Dr Nigel Watson discusses how practices in his area have fared in meeting the challenges posed by the medicines management indicators
Medicines management is a significant part of the organisational indicators of the QOF 1 of the nGMS contract introduced in April 2004 (Table 1, below). The medicines management section accounts for 42 points, out of a total of 184 points available for the organisational indicators. For the average practice of 5891 patients this equates to approximately £5200, if all points are achieved in the medicines management section in 2005/6.
|Table 1: Organisational indicators for medicines management|
Details of prescribed medicines are available to the prescriber at each surgery consultation
The practice possesses the equipment and in-date emergency drugs to treat anaphylaxis
There is a system for checking expiry dates of emergency drugs on at least an annual basis
The number of hours from requesting a prescription to availability for collection by the patient is 72 hours or less (excluding weekends and bank/local holidays)
A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed four or more repeat medicines, standard 80%
The practice meets the PCO prescribing adviser at least annually and agrees up to three actions related to prescribing
Where the practice has responsibility for administering regular injectable neuroleptic medication, there is a system to identify and follow up patients who do not attend
The number of hours from requesting a prescription to availability for collection by the patient is 48 hours or less (excluding weekends and bank/local holidays)
A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines, standard 80%
The practice meets the PCO prescribing adviser at least annually, has agreed up to three actions related to prescribing and subsequently provided evidence of change
This article is a reflection of the issues relating to medicines management raised by individual practices and PCTs with the local medical committees (LMCs), in Wessex. Wessex represents approximately 3000 GPs,working in more than 450 practices, in 19 PCTs and three strategic health authorities.
This indicator states that details of prescribed medicines should be available to the prescriber at each surgery consultation. With the majority of practices using computerised medical records, this indicator has not been difficult to achieve.
One area of concern involves nurse prescribers within the practice – both district nurses and practice nurses can be accredited prescribers.2 On the grounds of clinical safety, all prescribers should have access to patients’ primary clinical records, whether these are paper or computerised records. One PCT in Wessex suggested that a practice had failed to meet this target because the district nurses did not have access to the practice computerised clinical records. As a result, the practice would fail to achieve the points in this area.
Under the new contract, the PCT is responsible for funding 100% of the IT system within a practice.1 After an appeal from the LMC, the PCT agreed that the lack of access to the computerised medical records was the responsibility of the PCT, not the practice, and awarded the points accordingly.
Medicines 2 and 3
To gain the points in the second category, you must have a list of drugs and equipment used for the management of anaphylaxis. These must be in date and there must be a system for checking expiry dates at least annually.
Practices should consider providing a box with all the drugs required for the treatment of anaphylaxis, together with a practice agreed action chart with drugs and doses listed. This should be kept in the treatment room,or in an agreed place known to all, and checked regularly by the practice nurses.
This was done in my practice and within two weeks a child was brought in with a severe allergic reaction to penicillin. I was very grateful for the easy access to all the drugs and a comprehensive chart with detailed lists of drugs, doses and advice.
Medicines 4 and 8
There have been no particular problems meeting indicators 4 and 8 if the practice has a system in place and ensures prescriptions are available within 2 working days.
An annual audit must also be performed that confirms this.
Medicines 5 and 9
Indicators 5 and 9 relate to reviewing medication – practices need to record when a medication review has taken place.
Medication reviews can be carried out by a GP, or appropriately trained nurse. If a patient is attending the nurse-run asthma clinic and is on asthma medication only, it is entirely appropriate for the nurse to review the medication.
Questions have been asked about what constitutes a review. The review does not need to be face-to-face, but does need to address both the medication and the clinical indication for which it is prescribed. The practice may find it easier to have a practice protocol to show to the QOF assessors.
An audit needs to be carried out on at least 50 patients to demonstrate that the 80% target has been met.
It is worth remembering that the QOF visits for 2005/6 are likely to be more clinically focused than last year, and practices will need to show robust evidence that they have met the criteria.
Medicines 6 and 10
Some practices have had great difficulty in arranging a meeting with the PCT prescribing advisor. If the PCT is unable to arrange a meeting, the practice should be credited with the points if it has agreed with the prescribing advisor up to three actions related to prescribing (indicator 6) and subsequently provided evidence of change (indicator 10).
Although improvements would generally be expected to be shown in all three areas, practices can still achieve this indicator if they can show they have good reason for not achieving improvements.1
The meeting with the prescribing advisor is to discuss prescribing in general as well as to agree up to three actions related to prescribing. Some PCTs have given a restricted list of actions for the practice to agree to, insisting that at least one is related to financial savings.
Most practices have no problems with the PCT suggesting a number of areas to be considered, but the choice lies with the practice – the PCT cannot insist that they are focused on making financial savings. The practice should also be given the opportunity to suggest some areas themselves.
Keep actions simple, achievable and relevant, as indicator 10 rewards practices for achieving the actions agreed.
If you are unable to reach an agreement, or think the PCT is being unreasonable, contact your LMC for help.
Indicator 7 has caused the most problems for Wessex. The indicator states "where the practice has responsibility for administering regular injectable neuroleptics, there is a system to identify and follow up patients who do not attend”.
The problem lies with the different ways PCTs have interpreted this statement. Some PCTs will credit a practice that has a policy and is prepared to administer injectable neuroleptics, even if they are not currently performing this service.
Other PCTs will reward a practice only if they have patients who are having the medication regularly administered for a significant part of the year, and exclude practices that prescribe neuroleptics which are administered by the community psychiatric nurse.
This indicator needs significant clarification during the review process of the QOF.
Prescribing is an important part of general practice. Most practices have gained maximum points in this area. Challenges have been met and it is essential that both practices and PCTs evaluate progress in this area and set some realistic goals for the future.
The QOF was agreed until 2006 and is currently under review to assess if any additions or amendments are required. It will be interesting to see if the medicines management module is broadened or modified.
- General Practitioners Committee. New GMS contract 2003. Supporting documentation. British Medical Association and the NHS Confederation. London 2003.
- www.dh.gov.uk/PolicyAndGuidance/ MedicinesPharmacyAndIndustry/Prescripti ons/NursingPrescribing/fs/en