Committee
Audit Committee, 02 Sep 2003
02 Sep 2003 · S2 · Audit Committee
Item of business
“Supporting prescribing in general practice”
Mr Black:
Watch on SPTV
I will introduce the report to the committee. I have with me colleagues from Audit Scotland who worked on the detail of the report, and who will answer any questions that members might have.In 1999, I published a baseline report on prescribing in general practice, which made a number of recommendations that were aimed at improving the quality and efficiency of primary care prescribing. We invited trusts to take action on those recommendations and to use some of the indicators that we provided to improve the quality and efficiency of the service. The latest report considers progress against that baseline. The main report, which is a substantial document of more than 50 pages, considers three broad areas. The first involves factors that influence prescribing quality and cost, the second relates to prescribing quality and efficiency and the third covers issues that relate to achieving further improvements in prescribing. There is also a summary report, which members might find helpful.The issue is a big one. The total prescribing expenditure for 2002-03 in Scotland was around £850 million, which is about 12.5 per cent of total national health service expenditure. Moreover, prescribing expenditure has been rising steadily each year, with a 13 per cent rise in 2002-03 compared with the previous year. Big resource issues are involved. The quality of prescribing has a direct impact on the quality of patient care, both in treating existing conditions and in preventing ill-health.I am pleased to report to the committee that all trusts have improved prescribing quality significantly against the indicators in the baseline report. For example, there has been a significant increase in the prescribing of medicines such as angiotensin-converting enzyme inhibitors, low-dose aspirin and statins, which all treat, or help prevent, coronary heart disease. That significant development has taken place over the past few years.Trusts have also achieved efficiency savings by taking action on issues such as generic prescribing and by reducing the use of medicines that are considered to be of limited value. The report identifies room to make further savings of around £14 million. Although that is a substantial saving and is worth achieving, we must recognise that it is a relatively small amount compared with the overall prescribing expenditure and that it will take some time to achieve.Almost without doubt, those savings will be overshadowed by the rising cost of new drugs, of which the report gives some examples. To take one such example, there will be an increase of £28 million in the cost of prescribing for treatment of cardiovascular and central nervous system diseases alone. A number of evidence-based guidelines recommend the use of particular drugs to treat or prevent particular diseases, such as statins for coronary heart disease. Such drugs improve the quality of patient care, but they have significant cost implications. To stick with statins as an example, our report estimates that the annual cost to the health service in Scotland of providing statins is expected to grow to at least £95 million—the present figure is around £65 million—which is slightly less than 12 per cent of the total prescribing budget.It is important that prescribing is targeted accurately and in line with the evidence so that extra spending achieves the greatest benefit. We also recommend that the cost of implementing the guidelines that I mentioned is calculated and made available to the health service so that the financial implications are understood fully. None of the drugs involved is cheap and each of them, if chosen for prescription, would entail significant cost to the health service. It is important that health boards consider implementing those guidelines along with other service developments. There are difficult choices to be made.Further work is needed in a number of areas. As a result of our initial report, all primary care trusts now have prescribing strategies, but more needs to be done in developing health board-wide prescribing strategies and area-wide formularies, which are lists of selected drugs with guidance and protocols for their use. We have used commonly accepted indicators for prescribing quality and efficiency and we recommend that the health service should consider putting together a set of national prescribing indicators. That development, along with the sharing of good practice, would help trusts to benchmark their performance as they go along. There is also a need to link prescribing information with related information about the impact on patients, such as morbidity and diagnosis information, which is not possible at present. That situation makes our analysis rather difficult because we cannot relate prescribing interventions to patients' health.The two other important areas in which improvements are required are in the development of universal and rigorous repeat prescribing systems and the further development of computerisation.I invite Barbara Hurst to expand on one or two of the key points and to set them in the current context.
In the same item of business
The Convener:
Con
Agenda item 3 is on general practice prescribing. I invite the Auditor General and members of his team to brief the committee on "Supporting prescribing in g...
Mr Black:
I will introduce the report to the committee. I have with me colleagues from Audit Scotland who worked on the detail of the report, and who will answer any q...
Barbara Hurst (Audit Scotland):
The present report and the 1999 baseline report were both big pieces of work. We were careful about the choice of indicators because the issue is a clinical ...
Margaret Jamieson:
Lab
The report mentions the waste in prescribing, which was also touched on in the baseline report. However, it does not really mention the work that has been un...
Barbara Hurst:
A number of health boards have done quite a bit of work in that area. On the reuse of drugs that have been prescribed to other people, lack of knowledge of h...
Margaret Jamieson:
Lab
In future, I hope that people who are prescribed a new drug for their symptoms will be given the drug only for the trial period initially, as that will reduc...
Barbara Hurst:
We were speaking about cost-effectiveness in the widest sense, but I must add a caveat. We cannot tell whether people are being prescribed a drug for their d...
Margaret Jamieson:
Lab
The report mentions that transdermal oestrogen-only hormone replacement therapy patches are very expensive, but it does not expand on that comment in relatio...
Barbara Hurst:
That is a crucial point. That is why we have been quite conservative with the savings. Patient compliance is an issue, and some patients definitely need the ...
Mr Black:
The questions that we are being asked are highly relevant. When the committee decides whether to take evidence on the subject, it might want to bear in mind ...
Mr Kenny MacAskill (Lothians) (SNP):
SNP
My question is about computerisation. Government and agencies are attempting to make progress in that area, for example through digital Scotland and broadban...
Barbara Hurst:
That would be a massive study in its own right, so I will give you a partial answer. On prescribing, we found that many pilots go on and on, but we are not l...
Susan Deacon:
Lab
I found "Supporting prescribing in general practice—a progress report" interesting and informative, just as I found the baseline report interesting and infor...
The Convener:
Con
We will come back to those.
Mr Black:
I will respond first to the point on whether we could do more work on the effectiveness of implementation. We should take that issue on board. I give the com...
Barbara Hurst:
I agree entirely with Susan Deacon. The link between community pharmacists and GPs is the way forward. That takes us back to computerisation, which would off...
Susan Deacon:
Lab
I am grateful for that diplomatic response. I hope that we will have the opportunity to probe the matter further.The first of my two final questions concerns...
Barbara Hurst:
I will have a go at those questions.As far as clinical audit is concerned, I should have mentioned in response to one of Margaret Jamieson's questions the ro...
Susan Deacon:
Lab
What about the question of training?
Barbara Hurst:
The training of doctors has come up as an issue in a study that we have started on the use of medicines in hospitals. I think that you are right to highlight...
George Lyon (Argyll and Bute) (LD):
LD
Given the report's recommendations on prescribing and extracting better value, the issue of implementation seems to be pretty critical. Is the roll-out of im...
Barbara Hurst:
I am going to cop out, slightly, of answering that question until we do a bit more work. A lot of money is certainly going into the IT budget, but we need to...
The Convener:
Con
Okay?
George Lyon:
LD
That did not answer any of my questions.
Mr Black:
I apologise for repeating what I said a moment ago, but I should point out that we must always operate within the boundaries of the evidence that we find and...
The Convener:
Con
Obviously we can discuss the matter when it comes back on to the agenda.
Rhona Brankin (Midlothian) (Lab):
Lab
I wanted to pursue the issue of sharing good practice, which links into the business of information and communication technology and how people access what i...
Barbara Hurst:
The committee could certainly explore that area. The situation is fairly ad hoc at the moment; for example, good practice might not be universally shared eve...
The Convener:
Con
I think that we have exhausted our questions, but we will discuss later how the committee will approach the matter. I thank Barbara Hurst for answering the c...