Excessive or inappropriate prescribing

Guidance for health professionals on prescribing NHS medicines

Improving the quality, cost effectiveness and affordability of prescribing in the context of the overall use of NHS resources is of benefit to patients.

The guidance provided here is designed to support those objectives and to guide all health professionals who prescribe and/or dispense NHS medicines, or who have responsibilities in practices, services, clinics etc. and in Primary Care Organisations (PCOs) for promoting appropriate, effective and efficient prescribing.

Comments on this guidance and suggestions for amendment should be addressed to NHS Employers or the General Practitioners Committee of the British Medical Association.

1. Introduction

1.1.The aim of this guidance is to outline and provide examples of what might be considered to be excessive or inappropriate prescribing.

1.2. It has been developed by NHS Employers and the GPC. It will be subject to subsequent discussion with the bodies representing the other professions who have or are being given prescribing rights through changes in legislation.

1.3. "Excessive prescribing" is defined within contractual regulations for GPs. GP practices can be in breach of their contract by "prescribing drugs, medicine or appliance whose cost or quantity, in relation to any patient, is, by reason of the character of the drug, medicine or appliance in question in excess of that which is reasonably necessary for the proper treatment of that patient (NHS General Medical Services Contracts Regulations 2004, Schedule 6, Part 6, Paragraph 46).

1.4. Any health professional believed to be prescribing excessively may be subject to challenge by their PCO and required to justify their prescribing behaviour. PCOs are authorised to -manage excessive prescribing under paragraph 46 of Schedule 6 to The NHS (General Medical Services Contracts) Regulations 2004, paragraph 44 of Schedule 5 to The NHS (Personal Medical Services Agreements) Regulations 2004 and Schedule 1, Part 4 of the Terms of Service of Pharmacists in the NHS (Pharmaceutical Services Regulations) 2005.

1.5. It is possible that potentially excessive prescribing will be identified in the first instance by the local PCO prescribing adviser. In the interests of developing good prescribing practice it is recommended that the initial approach to health professionals who are perceived to prescribe excessively should be by way of education. Appropriate remedial action should be instituted if the practice agrees that such action is warranted.

1.6. In the absence of an agreed course of action the PCO will need to consider whether there is sufficient evidence to demonstrate that the contractor's prescribing practice constitutes a breach of their contractual requirement (see paragraph 1.3 above). If there has been a breach of contract then the PCO will need to consider what action it wishes to take against the contractor. This might involve issuing a breach or remedial notice or invoking a contract sanction. If the contractor does not accept that they have breached their contract or that the PCO's action is appropriate it can challenge the PCO action by invoking the dispute resolution mechanism. The LMC may be involved as appropriate and must be involved where this is a requirement of the contract.

  2. Principles

2.1. NHS cash for prescribing is part of the wider resource available for the care of patients.

2.2. Professional guidance on standards of practice states that it is the responsibility of every prescriber to make efficient uses of the resources available (e.g. GMC Good Medical Practice). The GMC advises doctors that they have a responsibility to consider the impact of their actions, such as prescribing, on resources available to other patients; it also states that doctors must not deliberately withhold appropriate treatment. Judgement of excessive or inappropriate prescribing by any health professional will need to reflect the balance between these duties.

2.3.As a guiding principle it is appropriate to prescribe the most cost effective medication for a patient. It follows that switching patients to less expensive drugs usually within a therapeutic class is generally appropriate where there is no contra-indication and where there is evidence of equal or greater efficacy. This may release cash within the system that can be invested in additional and different care for patients. Patients should be informed of the rationale for these changes, for example via patient information handouts.

2.4. Switching significant numbers of patients' drugs within a therapeutic class (e.g. either by changing to brand or by changing the drug) should only be undertaken where the predicted NHS savings is expected to be sustained and provided there is no clinical disadvantage for the patient.

2.5.There may be occassions where switching patients may be clinically inappropriate e.g. in line with BNF or MHRA guidance certain drugs should be prescribed by brand to ensure continuity with regard to bio-availability.

2.6. It is appropriate that doctors and health professionals have the clinical freedom to switch individual patients to higher priced drugs (branded or otherwise), or to alternative drugs, for clinical reasons.

  3. Due Process

3.1. PCOs are recommended to demonstrate due process e.g. that the development of prescribing incentive or improvement schemes are supported by appropriate processes involving local clinicians, and that the process of developing and implementing such schemes is evidence-based and appropriately documented. Where practices are expected by PCOs to change prescribing practice to improve the quality and/or cost-effectiveness of prescribing, or to make prescribing budget savings, PCOs are recommended that information about the rationale behind such prescribing changes should usually be available for patients, e.g. from the PCO prescribing advisory group.

3.2. Similarly, prescribers and dispensers should also demonstrate due process e.g. it is reasonable and appropriate for health professionals to exercise wise buying in the purchase of drugs from wholesalers and manufacturers. This acts as a driver for manufacturers and suppliers to reduce prices which in turn reduces the NHS drugs bill via the discount claw back systems that apply to dispensing doctors and community pharmacy.

3.3. However, other than as outlined in 3.2, substantial sponsorship or financial deals that could reasonably be perceived to affect the choice of treatment in a way that is financially beneficial to the prescriber but significantly increases NHS costs, other than where there is clear evidence of clinical benefit to patients, should be recorded in a register of "Gifts and Hospitality".

  4. Examples that may be judged to indicate excessive prescribing

4.1. The following examples illustrate behaviours that may be judged to indicate excessive or inappropriate prescribing, particularly where this has been done for a significant proportion of patients and/or in a systematic manner by health professionals or their staff:

·        prescriptions where the drug is initiated or switched, e.g. within a therapeutic class/indication, with the effect that reimbursement is based on a product that provides a larger purchase margin for the prescriber(s) and the product(s) selected cost the NHS more, unless there is good clinical evidence to support the switch or the exceptions noted in paragraphs 2.5 or 2.6 apply

·        prescribing that is varied according to the impact on reimbursement to the practice, e.g. differences between patients to whom the practice directly supplies medicines (including personally administered drugs and through NHS dispensing) and those to whom they supply prescriptions for dispensing elsewhere, and where the prescriber(s) is/are unable to provide a reasonable explanation

·        profligate prescribing may be considered to exist where the prescriber(s) consistently prescribes excessive amounts of high cost products or inappropriate, high quantities of medicines that are significantly at variance with comparable clinical scenarios and where the prescriber(s) is/are unable to provide a reasonable explanation

it may also be appropriate for a PCO to investigate a prescriber that consistently significantly under-prescribes where there is evidence to suggest that there is a failure to adhere to good clinical prescribing practice.