Prescribing Analysis and Audit

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 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; 14.3 prescription items per head of population were dispensed in 2005 (compared to 13.7 in 2004 and 9.8 in 1995).³

Every GP needs to demonstrate that they prescribe effectively and safely, by regularly analysing and changing their practice where necessary.⁴

Benefits include:

• Developing a Personal Learning Plan for self-appraisal.⁵
• Fulfilling many criteria in different areas for the GP contract.²
• Reducing prescribing costs by reducing unnecessary prescriptions (e.g. antibiotics⁶), making most efficient use of therapeutic agents, encouraging generic prescriptions within the bounds of bioavailability, and reducing polypharmacy.⁷
• Improving patient care and management, and reduce non-compliance and waste.⁸

PACT data

As each GP is clinically and legally responsible for their own actions, it is important to consider your own prescribing. Each GP has access to their own prescribing analysis using PACT (Prescribing Analysis and CosT) data. This is a series of reports, which tells GPs what they have prescribed and how much their prescribing has cost. The data is produced by the Prescription Pricing Authority (PPA) and give information on both individual GP’s and practice’s prescribing costs, comparing them with other doctors in the same primary care organisation and also nationally.⁹ 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 on-line system called ePFIP (electronic and Prescribing and Financial Information for Practices, also known as ePACT). This is available to practice users via the Internet as well as via the NHS internal network.¹⁰

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 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 regular both patient medication reviews (see below), and analysis and audit. Computer records can highlight both over- and under-use enabling therapeutic failure or abuse, and non-compliance 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.³ 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 an 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 analytic approach; research suggests there is room for improvement in this respect.¹¹

Support

• The National Prescribing Centre NHS website also offers support to enable GPs to improve prescribing quality and analysis.¹²
• Organisations such as SIGN¹³ and NICE¹⁴ 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 (formerly PRODIGY) can also be very helpful.¹⁵

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 last 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 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.¹⁶ Examples include warfarin, amiodarone, lithium, penicillamine, sulphasalazine, 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 prescribe more safely.

1. GMC; Good Medical Practice 2006.
2. GMS Contract; Department of Health General Medical Services 2008.
3. The Value of General Practice; Royal College of General Practitioners Fact Sheet 2006.
4. Avery AJ, Sheikh A, Hurwitz B, et al; Safer medicines management in primary care. Br J Gen Pract. 2002 Oct;52 Suppl:S17-22. [abstract]
5. Appraisal for general practitioners: guidance; Department of Health 2002
6. 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]
7. 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]
8. Jesson J, Pocock R, Wilson K; Reducing medicines waste in the community Primary Health Care Research & Development (2005), 6: 117-124.
9. Prescription Analysis and CosT (PACT) National Prescribing Centre (only available within NHS net)
10. Electronic Prescribing and Financial information for Practices (ePFIF), NHS Business Services Authority 2009.
11. 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]
12. National Prescribing Centre
13. Scottish Intercollegiate Guidelines Network
14. National Institute for Health and Clinical Excellence
15. Cinical Knowledge Summaries
16. 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]