Primary Care Prescribing

REPORT BY THE COMPTROLLER AND AUDITOR GENERAL

27 November 2014

Published 27 November 2014

This report is being published under Article 8 of the Audit (Northern Ireland) Order 1987 for presentation

to the Northern Ireland Assembly in accordance with Article 11 of that Order.

K J Donnelly Northern Ireland Audit Ofﬁce

Comptroller and Auditor General 27 November 2014

The Comptroller and Auditor General is the head of the Northern Ireland Audit Ofﬁce employing some

145 staff. He and the Northern Ireland Audit Ofﬁce are totally independent of Government. He certiﬁes

the accounts of all Government Departments and a wide range of other public sector bodies; and he

has statutory authority to report to the Assembly on the economy, efﬁciency and effectiveness with which

departments and other bodies have used their resources.

For further information about the Northern Ireland Audit Ofﬁce please contact:

Northern Ireland Audit Ofﬁce

106 University Street

BELFAST

BT7 1EU

Tel: 028 9025 1100

email: info@niauditofﬁce.gov.uk

website: www.niauditofﬁce.gov.uk

Primary Care Prescribing

Contents

Executive Summary 1

PART 1: Background and Scope of Report 7

In Northern Ireland, the Health and Social Care Board contracts external

providers to supply pharmaceutical services to the public 8

In 2013 community pharmaceutical services cost £460 million and CPCs

dispensed almost 39 million prescription items 8

High level comparison of the number and cost of prescriptions elsewhere in

the United Kingdom indicates that there is potential for improving cost effective

prescribing in Northern Ireland 9

Purpose and Scope of our review 14

PART 2: Community Pharmacy Contractors’ Reimbursement 15

Over time, the number of pharmacy outlets in Northern Ireland has risen while

the number of CPCs has fallen 16

Northern Ireland CPCs dispense more prescriptions per head of population

than those in England and Scotland 17

In 2012-13 CPCs received £460 million for providing community

pharmaceutical services 18

Reimbursement costs are the most signiﬁcant element of the funding package 19

The majority of reimbursement costs each year relate to ‘branded’ drugs 19

NI reimbursement rates for dispensing certain ‘generic’ drugs were based

on the Scottish Drug Tariff but this led to legal challenge 19

The legal action has cost the Department £550,000 CPCs received

compensation of some £6 million. A further £40 million was made available

to CPCs over the seven year period to 2011 23

Part 3: Trends in General Practitioner (GP) Prescribing Practice 25

The volume of prescribed drugs has increased at a steady rate over recent

years but costs have fallen substantially since 2010 27

Primary Care Prescribing

Contents

There have been a range of inﬂuences which have helped to contain the

cost of primary care prescribing 29

HSC Board Medicines Management Advisors have been instrumental in

ensuring prescribing efﬁciencies are generated 30

British National Formulary (BNF) 31

The use of an ‘unclassiﬁed’ category prevents comprehensive analysis

of prescribing patterns 33

Variations in regional prescribing rates which cannot be fully explained by

differences in population demographics suggests that it may be possible to

improve the quality of prescribing further 35

Part 4: The Scope for More Efﬁcient and Effective Prescribing 39

The Department, HSC Board and GPs are to be commended for the savings

generated from improving the rate of generic prescribing 41

There is wide variation in the cost of prescribing per head of population

across individual GP practices locally 42

There is scope to make further savings from prescribing without affecting

patient care 44

Earlier switching to cheaper generic stomach acid treatments (Proton Pump

Inhibitors (PPI)) would have resulted in additional efﬁciency savings of

£2.2 million in 2012 and £1 million in 2013 45

Switching to less expensive statins would have saved around £2.7 million

in 2012 and £2.5 million in 2013 47

Earlier switching to alternative generic drugs in the treatment of depression

would have resulted in additional efﬁciency savings of £2.7 million in

2012 and £1.6 million in 2013 51

More money is spent prescribing Pregablin in NI than on any other drug.

Pregablin is more frequently prescribed in NI than elsewhere in the UK 55

Appendices 59

Appendix 1: Generic Drug Categories 60

Appendix 2: Legal challenge to new Drug Tariff 61

Primary Care Prescribing

Abbreviations

ABPI Association of British Pharmaceutical Industry

APP Annual Professional Practice Allowance

BNF British National Formulary

BSO Business Service Organisation

CoSI Cost of Service Investigation

CPC Community Pharmacy Contractor

CPNI Community Pharmacy Northern Ireland

DHSSPS Department of Health, Social Services and Public Safety

GMS General Medical Services

GP General Practitioner

HSC Health and Social Care

HSCB Health and Social Care Board

JR Judicial Review

LDL Low Density Lipoprotein

MMA Medicines Management Adviser

NAO National Audit Ofﬁce

NHS National Health Service

NI Northern Ireland

NIAO Northern Ireland Audit Ofﬁce

NICE National Institute of Health and Clinical Excellence

PCC Pharmaceutical Contractors Committee

PCEP Pharmaceutical Clinical Effectiveness Programme

PIS Prescibing Incentive Scheme

PPI Proton Pump Inhibitor

PPRS Pharmaceutical Price Regulation Scheme

PU Prescribing Unit

QOF Quality and Outcomes Framework

RIA Regulatory Impact Assessment

UK United Kingdom

WTE Whole Time Equivalent

Primary Care Prescribing

Contents

Glossary of terms

Association of British

Pharmaceutical

Industry (ABPI)

Represents biopharmaceutical companies and is recognised by government

as the industry body negotiating on behalf of the branded pharmaceutical

industry for statutory consultation requirements including the pricing scheme for

medicines in the UK.

British National

Formulary (BNF)

A joint publication of the British Medical Association and the Royal

Pharmaceutical Society. It aims to provide prescribers, pharmacists, and other

healthcare professionals with sound, up-to-date information about the use of

medicines.

Community Pharmacy

Contractor (CPC)

Dispenses health service prescriptions after application and acceptance

onto the Health and Social Care pharmaceutical list. Applications can be

made by registered pharmacists or non-pharmacists, partnerships or bodies

corporate, as long as a registered pharmacist is employed.

The Comprehensive

Spending Review

(CSR)

The Comprehensive Spending Review sets out the Government’s objectives

and priorities and allocates resources accordingly.

Cost of Service Inquiry

(COSI)

Identiﬁes and quantiﬁes the various NHS costs involved in delivering

community pharmacy services.

Generic drugs

A pharmaceutical product no longer protected by a patent which can be

copied by other companies. It may be marketed either under its own brand

or as an unbranded product. Generic drugs are frequently as effective as,

but much cheaper than, brand-name drugs, because their manufacturers do

not incur the risks and costs associated with the research and development of

innovative medicines.

Generic Prescribing

Current policy is that generic medicines should be prescribed in all

appropriate circumstances. It is considered that around 75 per cent of

medicines can be dispensed generically.

Judicial Review

A process by which the courts review the lawfulness of a decision made (or

sometimes lack of a decision made) or action taken (or sometimes failure to

act) by a public body. A judge considers whether a public body has acted in

accordance with its legal obligations and if not, can declare a decision taken

by it invalid.

Local Commissioning

Groups (LCGs)

There are ﬁve Local Commissioning Groups in Northern Ireland (Belfast,

Northern, South Eastern, Southern and Western). LCGs are committees of the

Health and Social Care Board and are responsible for commissioning health

and social care for their local population. They also have responsibility for

planning and delivering health and social care to meet assessed needs.

Primary Care Prescribing

Medicines Management

Advisers (MMAs)

Pharmacists employed by the Health and Social Care Board who work

with GP surgeries in order to support the safe effective and efﬁcient use of

medicines in primary care.

Prescription Item

A medicine, appliance or device written by a practitioner onto an appropriate

prescription form.

