Purpose of a formulary

With all the fuss about formularies, you might want to spend a few minutes to reflect and think about it before you rush in.

Yes – I know – you have to produce a formulary on line to show that your organisation complies with NICE recommendations. That seems to be a given now following a strong direction from both Keith Ridge and David Nicholson. No getting away from it really and they will be checking up on you.

But what is a formulary for? What do you hope to achieve from it? By now you might think that it is not as easy a question as it first sounds. And your answer will guide the way that you work towards reviewing and developing a formulary process.

About 100 years ago (even before my days) the formulary was a list of formulas – preparations that a pharmacy would make up and supply. And that is, perhaps, where the word came from – meaning a list of formulas/medicines stocked and supplied.

About 20 years ago I would say that it was a stock control mechanisms, stopping the shelves becoming full and swelling our capital investment in drugs and pushing wastage to an unacceptable level.

Today – in the age of medicines optimisation?

Well here are a few thoughts. You can tick any of them you like, but then think whether your existing formulary and formulary process is compliant.

  •  The formulary process should support the rapid introduction of new medicines (not just NICE recommendations) that have the opportunity to improve the outcomes for patients. (note my previous blog on medicines management)
  • The formulary process should support better integration of primary, secondary and tertiary care through clinical engagement.
  • The formulary should promote and secure patient safety
  • The formulary process should engender public and stakeholder confidence, by being open and transparent with a rigorous process and consistent decision making
  • The formulary should provide the central hub for all local guidelines protocols and pathways and be the signpost to good practice
  • A process supporting the education of clinicians in the best use of NHS resources

You will note that I have been very careful not to use such terms as cost-effective, simply because it is a badly used term. Nice uses a definition of £20,000 a QALY – well it actually seems to be falling every day – but they recognise that this is an inexact science and there is a lack of social and personal costs in their calculations. I am also sure that if you pick any drug it will be highly cost-effective in an individual patient and useless in someone else.

I have not mentioned prescribing budget control. I am not saying that budgetary control is not important, but this focus has sometimes made medicines management the local heroes and the national villains. And today – the GPs are in control of the budgets – they are responsible – let them stand up and be counted.

From today I will think differently about my formulary and the process that I am adopting and work to set things up together. Thank you Andrew Lansley for giving us the opportunity through changing the structure and thank you Jeremy Hunt for continuing the drive towards local determination.


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