GPs will need to make a sound business case to their primary care organisation (PCO) to be able to prescribe the newer, more expensive combined oral contraceptives (COCs).
When they are not on formularies, women in that area are being denied choice and GPs' clinical judgment is being restricted, says Dr Martyn Walling, a GP in Boston, Lincolnshire. He believes that an appreciation of the clinical reasons for prescribing some COCs is either lacking in some PCOs or is overlooked because of the perceived cost.
'GPs need access to a range of methods,' he says. 'PCOs prescribing the cheapest Pill as a matter of course is a false economy because it will not suit all women and this could lead to unplanned pregnancies if she stops taking it.
Waltham Forest PCT pharmaceutical advisor Mona Sood explains that from the PCO perspective, prescribing advisers want GPs to prescribe the most cost-effective clinically appropriate Pill first-line, followed by an alternative if this Pill is found to be unsuitable.
Dr Walling points out that the most cost-effective, clinically appropriate Pill, however, does not equate to the cheapest: 'The most cost-effective Pill is the one that is most clinically appropriate for an individual.
'The biggest reason for stopping is the side-effects.
Some third-generation pills are less androgenic and are associated with fewer side-effects.'
Against this background, PCO pharmacists recommend that GPs wanting to prescribe a more expensive COC should have robust reasons and present a business case for it. This should convince formulary decision makers that the incremental costs of a product are justified.
In the absence of hard data, Dr Walling advises GPs to focus on explaining the exact circumstance and group of patients in which a particular COC is considered to be most suitable.
'Each COC is oestrogenic or progestogenic dominant or somewhere in between, and this categorisation influences choice,' he said. 'For example, a progestogenic-dominant pill is not the best choice for a 16-year-old girl with bad acne.'
Another useful inclusion would be an algorithm that positions prescribing of more expensive COCs for some patients within an approach based on a first-line, cost-effective choice for the majority.
Practices with high prescribing costs for oral contraception would need to demonstrate an understanding of the differences between COCs and why particular pills are preferred for particular circumstances. According to Jane Moffatt, head of medicines management at Brighton and Hove City PCT, this would avoid any inappropriate savings targets.
While querying contraceptive budgets is currently a lower priority than reviewing budgets for chronic disease prescribing, Dr Walling says that 'the time will come when these budgets are more closely scrutinised' and recommends that GPs work more closely with prescribing advisers.
Ms Sood concludes: 'PCO pharmacists can't be directional in their approach.
But with the advent of practice-based commissioning, our advice on evidence-based decision-making is now more important. If I was given a free, credible professional resource, I would use it.'
BUSINESS CASE FOR COC: WHAT TO LOOK AT
- Mechanism of action: how does the drug work?
- Evidence of effectiveness: give evidence of its efficacy.
- Budgetary impact: how much does it cost and what financial benefits does it bring?
- Impact on quality of life: what side-effects does the drug have? How do these compare with alternatives' side-effect profile? What are the costs associated with discontinuation?
- Clinical and patient experience: anecdotal evidence of use.
- Guideline recommendations: how do they support the use of particular COCs?
- Prescribing algorithm: on which patients and under what circumstances will the COC will be prescribed?
BEST PRACTICE PRESCRIBING PRINCIPLES
- Use national guidelines and protocols to guide prescribing recommendations.
- Prescribing decisions should be evidence based where good evidence of clinical and cost-effectiveness exists.
- Base repeat prescribing on an evidence-based and patient-friendly policy.
- Review prescribing annually.
- Seek input to prescribing decisions and prescribing patterns from other healthcare team members.
- Prescribing decision should be based on a concordant relationship with patients.