National Institute

for Health and Care

Excellence (NICE)

An executive non departmental public body of the Department of Health in

the United Kingdom. NICE provides guidance on current best practice in

health and social care, including public health, to the NHS in England and

Wales. All NICE guidance published since 1 July 2006, is reviewed locally,

for its applicability to Northern Ireland and, where applicable, is endorsed

for implementation.

Community Pharmacy

Northern Ireland

(CPNI)

The local representative body for community pharmacist contractors provide

services under the National Health Service in Northern Ireland. It negotiates

on services, the pharmacy contract and remuneration and reimbursement

with the Health and Social Care Board and the Department of Health, Social

Services and Public Safety.

Pharmaceutical

Clinical Effectiveness

(PCE)

A systematic approach to rational product selection and use, consistently

applied across secondary and primary care, taking account of clinical

need, evidential product clinical performance, product presentation, safety

characteristics and economic factors. The process can be applied to

medicines, wound care and medical and surgical disposable products.

Pharmaceutical Price

Regulation Scheme

(PPRS)

A non-contractual, 5 year, voluntary scheme between UK Government and

Industry covering all the relevant key issues that underpin the pricing of the

majority of NHS branded medicines.

Northern Ireland

Prescribing Units

(NI-PU)

Weight individual General Practitioner (GP) practices or Local Commissioning

Groups’ populations for age, gender and need to enable comparison of

prescribing patterns. The ﬁgures are based on cost of prescribing across all

therapeutic areas. The cost based weightings are standardised (based on a

female aged 5-15). Comparisons can therefore take account, for example, of

the greater needs of elderly people and of people living in deprived areas or

whose socio-economic circumstances mean they have higher than NI average

need for prescribing resources.

Regulatory Impact

Assessment (RIA)

A detailed and systematic appraisal of the potential impacts of a new

regulation. New regulations should only be introduced when other

alternatives have been considered and rejected and where the beneﬁts justify

the costs.

Executive Summary

1. Most health service drug expenditure is

incurred in primary care where General

Practitioners (GPs) prescribe medicines

or treatments to address the clinical

needs of patients. The role of GPs in

deciding how resources should be spent

on these drugs is, therefore, key. Patient

consultations with GPs have increased

by almost 22 per cent over the six year

period to 2013-14. The trend in rising

patient consultations with GPs is likely to

continue due to the following drivers:

• Like all UK regions the population of

older people is increasing

;

• Poor lifestyles are a threat to

population health particularly in

lower socioeconomic groups;

• Overuse, sub optimal use and abuse

of prescription medicines; and

• Pharmaceutical innovation and

medical advances.

2. Decisions on which medication or

treatment is prescribed rests with the

GP and these decisions are highly

regulated and controlled. However,

patients’ requests and expectations

(and prescribers’ perceptions of these)

2 Primary Care Prescribing

Executive Summary

can inﬂuence prescribing behaviour.

Further, the decision on whether or not

to consume prescribed medication rests

with the patient.

3. Once in receipt of a prescription,

the patient takes it to a Community

Pharmacy Contractor (CPC)

. The

CPC dispenses the drug in question,

currently at no charge to the patient.

CPCs are responsible for purchasing the

drugs either directly from manufacturers

or through wholesalers. They are

subsequently reimbursed by the Health

and Social Care (HSC) Board for the

cost of these drugs.

4. In 2013 CPCs received almost

£460 million for providing community

pharmaceutical services, which included

reimbursement

of £381 million for

dispensing almost 39 million items

prescribed by GPs.

5. This report demonstrates that demand for

primary care medicines is characterised

by a particularly complex and unique set

of relationships, in which:

• Patients neither decide nor directly

pay (currently) for the medicines they

consume;

1 Ofﬁce of National Statistics, National Population Projections, 2012-based Statistical Bulletin

2 The Health and Social Care (HSC) Board is legislatively required to make arrangements for the provision of community

pharmaceutical services in Northern Ireland. In practice, it contracts out these services to Community Pharmacy Contractors

(CPCs). In 2014, the HSC Board had contracts with 225 CPCs who dispensed prescriptions from 535 pharmacies.

According to Ofﬁce of Fair Trading (Evaluating the Impact of the 2003 OFT Study on the Control of Entry Regulations in the

Retail Pharmacies Market (March 2010)); NHS Information Centre, (General Pharmaceutical Services in England, 2001-

2002 to 2010-2011 (November 2011)), the combined share of this market among the larger multiples and supermarkets

is now estimated to be slightly over 50 per cent.

3 Traditionally arrangements for reimbursing NI CPCs followed those in place elsewhere in the UK. However, new contractual

arrangements which were adopted in England, Wales and Scotland were rejected by NI CPCs and they subsequently

legally challenged the continued reliance on the UK Drug Tariff in NI. The legal challenge was upheld. Subsequent

negotiations failed to ﬁnd a resolution and NI CPCs again took legal action. Again the legal challenge was upheld. No

resolution has yet been found and negotiations continue.

Primary Care Prescribing 3

• GPs decide which medicines should

be used but are not responsible

for the cost of what they prescribe;

whereas

• the HSC Board pays for medicines

by reimbursing pharmacies

for dispensing them but is not

responsible for deciding which

medicines are to be prescribed.

6. Against the background of these

relationships, the main thrust of this report

is that more rational prescribing by

GPs can achieve signiﬁcant economies

in drug expenditure and release

money from within the drugs budget

without compromising patient care. It

is acknowledged that between 2006

and 2013, the cost of prescribing was

reduced in real terms by 18 per cent.

7. As the drugs budget is spent

predominantly by GPs, the HSC Board

does not directly control prescribing

behaviour. Moreover, the prescribing

decisions GPs make can be affected

by a range of factors, such as patient

need, clinical guidance, access to good

information and the marketing activities

of the pharmaceutical industry

. A key

challenge for the Board, therefore, is

to effectively inﬂuence the prescribing

behaviour of GPs.

8. We acknowledge the key role played

by the Board’s Medicine Management

Advisers (MMAs) in instigating and

facilitating change through the promotion

of more rational, safe, economic

and effective prescribing among GP

practices. While MMAs have little

power to compel doctors to prescribe

in a particular way, they have had

considerable success in working

alongside GP practices to facilitate

change and generate savings in the

prescribing budget. For instance, while

the volume of prescriptions increased

by around 5 per cent between 2010

and 2012, the cost of prescribing these

drugs has decreased by just over 7 per

cent in the same period. Commendably,

one of the reasons for the reduction in

costs is that generic prescribing rates

have improved considerably in NI over

recent years and are now on a par

with levels elsewhere in the UK. Also,

the variations between practices have

reduced signiﬁcantly over the period

2010 to 2013.

9. The report draws particular attention to

the continuing variations shown by data

on prescribing activity and prescribing

expenditure, both between GP practices

locally and with their peers in other

parts of the UK using national data. We

found variations in the volumes and cost

of prescribing which did not appear to

match variations in indicators of clinical

need, such as disease prevalence.

The HSC Board regard Quality and

Outcomes Framework (QOF) data on

disease prevalence as extremely useful

4 House of Commons Health Committee, The Inﬂuence of the Pharmaceutical Industry, 5 April 2005.

4 Primary Care Prescribing

Executive Summary

for assessing clinical need and planning

service development. However, the

Department considers that the use of

QOF data in reaching any conclusion

on relative need between populations

is erroneous. It told us it had been

advised by the Northern Ireland Statistics

and Research Agency and the Health

and Social Care Information Centre in

England that QOF data is unsuitable as

a measure of need in this context. Our

report stresses the importance of the

HSC Board and GPs using all available

sources of relevant data to support

the benchmarking of GP practices in

identifying prescribing patterns which are

signiﬁcantly different between peers and

which warrant further examination.

10. We acknowledge that high-level

prescribing cost comparisons with the

other UK regions have to be drawn with

great caution. In the Department’s view,

such comparisons are deeply ﬂawed

given the differences in data deﬁnitions

and prescribing practices within the

jurisdictions. However, available national

statistics would suggest that if prescribing

expenditure here had been in line with

that in Wales in 2013, costs would

have been reduced by £73 million.

