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April 2008

Industry intelligence in association with STAR

This month, Customer Insights examines the situation north of the border. Whilst PBC has not reached the NHS in Scotland, some of the pressures on prescribing appear remarkably familiar.
Name: Dr Ewan Crawford, GP, Edinburgh

What is your role and where does it sit within the structure of NHS Scotland?

I am a GP working in Murrayfield, Edinburgh as part of North West Edinburgh Local Health Partnership (LHP), where there are 19 GP practices serving around 136,000 patients. This is one of five LHP in Edinburgh Community Health Partnership (CHP). I also have an interest in Diabetes. CHPs are set up across Scotland to provide a wide range of health services delivered across the community in homes, health centres and clinics. Overall, NHS Scotland is divided into 14 Health Boards, our Health Board being Lothian. Edinburgh is one of four CHPs in Lothian.

Who sets health targets in Scotland, and how are they measured?

Each Health Board has targets that are set by the Scottish Government. It is the responsibility of the Health Board to determine how those targets are dealt with. Notionally, we work in a single system but, in reality, some targets are more applicable to hospital care – such as waiting times and hospital-acquired infection targets – while others, such as 48-hour access to primary care, belong in ‘GP land’. There are other targets around admissions and discharges that are far greyer that we have to work together to reach. Targets are known as HEAT targets, and measure Health Improvement, Efficiency, Access and Treatment.

What are the differences in how the Scottish system works?

A big difference between north and south is that we don’t have PBC. For GPs, many of the incentives for prescribing aren’t applicable north of the border. We can’t readily effect prescribing change with a view to hoping to have an impact on admissions or emergency care, or that sort of thing. As a GP, my responsibility is to the patient population. There is, however, a responsibility to ‘the system’ to manage the books and to manage the prescribing budget efficiently. There needs to be some awareness that drugs over-prescribed in one area have an impact on what can be prescribed in another.

How do you manage your prescribing budget?

We are encouraged to prescribe 80% from formulary, meaning 20% can be off-formulary. 20% is fairly generous, to my mind, and should cope with most patient variations. When it comes to selling a drug, I think if it’s on formulary you don’t need to sell it. If you’re off formulary then you need to have a defined niche that you can target within that 20%. For example, if your drug is for diabetes, you accept that most people are going to be on metformin or a glitazone – but if you have a new drug then you need, perhaps, to be targeting the overweight patients because they might be weight neutral (or some other defined advantage) or just accepting that your drug is going to be third line, and that the GP is going to try the two formulary choices first and seek an alternative only if there’s a problem. For the rep the challenge is that not only is the pool small at 20% but that also there is a large number of other fish in it.

What sort of things would persuade you to prescribe off-formulary?

I’m looking for a clinical niche. Unless there is a huge financial incentive, which given that most drugs on formulary are actually off-patent is not likely, then the comparator in terms of cost is the other non-formularly drugs. You need to find something that makes your drug different clinically from the others. Clearly that is going to be difficult because if they were that much better they would have been on the formulary in the first place. The door is not closed on the economic argument, but as a GP, my decision is a clinical one with a patient present. How that impacts on HEAT targets and helps the Health Board sort out their challenges is really not for me to worry about. I’m happy to play a part in that, but that’s as part of the GP body rather than as an individual.

What does a typical working week look like?

I run six patient-facing sessions a week, and have slots to see one representative a week. I also do three formal sessions of Medical Management for the LHP. This entails providing leadership for primary care in the area and includes not only GPs but also district nurses and other non-hospital bits of healthcare. The concept behind the CHPs is that we try to work closely with the councils and local authorities, working on the principle that having good schools, good homecare and strong education does as much to create a healthy population as having doctors prescribing drugs.

What about your role as Clinical Lead?

As a Primary Care Lead for diabetes, I am a kind of ‘disease champion’ within the Managed Clinical Network for Diabetes in Lothian – which means that I do have an influence on what drugs may be used elsewhere in the LHP. But it is at each GP’s discretion that they choose to prescribe what they do. I am relaxed about being in discussions with the pharma industry, but other GPs in my position are less comfortable.

What do you want to see from your exchanges with representatives?

Representatives offer a valuable form of information, but there have been instances where approaches to GPs have been over exposed and we’ve had high numbers of reps selling the same products to the same customers. This has led to GPs closing their doors to them. Once a door is shut, it is a very difficult negotiation to get it back open again. As such, reps need to be aware of the pressures on the health service. They need to understand the environment and be realistic. Reps don’t always seem to understand the pressures that GPs are under in terms of prescribing and adherence to formularies. It is about going in with a realistic target. Sales professionals should perhaps be more realistic and less arrogant that they can break through a formulary.

What other services could the industry help provide?

Audit services, where companies help to identify patients with defined conditions whose health could be improved by moving onto a new treatment, have become a common and valuable activity. Other companies have provided services of a more general nature, such as giving you a practice nurse for a short period of time.

One of the areas that I am interested in at the moment is the area around motivational interviewing and behavioural change. This involves getting patients to a point where they realise medicine has done all it can, and that to make them better, they’ve actually got to do something themselves – whether that’s lose weight, give up smoking or exercise. Generally, telling patients to do any of these things is not very effective. By looking at their behaviours and looking at how they respond to stresses makes it more real to them and allows them to come to the realisation that ‘if I want this, I can’t rely simply on medicines, I’ve got to do this, this and this myself ’. Pharma companies, completely outside of their drugs, could do something to help with that exchange. Some of them do, but only a few. I’d happily talk to a representative about this sort of thing.

What advice would you give to representatives?

Understand the environment you are prescribing into. Not enough representatives do. There are plenty of friendly people around and information on websites – don’t bang your head against a brick wall when there’s probably a door within that wall somewhere. Other than that, be nice, look smart and smile!

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