How to use the measuring prescribing education package
Learning Objectives
On completion of this package you will be able to:
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Identify who in the NHS is interested in measuring prescribing
Outline how you could measure prescribing, explaining when you would
use the different units of measurement and patient denominators
Recognise why measuring prescribing is important
Discuss why both cost and quality of prescribing should be measured
The package is divided into the following sections:
Who?
How?
Why?
Who?
There are many different people who are interested in measuring prescribing at
both a local and national level.
Make a list of the people/bodies within the NHS that you think will have
an interest and then follow this link to check your answer.
The number of General Medical Practitioners (GPs) and nurse prescribers is
growing and the range of professionals who can prescribe is increasing in light of
the Crown Report. To find out more information on who can prescribe follow this
link
http://www.nhsbsa.nhs.uk/PrescriptionServices/Documents/EDUCATION_PACK
AGE_-_Prescribers_and_FP10_prescriptions.doc
In order to understand fully who might be interested in measuring prescribing you
need to have some understanding of the NHS Primary Care structure (see
diagram).
Primary Care, as its name suggests is the first care a patient would usually
receive i.e. care given by GPs etc.
Secondary Care refers to the treatment of patients within hospitals.
Individual prescribers need to look at what they have prescribed to
benchmark their own performance. They can use this information to
improve their prescribing and therefore provide a better service for their
patients.
GP Prescribing Leads and Primary Care Pharmacists within practices and
Primary Care Trusts (PCT) also wish to measure prescribing. They use the
information to compare either prescribers within a practice or practices within a
PCT. Formularies can be developed and monitored. PCT executives and their
Boards need assurance about the quality of prescribing and how much they are
spending.
Strategic health authorities examine prescribing habits for public health and
performance management purposes.
Area Prescribing Committees (APC) are interface groups set up to develop
effective dialogue between clinicians and managers in primary and secondary
care. Most former health authorities set up these committees of GPs, Trusts and
themselves in response to a Department of Health Circular (Executive Letter EL(94)72) in 1994. Their 2 key objectives are the better management of new
drug entry into the NHS and ensuring the appropriateness of hospital led
prescribing. Further information on APCs can be found in 'Area Prescribing
Committees - maintaining effectiveness in the modern NHS' on the NPC website
http://www.npc.co.uk/
At national level there are several bodies interested in prescribing
trends. The following are acronyms of some of these bodies. What do
the acronyms stand for and what is their interest / role? Jot down your
ideas and then follow this link to check your answers.
N.I.C.E.
N.P.C..
P.S.U.
D.H.
Healthcare Commission
Discuss with colleagues or your tutor/lecturer what you think are the
roles of a primary care pharmacist? Further information on this subject
can be found in ‘Competencies for pharmacists working in primary care‘
and ‘GP Prescribing Support’ on the National Prescribing Centre (NPC)
website – www.npc.co.uk
These are some of the national bodies who are interested in prescribing
trends:
N.I.C.E. - National Institute for Health and Clinical Excellence
NICE has been established to provide authoritative guidance on new
technologies and drugs and to produce evidence-based clinical guidelines and
referral protocols.
http://www.nice.org.uk/
N.P.C. - National Prescribing Centre
The NPC promotes high quality, cost-effective prescribing to relevant
professionals and senior managers working in the NHS through a programme of
activities.
http://www.npc.co.uk/
P.S.U. - Prescribing Support Unit
This is a service of the NHS Health and Social Care Information Centre, a special
health authority. The Prescribing Support Unit (PSU) manages three clinical and
prescribing databases, provides information services based on those databases,
and services based on access to information at NHS Prescription Services. It is
committed to the dissemination of information through regular reports and
standard tables. The PSU will also, whenever able, respond to individual
requests for information and will provide reports within the terms of the Freedom
of Information Act. Information available from its databases will soon be
described within the authority's publication scheme. See
http://www.ic.nhs.uk/data-protection/freedom-of-information
D.H. - Department of Health
The Government sets policies on health related matters and the Department of
Health is responsible to government ministers for ensuring that these are carried
out. The Department of Health are also responsible for the National Service
Frameworks (NSFs). More information can be obtained from the Department of
Health’s website http://www.dh.gov.uk/en/index.htm
Healthcare Commission
Commission for Healthcare Audit and Inspection (C.H.A.I.) is the legal name for
the Healthcare Commission and was launched on the 1st April 2004 succeeding
the Commission for Health Improvement. This organisation exists to promote
improvement in the quality of healthcare in England and Wales. In England only,
this includes regulation of the independent healthcare sector.