The Department does not accept that

these statistics are a measure of relative

efﬁciency and would not support the

view that costs could be reduced by

£73 million, as in its view, the statistics

do not compare jurisdictions on a like for

like basis.

11. More pertinent are the large variations

we found in prescribing costs between

local GP practices after standardising

their caseloads, meaning that there

is scope for GP practices to improve

efﬁciency, without affecting clinical

outcomes. As a result, we estimated

that, in 2013, potential savings of £19

million could have been realised if all

GP practices had achieved at least the

standard of the average practice. We

recognise that it will be challenging for

GPs to achieve all such potential savings

given that the savings need to be made

across a wide range of prescribed

drugs. The department has commented

that such estimates are crude and do not

take into consideration the other factors

associated with prescribing such as

access to other services; the impact of

cross-border workers; private healthcare.

The Department considers that there

will always be a degree of variability

between GP practices and therefore the

full quantum of such efﬁciencies will not

be realisable.

12. We also examined three groups of drugs

used to treat conditions for which there

are several suitable drugs available

at differing prices. We found large

variations in the extent to which local GP

practices prescribed lower cost drugs in

comparison to GP practices in the rest

of the UK. We also examined use of the

drug which has incurred the highest cost

in NI in the last number of years. We

calculated that the opportunity cost to

health and social care services here of

Primary Care Prescribing 5

not meeting UK levels was £17 million in

2012 and £15 million in 2013.

13. Potential economies may also be

achievable in other areas. For example,

research published in England estimated

that NHS primary and community care

prescription medicines waste cost £300

million. This indicates that an estimated

£18 million may be lost every year in

Northern Ireland in wasted prescriptions.

However, we have been advised

by the Department that while there is

potential waste, the interventions needed

to address this issue would offset the

potential savings. It is also important

to note that this is not in addition to the

monies referred to above. There may

also be potential for generating further

savings by reducing the number of

prescriptions for drugs of limited clinical

value or drugs which are not clinically

necessary. In this report we looked at

the potential for generating savings

by moving from off-patent branded

medicines to much cheaper generic

equivalents.

6 Primary Care Prescribing

Executive Summary

Part One:

Background and Scope of Report

8 Primary Care Prescribing

Part One:

Background and Scope of Report

In Northern Ireland, the Health and

Social Care Board contracts external

providers to supply pharmaceutical

services to the public

1.1 The Health and Social Care (HSC)

Board

is legislatively required to

make arrangements for the provision of

community pharmaceutical services in

Northern Ireland. These services include

dispensing those drugs prescribed

by General Practitioners (GPs)

. In

practice, it contracts out these services

to independent, retail pharmacy-outlet

owners (known as Community Pharmacy

Contractors (CPCs)).

1.2 CPCs can be registered pharmacists,

non-pharmacists, partnerships or bodies

corporate (providing a registered

pharmacist is employed in each

pharmacy outlet). In 2014, the HSC

Board had contracts with 225 CPCs

to provide community pharmaceutical

services from 535 pharmacies.

1.3 In 2014, 51 per cent of NI Pharmacies

were small independent businesses, 30

per cent operated in local partnerships

and the remainder, 19 per cent, formed

part of UK or multi-national groups.

In 2013 community pharmaceutical

services cost £460 million and

CPCs dispensed almost 39 million

prescription items

1.4 In Northern Ireland, in 2013, almost

39 million items prescribed by GPs,

were dispensed by CPCs. That year,

funding to CPCs for providing community

pharmaceutical services amounted

to £460 million. This represents

approximately 10 per cent of the total

spend on health and social care in

Northern Ireland.

1.5 Research published by York Health

Economics consortium in An Evaluation

of the Scale, Causes and Costs of Waste

Medicines reported that in England NHS

primary and community care prescription

medicines waste cost £300 million.

This indicates that a level of £18 million

may be lost every year in Northern

Ireland in wasted prescriptions

. This

estimate reﬂects patients’ failure to take

appropriate medicine which in turn

impacts on:

• the patient – who may not see an

improvement in their condition or

whose health may deteriorate;

5 Under Article 63 of the Health and Social Services (NI) Order 1972.

6 GPs are medically-qualiﬁed doctors with responsibility for attending to the everyday medical needs of a community. They

operate in the primary care sector. In Northern Ireland, the term ‘primary care’ refers to any of ‘the many forms of health

and social care and/or treatment accessed through a ﬁrst point of contact provided outside hospitals’. Treatment provided

in a hospital setting is referred to as ‘secondary care’.

7 NI Direct website – Health and Well-being.

Primary Care Prescribing 9

• the HSC Budget – which could

re-direct resources within the HSC

sector; and

• the pharmaceutical industry –

which may struggle to prove the

effectiveness of new and innovative

drugs through post-marketing

surveillance.

1.6 Since 2010-11, the Department and the

Health and Social Care (HSC) Board

ran an annual ‘Don’t Use It, Don’t Order

it’ prescriptions medicines wastage

advertising campaign. In 2013-14, the

campaign included a new message

‘Wasting Medicines Wastes Money’

with the aim of inﬂuencing patients’

attitudes and behaviours to prevent

over-ordering of repeat prescription

medicines.

1.7 However, we have been advised

by the Department that while there is

potential waste, the interventions needed

to address this issue could offset the

potential savings. Since a proportion of

medicines waste is therefore inevitable,

complementary measures which improve

the quality and safety of prescribing are

required. We welcome the introduction

of such initiatives which have the

potential to reduce expenditure.

High level comparison of the number

and cost of prescriptions elsewhere

in the United Kingdom indicates that

there is potential for improving cost

effective prescribing in Northern

Ireland

1.8 The number of items prescribed has

increased in each region of the United

Kingdom (UK) over the seven year

period to 2013. Figure 1 shows that

Wales has consistently prescribed more

items per head of population that any

other UK region. Prescribing levels in NI,

although lower than those in Wales have

been higher than levels in England and

Scotland in each of the last seven years.

Levels in England and Scotland are very

similar.

10 Primary Care Prescribing

Part One:

Background and Scope of Report

Figure 1: Number of items prescribed per head of population in the UK over the period 2007-2013

Source: Business Services Organisation – Prescription Cost Analysis Reports

1.9 Figure 2 compares the cost of

prescribing per head of population in

England, Scotland, Wales and NI over

the seven year period to 2013. Overall,

England has consistently had the lowest

cost per head of population in each

year since 2007. There are, of course,

regional variations across England.

For example, the number of items

prescribed per head of population in the

North East of England is 50 per cent

greater than the number in the South of

England. Costs in Scotland and Wales

are broadly similar, higher than those

in England but less than those in NI.

NI has had the highest cost per head

of population since 2007 and is the

only region in which costs per head of

population are higher in 2013 than they

were in 2007.

2013201220112010200920082007

Number of items per person

England

Northern Ireland

Scotland

Wales

8 Mid year population ﬁgures for 2012 were used as the 2013 population statistics were not available at the time of

publication.

Primary Care Prescribing 11

Figure 2: Prescribing cost per head of population

Source: Business Services Organisation – Prescription Cost Analysis Reports

100

150

200

250

2013201220112010200920082007

Cost per head of population £

England Wales Northern IrelandScotland

2007 2010 2013

£221.09 £243.94 £223.54

England

£162.95 £167.82 £160.12

Scotland

£187.92 £192.25 £183.73

Wales

£196.37 £193.05 £182.96

12 Primary Care Prescribing

Part One:

Background and Scope of Report

1.10 It is important to remember that this

form of high level analysis, while

demonstrating trends over time, does

not take account of deﬁnitional or

organisational differences across

regions. However, using these

comparative statistics as a very basic

measure of relative efﬁciency, the

variation in prescribing costs here

compared with other UK countries

provides some evidence that it is

possible for local GPs to prescribe less

expensively. For example, if prescribing

costs had been in line with those in

Wales in 2013, overall prescribing

costs could have been reduced by £73

million.

