An interview with a formulary expert – transparency

I have heard you talking about transparency before.

Yes transparency is a requirement for formularies and formulary processes. The MMP have been offering advice on this subject for some time now and are currently working with some forming CCGs to make sure that this is done…

…But it is not new is it?

No it is not new, but while decisions were made behind closed doors and often not written down, it hasn’t been important.

So how have things changed?

Well there is a requirement to publish on your formulary internet site all decisions to allow stakeholders including patients and members of the public to understand the decisions that have been made and the reasons behind them. This is very important if you expect prescribers to be able to explain why they are not using certain medicines.

So were decisions bad?

No certainly not, but some were made without a structured reference to the ethical framework and commissioning framework and many were hardly inclusive and very few actually had patient or public involvement. And some decisions have been presented in a poor way.

Do you have examples of these?

Yes lots, here is one as an example. It is a letter written to the consultant that made the application.

And what is wrong with it?

On its simplest level it hasn’t described the medicine properly. It is here as SR where it is a PR product.

But that is a minor error?

Agreed, but for me, it is a matter of professional pride. If you can’t describe the product correctly then what trust can I put in the rest.

Are there any other issues?

Numerous – a claim about license that is incorrect, a suggestion that in-patients would react to a medicine differently from the general population, a statement about lack of evidence in a specific hospital population and a claim that it would be difficult for a specialist in this area to ‘determine a tight cohort of patients’. So generally incorrect and frankly insulting. It shows a complete lack of understanding of concept of evidence based medicine. And a complete lack of understanding of the licensing process and the development of evidence in the UK.

So it makes them look silly?

I would probably say incompetent, but there is more. A statement that the CCG would be unwilling to recommend it as a product for GP continuation.

But that is fair isn’t it?

It would be if there was evidence in the public domain that confirmed that the CCG had in deed made that recommendation, but there is not. And this leads to the  ‘he said, she said’ culture that we can see which generates a lack of trust. And worse a feeling of collusion to refuse patients access to a medicine that might actually help. In this case there is no real credible alternative that they could offer in its place.

I see what you mean. I notice the final paragraph.

Yes – now that is what makes them look silly. Fancy suggesting that the consultant, an expert in her own field, should approach the company  and ask them to sponsor a small in-house trial. Frankly it beggars belief. I don’t know what they are thinking here. Perhaps that are actually trying to make the consultant look like a fool.

So there is a lot of work to do?

Yes – a lot of work. The NICE Best Practice Guidance does help, but some of the meaning and implementation must be carefully thought through and it needs to be executed with total transparency.

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