Seamless Care Aided by Smoother Prescribing at the UK Primary/Secondary Care Interface

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Making GPs the Driving Force

A set of healthcare reforms are underway in the UK. The new structure of the NHS is built around primary care groups (PCGs), groupings of around 50 general practitioners (GPs) caring for a population of approximately 100 000 people.[1] These groups will receive an overall budget in which to:

  • manage purchasing of hospital services

  • pay for treatment (including drugs)

  • employ staff.

PCGs are likely to be very rigorous in controlling their drugs budget and to achieve this it is possible that they will develop very restrictive drug formularies. Formularies can be defined as lists of medicines, to which prescribers are encouraged or required to adhere.[1] The concept of formularies is to help prescribers make good prescribing choices and to encourage prescribing that is good value for money.

When drawing up contracts with hospitals, PCGs will probably require hospitals to use treatments that fit into their own formulary, unlike more traditional approaches where hospitals have driven these initiatives or health authorities have included drugs into contracts. However, each hospital will deal with several PCGs and some coordination and agreement between PCGs and hospitals will be needed.[1]

Part of this coordination will take place at a national level with the development of clinical service frameworks (i.e. frameworks for the management of key diseases) and the National Institute for Clinical Excellence (NICE). The purpose of NICE is to provide guidance on the clinical and cost effectiveness of health technologies, including drugs.[2] This body will establish and disseminate national guidelines on the management of key conditions, and undertake assessments of new technologies. Hopefully this initiative will help facilitate coherent decision making.

By tradition, all drugs licensed in the UK are available for NHS prescription unless specifically excluded. Since the inception of NICE, however, decisions will be made about the national availability of drugs in addition to the requirements of the licensing system. These decisions will, in effect, establish a national formulary.[3]

NICE issued its first recommendation to the NHS late in 1999. The agency advised against the prescription of zanamivir for the treatment of influenza virus infection.[4] Although the drug has been approved, NICE cited evidence that zanamivir has only modest benefit in otherwise healthy individuals with influenza. Although the costs of achieving this benefit are uncertain, they are expected to be significant. Furthermore, NICE decided that there was insufficient evidence to recommend the use of zanamivir in high-risk patients.[4]

This decision by NICE, even though supported by the UK Secretary of State for Health, is not legally binding.[4] Individual health professionals still have the responsibility to determine whether the drug is appropriate for the treatment of individual patients under their care.

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