Levelling up on prescribing, acting on variations in prescribing practice and solving health inequalities have provided the NHS with an era-specific agenda

The presence of sharp, unwarranted variations in high-cost prescribing is hardly new, but how can pharma help the NHS to solve the conundrum? Drawing on a series of expert interviews with senior NHS practitioners, Wilmington Healthcare consultant, Jyotika Singh – herself a former pharmacist – looks at the key causes and what can be done about them.

Wilmington Healthcare has published its first ‘State of the Nation’ report on NHS prescribing patterns. Much of our analysis is focused on the impact of the pandemic, where we saw steep rises in the primary care prescribing of antidepressants and gastric drugs, and significant falls in some secondary care medicines due to restricted access to outpatient appointments – all of which highlight the extraordinary times we have lived through.

Yet, as a former practising NHS pharmacist, the report also pinpointed a more familiar and enduring issue; namely, the stark variations seen in prescribing costs across different parts of the country. At headline level, we found per capita spend on drugs ranged from over £400 per person in the highest spending regions, to just over £200 per person in the lowest spending regions.

Of course, there are factors behind this which are likely to be entirely benign – the demographic profile and disease patterns in some communities will naturally result in increased spend on high-cost drugs relative to other regions, for example. But the scale of difference also implies a degree of unwarranted variation that may put certain patients at a disadvantage.

This is borne out when we look in depth at our Specialist Shared Data (SSD), which allows us to see product usage across a number of Trusts at indication level over time. Analysis of one popular lung cancer molecule mapped out across 20 leading cancer centres reveals sharp differences in prescribing uptake by institution. Some Trusts with high numbers of patients saw low prescribing rates of the drug, while other centres with far fewer patients saw high rates of prescribing.

What is actually going on here? What lies behind these disparities and what should pharma companies be looking out for if they want to broaden access to new medicines?

Over the past month, I spent some time exploring this in depth with senior pharmacy colleagues from across the NHS, spanning both primary and secondary care roles. Few were surprised by the level of variation in practice, but our conversations helped to uncover the five most common determinants that may be contributing to it.

The first relates to personnel and specifically the presence of a senior high-cost drug pharmacist within the institution.

The practitioners we spoke to reflected that these are essential to forge the connections necessary to make changes happen. If you have, for example, a district general hospital within a hub-and-spoke model and they do not have a high-cost drugs pharmacist in place then they may find themselves disconnected from the secondary or tertiary care organisation that may be leading changes in prescribing practices. In effect, there is no driving force at the local level to negotiate and implement the adoption of novel medicines.

A second determinant – often closely linked to the first – is the presence and visibility of pharmacists at ICS level.

If a district general hospital is not present in discussions about clinical strategy, then this can also frustrate any momentum towards new prescribing practices. If there is no clear line of sight in terms of understanding the strategic context for commissioning and quality improvement plans, the institution may lack the corporate knowledge and savviness in terms of navigating the necessary processes to make change happen.

As a consequence, that institution’s prescribing regime might suffer in comparison with others that have more proactive, canny operators better able to negotiate a more positive outcome for their patients.

A third determinant – geography – can also play its part. The quirks of localism may mean it can simply be easier to implement certain things at certain sites depending on local custom and practice.

The relationship with commissioning authorities can be particularly important. One of the practitioners I spoke to described a situation where a Trust had one cohort of patients at a site facing towards one Clinical Commissioning Group (CCG) and another facing a second one.

Their experience of implementing drugs changes differed markedly as a result of the differences in commissioning behaviours. Of course, these in turn are often heavily influenced by the strategic priorities and financial parameters the NHS is working to within that footprint. Understanding the wider operational context within a system or locality therefore remains key.

The fourth determinant, meanwhile, is patient voice. The presence of informed patients with strong opinions and sharp elbows can be a further driver for action. Well-aimed, carefully argued complaints, in particular, have a habit of forcing an institution to justify its prescribing decisions or change them.

One of the big implications here is that mobilising patient representative groups can be a powerful avenue for industry to pursue. If pharma can be shown that there is significant, unwarranted variation in access to new drugs, then making these groups aware of this and providing them with compelling evidence to take forward can help them challenge decisions made by a local Trust.

Finally, a fifth determinant is the capacity and resource implications of administering a particular drug. This can manifest itself in different ways. In primary care, the choice of drugs may depend on whether it requires a doctor’s appointment or a transfusion in a hospital.

If the service has not been commissioned, agreed and paid for then a primary care network is unlikely to allow its adoption. Capacity issues in other parts of the system can be a limiting factor too: for example, in mental health, the use of certain antipsychotic medication can be limited by the availability of mental health teams to review patients for clinical side effects.

There was also a feeling that intravenous drugs were particularly vulnerable to postcode lottery-style variation because of capacity issues – in some hospitals, COVID-era infection control measures mean that the number of people allowed in infusion rooms is limited, particularly if ventilation flows into the room are weak.
While not a determinant in itself but amplifying all the others, there was a clear recognition that inequalities can sometimes beget inequalities.

In effect, communities that are particularly prone to health inequalities may also see these manifested in prescribing patterns. One of the aggravating factors can be digital capability: if prescribing of certain medications is only permitted via online methods then this can limit the ability of some groups to access these medicines. Another is a lack of patient advocacy – areas with the poorest health are often the least able to argue for the changes necessary to improve outcomes, including access to new medicines.

When so much of the NHS is focused on improving population health management and reducing disparities in health, it is vital that the anomalies within prescribing data are fully recognised, interrogated and acted on.

Once you move beyond the abstract data, what we’re ultimately talking about is a question of human dignity and equality; where you live should not determine how you are treated, but sadly too often it does in modern healthcare systems.

The latest reforms mean there is now a new momentum within the NHS to act decisively on these inequalities, and pharma can play a key role by exposing unwarranted variation in prescribing. In short, the time to speak up is now.

Jyotika Singh is a consultant at Wilmington Healthcare.
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