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Small practices taking big steps - together

Improving prescribing across a group of small practices in the North Walsall Primary Care Group
Why was the initiative launched?
What was done?
Suitable targets for attention
Did it work?
Reducing variations across the PCG
Tips for success

Why was the initiative launched?

The move to create primary care groups prompted 25 mainly single-handed GPs in Walsall to propose that they should form one PCG. They saw few attractions in joining with larger practices without much in common with them. They were a stable group and all knew each other well. They thought that success would be more likely if they could show that they could work together to improve the quality of care for patients. They needed a focus for their efforts: aspects of prescribing seemed to be a promising area.

What was done?

Tom Dent, the clinical governance lead, started things rolling. The first step should be a meeting to debate possible topics. He wanted his fellow GPs to have an opportunity to have their say so chose not to present his own ideas. The aim was to achieve a consensus for action with ownership of the agenda rather than to sell a package of proposals. A work programme that could be monitored was a specific concern. Six of the twenty practices did not have IT systems so reliance on PACT data would be essential.

The meeting was held in February 1999 and was attended by about half of the GPs in the shadow PCG. The agenda included presentations by colleagues from local hospitals and the health authority on a range of topics. Cardiovascular, GI and mental health were addressed, as well as general prescribing issues such as the list of drugs of limited value identified by the Audit Commission. Evidence about the effectiveness of specific interventions was described. The challenge facing the group was illustrated by information about the variations across the practices in the PCG.

Suitable targets for attention

After the presentations, those present split into two groups to debate issues and identify themes for action. A range of issues was identified, including broad policy issues, such as the need for more information sharing across practices, the development of local guidelines and patient education. There was consensus that four specific prescribing issues merited attention:

A second meeting in April 1999 addressed the four specific prescribing issues in more detail and plotted a way forward. Dennis Ray, a lay member of the PCG, suggested that role-play could be used to illustrate the challenge of changing prescribing practices. This illustrated problems faced by a GP who was reluctant to prescribe the antibiotics demanded by an elderly patient. The meeting was well attended with all practices represented. The use of role-play was a success, and got over the message without lecturing.

GPs agreed to review their prescribing practices in the four areas. Targets would be set based on trends data available against a 1999 baseline. For example, the group agreed a target generic prescribing rate of 70% across the PCG as a whole. The targets would be followed up in two ways:

Did it work?

In a short time encouraging changes in the prescribing practices have become evident. There was significant progress towards the PCG targets (Table 1) allowing more challenging targets to be set for future years. Care is being taken to ensure that the targets are realistic. For example, there is doubt about whether a target of more than 75% for generic prescribing is sensible. This might be the ceiling. Further effort here might be counter-productive.

Table 1: North Walsall PCG - changes in prescribing

Prescribing Indicators Baseline Feb 1999 Performance 1999 v 2000 Target 1999 v 2000 Percent change 1999-2000
Generic rate 61% 70% 65% +9
Antibiotic items per 1000 STARPU 416 308 360 -19
Drugs of Limited Clinical Value cost (p) per PU 27 21 22 -22
Proton Pump Inhibitors prescribed as low dose* Not available 50% 40% +28
Prescribing indicators from the incentive scheme 1999/2000 (February 1999 – March 2000) taken from PACT data
Percent Change is based on prescribing performance from February 1999 to March 2000. Baseline taken in February 1999 and compared with data in March 2000)
* PPI data from June 1999 onwards.

Table 2: North Walsall PCG - illustrations of variations in prescribing

  Feb-99 Dec-99 Jun-00
Generic prescribing rates    
Lowest 42 49 61
Highest 74 74 75
PCG mean 64 66 70
Expenditure on drugs of limited clinical value (p)  
Lowest 0.04 0.05 0.03
Highest 0.50 0.43 0.44
PCG mean 0.27 0.23 0.20

Reducing variations across the PCG

Before the initiative was launched there were significant variations in prescribing across the PCG. There is particular satisfaction locally that these variations are narrowing (Table 2). All practices performed well overall. Some concentrated their efforts in certain areas and produced significant prescribing changes. The changes have been achieved by the GPs themselves without major external efforts to influence them. Engaging their interest, explaining the benefits and demonstrating the scale of local variations have been sufficient.

Some of the changes are quite dramatic:

For generic prescribing between February 1999 and June 2000
Dr A has increased the proportion by 47%
Dr B has increased the proportion by 28%

For antibiotic prescribing between June 1999 and June 2000
Dr B has achieved a reduction of 45%
Dr C has achieved a reduction of 26%

For drugs of limited clinical value between February 1999 and June 2000
Dr D has achieved a reduction in expenditure of 51%
Dr E has achieved a reduction in expenditure of 46%

For the use of low dose PPI between June 1999 and June 2000
Dr F has increased prescribing by 195%
Dr G has increased prescribing by 200%.

These changes have stimulated greater interest across the local GP community in prescribing issues. Discussion at the regular GP Forum is increasingly ambitious with GPs keen to explore other ways to improve the quality of the care they provide for their patients. Currently the use of blood tests and hospital referrals is being compared.

Tips for success

For more information contact

Dr Tom Dent, Pinfold Health Centre
Field Lane, Bloxwich, Walsall WS3 3JP
Telephone 01922 775135 Fax 01922 775132

Wing Koo, PCG Pharmacist/Prescribing Adviser
North Walsall PCG, Birchills Health Centre,
23 - 37 Old Birchills,Walsall WS2 8QH
Telephone 01922 614896 Fax 01922 625973


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