1.11 The Department does not accept that

these statistics are a measure of relative

efﬁciency across the UK and would not

support the NIAO view that costs could

be reduced by £73 million if prescribing

costs here were in line with Wales. In

its view, the statistics do not compare

jurisdictions on a like for like basis: for

example, the Department told us that

they do not take account of variations

in the ratio of community to hospital

prescribing that exist across jurisdictions.

In England in 2012, 63.5 per cent of

total medicines expenditure took place in

the primary care setting, the comparable

ﬁgure here was 72.7 per cent.

1.12 We acknowledge that prescribing

arrangements can differ between the

four countries: for instance, outpatients

who are prescribed drugs by consultants

here will have that prescription ﬁlled out

by their GP; in England, by contrast,

such a prescription will be dispensed by

the hospital and therefore will not be a

charge on the primary care budget.

1.13 As a result, we recognise that it

will be important to account for the

precise differences in the prescribing

patterns of GPs here when comparing

them with elsewhere in the UK. This

basic comparison, which is based on

published data, points up the need

for a comprehensive examination of

the cost implications of prescribing in

order to explore and implement speciﬁc

measures to promote more cost-effective

prescribing patterns among local GP

practices. Our study looks in more detail

at this in Part 4.

1.14 In addition to variations in prescribing

arrangements, the higher cost of

prescribed medicines in primary care in

Northern Ireland is due to, for example:

• progress in achieving savings

through generic, rather than

branded, prescribing has been

slower here than elsewhere in the UK

(see paragraph 4.5);

Primary Care Prescribing 13

• unlike the other UK regions, the

introduction of new drugs was not

as tightly controlled here, therefore

the prescribing of newer, and usually

more expensive drugs (including

generics) can be more widespread

in NI; and

• secondary care (hospital) prescribing

practice has more impact on GP

prescribing practices in NI than

elsewhere in the UK .

The Department has advised us that

it does not accept the ﬁnal two bullet

points.

1.15 The Department told us that prior to

2004, the approach taken to reducing

medicines expenditure had been to

focus on the costs and seek to deliver a

range of cost cutting initiatives. However

an exclusively ﬁnancial focus can have

far reaching consequences in respect

of quality, safety and well being of

patients. This has been borne out in

recent times in the Francis Report into the

Mid -Staffordshire Trust. A sole ﬁnancial

focus in the management of medicines

has only limited success and does not

address the challenge of optimising

the outcomes for patients through the

use of prescribed medicines. Since

2004, medicines optimisation policy in

Northern Ireland has been predicated

on quality and safety improvement

delivering improved health outcomes and

realised efﬁciencies. Such an approach

addresses value for money requirements

in addition to important medicines

optimisation principles including:

• Rationality Attention to the

evidence base for the prescribing of

medicines;

• Safety Address avoidable

medication related errors and

adverse incidents;

• Individuality Optimise outcomes for

individual patients;

• Equity Ensuring equality of provision

across the population, therapeutic

conditions and new medicine;

• Consistency Prescribing practice that

conforms to acceptable standards;

• Continuity Optimised medicines

outcomes across sectors and

professional groups; and

• Innovation Removing barriers to

continuous quality improvement.

14 Primary Care Prescribing

Part One:

Background and Scope of Report

Purpose and Scope of our review

1.16 This report looks at the value for money

of primary care drugs prescribing and

dispensing:

• Part 2 considers the arrangements for

reimbursing CPCs;

• Part 3 looks at trends in GP

prescribing, the volume of

prescriptions and the cost pressures

on the prescribing budget; and

• Part 4 examines the potential for

further cost savings.

1.17 The report does not examine secondary

care (hospital) prescribing or quantify

its impact on primary care prescribing.

It is important to note, however, that

secondary care prescribing decisions

often impact on primary care prescribing

decisions and costs (see paragraph

3.2). Further, this report does not

consider in detail the potential for

generating savings by reducing drug

wastage.

Part Two:

Community Pharmacy Contractors’ Reimbursement

16 Primary Care Prescribing

Part Two:

Community Pharmacy Contractors’ Reimbursement

Over time, the number of pharmacy

outlets in Northern Ireland has risen

while the number of CPCs has fallen

2.1 In 2012, the HSC Board had contracts

with 243 CPCs to provide community

pharmaceutical services (including

dispensing health service-prescribed

medicines) from 547 pharmacies.

Twelve years ago, 320 CPCs were

contracted to provide services in 509

pharmacies in Northern Ireland (see

Figure 3). Therefore, over time, while the

number of pharmacy outlets increased,

the number of CPCs decreased by

almost 25 per cent. The Department told

us that in 2014, the HSC Board had

contracts with 225 CPCs to provide

community pharmaceutical services from

535 pharmacies.

Number of Pharmacies

Number of Contracted Providers

Pharmacies Contracted Providers

500

510

520

530

540

550

201220112010200920082007200620052004200320022001

200

220

240

260

280

300

320

340

Figure 3: The number of providers contracted to provide pharmaceutical services and the total number of

pharmacies over the period 2001 to 2012

Source: The Department of Health, Social Services and Public Safety

Primary Care Prescribing 17

Northern Ireland CPCs

dispense more prescriptions

per head of population

than those in England and

Scotland.

2.2 Northern Ireland has a lower average

population per service provider than

England and Wales. The average

number of prescriptions dispensed by

service providers in Northern Ireland

is higher than those in England and

Scotland but lower than Wales. Figure

4 provides comparative ﬁgures.

Figure 4: UK Comparative Pharmacy Information -2013

Northern

Ireland

England Scotland Wales

Population Estimate (millions)

1.8 53.9 5.3 3.1

Total Service Providers

547 17,823 1,580 1,067

Total Prescriptions (millions)

38.7 1,003.8 97.7 76.2

Number of Service Providers/1000 population

0.30 0.33 0.30 0.34

Average population per service provider

3,291 3,024 3,354 2,905

Average prescriptions per service provider

70,750 56,320 61,835 71,415

Prescriptions per head of population

21.50 18.62 18.43 24.58

Source: Business Services Organisation

Notes: Data is for calendar year 2013 with exception of England which is only available as ﬁnanciaL year 2012-13

Total Prescription Items includes items dispensed by community pharmacies, appliance contractors and dispensing doctors

Service provider refers to Pharmacies, Appliance Contractors and Dispensing GPs (i.e. individual GPs not

Dispensing Practice)

18 Primary Care Prescribing

Part Two:

Community Pharmacy Contractors’ Reimbursement

2.3 In looking at the numbers of pharmacies

for each population it is worth

considering the issue of access to

services for service users. Pharmacies

in NI offer some, or all, of the following

examples of services:

• minor ailments scheme;

• smoking cessation scheme;

• medicines management services;

• medicines use reviews;

• repeat dispensing services;

• oxygen supply;

• emergency hormonal contraception;

• Helicobacter Pylori testing;

• supply of palliative medicine (out of

hours);

• measuring and ﬁtting of hosiery

garments;

• supply of substitution medicines to

addicted persons;

• needle exchange schemes; and

• receipt and disposal of unwanted

medicines.

2.4 Pharmacists are often the ﬁrst port of

call for sick persons seeking advice or

treatment of minor ailments and are able

to refer patients with more serious injuries

to the appropriate treatment channels.

Some pharmacies also offer services

such as blood sugar testing, cholesterol

testing, blood pressure measurement,

body mass index measurements

and weight management schemes

which do not form part of contractual

arrangements.

2.5 Contracts are regulated by the Control

of Entry Regulations which set out the

criteria which must be met before the

HSC Board can commission a CPC to

provide pharmaceutical services. There

are currently no established legislative

mechanisms or processes in place to

either remove commissioned CPCs who

continue to meet the relevant criteria from

the pharmaceutical list or to reduce the

overall number of contracts. However,

the Department and the HSC Board

are currently undertaking a Needs

Assessment to identify areas of under

or over provision of pharmaceutical

services in Northern Ireland.

