“Supporting prescribing in general practice”
Agenda item 3 is on general practice prescribing. I invite the Auditor General and members of his team to brief the committee on "Supporting prescribing in general practice—a progress report". Members may make comments and ask questions after that, but I remind the committee that we will discuss the report more fully later in the meeting.
I will introduce the report to the committee. I have with me colleagues from Audit Scotland who worked on the detail of the report, and who will answer any questions that members might have.
In 1999, I published a baseline report on prescribing in general practice, which made a number of recommendations that were aimed at improving the quality and efficiency of primary care prescribing. We invited trusts to take action on those recommendations and to use some of the indicators that we provided to improve the quality and efficiency of the service. The latest report considers progress against that baseline. The main report, which is a substantial document of more than 50 pages, considers three broad areas. The first involves factors that influence prescribing quality and cost, the second relates to prescribing quality and efficiency and the third covers issues that relate to achieving further improvements in prescribing. There is also a summary report, which members might find helpful.
The issue is a big one. The total prescribing expenditure for 2002-03 in Scotland was around £850 million, which is about 12.5 per cent of total national health service expenditure. Moreover, prescribing expenditure has been rising steadily each year, with a 13 per cent rise in 2002-03 compared with the previous year. Big resource issues are involved. The quality of prescribing has a direct impact on the quality of patient care, both in treating existing conditions and in preventing ill-health.
I am pleased to report to the committee that all trusts have improved prescribing quality significantly against the indicators in the baseline report. For example, there has been a significant increase in the prescribing of medicines such as angiotensin-converting enzyme inhibitors, low-dose aspirin and statins, which all treat, or help prevent, coronary heart disease. That significant development has taken place over the past few years.
Trusts have also achieved efficiency savings by taking action on issues such as generic prescribing and by reducing the use of medicines that are considered to be of limited value. The report identifies room to make further savings of around £14 million. Although that is a substantial saving and is worth achieving, we must recognise that it is a relatively small amount compared with the overall prescribing expenditure and that it will take some time to achieve.
Almost without doubt, those savings will be overshadowed by the rising cost of new drugs, of which the report gives some examples. To take one such example, there will be an increase of £28 million in the cost of prescribing for treatment of cardiovascular and central nervous system diseases alone. A number of evidence-based guidelines recommend the use of particular drugs to treat or prevent particular diseases, such as statins for coronary heart disease. Such drugs improve the quality of patient care, but they have significant cost implications. To stick with statins as an example, our report estimates that the annual cost to the health service in Scotland of providing statins is expected to grow to at least £95 million—the present figure is around £65 million—which is slightly less than 12 per cent of the total prescribing budget.
It is important that prescribing is targeted accurately and in line with the evidence so that extra spending achieves the greatest benefit. We also recommend that the cost of implementing the guidelines that I mentioned is calculated and made available to the health service so that the financial implications are understood fully. None of the drugs involved is cheap and each of them, if chosen for prescription, would entail significant cost to the health service. It is important that health boards consider implementing those guidelines along with other service developments. There are difficult choices to be made.
Further work is needed in a number of areas. As a result of our initial report, all primary care trusts now have prescribing strategies, but more needs to be done in developing health board-wide prescribing strategies and area-wide formularies, which are lists of selected drugs with guidance and protocols for their use. We have used commonly accepted indicators for prescribing quality and efficiency and we recommend that the health service should consider putting together a set of national prescribing indicators. That development, along with the sharing of good practice, would help trusts to benchmark their performance as they go along. There is also a need to link prescribing information with related information about the impact on patients, such as morbidity and diagnosis information, which is not possible at present. That situation makes our analysis rather difficult because we cannot relate prescribing interventions to patients' health.
The two other important areas in which improvements are required are in the development of universal and rigorous repeat prescribing systems and the further development of computerisation.
I invite Barbara Hurst to expand on one or two of the key points and to set them in the current context.
Barbara Hurst (Audit Scotland):
The present report and the 1999 baseline report were both big pieces of work. We were careful about the choice of indicators because the issue is a clinical one and we had to work with experts in the field. We worked with prescribing advisers and used existing research to choose the indicators. Given the limitation that, at present we cannot link prescriptions with diagnosis, which the Auditor General outlined, we are confident that the indicators are the best available.
There is also the issue of the new general practitioner contract, which will have to build on those indicators. There will certainly be a closer link between pay and performance and some of the clinical indicators that are used in the contract will take into account such things as the prescription of ACE inhibitors. The report is early work in advance of the new contract.
One key area that the report picks up on is repeat prescribing, which is a huge issue and which accounts for around 75 per cent to 80 per cent of all GP prescribing. As a broad estimate, the annual wastage through drugs that are prescribed but not used is around £15 million. The report highlights that further action is required to ensure that peoples' prescriptions are reviewed regularly and that there is no over-prescribing.
