Last December in GP I related how my practice saved £500,000 from its practice based commissioning (PBC) budget by reducing secondary care usage. Over the past three years we have also succeeded in making large savings in our prescribing budget.
Ours is a big practice with around 13,000 patients in Fleetwood, Lancashire and our healthcare team includes a pharmacist practitioner.
In 2005/6 we cut our drugs spend by £185,000. The following year we made a further saving of £85,000 and for 2007/8, we estimate a reduction of costs in this area of £122,000.
So how did we do this? Firstly by spending more. As a significant number of patients with COPD, heart failure and osteoporosis were under-treated in primary care, we calculated that we needed to invest an additional £100,000 a year in prescribing for them to cut acute hospital care episodes.
Despite this extra expense we were confident about reducing costs in other areas and our pharmacist practitioner drew up a plan for doing this involving switching patients to less expensive drugs. All the 1,000 patients affected received a detailed letter and, because there were few queries, disruption to the practice was minimal.
Our team developed evidence-based, cost-effective prescribing protocols based on national guidelines for all long-term conditions such as diabetes, heart disease and COPD.
The protocols standardised the range of medicines prescribed. Where possible a single drug in a class was specified - for example, bisoprolol for beta-blockers. We put the protocols on our intranet so prescribers had instant access and all prescribers undertook a prescribing education programme.
With drug switches we focused mainly on lipid-lowering drugs, ACE inhibitors, proton pump inhibitors, antidepressants and bisphosphonates.
The appropriateness of NHS prescribing for erectile dysfunction was checked and patients were given private prescriptions where possible.
At the time, some generics were available at lower prices via branded generics prescriptions - for example, Simvador (simvastatin) and Oxactin (fluoxetine) - so prescriptions were written to take advantage of this.
Practice audits had shown that the diagnoses were not always right, so prescribers were encouraged to ensure correct diagnosis was obtained before prescribing for a presumed long-term condition.
The main symptoms we considered important were indigestion, breathlessness and chronic pain. Access to speedy diagnostics was essential and this became part of our overall PBC service redesign.
Dyspepsia management clinics including breath testing were started and we also have in-house spirometry, ECG and echocardiography.
We arranged identification of postmenopausal patients at risk of osteoporosis and those with history of previous fragility fracture by the local DXA scan service. Around 200 patients were scanned and followed up with lifestyle advice, falls risk assessment and drug treatment.
Likewise, spirometry was carried out on all known smokers over 50 who had presented with cough or chest infection over a 12-month period. Around 1 in 4 of such patients were diagnosed with COPD. Where possible, we included access to non-drug treatments and set up several new services including acupuncture and physiotherapy at the surgery. All our hard work has paid off.
Dr Spencer is a GP in Fleetwood, Lancashire
| Drugs switches |
|Old drug||New drug|
New in-house services
- Rapid access to in-house physiotherapy.
- TENS machines.
- Mental health support and CBT.
- Falls advice.
- Expert patient.
- Visiting Citizen's Advice Bureau service.