In 2012-13 CPCs received £460

million for providing community

pharmaceutical services

2.6 CPCs attract a range of funding for

the services they provide on behalf

of the HSC Board. In 2012-13, just

under £460 million was paid to CPCs.

Figure 5 provides a breakdown of the

various elements of the 2012-13 funding

envelope.

Primary Care Prescribing 19

Reimbursement costs are the most

signiﬁcant element of the funding

package

2.7 The most signiﬁcant element of CPC

funding relates to reimbursement for

purchasing and dispensing drugs.

During 2012-13, reimbursement fees to

pharmacists amounted to £381 million

(see Figure 5).

The majority of reimbursement costs

each year relate to ‘branded’ drugs

2.8 About 70 per cent of the reimbursement

cost in 2012-13 related to the supply of

‘branded’ drugs – drugs still protected

by patent and known by the trade

name given by the manufacturer. While

branded drugs account for nearly 70

per cent of reimbursement costs, they

only account for about 30 per cent

of the total volume of items dispensed

each year.

2.9 Reimbursement levels for branded

drugs are determined by the published

list price

which balances the need to

ensure that safe and effective medicines

are provided on terms acceptable to

the health service against the need to

support a proﬁtable pharmaceutical

industry in the UK.

2.10 The Pharmaceutical Price Regulation

Scheme (PPRS) is a voluntary agreement

between government

and the UK

pharmaceutical industry covering the

supply of most branded medicines. The

latest PPRS runs for ﬁve years from 1

January 2014. Under the terms of the

current PPRS, the pharmaceutical industry

has guaranteed that it will underwrite

any additional cost of supplying branded

medicines in the next two years. The

industry has also agreed to absorb an

element of any additional costs incurred

in the ﬁnal three years of the PPRS.

2.11 The latest PPRS offers predictability (for

government and the pharmaceutical

industry) in the cost of branded

medicines for the next ﬁve years. As

a result of the increased certainty over

cost, the NHS hopes to move more

rapidly in adopting innovative medicines

and treatments where these will improve

patient outcomes. As PPRS is a UK wide

scheme further work is underway to

determine how its ﬁnancial receipt for NI

is calculated.

NI reimbursement rates for dispensing

certain ‘generic’ drugs were based on

the Scottish Drug Tariff but this led to

legal challenge

2.12 The majority of items dispensed by

CPCs are generic drugs – that is,

drugs comparable to branded drugs in

dosage, strength, route of administration,

intended use, quality and performance

characteristics but created after expiry

of a patent. The Department has a

statutory obligation to compile and

9 The Pharmaceutical Price Regulation Scheme (PPRS) determines the prices drug manufacturers can charge for branded

drugs. Agreed prices follow negotiations between Association of the British Pharmaceutical Industry and the Department

of Health (acting on behalf of England, Scotland, Wales and Northern Ireland). In November 2013, a new PPRS was

announced which took effect from January 2014 and will last for ﬁve years.

10 Although the agreement is made by the Department of Health, the arrangements apply to England, Scotland, Wales

and Northern Ireland. The Association of the British Pharmaceutical Industry (ABPI) negotiates on behalf of the entire UK

pharmaceutical industry.

20 Primary Care Prescribing

Part Two:

Community Pharmacy Contractors’ Reimbursement

Figure 5: Breakdown of the funding provided to CPCs in 2012-13

Element Deﬁnition Amount Paid in

2012-13

Reimbursement

costs

Contractors receive reimbursement for purchasing and

dispensing drugs on behalf of the HSC Board. The

actual price reimbursed to contractors for individual items

dispensed is set out in the Northern Ireland Drug Tariff.

The payments made are net of discounts to list prices, in

line with the process set out in the Drug Tariff.

(£409 million - £28.1 million discount)

Contractors achieve a level of ‘retained proﬁt’ through

their purchase of medicines. Retained proﬁt is the

difference between the price a contractor pays for a

drug and the price at which the contractor is reimbursed

(as set out in the Drug Tariff). The 2011-12 Margin

Survey demonstrated that contractors were generating an

estimated proﬁt of £28 million through their procurement

activities. The estimated rate of the margin for branded

and generic medicines is similar to those identiﬁed in the

rest of the UK.

Propriety mitigation payments (amounting to £3.6 million

in 2012-13) were paid to contractors prior to completion

of the Margins Survey. Depending on the results of

the Margins Survey for 2012-13, propriety mitigation

payments may be subject to clawback.

The Department has commenced a Cost of Service

Investigation. The outcome of this investigation will be used

to inform future negotiations with community pharmacy

contractors and will inform the allowed level of retained

proﬁt.

£380.9 million

Primary Care Prescribing 21

Global Sum Consists of two components:

(i) Annual Professional Practice Allowance

(APP Allowance)

Each year, a payment of £18,000 is paid for each

pharmacy in recognition that contractors contribute to the

provision of public health services.

(ii) Dispensing Fee

Contractors receive a ﬁxed fee for dispensing an

approved drug or appliance to a public health service

patient. In 2012-13, the basic dispensing fees were:

Ordinary Fees: £1.03

Multiple Dispensing Fee: £0.49

Since 2009-10, a cap has been introduced on the total

Global Sum payable. In 2012-13, the number of ordinary

items dispensed was higher than anticipated. An amount

of £0.5 million was adjusted in 2013-14 to realign the

payments to the Global Sum, in line with the standard

operating process.

£51.4 million

£9.6 million.

£41.8 million

Additional

Non-Recurrent

Funding

The HSC Board also paid £7 million to contractors in

2012-13. This ﬁgure relates to a negotiated settlement

with CPCs following the outcome of a judicial review of

the Northern Ireland funding arrangements.

£7 million

Ancillary

Services and

Other Fees

Pharmacists can attract additional payments where they

provide supplementary services to patients. These services

may include availability of out of hours, the provision of

pharmacy advice to nursing and residential homes, or the

provision of training to non-qualiﬁed pharmacists. Remu-

neration rates for supplementary services are set out in the

Drug Tariff.

£19.8 million

TOTAL FUNDING

2012-13

£459.1 million

Source: HSC Board

22 Primary Care Prescribing

Part Two:

Community Pharmacy Contractors’ Reimbursement

publish a statement known as the

Northern Ireland Drug Tariff. The Tariff

sets out pricing models for generic drug

categories (Appendix 1). In July 1994,

the Department and the Pharmaceutical

Contractors Committee (PCC)

agreed

that it was appropriate to adopt the

Scottish Drug Tariff model in Northern

Ireland. Prices listed in the Scottish Drug

Tariff reﬂect prices set by the Department

of Health (England) since the UK

operates as one medicines market.

2.13 In 1999, following turbulence in the

pharmaceutical market, the Department

of Health (England) sought to rationalise

the prices of medicines to the NHS.

Research

published by the Department

of Health in England in 2003 estimated

that CPCs were typically able to make

30 per cent or more retained proﬁt on

generic drugs. Research undertaken to

establish proﬁt margins on ‘branded’

drugs in NI revealed similar trends to

other parts of the UK.

2.14 The research was not extended in

Northern Ireland to cover generic

drugs because local CPCs refused to

provide the required information. Later

research

13/14

has supported the view

that Northern Ireland CPCs, as part of

the UK-wide medicines market, enjoy

similar levels of proﬁt to those generated

elsewhere in the UK. The on-going

Margins Survey estimates that CPCs

typically generated proﬁt levels of 40

per cent in 2011-12.

2.15 On foot of the UK research, the

Department of Health (England)

launched a revised community pharmacy

contract in England and Wales in April

2005. In Scotland the contract was

phased in during 2006. An integral

part of that contract was the introduction

of a signiﬁcant new category within

the UK Drug Tariff - Category M.