We are pleased by the amount of work that the health service has done since the initial report and we give due credit for that. I am happy to take any questions.
The report mentions the waste in prescribing, which was also touched on in the baseline report. However, it does not really mention the work that has been undertaken in certain areas to try to minimise waste. The report indicates that there is a significant amount of waste through repeat prescribing. What discussions did you undertake to try to reduce that waste? I understand that, in Scotland alone, there are several million pounds-worth of unused drugs, which, because of some of the organisations involved, cannot be allowed back into the system. The fact that many drugs are now in bubble packs means that they could be reused, but we still seem to be unable to get over that barrier. What can we do to ensure that we recirculate drugs and thereby reduce the cost?
A number of health boards have done quite a bit of work in that area. On the reuse of drugs that have been prescribed to other people, lack of knowledge of how the drugs have been stored presents a safety issue—we do not know whether they could be brought back into the system. That is why we have focused on repeat prescribing. Tackling the problem at the beginning of the process avoids having to worry about it so much at the end, but I accept the member's point.
I think that I am right in saying that, among other boards, Tayside NHS Board had done work in that area.
In future, I hope that people who are prescribed a new drug for their symptoms will be given the drug only for the trial period initially, as that will reduce the waste.
On clinical audit, Audit Scotland's report refers to cost-effectiveness. Did you mean cost-effectiveness in monetary terms or cost-effectiveness in its widest sense, which involves consideration of quality of life and the suitability of particular drugs for particular patients?
We were speaking about cost-effectiveness in the widest sense, but I must add a caveat. We cannot tell whether people are being prescribed a drug for their diagnosis. It is a vicious circle. We must ensure that we can make that link and can consider the quality-of-life issues. NHS Quality Improvement Scotland will also have an interest in clinical audit issues and will pick up some of them.
The report mentions that transdermal oestrogen-only hormone replacement therapy patches are very expensive, but it does not expand on that comment in relation to patient compliance. Someone who uses a patch is more compliant than someone who takes pills once or twice a day. You do not comment on the cost-effectiveness of that.
That is a crucial point. That is why we have been quite conservative with the savings. Patient compliance is an issue, and some patients definitely need the patches. We are not saying that the patches should not be prescribed to anyone, but there are people for whom their use is simply a convenience. The GP would need to make such a decision with the patient. In such areas, the saving is not 100 per cent.
The questions that we are being asked are highly relevant. When the committee decides whether to take evidence on the subject, it might want to bear in mind the fact that members of the health service are much better placed than we are to answer such questions.
I want to return to an issue that I mentioned earlier, which Barbara Hurst hinted at. Finding a way of linking prescribing to diagnosis and the condition of the patient would be one of the most significant developments in allowing the health service to demonstrate the effectiveness of prescribing policies. The committee might wish to give further consideration to that issue.
My question is about computerisation. Government and agencies are attempting to make progress in that area, for example through digital Scotland and broadband Scotland and their application in the present context. What mechanism could break the logjam? Although we, like many agencies, discuss computerisation, there seems to be a lack of joined-up working between Government and agencies. Are there any specific developments—for example, in software or digital take-up—that would enable us to deliver more effectively? Would it be best to implement such developments through the health boards or would a more over-arching strategy, which might be being considered rather than actually implemented, be necessary?
That would be a massive study in its own right, so I will give you a partial answer. On prescribing, we found that many pilots go on and on, but we are not learning the lessons from them. That is a great problem for the health service. Until we obtain some realistic time scales for those pilots and can assess whether they are worth rolling out, the health service will be in a difficult position. In relation to computerisation, we would push the Scottish Executive Health Department on that.
I found "Supporting prescribing in general practice—a progress report" interesting and informative, just as I found the baseline report interesting and informative in a previous life. I would like to probe some of the concerns that I share with my colleagues.
The Auditor General will know about my hobby-horse on implementation, as will members. I share Kenny MacAskill's concerns. Does the Auditor General's office have any plans to draw together some of the generic strands that come through in a number of reports—including the two that we are considering today—on the pace of implementation on computerisation in the NHS. I am enormously concerned about how far behind the NHS lags in making effective use of current technology. I would be interested to hear what further measures the Auditor General's office could take to accelerate the pace of change in that area.
I invite the Auditor General to comment on pharmacy. Although the report mentions community pharmacists several times, I was surprised that the issue was not given greater emphasis, given that "The Right Medicine: A Strategy for Pharmaceutical Care in Scotland" dovetails neatly with the report and contains similar objectives. As Barbara Hurst indicated, much work is stuck in the loop of pilots and testing. For a number of years, it seems to have been well established that the linkages that have been made in trials and pilots between community pharmacists and GPs on repeat prescribing could deliver a step change in practice and in cost, if those initiatives were rolled out nationally.
