I am a great supporter of NICE. It makes reasonable decisions based on a level of uncertainty. When it has been misguided, I have even written a report for the ERG giving them more information and NICE responded.
I was looking at a product recommended by NICE for a common, but high impact on the individual condition. There is some uncertainty about comparable effectiveness to existing medicines, but some certainty about reduced risk of side effects. So NICE says, quite rightly, use it after older medicines unless you are worried about the potential side effects or the patient has experienced the side effects before and then use it first.
Bing, bang, boom – stick it in the formulary – word for word – and translate it into local guidelines – job done – move on. I am not too worried about this as it is actually LESS expensive that the market leader. As I look, it would seem that most of the Pharmacists out there do this – generally we are a very reasonable bunch.
But obviously not all medicines managers follow my lead.
The Medicines Optimisation Pharmacist notices that they use additional medicines to treat the side effects of the older products. So he promotes the product, reduces costs and starts to investigate within a pilot whether the new medicine would improve outcomes. He believes he can reduce cost within this class, reduce the use of additional medicines to deal with side effects, make life simpler for GPs and have a serious look at adherence and longer term outcomes for patients, adding quality to life and perhaps some large savings for the whole system, particularly community and social care. Damn I wish I thought of this!
The ‘not in my budget’ Medicines Manager puts a line in his formulary that says this newer medicine should be initiated by specialists only and they should continue prescribing for three months before transfer to general practice. Good plan, but this area now has three times the level of referrals for that speciality than the regional average and over 60% are single visits. I am sorry; I don’t see the point of paying for a referral to secondary care to get prescribed a cheaper, safer and easier to use medicine than the most commonly prescribed medicine in the area. My GP prescribing lead would have rightly cut my legs of for even suggesting this insult. I can hear his voice boom out ‘are you suggesting that a GP would not be able to prescribe and manage this medicine’. And of course he is right. I doubt that this is in the spirit of NICE, although I am sure they would argue that the recommended medicine was available.
The ‘life’s gone mad’ Medicines Manager puts an incentive scheme for GPs to prescribe the cheapest agent in class first. So GPs accept a payment to use a medicine that, personally, I wouldn’t use in my practice, nor would I want anyone in my family put on and incidentally didn’t have on my formulary. Knowing that more than 4 in 5 people discontinue this drug within 6 months must say something about it and the market leader and medicine that NICE recommends have two to three times this persistence rate. I can’t really get my head around this – life has gone mad. Is it legal? Was there a GP on the board that approved this? So there is a CCG out there that incentivises their GPs to use nasty cheap medicines that patients won’t take to save money in their prescribing budget.
I appreciate that the NHS is strapped for cash and has to make efficiency savings, but these should be made right across the board – the prescribing budget is just one point of expenditure.
Medicines optimisation – the creative use of medicines to improve outcomes for the individual patient is the way forward. There is a need for creative investment of the medicines budget to create savings right across the whole system because patients do better.