The Drug Tariff provides a funding

mechanism for pharmacists as well as

stimulating competition in the supply

chain. Financially, the Drug Tariff is set

to deliver a target level of retained proﬁt

for CPCs and in Northern Ireland this is

set at £16.5m. Funding released from

the new Category M arrangements

are available to fund additional patient

focussed pharmaceutical services in the

community setting.

2.16 The revised contract was not introduced

in NI because pharmaceutical

representatives here contended that,

because the supporting information-

gathering exercise had not been

extended to NI, it could not be assured

that the new Category M would fairly

remunerate NI CPCs.

2.17 Despite the absence of agreement with

the local representatives, the Department

continued to apply the Scottish Drug

Tariff in Northern Ireland

. On

the basis that Northern Ireland was

recognised as part of a UK wide Drugs

Market and had been since 1998. In

effect, Category M was introduced in

11 The Pharmaceutical Contractors Committee (PCC) is the local representative body for community pharmacists providing

services under the National Health Service in Northern Ireland.

12 A pharmacy Cost of Service Inquiry (CoSI) report 2003.

13 NI - True Costs of NHS Pharmacy, The Tribal Report, 13 January 2011.

14 The on-going Margins Survey commenced in April 2011.

15 The drugs market operates on a UK-basis. All generic prices are set by the Department of Health (England) and included in

an English Drug Tariff. That Tariff covers England and Wales and is applied in NI. Scotland applies the English Drug Tariff

(after amendment to reﬂect variations in discount rates).

Primary Care Prescribing 23

Northern Ireland and CPCs in Northern

Ireland (as in other regions) saw their

reimbursement levels reduced.

2.18 Category M covers over 500 of the

most common generic medicines

dispensed. In NI, category M

covers about 55 per cent of all items

reimbursed and about 86 per cent of all

generic items reimbursed.

2.19 Given the concerns of CPCs, the

Department proposed that a proportion

of savings generated through Category

M would be paid where other services

were delivered (as in England, Scotland

and Wales). A subsequent disagreement

over whether payments should have

been made when these other services

were not provided, culminated in legal

challenge by CPCs. (Details of legal

proceedings against the Department are

set out in Appendix 2).

2.20 In 2010, a Judicial Review found in

favour of the CPCs and concluded

that the Department’s continued use of

the Scottish Drug Tariff did not meet

the statutory obligation to provide

fair and reasonable remuneration to

CPCs. The Department and HSC Board

subsequently took steps to put in place a

lawful Drug Tariff. A subsequent Judicial

Review in 2011 also found in favour

of CPCs but crucially, the revised Drug

Tariff was not deemed to be unlawful. In

December 2012, the Department and

HSC Board withdrew an appeal of the

Judicial Review decisions and a further

interim agreement was reached with

Community Pharmacy Northern Ireland

(CPNI).

The legal action has cost the

Department £550,000. CPCs received

compensation of some £6 million.

A further £40 million was made

available to CPCs over the seven

year period to 2011

2.21 The Judicial Review process has cost

the Department almost £550,000.

In addition, and outside the Judicial

Review process, the Department paid

£6 million to CPCs in 2006-07.

Following the outcome of the ﬁrst Judicial

Review, the Department negotiated

an Interim Agreement with CPNI. As

part of that agreement, the Department

acknowledged the revised arrangements

resulted in lower reimbursement rates

and provided £40 million to CPCs

over the seven year period to 2010-11

inclusive of previous payments that had

already been made on account.

2.22 The Department has begun a NI Cost

of Service Investigation (CoSI)

and

anticipates that the data collection phase

will be completed by April 2015. The

outcome of the 2011-12 margins survey

became available in May 2014. A

2012-13 margins survey is currently

being undertaken. The Department

expects that the results of that will be

available by the end of 2014. The

outcomes of these investigations and

surveys will form the basis of further

negotiations with CPNI. The decision to

exclude multiples companies (as in the

rest of the UK), however, will limit the

extent of increased transparency.

16 The objective of the Cost of Service Investigation (CoSI) is to quantify the level of proﬁt generated by CPCs.

24 Primary Care Prescribing

Part Two:

Community Pharmacy Contractors’ Reimbursement

2.23 While we accept that the Department

faced considerable opposition to

the implementation of Category M

in the Northern Ireland Drug Tariff,

in our view, many of the stumbling

blocks should have been foreseen

by the Department and overcome.

In particular, the Department should

have ensured that it was fully informed

about the likely economic impact

of introducing the revised tariff and

should have completed a Regulatory

Impact Assessment (RIA). Following the

outcome of the ﬁrst Judicial Review,

it would have been prudent for the

Department to have completed an RIA

and investigation prior to enforcing

further change. The Department told us

that it completed, and consulted on an

economic analysis which supported

its view that no RIA was required.

We note however, that this was not

accepted as sufﬁcient by the Court.

2.24 In addition to damaging relationships

with CPCs, the Judicial Review

process had a ﬁnancial impact. While

no ﬁnancial remedy was imposed by

the Courts, the Department told us that

the total cost incurred through both

Reviews amounted to £550,000.

2.25 We acknowledge that the Cost of

Services Inquiry and Margins Survey

will produce useful information on

the level of proﬁt generated by

contractors. In our view however, the

decision to exclude multiples (as in

the rest of the UK) from the margins

survey, will limit the extent of increased

transparency. We recommend that the

Department reconsiders this decision.

Part Three:

Trends in General Practitioner (GP) Prescribing Practice

26 Primary Care Prescribing

Part Three:

Trends in General Practitioner (GP) Prescribing Practice

3.1 GPs use independent clinical judgement

to decide which drugs to prescribe. A

complex relationship of activities including

procurement, selection, prescribing,

dispensing, administration, monitoring

and review of medicines impact on both

clinical outcomes and cost. Research

has shown that GP prescribing behaviour

is inﬂuenced by many factors, which

operate at different levels in the health

and social care system. At the national

or international levels, clear evidence

on treatments and drugs presented in

authoritative journals is a signiﬁcant

inﬂuence. The Department has noted

that it is therefore to be expected that an

equally complex array of activities are

required to ensure that optimal therapeutic

gains can be achieved from investment in

medicines while at the same time ensuring

value for money.

3.2 At the HSC level, inﬂuences include

local guidelines, newsletters, site visits

by HSC Board Medicines Management

Advisers, personalised contacts, and

recommendations from specialist or

consultants in the secondary health

care setting. At the practice level, the

professional experience of the GP, the

clinical needs of the patient, patient

demand, peer networks, and drug

company representatives may inﬂuence

prescribing. Decisions can, to an

extent, be inﬂuenced by the HSC Board

efﬁciency initiatives (see paragraph 4.2)

and by several other factors. A number of

examples are listed below.

• Legislation: The Health and Personal

Social Services (General Medical

Services Contracts) Regulations

(Northern Ireland) 2004 applies to

prescribing by GPs and requires that

a prescriber shall order any drugs,

medicines or appliances which are

needed for the treatment of any

patient.

• Guidance: A GP’s clinical decision

as to whether a drug is required

is complex. The General Medical

Council

(GMC) requires GPs “in

providing clinical care [to] provide

effective treatments based on best

available evidence”. It is policy in

NI to follow guidance provided

by The National Institute of Health

and Clinical Excellence (NICE)

guidance which is evidence based

and considered to be best practice.

GMC also advises GPs “To minimise

waste, improve services and promote

the effective use of resources, you

should take ﬁnancial responsibility for

the delivery of your service at a level

appropriate to your role”.

• General Medical Services

contract

: The Quality and

Outcomes Framework (QOF) is part

of the General Medical Services

(GMS) contract for general practices

and was introduced on 1 April

2004. The QOF rewards practices

for the provision of ‘quality care’ and

helps to fund further improvements in

the delivery of clinical care. Practice

participation in QOF is voluntary

17 RAND Europe, Prescribing in primary care, Understanding what shapes GPs’ prescribing choices and how might these be

changed, 2006

18 General Medical Council Guidance: http://www.gmc-uk.org/index.asp

19 GMS Contract details are available at: http://www.nhsemployers.org/your-workforce/primary-care-contacts/general-

medical-services

but most practices take part. Given

that QOF provides incentives for

better disease management, it may

therefore have an inﬂuence on GPs’

prescribing behaviour.

