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

In This Article

Many Barriers to Seamless Care Prescribing

Many initiatives have been suggested and tried in the past with varying degrees of success. Drug formularies have been used by GPs and hospitals for many years (see table 1), but this has not necessarily helped smooth the transition of patients between primary and secondary care. Although formularies are common, both in general practice and in hospitals, the degree to which they are used or referred to varies.[1] Formularies in these different healthcare sectors are often written independently of each other. Thus when patients move between primary and secondary care, the use of dissimilar formularies could result in considerable confusion, harm to the patient and/or wasted healthcare resources.

Joint formularies would improve overall care and raise awareness of the need to consider overall healthcare costs within in a system where hospital and GP formularies vary considerably (see table 1).[1]

However, there are few examples of successful working of a joint formulary in the UK. One is the Grampian formulary in the Grampian area of Scotland.[5,6]

In a survey it was found that 84% of the drugs taken by 89 elderly patients admitted to a hospital in the Grampian area were those recommended in the formulary.[7] The organization of the NHS in Scotland with responsibilities for both hospital and primary care budgets are held by 1 authority may have contributed towards the success of the Grampian formulary as this has fostered a greater enthusiasm for joint management of both primary care and secondary care prescribing.[1] In addition, relationships between hospital doctors and GPs, often dating back to their training, are often closer in Scotland than in England. This leads to improved communication and, to some extent, a greater acceptance of GPs of a role as agents of hospital consultants.

Another approach is the inclusion of prescribing issues in the contracts between purchasers (primary care) and providers (secondary care) of healthcare. Purchasers were encouraged to develop strategies for improving the cost effectiveness of prescribing across the secondary/primary care interface.[8]

In a letter from the NHS Executive the need to consider total NHS costs despite the division of budgets for prescribing was emphasized. However, as prescribing is only a very small part of the contracting process, the actual changes which occurred in prescribing were less than hoped for.[1] Moreover, the process was hindered by tension between managers and health professionals.

The creation of joint prescribing committees within individual health authorities is 1 of the mechanisms used to action the NHS Executive Letter.[1] These groups typically consist of representatives of local major hospitals, the health authority and, particularly strongly, the GPs in the area. Although these committees have been helpful, there are concerns that local decisions made by these groups on the provision of some therapies has caused 'rationing by postcode' (i.e. availability of certain treatments in some areas but not others). This approach is less than ideal.

In addition, there are concerns that attempts to define local formularies are inappropriate, both because of the likelihood of limited acceptability and also because formularies may be taking drugs out of the context of overall patient management.[1]

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