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February 2008

Industry intelligence in association with STAR

In the second instalment of our series looking at the different roles in the industry’s NHS customer-base, Pf this month spoke to Mark, a Secondary Care Physician who also sits on a local prescribing committee.

What does your role as a Secondary Care Physician entail?

I am a consultant physician in general and acute medicine, diabetes and endocrinology. General and acute medicine is what comes in through the door of A&E, and that means getting involved in emergencies and overseeing the management of people with conditions such as heart attacks, strokes and pneumonia, as opposed to people who need an operation. About 80% of my time is spent in patient management, of which generally a third is doing acute medicine, and two thirds is outpatient consulations in diabetes and endocrinology.

What are your main objectives?

The main objective of my role is to improve the health outcomes of our patient groups.This is divided into two aspects.The first is to provide a safe and comprehensive service for dealing with acute emergencies within the government’s targets of getting people seen in A&E within four hours.The second is to get people out of hospital as quickly as possible.

In short,my role involves sorting people out who come in through the door, and getting them back out again quickly and in the best possible state.This would be the same for any consultant physician in acute care, whether a cardiologist, an endocrinologist or anything else. I also have inpatient beds.When people come in through our admissions unit, they tend to filtered through to where specific expertise is required. People with diabetes problems, for example, tend to end up on our ward where we can provide more specialist care and provide quicker and better resolution of their problems.

The objective to get patients treated out of hospital and nearer to their homes has always been a priority, but the main problem is that the vast majority of acute admissions are elderly and have got multi-system pathology.That’s the main reason that they end up in hospital – a 30 year old with the same condition would probably be treated as an outpatient.There have been great changes within the health service and social services in recent years so that there are fewer beds and a greater onus on local authorities providing social care for people rather than the health service providing that care.

What prescribing decisions do you make as a secondary care consultant?

In my area of acute care, very few. Generally speaking, all of the prescribing decisions we make are via protocol, or patient pathway stuff.What is prescribed is virtually automatic.You can only prescribe things that are on the formulary because other things will not be stocked in the hospital.

Do you encounter medical representatives?

Yes, but they don’t tend to visit me in my office. Most of my encounters occur through my work on the prescribing committee, through the educational meetings we have.

What is this committee?

I am a member for my speciality of an interface formulary prescribing committee for my local area.This is essentially a committee that discusses which drugs are put on the formulary, across both primary and secondary care. I don’t sit on the committee unless there is anything relevant to our speciality, but when it is, I can influence what ends up on the formulary.

What is your general perception of medical representatives?

Personally, I’m not sure that medical reps are always the best route for information. Sometimes I find they are not knowledgeable enough about the wider subject – they know lots about their product and its indications, but can often be rather blinkered in their approach. As a member of the committee, people tend to approach you even more because they know that you can potentially influence things – as such, there’s an aspect that I can sometimes feel pestered by medical representatives. Generally, when representatives try to manufacture meetings on the offchance, bumping into customers in hospital corridors, you feel kind of trapped. Sometimes an invitation to correspond, via a letter or email, can help so that people don’t feel under pressure.

How could interaction with medical representatives improve to offer greater value?

There should be more liaison at pharmacy level.The pharmacists very much control these committees, in terms of the technicalities in the applications for new drugs. It is also important to emesh drug company involvement within a practice. For example, in our unit we used to have a meeting every week where a rep could come along and present what they wanted to do. This would be often look right across a therapeutic area and discuss the pros and cons of using the different drugs available – a lot of them don’t like doing that for obvious reasons.

What other advice would you offer representatives?

Do not underestimate the role of the GP. Most drug spending is done in the community and not in the hospital – often representatives fail to understand that. In my role, the GP is a vital stakeholder and sussing out what he/she is prepared to prescribe is imperative. PCTs and PBCs will fight tooth and nail to limit unnecessary prescribing, largely on the basis of cost. If I want to get a drug through onto a formulary, I will not achieve it without the support of local GPs.

What process do you go through to submit a new drug onto the formulary?

You have to fill out a form detailing the drug that you want, what evidence exists, what drug it would replace, its price and any other characteristics. That gets it to the meeting.Then you sit in a room with anything between five and 20 stakeholders – often GPs, PCT pharmacists, the Director of Public Health and representatives of the Acute Trust. You have to do a presentation about the drug, and then you’re cross-examined regarding it. It is subsequently debated before a decision is reached..

What does a drug need to demonstrate to make it through onto a formulary?

Primarily new drugs need to do something different to the current drugs available for a condition, in a way that will be of some benefit to a patient. If, for example, I try to push a diabetes drug onto the formulary, it will be because it increases diabetes control or control of cardiovascular risk factors – and will have benefits that outweigh the side-effects.That doesn’t necessarily benefit me – as an Acute Trust we want people to come into the hospital, as we get paid for that – but realistically, we want to see them as out-patients.That way we can sort them out in one go and recommend to the GP what to do. Ultimately, you want to do what is right for your patient. That is what all doctors should be doing – getting their patients onto what they believe is the right drug. Most of the time we are able to do that..

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