• Access to information: GPs’

assessment of the clinical and cost

effectiveness of the drugs they

prescribe will be inﬂuenced by a

range of factors. The Department has

advised us that the Northern Ireland

formulary

is in place and is an

unbiased review of the medicines

and recommendation for ﬁrst and

second line choices.

• Interaction with representatives

from the pharmaceutical industry:

In 2005, it was estimated that

the UK pharmaceutical industry

spends £1.65 billion a year on

drug promotion and marketing

It is likely, therefore, that marketing

activities can have an inﬂuence on

prescribing decisions.

• Secondary Care Prescribing:

Another inﬂuence on GPs’

prescribing is the secondary care

sector. In some cases, hospital

consultants specify a particular drug

for a patient leaving hospital and/

or an outpatient. While ultimately the

decision to prescribe rests with the

GP, it is likely that his decision will

be inﬂuenced by the clinical opinion

of the secondary care consultant.

The volume of prescribed drugs

has increased at a steady rate over

recent years but costs have fallen

substantially since 2010

3.3 In 2000, over 23 million items were

prescribed by GPs at a cost of just over

£245 million. Figure 6 shows that by

2010, the number of items prescribed

had increased to almost 36 million at

a cost of £440 million. Along with the

inﬂuences set out in paragraph 3.1, the

Department considers that the increase

also reﬂects the impact of a steadily

growing older population and the fact

that they consume more medicines.

3.4 The Pharmaceutical Clinical Effectiveness

(PCE) Programme

is a suite of

medicines management initiatives,

initiated by the Department in 2005 and

now implemented by the HSC Board.

Primary Care Prescribing 27

20 The NI formulary is available at: http://niformulary.hscni.net/Pages/default.aspx

21 House of Commons Health Committee, The Inﬂuence of the Pharmaceutical Industry 5 April 2005.

22 Pharmaceutical clinical effectiveness (PCE) is the outcome of the application of pharmaceutical skills directed to providing a

systematic approach to rational product selection and use, consistently applied across secondary and primary care, taking

account of clinical need, evidential product clinical performance, product presentation, safety characteristics and economic

factors. The process can be applied to medicines, wound care and medical and surgical disposable products. It employs

a multidisciplinary collaborative approach to reach consensus on the most appropriate clinical products and achieve the

ownership and behavioural change necessary to make the decisions operational. Effectively, in medicines terms, it is the

right medicine for the right patient at the right time and for the right cost. The PCE programme has been in operation since

2005 and represents the synergistic combination of a number of initiatives designed to optimise the implementation of the

product selection process through effective procurement, prescribing policy and guidelines and pharmaceutical service

improvements.

28 Primary Care Prescribing

Part Three:

Trends in General Practitioner (GP) Prescribing Practice

3.5 In the three year period, following the

introduction of PCE the rate of growth

in expenditure on drugs was reduced

to less than 5 per cent per annum (see

Figure 6) which, according to the

Department, resulted in £75 million in

savings having been made as part of

the targeted Comprehensive Spending

Review 2002-08 efﬁcencies. The

Department also told us that between

2006-13, the cost of prescribing was

reduced in real terms by 18 per cent.

3.6 On 1 July 2010 responsibility for

managing the General Pharmaceutical

Services budget

was devolved from

the Department to the HSC Board. Since

2010, while the volume of prescriptions

continued to increase (by almost 5 per

cent to 2012), the cost of prescribing

these drugs has decreased by just over

7 per cent in the same period.

Spend (£ Million)

number of items (millons)

Spend Number of prescriptions

150

200

250

300

350

400

450

500

550

2012201120102009200820072006200520042003200220012000

Responsibility for the

General Pharmaceutical

Budget transferred to HSC

Board on 1 July 2010

Implementation of PCE

Figure 6: Percentage increases in the number and cost of items prescribed

Source: Business Services Organisation – Prescription Cost Analysis Reports

23 Responsibility for the entire Family Health Services Budget was devolved to the HSC Board on 1 July 2010. Family Health

Services expenditure includes General Medical Services, General Dental Services, General Pharmaceutical Services and

General Opthalmic Services.

Primary Care Prescribing 29

There have been a range of inﬂuences

which have helped to contain the cost

of primary care prescribing

3.7 GP prescribing decisions are tightly

regulated and monitored. Each year,

GP practices are subject to prescribing

reviews and repeat prescription audits.

The purpose of these reviews and audits

is to demonstrate that GPs have:

• implemented the National Institute for

Health and Care Excellence (NICE)

guidelines on prescribing and cost-

effectiveness;

• selected only medicines listed in the

NI Formulary; and

• implemented the Pharmaceutical

Clinical Effectiveness Programme

which sets key therapeutic objectives

that GP practices are encouraged

to implement which will deliver

improved quality, safety, effectiveness

and efﬁciency

3.8 Safe and cost-effective primary care

prescribing requires that:

• GPs have access to up-to-date

information about medicines;

• GP, hospital staff and pharmacy staff

co-ordinate prescribing activity;

• all new prescribers and prescribing

support staff receive sufﬁcient, robust

training;

• generic medicines are used where

clinically appropriate; and

• medicine management advisers work

in tandem with practices.

3.9 GP Prescribing Incentive Schemes

played a part in inﬂuencing effective

prescribing. The schemes, which were

largely budgetary focused, were based

upon the principle that savings made

on the prescribing budget should be

shared between GP Practices and their

Local Commissioning Groups (LCGs).

The savings were retained by GP

Practices for reinvestment in services

designed to improve or enhance patient

care, without adding any additional

layer of bureaucracy. The savings

earmarked were also designed to assist

in reinvestment with health and social

care aimed at delivering improvements

to patient care. It is essential, especially

given the current ﬁnancial constraints

within which the public sector ﬁnds

itself, that every opportunity to deliver

efﬁciencies is pursued.

30 Primary Care Prescribing

Part Three:

Trends in General Practitioner (GP) Prescribing Practice

HSC Board Medicines Management

Advisors have been instrumental in

ensuring prescribing efﬁciencies are

generated

3.10 Containing the cost of prescribing

by GPs is primarily managed by the

HSC Board’s Medicines Management

Advisers (MMAs) who seek to inﬂuence

the prescribing behaviour of GPs. As

qualiﬁed pharmacists, MMAs perform

two main functions:

• each MMA monitors the prescribing

patterns of an allocated number of

GP practices (approximately 25 for

a full-time MMA) with a focus on

safety, effectiveness and efﬁciency.

By identifying high value expenditure

and variations in prescribing

patterns, MMAs are well placed

to highlight areas where ﬁnancial

savings could be generated without

impacting on the quality and safety

of care; and

• each MMA is responsible for

reviewing prescribing patterns

within given therapeutic areas

(such as obesity or asthma). The

MMA is set a speciﬁc effectiveness

target for this area and inﬂuences

prescribing practice by providing

comprehensive, up to date advice to

GPs on the most effective treatments.

3.11 In part, the success of MMAs is reﬂected

in achievement against annual GP

prescribing efﬁciency-saving targets

which have been in place since

2010-11

(see Paragraph 4.2). By

encouraging GPs to prescribe more cost-

effectively by, for example, increasing

the level of generic prescribing and

identifying areas where cheaper

alternatives (proven to have the same

outcomes) can be used, MMAs have

played an important role in helping

to slow the year-on-year increase in

the number of items dispensed and to

reduce costs.

