Why prescription assessment?

Although it is often a daunting prospect at the outset, self-appraisal in general practice enables continuing professional and personal development for each GP and helps to identify, analyse and plan future development needs.

The General Medical Council¹ and the new General Medical Services (GMS) Contract² emphasise the need for appraisal and continuing personal development in general practice.

Prescribing makes up a large portion of a GP's clinical care of a patient and is the most common therapeutic approach offered to patients; 17.1 prescription items per head of population were dispensed in 2009 (compared with 16.4 in 2008 and 10.8 in 1999).³

A systematic review found that there was a high proportion of errors in primary care prescribing. Factors identified in contributing to errors included the repeat prescribing system, the interface between hospital and GP, communication and patient adherence. When efficacy was included in the analysis it was calculated that only between 4% and 12% of patients achieved optimum benefit from their medication.⁴

Every GP needs to demonstrate that they prescribe effectively and safely, by regularly analysing and changing their practice where necessary.⁵

Benefits include:

• Developing a Personal Learning Plan for self-appraisal.⁶
• Fulfilling many criteria in different areas for the GP contract.²
• Reducing prescribing costs by reducing unnecessary prescriptions (e.g. antibiotics, ⁷) making most efficient use of therapeutic agents, encouraging generic prescriptions within the bounds of bioavailability and reducing polypharmacy.⁸
• Improving patient care and management and reducing noncompliance and waste.⁹

Getting started

Prescribing analysis and cost tabulation (PACT) data

As each GP is clinically and legally responsible for their own actions, it is important to consider your own prescribing. Each partner has access to their own prescribing analysis using PACT data. This is a series of reports, which tells GPs what they have prescribed and how much their prescribing has cost. The data are produced by the Prescription Pricing Authority (PPA) and give information on prescribing costs for both individual GPs and practices, comparing them with other doctors in the same primary care organisation and also nationally.¹⁰ It also tells you the areas in which generic prescribing would be cheaper.

Since January 2007, circulation of hard copies ceased and was replaced with an online system called electronic Prescribing and Financial Information for Practices (ePFIP), also known as electronic Prescribing Analysis and Cost Tool (ePACT)). This is available to practice users via the Internet as well as via the NHS internal network.¹¹

Start with identifying if there are any areas that need addressing in the ePACT data; for example, do you consistently mismatch best practice, or overspend in a particular area of therapeutics? Your primary care organisation (PCO) prescribing adviser will also be able to give you comparisons between your prescribing and those of neighbouring practice to help you focus on areas where you differ to your colleagues.

Data record

Medicines that a patient is receiving need to be clearly indicated in their record.² A computer prescribing system, as used by virtually all practices, makes this easy to demonstrate as well as facilitating both regular patient medication reviews (see below under 'Practice prescription reviews') and analysis and audit. Computer records can highlight both overuse and underuse, enabling therapeutic failure or abuse and noncompliance issues to be addressed.

Practice formulary

Many practices use a practice formulary, which can be developed in-house but is more commonly developed according to local guidelines and national recommendations. Formularies can be set to revert to generic drug names, which may be cheaper than alternatives, remembering the exceptions of varying bioavailability where generic substitution is not recommended. Interactions, allergies and cautions can also be highlighted and act as a reminder for GPs to ensure patient safety.¹² Many computer systems allow you to import your local PCO formulary automatically and transfer it from practice to practice with minimal effort.

Formularies may also help to remind you of the first-line recommended treatment in any particular condition and may help as a memory aid to the many guidelines and government recommendations that we are faced with on a daily basis.

Basing practice formularies on local guidelines requires local formulary committees to take a robust analytical approach; research suggests there is room for improvement in this respect.¹³

Support

• The National Prescribing Centre NHS website also offers support to enable GPs to improve prescribing quality and analysis.¹⁴
• Organisations such as the Scottish Intercollegiate Guidelines Network (SIGN)¹⁵ and the National Institute for Health and Clinical Excellence (NICE)¹⁶ can help with guidelines on prescribing and cost-effectiveness in the context of quality patient care.
• Internet-based resources such as NHS Clinical Knowledge Summaries (CKS) - formerly 'PRODIGY' - can also be very helpful.¹⁷

Practice prescription reviews²

As a GP, over 75% of your prescriptions will be issued without a consultation, as repeat prescriptions. Regular review of this is essential for self-appraisal as well as for the GP contract. All practices need to demonstrate that over 80% of repeat prescriptions have been reviewed in the preceding 15 months, this review recorded on the patient's clinical record and that the indication for the drug is clearly stated.

Trying to tackle your repeat prescribing all at once can be daunting but using the Quality and Outcomes Framework (QOF) in the GP contract it is easy to break down prescribing review into small manageable items. These individual requirements in areas such as chronic disease control and local and national enhanced services can be audited and the audits used as self-assessment as well as documentation for the contract.

For example, ensure that there is adequate recall for specific drug classes. An audit looking at your prescription of drugs with potentially serious side-effects and requiring ongoing monitoring would involve small numbers of patients but may prevent serious problems. Hospital letters do not always identify patients who require such monitoring in primary care.¹⁸ Examples include warfarin, amiodarone, lithium, penicillamine, sulfasalazine and methotrexate.

Many computer systems can run protocols in the background when prescriptions are issued to check that the necessary blood tests and monitoring are being performed (e.g. has there been a lithium level in the last 6 months and was it in the therapeutic range?). Such automatic checks with suitable prompts may help to prescribe more safely.

Document references

1. Good Medical Practice, General Medical Council, 2006
2. GMS Contract, General Medical Services, Dept of Health, 2009
3. The NHS Information Centre 2010; Prescriptions Dispensed in the Community: England, Statistics for 1999 to 2009
4. BMJ Learning; Learning home page
5. Smith L, Ewings P, Smith C, et al; Ear discharge in children presenting with acute otitis media: observational study Br J Gen Pract. 2010 Feb;60(571):101-5. [abstract]
6. Appraisal for general practitioners: guidance, Dept of Health, 2002
7. Williamson I, Benge S, Mullee M, et al; Consultations for middle ear disease, antibiotic prescribing and risk factors for reattendance: a case-linked cohort study. Br J Gen Pract. 2006 Mar;56(524):170-5. [abstract]
8. Denneboom W, Dautzenberg MG, Grol R, et al; Analysis of polypharmacy in older patients in primary care using a multidisciplinary expert panel. Br J Gen Pract. 2006 Jul;56(528):504-10. [abstract]
9. Jesson J, Pocock R, Wilson K; Reducing medicines waste in the community Primary Health Care Research & Development (2005), 6: 117-124
10. Prescription Analysis and CosT (PACT) National Prescribing Centre (only available within NHS net)
11. electronic Prescribing and Financial information for Practices (ePFIF), NHS Prescription Services
12. The Value of General Practice; Royal College of General Practitioners (RCGP), Fact Sheet 2006
13. Williams IP, Bryan S; Cost-effectiveness analysis and formulary decision making in England: findings from research. Soc Sci Med. 2007 Nov;65(10):2116-29. Epub 2007 Aug 14. [abstract]
14. Supporting Prescribers, National Prescribing Centre
15. Scottish Intercollegiate Guidelines Network; Home page
16. National Institute for Health and Clinical Excellence; Home page
17. Cinical Knowledge Summaries
18. Corry M, Bonner G, McEntee S, et al; Hospitals do not inform GPs about medication that should be monitored. Fam Pract. 2000 Jun;17(3):268-71. [abstract]

Acknowledgements