Prescribing decisions

Prescribing decisions are made in the majority of consultations. The use of safe, cost effective and appropriate drugs is the mainstay in the treatment of many chronic disease conditions. By using some of the exercises contained within this pack you should be able to demonstrate your prescribing behaviour and perhaps move forward in some areas.

Annual HB prescribing visit and report

Each year, practices are invited to sit down with their HB prescribing advisors and read and reflect on the annual practice prescribing report, discuss agreed actions from the previous year and agree more actions for the year ahead. The report contains information on prescribing within certain areas of interest to the HBs such as the use of antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs), the rates of use of drugs not favoured for their efficacy etc. and compares the results to the average for the HB area and Wales as a whole. Practices and individuals are encouraged to reflect on these results and plan action as necessary. The actions arising from the report and the agreed objectives chosen from a list of tasks proposed by the HBs will have implications for the appointed HB prescribing advisors, the practice as a whole, the prescribing lead GP (if one exists) and individual GPs where appropriate. Further prescribing information may be available from quarterly local prescribing meetings where representatives from practices are invited to attend and disseminate information back to their practices.

The Annual Practice Prescribing Report, annual prescribing meeting and quarterly update meetings may be used to examine the overall prescribing trends of your practice. A suggested template for this analysis is available here. Reflection on the report can be entered as an appraisal entry and the document uploaded as supporting documentation.

Annual Prescribing and Medicines Management Report
What were the agreed actions from last year’s meeting?
  1.  To review patients on hypnotics and introduce withdrawal schedules
  2.  To review patients on Buprenorphine patches against guidelines and switch where appropriate
  3.  To review patients prescribed ferrous sulphate and gluconate and switch to ferrous fumarate
What progress has been made?
  1.  On-going, reduction in some patients demonstrated
  2.  Completed, reduction demonstrated
  3. Completed, increase in ferrous fumarate and reduction in sulphate and gluconate
Any Further action required? Not all patients on hypnotics have been started on withdrawal regimes, this is ongoing and in hand. The prescribing advisors are working their way through the list. No further GP input needed.
Prescribing Management Scheme
What areas of the Prescribing Management Scheme were agreed for the practice last year?
  1.  Top 9 antibacterials as a % of antibacterials
  2.  Low acquisition cost (LAC) statins as a % of total statins and Ezetemibe
  3.  NSAIDs DDDs per 1000 Pus
What were the targets for these areas and how did the practice do?
Area Target for full payment Target for partial payment Points achieved
  Top 9 antibacterials   > 84.65%   80-84.64%   84.21
Low acquisition cost (LAC) statins   >95.29%   90-95.28%   91.97
NSAIDs   <1739.89   1739.9 - 3000   3202.94
Any Further action required? We were just outside the maximum points for antibacterial, just made the lowest payment for LAC statins and way off for NSAIDs. The latter has been an on-going issue for us and we seem to have a culture of prescribing these rather than suggesting patients buy their own. We will continue the progress made on the other two areas and expect the position to change on statins given that atorvastatin is now off patent and have all agreed to push over the counter (OTC) NSAIDs rather than prescribe.
National Prescribing Indicators
How did the practice perform in the National Prescribing Indicators?
We were positioned roughly mid way for most of the national indicators, which included the three agreed above. We were less than average for the following:   These results further shed light on our NSAID issue where we were not just higher prescribers of NSAIDs but also had a low rate of ibuprofen and naproxen prescriptions as a % of total NSAIDs. This means we are prescribing too much of drugs like diclofenac still which I’m aware carries a higher embolic risk than other NSAIDs. We also had a high PPI prescribing rate compared to most other practices and this may reflect our higher NSAID rate if being used appropriately for GI protection. Even so, reducing NSAIDs will then reduce PPI usage.   The statin that stopped us achieving the higher rate for LAC statins was rosuvastatin! – This will need looking into.   Finally, our triptans were higher than average and we all agreed to review our migraine management in line with current guidance.  
Any Further action required?
  1.  Agree a policy on NSAIDs
  2.  Review Olmesartan prescriptions
  3. Agree a guideline on migraine management
Agreed Actions For The Next Twelve Months
  1.  Repeat prescribing audit
  2.  Review patients on NSAID repeats and change to naproxen or ibuprofen s appropriate
  3.  Review patients on Minocycline as repeat and switch to suitable alternative
Will you have any personal involvement?
I volunteered to review patients on Minocycline and check their management against guidelines for acne and rosacea as appropriate. If patients will not come off it, I will check if they have had relevant blood tests where necessary and have had the potential side effects explained and recorded. I will then attempt to switch others where appropriate. In addition I will prepare a practice protocol for acne management, as this seems to be very variable within the practice. I will source this from the local dermatology guidance on the LHB portal and triangulate with evidence-based sources such as NICE, SIGN and TRIP database. We will then meet to agree it (or amend it) at a practice meeting. I plan to do this in the next 6 months and it will then be ready to discuss at my next appraisal as another piece of quality improvement evidence.



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