The Healthcare Commission have also taken over the private and voluntary
healthcare functions of the National Care Standards Commission and covers the
elements of the Audit Commission’s work relating to efficiency, effectiveness and
economy of healthcare.
http://www.healthcarecommission.org.uk/homepage.cfm
How?
This section provides the opportunity to learn more about how prescribing can be
measured. It covers:
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The different systems and reports that are available
The use of different patient denominators
The different units of measurement that can be used
NHS Prescription Services provides prescribing data to a variety of stakeholders.
Follow this link for Measuring Prescribing - Who?
Prescribing Information data provide GPs, Nurse Prescribers and Supplementary
Prescribers with reliable and regular information on their NHS prescribing habits
and costs. Prescribing Information data are available in electronic format.
Follow the links below to find out more information about Prescribing
Information. You may wish to make a note about the differences
between the different forms of Prescribing Information and discuss their
advantages and disadvantages with your colleagues or tutor.
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For Prescribing Information
http://www.nhsbsa.nhs.uk/PrescriptionServices/941.aspx
For ePACT.net
http://www.nhsbsa.nhs.uk/PrescriptionServices/960.aspx
There are several Prescribing Information reports, including the Prescribing
Analysis Reports and the Practice Prescribing Report.
The Prescribing Analysis Report contains an analysis of the prescribing which
has taken place during the reporting period. A quarterly and monthly report is
produced at Practice level with details of each individual practice prescriber. The
report shows the total level of prescribing, a breakdown of prescribing in the 6
highest cost BNF Therapeutic Groups, the top 20 leading cost drugs in the
practice and the top 40 BNF Sections by cost in the practice. The practice
prescribing is also compared with the previous year, with the PCT and nationally.
PACT is available electronically (ePACT.net). This system allows users real time
on-line access via NHSnet to the five years prescribing data held on the NHS
Prescription Services Prescribing Database.
To compare one GP practice or Primary Care Trust to another, the size of the
practice or PCT has to be taken into account. Practices with more patients on
their lists will need to prescribe more (GP list size is the number of patients
registered with the GP). Prescribing rate can be expressed as the number of
prescriptions per patient (or per number of patients) on the practice list. However
comparative data can be analysed using a variety of patient denominators such
as:
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Patient
Prescribing Unit
ASTRO-PU (Age Sex Temporary Resident Originated Prescribing Unit)
STAR-PU (Specific Therapeutic group Age-sex Related Prescribing Units)
NB we have given an explanation of these patient denominators after the
following question:
Why might you want to analyse the prescribing data using different
patient denominators? Discuss the reasons with your colleagues or tutor
and then follow this link to check your answer
Other reports and 'on-line' systems NHS Prescription Services provides are:
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The Prescribing Toolkit
PCT Prescribing Report
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Electronic Prescribing and Financial Information for Practices (ePFIP)
Prescribing Monitoring Documents (PMD)
Itemised Prescribing Payment Report (IPP)
For further information see
http://www.nhsbsa.nhs.uk/PrescriptionServices/941.aspx
Prescription Cost Analysis (PCA) reports are provided to the Department of
Health by NHS Prescription Services. PCA data cover all prescriptions dispensed
in the community in England. The report covers prescriptions dispensed by
community pharmacists, appliance contractors, dispensing doctors and items
personally administered by doctors. GPs, nurses and other supplementary
prescribers in England write the vast majority of prescriptions included in PCA
data, prescribing by dentists and hospital doctors is included provided that the
prescriptions were dispensed in the community. As PCA data includes
prescriptions dispensed in England, those prescriptions written in Scotland,
Wales, Northern Ireland or the Isle of Man but dispensed in England are
included. Prescriptions written in England but dispensed outside England are not
included. Items dispensed in hospitals or on private prescriptions are also not
included.
