IRELAND 21 September 2018
Value for Money Examination 19: Prescribing Practices and the Development of General Practitioner Services Summary
Entitlement to State funded health care is divided into two categories. Category One provides entitlement to a means tested medical card under the General Medical Services (OMS) scheme with eligibility to a comprehensive range of health services free of charge, including general practitioner services and prescribed drugs and medicines. Category Two provides entitlement to public hospital services subject to statutory charges.
At 31 December 1996, the GMS scheme provided for the health care needs of 1.25 million people, representing 34.6% of the population, at a total cost of ?264.1 million. The cost of drugs and medicines prescribed under the GMS scheme has increased by over 100% in the ten year period to 1996, rising from ?63.9 million to ?130.3 million.
During a review of the scheme in 1990/9 1 the Department of Health and Children (the Department) and the Irish Medical Organisation (IMO) agreed that the level of prescribing cbuld be reduced without having an adverse effect on the quality of patient care. Following this review the Department and the IMO agreed to introduce an incentive scheme known as the Indicative Drug Target Scheme (IDTS), with effect from 1 January 1993, to encourage more rational and economic prescribing. The Department also agreed to establish a General Practice Development Fund which would also provide for investments in general practice.
In 1994 the Department published a Strategy document, which identified organisational and service problems in the health services. The steps to be taken to develop the service were set out in an action plan covering the period 1994 to 1997.
The examination focused on
- the steps being taken to promote more cost effective prescribing within the OMS scheme and to determine whether there is potential for further savings
- the extent to which the required improvements identified in the 1994 Strategy document have been implemented.
The Indicative Drug Target Scheme
The IDTS provides for the calculation of monetary prescribing targets for each General Practitioner (GP) taking into consideration the make-up of his/her patient panel. Savings from achieving the targets are apportioned between the doctors concerned and the health boards to be spent on specific improvements to practices and for the overall development of the service.
An analysis of the operation of the scheme showed that GPs who came in under target achieved savings of ?18.3 million over the four year period to 1996. GPs who exceeded their targets in the same period overspent by ? million. The analysis also revealed that only 5% of the 1,395 GPs who were continuously in the scheme over the four years achieved savings in each year while 27% did not achieve savings in any year.
Economy in Prescribing Practices
The choice of drug prescribed for each patient is the prerogative of the individual GP and will depend on the individual circumstances of each patient. However, in exercising this prerogative it is important for the GP to have regard to any economies which can be made which do not have a detrimental effect on patient care.
Data for five individual months (within the period January 1995 - May 1996) was acquired from the OMS (Payments) Board to establish the trend in prescribing costs and the scope for savings through more rational prescribing. Analysis of the data showed that the percentage of all items prescribed which were at their lowest possible cost increased from 10.41% to 14. 13% in the period. Prescribing in May 1996 was marginally more economical than in January 1995.
Examination of the May 1996 data indicated that the maximum possible savings achievable, if every item prescribed was at its lowest unit cost, would amount to ?0.46 million per month, equivalent to ?5.5 million per year. It is recognised that substitution is not feasible in all cases and that other factors would limit substitution in practice. While the trend in substitutions over the period January 1995 to May 1996 suggests that some progress has been made in substituting lower cost equivalent drugs, there is still clearly considerable scope for the achievement of further savings.
The analysis also showed that annual savings from the substitution of generic drugs for more expensive proprietary items could yield savings of over ?1.3 million based on replacing proprietary items with equivalent branded generic items while maintaining
the same level of prescribing.
The examination also identified the following areas where there was scope for further significant savings from alternative therapies which, while being more economic, would not compromise patient care.
- One example of a switch to a less expensive but equally effective first line treatment for depression showed potential annual savings of ?640,000.
- A minor shift in some expensive therapies for the treatment of stomach ailments would provide significant savings.
- In the absence of good scientific evidence as to their effectiveness, the continued use of mucolytics, which cost some ?700,000 annually should be reviewed.
- A switch to less powerful forms of antibiotics would have long term benefits in medical care and reduce costs. For example, a 10% change in prescribing amoxycillin could save over ?100,000 a year.
- The prescribing of medical foods, which cost over ?3.8 million in 1996, should be subject to regular review to prevent over prescribing.
Improvements in General Practitioner Services
Up to 31 December 1996, ?49 million and ?15 million, respectively, had been paid from the General Practice Development Fund and the IDTS towards the development of GP services. The efficiency and effectiveness of the developments have not been evaluated by the health boards. However, since March 1996 new projects are required to have inbuilt evaluation mechanisms, but it is too early to assess their effectiveness. Each health board should also carry out an overall assessment of its programme of investments and a review at national level should be considered by the Department.
In order to improve practice management and the sharing of information, the Strategy document set a target of 80% for the computerisation of GP practices by 1997 but only some 58% of practices had been computerised by February 1997.
The examination established that none of the health boards were receiving data on the incidence of illnesses from GPs because of a lack of resources in their public health departments. Moreover, a patient registration system has not been introduced, apart from a pilot project in the North Eastern Health Board. The absence of data from these sources works against better planning and effective delivery of the health
Therapeutic committees have been set up in all health boards with the primary purpose of bringing together GPs and hospital doctors/consultants to define and implement agreed therapeutic regimes for specific ailments. However, there have been difficulties in their operation, particularly in the area of communications between hospitals and general practice.
Health boards should ensure that arrangements are in place for the refund of the unexpired value of any publicly funded grant in the event that the grant-aided premises cease to be used for the grant aided purpose. Only two health boards have done so.