Co-proxamol, liothyronine and trimipramine illustrate a concerning phenomenon, where despite successful efforts to limit prescribing numbers, costs have risen sharply.
- Dr Ben Goldacre, University of Oxford
Despite a fall in prescription numbers for low-value treatments, the overall cost of prescribing these items in English primary care has risen, according to new research published by a team from Oxford University's EBM DataLab in the Nuffield Department of Primary Care Health Sciences.
NHS England has identified low-value treatments deemed to be ineffective, over-priced and of low clinical value, in order to increase value from the £17.4bn NHS medicines bill. The researchers found a strong association between general practices with a higher proportion of patients over 65 and low-value prescribing. They also found prescribing behaviour clustered by Clinical Commissioning Group (CCG), the NHS bodies responsible for planning and commissioning health care services in their local area.
The researchers, from the Nuffield Department of Primary Care Health Sciences, University of Oxford, assessed the current use of low-priority treatments identified by NHS England, their change in use over time and the extent and reasons for variation in prescribing. The research is published in the Journal of the Royal Society of Medicine.
In addition to the national results presented in the paper, the researchers also shared all data on prescribing at all individual NHS practices. This is published through an interactive website, OpenPrescribing.net, which can be used by GPs, local commissioners, and even patients, to see where there are possible savings opportunities for individual prescribers.
Lead researcher Dr Ben Goldacre, said: "There were almost one million fewer prescriptions for low-value items between July 2016 and June 2017, compared with the previous year. Despite the consistent downward trend in items, costs have risen, increasing by £4.5m when comparing 2016/17 with 2015/16.
The researchers found that while the cost per item has remained stable for most low-value treatments, for three items identified by NHS England, liothyronine (for hypothyroidism), trimipramine (an antidepressant) and co-proxamol (a painkiller), the cost has risen dramatically, by £73, £168 and £71 per prescription, respectively.
Dr Goldacre said: "Co-proxamol, liothyronine and trimipramine illustrate a concerning phenomenon, where despite successful efforts to limit prescribing numbers, costs have risen sharply." Giving co-proxamol as an example Dr Goldacre explained: "It's expensive because it was removed from the drug tariff, meaning that any prescriptions for it have to be sourced as a 'special' order. There is limited regulation of the cost of such special orders, making real world cost savings on such drugs difficult until there are a very small number of total prescriptions."
The researchers found that the strongest association with the level of prescribing cost at practice level was with the proportion of patients over 65, although they noted that this is perhaps not surprising given that older patients are generally more likely to receive prescriptions.
Commenting on the large degree in variation according to CCG, Dr Goldacre said: "This is likely to be due to differences in policy between different CCGs and practices, rather than clinical need."
Trends and variation in prescribing of low-priority treatments identified by NHS England: a cross-sectional study and interactive data tool in English primary care
Alex J Walker, Helen J Curtis, Seb Bacon, Richard Croker and Ben Goldacre
Journal of the Royal Society of Medicine. DOI: 10.1177/0141076818769408