You need a decision map.

Hmmm I hear you say – What is that and why do you think I need one.

Well the answer is simple. We need to know where decisions are made. I recently spoke to a consultant who said that to get a medicine for a group of patients he had to fill in a drugs and therapeutics committee form for his own hospital. They approved the application, but referred the Consultant to the area prescribing committee (actually he called it another damned committee) which had a different form who then said it was a commissioning issue because there was an additional cost involved and it was referred to another committee (another group of bureaucrats I think was the term) who needed a business case. He said that it took him nearly a year to get it all sorted out and at several points in the process he was tempted to give in.

So how is that for integration and working together.

I must admit that sometimes I have been confused as to whether it is a drugs and therapeutics / formulary decision or a commissioning decision. And at some times it did depend – well on me. No not good enough.

So it is about time we sorted this out and made it clear to people – and foster a one stop shop for all decisions of this type if possible.

So here is an idea:

Medicines totally within tariff. If a hospital wants to decide which IV fluid or which anaesthetic it uses then fine. The consultant has to apply to the hospital committee. I would have said that they should be allowed to get on with it, but having watched a hospital get themselves into all sorts of problems with Sevoflurane and Isoflurane, I am not sure – they should have an external pharmacist from the CCG or CSU on their committee.

Medicines that are likely to be prescribed across the interface or are excluded from tariff. These should be decided within the APC, but there needs to be a clear financial limit set and reflected in the committees terms of reference.

Medicines where there is a cost implication. When the cost implication of introducing a new medicine is higher than the APC threshold then it needs to go to a priorities or commissioning committee with the authority to commit funds and the ability to generate policies and pathways.


So hello Mr consultant – you want to use a new medicine and want to know which committee to apply to. Well just a few simple questions. Is the medicine only going to be used within the hospital and included within tariff. No then do you have an estimate of the number of patients that might be prescribed the medicine in this area then calculate the total cost of the medicine. Will this medicine replace another medicine – one for one – then take of the cost of the replaced medicine  – is that below or above the threshold? Simples.

So the answer – a simple map that defines what each committee is able to deal with and make a decision – an algorithm perhaps or a decision pathway – it doesn’t really matter what you call it.

And the outcome – an applicant knows which committee to apply to that has the ability to make the decision that he/she needs. One form and hopefully a target decision time within weeks not months or even years.

And I won’t have to sit through a committee labouring over a decision that they are not authorised to make. And look into a consultant’s eyes watching his heart drop, his temper flair and answer the question – so what hoop do you want me to jump through now.


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