'Prescription Cost Analysis: England' data are available on the Internet.
For PCA data see
http://www.dh.gov.uk/en/PublicationsAndStatistics/Statistics/StatisticalWorkAreas
/StatisticalHealthCare/DH_4086488
Prescribing can be measured using a variety of different units. One way
would be to use the number of prescription items. A prescription item
refers to a single item prescribed on a prescription form. List as many of
these different measures as you can. What do you think are the
advantages and disadvantages of each?
Follow this link to check your answer
Patient Denominators
The volume and cost of prescribing are influenced by the demography
and morbidity of the population served. These should be taken into
account when comparing data either between GP practices or PCTs.
Elderly patients have a greater need for medication than younger adult patients.
The prescribing unit or PU was developed to take this need into account. To
calculate the number of PUs, each patient on a GP's list aged 65 years and over
is counted as 3 prescribing units, whilst each patient under 65 and temporary
residents count as 1 prescribing unit.
Age Sex Temporary Resident Originated Prescribing Units or ASTRO-PUs these were introduced in 1993 as a more sophisticated weighting system than
PUs. Research has shown that overall prescribing rates are higher in the elderly
and for females. Hence ASTRO-PUs weight individual practice populations for
age in a greater number of bands (0-4, 5-14, 15-24, 25-34, 35-44, 45-54, 55-64,
65-74 and 75+), by sex (different weightings for male and female) and by
temporary residents. In light of further research by the Prescribing Support Unit
(PSU) the weightings of the age bands were adjusted in 1997. These new values
became known as ASTRO(97)-PUs.
The original ASTRO-PU and ASTRO(97)-PU figures were based on cost, rather
than the number of prescription items. They are used to compare the cost of
prescribing between practices or PCTs. Item based ASTRO(97)-PUs are
available by request to the PSU. The Prescription Pricing Division has included
cost and item based ASTRO(97)-PUs on the ePACT.net system in order to give
an appropriate choice of patient denominator.
Because cost based ASTRO-PUs were devised from the total of all drug costs, it
is incorrect to use NIC per ASTRO-PU for making comparisons within a specific
therapeutic group. Some groups of drugs are specifically for one sex or used for
a distinct age band e.g. prostate cancer drugs - prescriptions will be for men and
the majority will be over the age of 55. Specific therapeutic group age-sex related
prescribing units or STAR-PUs have therefore been developed along the lines of
ASTRO-PUs. STAR-PUs have also been revised and updated as STAR(97)-PUs
and most recently STAR(01)- PUs
STAR-PUs have been developed for the 8 leading therapeutic groups;
gastrointestinal, cardiovascular, respiratory, central nervous system, infection,
endocrine, musculoskeletal and skin. These 8 therapeutic groups account for
85% of prescribing in England. Subsequently 2 more groups have been added by
the PSU; 'all other groups' (this group includes all those BNF chapters not
included in the 8 above) and 'Nurse Prescribing Formulary'.
As well as STAR-PUs for the therapeutic groups listed above, STAR-PUs
have been developed for sub-groups of the above, e.g. central nervous
system has values for: hypnotics, anxiolytics, antidepressant drugs, drugs
used in nausea & vertigo, analgesics, treatment of acute migraine,
antiepileptics, drugs used in Parkinsonism & related disorders, drugs for
dementia, drugs used in Psychoses & releated disorders and drugs used
in treatment of Obesity
Like ASTRO-PUs, item based STAR-PUs are only available by request
from the PSU or on the Prescription Pricing Division's electronic
information systems.