I have two further questions, but I will pause for breath to allow my question on pharmacy to be dealt with.
We will come back to those.
I will respond first to the point on whether we could do more work on the effectiveness of implementation. We should take that issue on board. I give the committee an undertaking that, when we think about our forward programme of studies—as the committee knows, we are committed for the next few months—we might consider doing more work in some of those areas. We are all conscious that there are major issues relating to information technology strategy, as Barbara Hurst mentioned. We must do some serious thinking about how we could engage more fully with that agenda in the coming months.
As Susan Deacon said, the report makes some mention of community pharmacists. I invite Barbara Hurst to give a fuller answer.
I agree entirely with Susan Deacon. The link between community pharmacists and GPs is the way forward. That takes us back to computerisation, which would offer a link between community pharmacists and GPs. There are different views on whether community pharmacists should be able to have access to a patient's records. We feel that they would probably need such access as far as prescriptions are concerned, but that view might not be shared more generally.
I am grateful for that diplomatic response. I hope that we will have the opportunity to probe the matter further.
The first of my two final questions concerns the link with clinical audit, which has been mentioned. The Auditor General and Barbara Hurst have both referred to the parallel work that various bodies are carrying out; however, I wonder whether they will tell us a wee bit more about the connection between Audit Scotland's work and clinical audit. As Margaret Jamieson pointed out, it is important that the two should work in tandem.
I note an awful lot of emphasis on what trusts and, in turn, NHS boards should do. However, not so much has been said about what should be done to influence individual practitioner practice, which is the key to much if not all of this matter. I wonder whether Audit Scotland could comment on measures that could be taken in our medical schools during medical training to influence practitioner practice and prescribing.
I will have a go at those questions.
As far as clinical audit is concerned, I should have mentioned in response to one of Margaret Jamieson's questions the role of prescribing advisers in the different health board areas. Although those advisers work closely with individual practitioner practices, they do different things—if you like, they offer a clinical audit, but in specific areas. That is good practice, and one of the reasons that we have published this weighty report is to highlight some of that good practice and ensure that it is shared more widely. Indeed, our report points out that there needs to be more of that kind of work.
As for our wider links with clinical audit and particularly with NHS Quality Improvement Scotland, we have been invited to sit on a group that is examining this issue with a view to taking it forward. We would certainly be able to feed our evidence into that group. Indeed, we try to do so whenever we can to ensure that no duplication occurs.
The challenge with influencing individual practitioners is that they are individuals, which is probably why we were so pleased to find such great improvement in this area. The matter is very difficult; after all, we are talking about individual GPs. However, the prescribing adviser's ability to work with individual practices is probably where their role has been most powerful at a local level. I am not sure that that has answered your question, but I think that it provides some background.
What about the question of training?
The training of doctors has come up as an issue in a study that we have started on the use of medicines in hospitals. I think that you are right to highlight the issue as one that might need to be picked up.
Given the report's recommendations on prescribing and extracting better value, the issue of implementation seems to be pretty critical. Is the roll-out of implementation being stopped by financial or IT barriers? As your comments have made clear, plenty of pilot projects have been introduced. Have they highlighted either that everyone cannot be linked or that there is a lack of incentives for independent GPs to take the technology on board?
I am going to cop out, slightly, of answering that question until we do a bit more work. A lot of money is certainly going into the IT budget, but we need to examine where and how it is being spent. We will come back to you on that matter once we begin to examine the area.
Okay?
That did not answer any of my questions.
I apologise for repeating what I said a moment ago, but I should point out that we must always operate within the boundaries of the evidence that we find and must not attempt to second-guess how the Scottish Executive Health Department might respond to such questions. Although we will always do our very best to answer questions as fully as possible, the committee ultimately can—and does—treat our documents as part of the evidence-taking. Some of the questions that have been addressed to Barbara Hurst and me this morning are critical, but it might be more appropriate to consider whether they should be put to the department if the committee has the opportunity.
Obviously we can discuss the matter when it comes back on to the agenda.
I wanted to pursue the issue of sharing good practice, which links into the business of information and communication technology and how people access what is going on out there. However, I will probably need to find out about that matter during evidence-taking sessions, if we decide to take evidence.
The committee could certainly explore that area. The situation is fairly ad hoc at the moment; for example, good practice might not be universally shared even within a single health board area. We were trying to push the message that we can learn from one another and that much good work is being done.
I think that we have exhausted our questions, but we will discuss later how the committee will approach the matter. I thank Barbara Hurst for answering the committee's questions in detail.