Promoting cost-effective prescribing in the UK National Health Service

Pharmaceutical prescribing currently represents around 10% of total National Health Service expenditure, and is one of the most inflationary elements of spending (Parliamentary Office of Science and Technology 1993). Between 1980 and 1990, the overall cost of a prescription increased by 19%. Pharmaceuticals are one of the most commonly used and important interventions available to doctors in clinical practice, and their appropriate use can reduce mortality, morbidity and costs falling on other parts of the health care system. However, evidence from systematic reviews demonstrates that current prescribing may not always be effective or cost-effective (Effective Health Care, 1993). A number of policy initiatives have been introduced which attempt to contain prescribing costs. These include provision of Prescribing Analysis and Cost (PACT) data; the limited list; the indicative prescribing scheme and GP fundholding. However, these schemes have had limited impact and tend to focus on cost containment rather than cost-effectiveness in prescribing. Confusion remains concerning current knowledge and good practice in cost-effective prescribing. This confusion could be reduced with appropriate research making use, where possible, of the valid and reliable routinely collected activity data available on prescribing in the UK. In other countries, particularly Australia and Canada, policies have been introduced to limit the introduction of new drugs to those which demonstrate cost-effectiveness. Other countries, including European countries and the United States, are encouraging provision of economic evaluations of pharmaceuticals and have introduced varying initiatives to control prescribing costs and increase cost-effectiveness. UK policy initiatives should be informed by the experience of other countries. There is a considerable inertia in prescribing habits, and evidence of effectiveness and cost-effectiveness, when it exists, is not always used. A number of organisations are attempting to improve this situation. The NHS Centre for Reviews and Dissemination, at The University of York, produces and commissions systematic reviews of specific health-related questions, and disseminates these findings throughout the NHS. The Cochrane Collaboration, at the UK Cochrane Centre in Oxford and around the world, aims to produce systematic reviews of randomised controlled trials. The Cochrane Collaboration for Effective Professional Practice, an international collaboration with an editorial office at The University of York, conducts systematic reviews of initiatives aimed at changing professional behaviour. These and other organisations all attempt to improve the process of getting good evidence about health care interventions (including prescribing) into practice.