/14.(2) This compares to the past decade in which the NHS has seen investment increase by 7% year on year.
The budget-cut forecast also needs to be considered in the context of rising demand for care of long-term conditions (LTCs), set to rise 60% by 2025 and 250% by 2050 due to an ageing population's increasingly high expectations of health in old age, a growing complexity of interventions and improving drug technology.(3)
NHS Alliance Chief Executive Michael Sobanja said: "In 20-30 years, the entire GDP should be spent on healthcare and we can't afford that, we have to reform. Primary care stands at a crossroads and we need to find ways to deal with the financial challenge."
Since its inception, the QIPP programme has included 'medicines use and procurement' and 'the management of LTCs' among its workstreams. The new 'Specials' drug tariff, for the reimbursement of unlicensed medicines, introduced on 1 November, coupled with the announcement by the Medicines and Healthcare products Regulatory Agency (MHRA) of a wider review of regulations relating to unlicensed medicines, demonstrate that in medicines procurement, at least, QIPP is not afraid to bare its teeth.
More effective management of LTCs was a key feature of the PSUK conference. QIPP has set targets to reduce unscheduled hospital admissions by 20%, reduce length of stay by 25% and maximise the number of people controlling their own health through the use of supported care planning.
At the PSUK conference, Rowe told delegates: "A business model based on patients waiting to present with worsening symptoms is not sustainable. We need to shift to using technology and techniques that prevent people's symptoms getting worse."
He told GP practices that they should aim, as a priority, to identify the cohort of the most intensive service users, and target their energies and resources accordingly. They can also engage, train and resource other healthcare professionals, such as nurses and pharmacists, in preventative care and helping patients to self-care, using resources such as the Expert Patient Programme.
"Achieving the targets set out by QIPP will take strong clinical leadership but practices have to grasp the fact that others are already making changes – and if they don't keep up, they will have to justify why not," said Rowe.
Among the technologies now being tested in the NHS to improve resource allocation is ACG (Adjusted Clinical Group) risk-modelling systems. In development in the UK since 2005, ACGs are designed to help healthcare service providers identify 'high risk' individuals who would likely benefit from care management interventions.
It is claimed that the technology could be more than 90% accurate in predicting the 5% of patients who use the most resources. In Torbay Primary Care Trust (PCT), for example, one of 16 PCTs to pilot the ACG system, 2% of patients were assessed as 'high' or 'very high' morbidity. These patients were found to consume up to 27.2% of resources, depending on the measure used.
In the test sites, ACGs have been used to predict a patient's need of primary and/or secondary care 'variables', such as inpatient admissions, outpatient visits, number of referrals and prescriptions (volume and costs).
In the new NHS, where GP-led clinical commissioning groups (CCGs) take the lead on service commissioning, it is the view of the test pilot sites that ACGs can be used to set budgets, cost-effectively commission preventative care services and monitor resource use.
Urging delegates to think about using their practice data to help them with resource allocation, Rowe said: "Knowing a patient's disease state and their risk prediction will allow practices to target efforts accordingly. Optimised medicines use can prevent or minimise the risk of exacerbation that lands a patient in hospital – which isn't good for anybody."
Telehealth is another technology currently under evaluation in NHS settings. Taking part in the Whole System Demonstrator national trial for telehealth is NHS Cornwall and Isles of Scilly, a PCT with around 1,800 patients using telehealth monitoring. As well as assessing the application of telehealth in general LTC monitoring, the trial aims to assess the technology for use in falls prevention, preventing urinary tract infections and testing new ways to support rapid assessment teams.
Dave Tyas, who is leading on the Cornwall telehealth project, says the technology offers a number of potential cost efficiencies. "Cornwall has a large number of patients with LTCs and an ageing population," he says. "The rural nature of the county means that finding new ways of supporting a large amount of patients is essential. Without technologies like telehealth, other clinical services will come under increasing pressure and may not be able to function effectively."
From 1 October, community pharmacies in England have been piloting a 'New Medicine Service' (NMS). Marketed as the medicine 'after-sales service', the NMS aims to offer compliance and waste-related support to people newly prescribed a medicine for a range of LTCs.
Urging doctors to refer patients to pharmacies delivering the NMS, Department of Health (DH) pharmacy 'tsar' Jonathan Mason said that healthcare professionals can work together much more effectively: "Part of the reason we have failed to contain medicines costs is that we don't help people once we have given them their medicine."
Another key influence on medicines optimisation is the patient-GP relationship, Rowe told the conference. The new NHS mantra of "No decision about me, without me" is no idle promise, he said, particularly as patients continue to report positive experiences and, increasingly, outcomes from the use of 'Personal Care Plans' (PCPs).
PCPs are designed to give patients more freedom over the healthcare they receive by putting them 'in the driving seat' of their care. Essentially an agreement between the PCT (soon to be the CCG) and the patient, PCPs set out the person's health needs, the amount of money available to meet those needs and how this money will be spent.
Currently, 20 pilot sites are providing the DH with periodic evaluation of their experience with PCPs. After three months of trialling PCPs, patient budget holders have reported a positive overall experience. In the fourth interim independent evaluation report, patients said that they were already experiencing improved health outcomes but that information provision and status (for example, eligibility for NHS continuing healthcare) were influencing factors.(4)
Rowe told delegates that PCPs put patients – not the doctor – in charge of the decision to access care, and he urged practices not to underestimate "patient power". Now that discussions have started with two sites about adding personal medicines budgets to the pilot – albeit still at a very early stage, Rowe revealed – this could lead to patients making cost-based decisions about where their drugs are dispensed.
Warning dispensing practices, in particular, to take note, Rowe asked the conference to consider: "Will this mean patients start asking questions about the size of the dispensing fee, or demanding that a specific medicine is dispensed?"
PCPs could potentially result in patients shopping around for the cheapest 'qualified provider' for drugs. "Different providers may be able to do things for less cost, due to efficiencies and their flexibility on wages," said Sobanja.
Reiterating the importance of encouraging patients to self-care, Minister for Care Services Paul Burstow told GPs that the government's current approach to self-care and identifying LTCs would be the "tilt" point that finally created the "fully engaged" scenario outlined in the Wanless report that considered future financial pressures on the health service almost a decade ago.(5)
Explaining the benefits for GPs, Professor Mike Pringle, the Royal College of GPs' revalidation lead, said that self-care by patients is one of the few effective strategies for demand management.
At a recent conference on self-care organised by over-the-counter industry representative body the Proprietary Association of Great Britain, the RCGP launched a new e-learning resource on self-care designed to develop GPs' self-care consultation skills, improve patient confidence
and autonomy, and reduce patient anxiety – one of the main reasons why patients continue to consult for minor ailments.
Professor Nigel Sparrow, chairman of the RCGP professional development board, said: "Self-care is important, as it improves GPs' time and resources for complex problems."
1. Department of Health. Securing good health for the whole population. London: DH; 2004. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
2. Appleby J. What's happening to NHS spending across the UK? BMJ 2011;342:d2982 [online]. Available from: http://www.bmj.com/content/342/bmj.d2982.full
3. Department of Health. Millions of patients set to benefit from a modern NHS. London: DH; 2011. Available from: http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_125042
4. Department of Health. Personal health budgets: early experiences of budget holders. Fourth interim report. London: DH; 2011. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
5. Department of Health. Securing good health for the whole population: final report. London: DH; 2004. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...