Follow this link to the Prescribing Support Unit (PSU) website to find out more
information on ASTRO(97)-PUs and STAR(01)-PUs, http://www.ic.nhs.uk/psu
Units of Measurement
The volume of prescribing can be measured in many ways; some
measures like the number of prescription items or the Net Ingredient
Cost are easily obtained from Prescribing Information data.
Others such as defined daily doses or average daily quantities require
manipulation of the basic data.
Follow these links to find out some of the advantages and disadvantages of the
various units of measurement.
Items
Quantity
Cost
Defined Daily Doses
Average Daily Quantities
Items - number of prescription items. A prescription item refers to a single item
prescribed on a prescription form. For example there are 2 prescription items on
the form below: atenolol and aspirin.
Dispenser's
endorsement
Pack &
quantity
Items are:
No. of days treatment
N.B. Ensure dose is stated
Atenolol 50mg tab
1 daily x 28
Aspirin 75mg Disp. tabs
1 daily x 28
NP
Pricing Office
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Easy to measure
Of value in measuring the frequency of prescribing where treatments are
given entirely as courses e.g. antibiotics
However:
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A GP issuing repeat prescriptions at monthly intervals would appear to
prescribe twice as much as another GP issuing repeats every 2 months
Quantity - number of tablets, millilitres, grams etc
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Easy to measure
However:
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Using the quantity of tablets prescribed could be misleading, especially
when different formulations with different dosing schedules are available,
e.g.
GP A prescribes Isosorbide Mononitrate 20mg tds
GP B prescribes Isosorbide Mononitrate 60mg od.
If you look at the quantity of tablets prescribed GP A will appear to
prescribe 3 times as much as GP B in order for them to both give the
patient one month's supply at the same dose.
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If you measure the amount of active ingredient, high potency drugs would
appear to have lower usage than those of low potency, e.g.
Patient A receives Atenolol 75mg daily
Patient B receives Bisoprolol 10mg daily
On a mg basis patient A is being prescribed 7.5 times more drug than
patient B.
Cost - cost of drugs prescribed:
Net Ingredient Cost (NIC) is the basic price of a drug, i.e. the price listed in the
Drug Tariff or if not in the Drug Tariff, the manufacturers price list. NIC is used in
ePACT.net.
'Actual Cost' is calculated by deducting the National Average Discount from the
basic price of the prescription items, then adding an allowance for the container.
Actual cost is used in Prescribing Monitoring Documents (PMDs).
The cost of drugs that have been prescribed has to be measured. For further
information follow this link for Measuring Prescribing - Why?
Is it possible to use NIC from Prescribing Information data to analyse the
volume of prescribing? What are the potential problems? Use the
following example to find the answer:
You are looking at the use of Angiotensin-converting enzyme inhibitors (ACE
inhibitors) and Statins between two very similar practices A and B.
Practice A has chosen lisinopril 10mg daily, enalapril 10mg daily and ramipril
2.5mg daily as their formulary ACE inhibitors. Their formulary also recommends
the use of simvastatin 20mg daily.
Practice B has chosen captopril 50mg daily, enalapril 10mg daily and ramipril
2.5mg daily as their formulary ACE inhibitors and atorvastatin 10mg daily.
Both Practive A and Practice B have given 10 patients a prescription for 28 days
supply of each of the ACE inhibitors and statins.
Over the last month Practice A has spent £7.60 on lisinopril, £6.30 on enalapril,
£9.00 on ramipril and £5.60 on simvastatin.
Practice B has spent £6.90 on captopril, £6.30 on enalapril, £9.00 on ramipril and
£180.30 on atorvastatin.
Practice A has spent £5.60 on their chosen statin whilst Practice B has spent
£180.30.
What conclusions can you draw about the use of ACE inhibitors and statins in
these two practices using NIC as the measure?
By just looking at how much each practice has spent (NIC) it would
appear that both practices are using a similar amount of ACE inhibitors
but that Practice B is using thirty two times more of their chosen statin
than Practice A. This is not true. NIC can be used to measure the
volume of similarly priced groups of drugs at equivalent doses, but
where there is a large price difference it is not an accurate measure of
use.
The cost for 28 days treatment of the drugs are as follows (based on Drug Tariff
June 2008):
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Lisinopril T. 10mg od £0.76
Captopril T. 50mg od £0.69
Enalapril T. 10mg od £0.63
Ramipril C. 2.5mg od £0.90
Simvastatin T. 20mg od £0.56
Atorvastatin T. 10mg od £18.03
Defined Daily Doses - DDDs:
The World Health Organisation, in an attempt to overcome some of the problems
in measuring the volume of prescribed drugs, developed and now maintains the
ATC/DDD system as an international standard for drug utilisation studies. Drugs
are classified according to the ATC system and DDDs are established for drugs
which have been assigned an ATC code.
In the Anatomical Therapeutic Chemical (ATC) classification, drugs are divided
into different groups according to the organ or body system on which they act
and their chemical, pharmacological and therapeutic properties.
The basic definition of the DDD unit is:
The DDD is the assumed average maintenance dose per day for a drug used for
its main indication in adults.
It must be stressed that the DDD is a unit of measurement; it is not a
recommended dose and it may not be a dose that a patient could practically
receive, for example simvastatin has a DDD of 15mg but the tablet strengths
available are 10mg or 20mg.
The advantage of the DDD system is that the consumption of an individual drug
can be expressed in DDDs and added to the number of DDDs of all the drugs
within the same broad therapeutic class enabling trends in drug consumption to
be assessed or comparisons between population groups to be made.
Follow this link for the website of the WHO Collaborating Centre for Drug
Statistics Methodology http://www.whocc.no/
There are particular groups of products where the concept of defined
daily doses is inappropriate. Jot down for which groups you think it may
not be possible to use a DDD.
Follow this link to check your answer
The following are groups where the concept of a DDD is inappropriate:
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Topical preparations e.g. skin creams and ointments. The majority of
prescribing is by tube; patients use different quantities depending on the
area of skin being covered and also the quantity applied to a particular
area. It is therefore not possible to produce a meaningful 'daily dose'.
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Contraceptive pills and hormone replacement therapy (HRT) - different
preparations are given for varying time periods, oral contraceptives may
be taken for 21 days out of 28 or continuously. With HRT patients can use
tablets, patches or a combination of both. Some patches are applied twice
weekly, whilst others are used once weekly.
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Combination products, mixtures and compounds. Combination products
contain more than one drug, it may be difficult to determine what the DDD
should be, if you use the DDDs for the single drugs. For example coamilofruse 5/40 is a combination of amiloride 5mg and furosemide 40mg.
The DDD for amiloride is 10mg whilst the DDD for furosemide is 40mg. If
a GP were to prescribe 28 x co-amilofruse 5/40 tablets the number of
DDDs would vary depending on which single DDD was used.
The WHO does not calculate DDDs for combination products in this way.
You can find out how to determine the DDD for a combination product on
their website http://www.whocc.no/
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As DDDs are defined as ….assumed average maintenance dose….
vaccines and other 'one-off' treatments should not be measured in DDDs.
Average Daily Quantities - ADQs
The WHO bases DDDs upon international prescribing habits and there are
occasions when prescribing in England differs from that internationally. In order
to reflect prescribing in England more accurately the Prescribing Support Unit
(PSU) has convened an expert group to develop Average Daily Quantities or
ADQs.
For example:
Oral metronidazole: DDD = 2g, ADQ = 1.2g
What do you think is the reason why these two values differ?
Follow this link to the Prescribing Support Unit website, http://www.ic.nhs.uk/psu,
to find out more information on ADQs including ADQ values.
Why?
Primary Care Trusts (PCT) have local unified cash limited budgets, which include
medicines expenditure. This means that cost effective prescribing has become a
top priority within the NHS.
As prescribing costs are now within an overall cash limit this means that if for
example a PCT overspends on its prescribing budget it will have to make savings
in other parts of the budget. Likewise if a PCT were to underspend on its
prescribing budget there would be more money available to spend on other
areas.
Health Improvement and Modernisation Plans (HIMPs) address health
improvement and the modernisation agenda. This includes tackling health
inequalities, responding to Local Modernisation Review outputs, delivery of key
NHS Plan priorities and tackling the wider determinates of health. Each PCT
develops their own HIMP to meet local priorities. Prescribing issues may form an
important part of many of these HIMPs e.g. use of statins to reduce coronary
heart disease (CHD).
PCTs must fund drugs recommended in the Technology appraisals and clinical
guidelines from NICE. They will also have to ensure that the targets in the
National Service Frameworks (NSF) for the use of particular groups of drugs are
met. Audit and monitoring of prescribing are essential to ensure that these
national initiatives achieve their goals of improving the care patients receive.
PCTs fund the new General Medical Services (GMS) contract which came into
force in April 2004. The contract contains a quality and outcomes framework
designed to improve services being delivered by general practice. It targets key
areas: clinical, organisational, patient experience and additional services.
Additional funding is available based on achieving quality standards and some of
the clinical indicators relate to prescribing appropriate medication.
For the last ten years there has been an increase each year in both the amount
spent on drugs in primary care and also in the number of prescription items that
have been dispensed. The graph below shows that for the financial year
(2007/08) 730 million prescriptions were dispensed by pharmacists and
appliance contractors at a cost of just above £8 billion.
Total Cost and Number of Prescriptions Dispensed by Pharmacists and
Appliance Contractors in England
800,000,000.00
9,000,000,000.00
8,000,000,000.00
No of prescriptions
Cost (£)
700,000,000.00
7,000,000,000.00
600,000,000.00
5,000,000,000.00
400,000,000.00
4,000,000,000.00
300,000,000.00
3,000,000,000.00
200,000,000.00
2,000,000,000.00
100,000,000.00
1,000,000,000.00
0.00
0.00
1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 2005- 2006- 20071998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Financial year
The average cost per prescription for 2007/08 is £11.13 compared to £9.45 in
1997/1998.
Average Cost per Prescription Dispensed by Pharmacists and
Appliance Contractors in England
14
12
Cost (£)
10
8
6
9.45
9.71
19971998
19981999
10.41
10.42
10.83
19992000
20002001
20012002
11.61
11.99
12.07
20022003
20032004
20042005
11.48
11.52
11.13
20052006
20062007
20072008
4
2
0
Financial year
Cost (£)
Items
6,000,000,000.00
500,000,000.00
The recent decrease in costs is due to Department of Health policies to control
drug prices.
From 1st April 2005 the Department of Health reduced the Drug Tariff price of
drugs which are readily available by introducing Category M. The prices of drugs
in Category M are reviewed quarterly and price changes are introduced when
appropriate.
Another mechanism to help maintain the downwards pressure on the drugs bill is
the PPRS (Pharmaceutical Price Regulation Scheme). This is a voluntary, nonstatutory scheme which 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.
These policies aim to slow down the growth in cost of prescribing that would
otherwise be seen from the increase in volume of prescriptions and the
introduction of new more expensive products.
Prescribing needs to be measured to ensure that the cost of prescribing remains
within the allocated budget. The quality of prescribing also needs to be
measured. By quality we mean that the patient receives the most appropriate
drug for the condition, given at the correct dose and for the correct length of time.
There is often dispute over what to prescribe and how to interpret the evidence
for a given treatment, hence the role of NICE in providing evidence-based clinical
guidelines.
Clinical governance has been defined as: 'A framework through which NHS
organisations are accountable for continually improving the quality of their
services and safeguarding high standards of care by creating an environment in
which excellence in clinical care will flourish'. The aim of clinical governance is to
improve patient care, through a framework of accountability, support and
continuing professional development. Prescribing is one area that PCTs are likely
to have focused on as part of clinical governance.
Measuring quality is more difficult than measuring cost. Prescribing data from
NHS Prescription Services tells you how many prescription items were
dispensed, the quantity and the net ingredient cost (NIC). Information about why
a drug was prescribed or for whom it was prescribed is not collected. This
information can currently only be obtained by auditing patient records. The
increasing use of electronic patient records and the introduction of the electronic
transfer of prescriptions (ETP) will enable this type of information to be more
easily captured.
A range of prescribing indicators has been developed based on Prescribing
Information data. Indicators are agreed by a range of stakeholders to be a valid
method to measure or monitor prescribing. Indicators are often used within the
performance management process or locally in prescribing incentive schemes.
Original prescribing indicators were based on the Audit Commission Report (A
Prescription for Improvement - Towards More Rational Prescribing in General
Practice, 1994) and further indicators were developed by the Prescribing
Indicators Group in 1997.The Prescribing Indicators Group also developed
criteria that can be used to assess the validity of prescribing indicators, or to
assist in the development of local indicators. For more information on Prescribing
Indicators click here.
Examples of some of the indicators which are useful measures of quality include:
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items per STAR-PU for antibiotics
ADQ per benzodiazepine STAR-PU for benzodiazepines
ADQ per NSAID STAR-PU for NSAIDs
Examples of some of the indicators which are useful measures of cost include:
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generic prescribing rate (%)
potential generic savings as a percentage of total drug expenditure
NIC per ADQ for ulcer healing drugs
overall prescribing costs per ASTRO-PU (excluding high cost and
specialist drugs)
From 2003, The Healthcare Commission (then known as CHAI) assessed
primary care trusts’ performance against a limited number of key targets and a
larger number and range of indicators, including four that related to prescribing:
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prescribing of antibacterial drugs
prescribing rates for drugs acting on benzodiazepine receptors
generic prescribing
prescribing of atypical antipsychotics
These four indicators are no longer used by the Healthcare Commission to
assess performance but PCTs may still continue to monitor these areas.
Generic prescribing is the prescribing of a drug by its generic name rather than
by a specific proprietary brand. For example if a prescriber writes a prescription
for Amoxil 250mg caps, the pharmacist must dispense the proprietary brand
Amoxil. If however the prescriber writes the prescription for amoxicillin 250mg
caps then the pharmacist may dispense any manufacturer’s amoxicillin 250mg
caps (since amoxicillin is in Part VIII of the Drug Tariff the pharmacist will be
reimbursed the Drug Tariff price). There are several manufacturers who make
amoxicillin 250mg capsules. The basic price of 21 amoxicillin 250mg caps is
£0.85 (Drug Tariff June 2008) whilst the price of 21 Amoxil caps is £3.59
(Chemist & Druggist June 2008).
Discuss with colleagues or your tutor the issues around generic
prescribing. Should all prescribing be generic? What percentage of
prescriptions should be written generically? What are the pitfalls of using
a set percentage for a generic prescribing rate?
There is no doubt that there are many drugs that can and should be prescribed
generically and these drugs are generally cheaper than their proprietary
equivalent.
The generic prescribing rate in England for 2007/08 was 83%. This figure does
not tell you what was prescribed generically. It is possible to increase your
generic prescribing rate by prescribing products generically that have no generic
equivalent or by prescribing products where generic prescribing is not
appropriate e.g. theophylline and certain modified release preparations. It is for
these reasons that prescribers are not aiming for a 100% generic prescribing
rate.
Occasionally the generic cost is more than the proprietary cost and as the idea of
generic prescribing is to give the patient the same effective treatment but at a
lower cost there would be little point in prescribing these products generically.
Generics are of the same quality as the equivalent proprietary and there is an
advantage to prescribing generically which is not cost saving i.e. the indication of
the drug class is often apparent from the generic name:·
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captopril, enalapril, fosinopril, lisinopril, ramipril are all angiotensinconverting enzyme inhibitors
atenolol, bisoprolol, celiprolol, labetalol, metoprolol, oxprenolol,
propranolol are all beta-blockers