3.12 The ratio of MMAs per head of

population has been used in Scotland

to demonstrate that prescribing

performance can be enhanced by

increasing MMA capacity. Compared to

Scotland

, the ratio is lower here with 1

whole time equivalent (WTE) MMA per

130,000 of the population compared

to between 3.5 and 6 WTE prescribing

support staff (similar to the role of MMAs

in NI) per 100,000 of the population in

Scotland.

24 Until July 2010, the Department had responsibility for the General Pharmaceutical Service budget. It set the efﬁciency target

of £40 million for that year. Responsibility was then devolved to the HSC Board.

25 Audit Scotland Report: Prescribing in General Practice in Scotland 2013.

3.13 While the relative impact of various

prescribing support activities is difﬁcult

to assess, in our view, MMAs play

a key role in controlling prescribing

costs by coordinating these activities.

We recommend that the HSC Board

should use available benchmarking

data to inform their consideration of

whether MMA stafﬁng levels in NI

are appropriate. The Department has

informed us that it recognises the role

of MMAs and will consider available

evidence from NI and elsewhere to

inform consideration of appropriate

and affordable stafﬁng levels.

Primary Care Prescribing 31

British National Formulary (BNF)

3.14 The British National Formulary (BNF) is

a publication which contains information

and advice on prescribing, dispensing

and administering medicines. It is used

by GPs and pharmacists to conﬁrm

drug dosages, indications, interactions

and side effects. Medicines are classed

in accordance with their therapeutic

actions and are categorised against

one of 15 BNF chapters. Some drugs,

such as aspirin, appear in a number of

BNF chapters since they can be used to

treat several conditions. Basic net prices

are given in the BNF to provide an

indication of the relative cost of different

drugs.

3.15 The NI administrative prescribing

database, hosted by The HSC Sector

Business Services Organisation (BSO),

classiﬁes medicines in accordance

with the BNF format in order to report

prescribing/dispensing activity by

therapeutic areas. BSO include

one additional section allocating

unclassiﬁed

medicines. Typically

over 60 per cent of the total cost

of prescribing falls to one of four

therapeutic areas (see Figure 7).

26 Unclassiﬁed are dispensed items for which there is no corresponding code in the NI Code book issued by BSO.

Figure 7: 2013 Expenditure in top four BNF Chapters

BNF Chapter Conditions

Commonly Treated

2013

Expenditure

Percentage of

overall prescribing

expenditure in

2013

BNF 4 –

Central Nervous System

Depression, dementia,

alzheimers disease, multiple

sclerosis, pain

£113 million 28 per cent

BNF 2 –

Cardiovascular System

Angina, heart attacks £48 million 12 per cent

BNF 3 –

Respiratory System

Asthma, emphyzema, chronic

obstructive pulmonary disorder,

acute respiratory distress,

sinusitis, tonsillitis, laryngitis

£48 million 12 per cent

BNF 6 –

Endocrine System

Diabetes, thyroid problems,

osteoporosis

£45 million 11 per cent

Source: Business Service Organisation

32 Primary Care Prescribing

Part Three:

Trends in General Practitioner (GP) Prescribing Practice

3.16 Around 20 per cent falls to a further ﬁve

therapeutic areas, with four per cent of

all prescribing expenditure allocated to

‘unclassiﬁed’ (see Figure 8).

100

120

Total for remaining

Unclassified

Skin

Obstetrics,

Gynaecology and

Urinary-Tract disorders

Gastro-Intestinal

system

Nutrition and Blood

Endocrine system

Respiratory system

Cardiovascular

system

Central Nervous

system

BNF Chapters

Spend (£ Million)

Figure 8: Analysis of 2013 Expenditure by BNF Chapter

Source: HSC Board

Primary Care Prescribing 33

The use of an ‘unclassiﬁed’ category

prevents comprehensive analysis of

prescribing patterns

3.17 Where a GP prescribes an unusual

item or a liquid form of a routinely

dispensed tablet, the items is allocated

to the ‘unclassiﬁed’ category. In 2013,

250,000 prescription items costing £15

million were charged to the unclassiﬁed

code. Figure 9 shows that the level of

unclassiﬁed expenditure has more than

doubled in the 10 year period to 2013.

Figure 9: Spend allocated to the unclassiﬁed category in NI over the period 2004 to 2013

2013201220112010200920082007200620052004

Spend (£ Million)

Source: HSC Board

34 Primary Care Prescribing

Part Three:

Trends in General Practitioner (GP) Prescribing Practice

3.18 It is, however, the view of the HSC

Board that the inclusion of an unclassiﬁed

category allows greater transparency

and allows the quantiﬁcation and

interrogation of the use of these products.

In Scotland, unclassiﬁed items (referred

to as dummies in Scotland) represented

less than two per cent of the prescribing

costs. England and Wales do not use

an unclassiﬁed category. All prescribed

items are allocated to a BNF chapter/

therapeutic area.

3.19 We examined the top 100 most

expensive items prescribed and

allocated to ‘unclassiﬁed’ in December

2013. In our sample we identiﬁed that:

• Just over half of all items selected

(costing £46,000) were liquid forms

of routinely dispensed medicines;

• Pharmacists had been reimbursed

between £622 and £1,230 for

dispensing individual liquid (rather

than tablet) doses of omeprazole.

Tablet form omeprazole costs

approximately £2.27;

• In one case, a pharmacist was

reimbursed £220 for dispensing a

‘special

’ suspension. We noted that

this product was available on the

market at a cost of £23.43; and

• An application for reimbursement

relating to a ‘special’ item costing

just over £400 was turned down

by the HSC Board. The HSC Board

advised the pharmacist to dispense

the treatment in tablet form at a cost

of £1.48.

27 Where a prescribed item or solution cannot easily be prepared by the pharmacist, it is categorised as a ‘special’ product.

Specials tend to be unusual items, such as appliances designed speciﬁcally for the patient, solutions which combine various

drugs or treatments which require an active ingredient at a level which is not available commercially. The pharmacist is

reimbursed the full amount he is charged by the drug company.

3.20 The use of an unclassiﬁed cost in

NI masks the overall cost of treating

various conditions. We recommend

that the HSC Board replicates the

arrangements in England and Wales

(where no unclassiﬁed code exists)

by removing the unclassiﬁed code in

an effort to improve transparency and

monitoring. We note that BSO has

introduced a new Family Practitioner

Service payment system which will

provide enhanced management

information and permit more detailed

classiﬁcation of uncoded items.

3.21 Although we note that the HSC

Board reviews applications for

‘special’ product reimbursement, in

our view, additional savings could be

generated by strengthening controls.

We recommend that the HSC

Board continues to work closely with

healthcare professionals to ensure

that all possible alternatives are

considered before a ‘special’ item is

dispensed.

Primary Care Prescribing 35

Variations in regional prescribing

rates which cannot be fully explained

by differences in population

demographics suggest that it may

be possible to improve the quality of

prescribing further.

3.22 Effective prescribing should ensure that

the clinical needs of a population are

met by prescribing a volume of drugs

which is consistent with the prevalence of

a disease. Paragraph 1.8 shows that the

overall volume of items prescribed has

been increasing across all UK countries

over recent years. While research

has

consistently shown health need here is

much greater than elsewhere in the UK,

data from other sources suggests that the

relationship between health need and

prescribing is not as straightforward as

may be expected.

3.23 Data on the prevalence of speciﬁc

diseases or health conditions are an

important element of the Quality and

Outcomes Framework (QOF) and

according to the HSC Board

“(disease) registers are particularly

valuable in recording both the number

of patients known to have the condition

and in calculating the prevalence locally

and regionally. This can be extremely

useful for assessing clinical need and

planning service development.....QOF

data can indicate variation in practice

and potential unmet need within the

population”.

3.24 The Department has told us that it has

been advised by the NI Statistics and

Research Agency and the Health and

Social Care Information Centre in

England that QOF data is unsuitable

as a measure of need in this context.

The QOF is primarily designed to

address primary care management not

prevalence or need. QOF data is not

statistically robust for this purpose. The

limitations inherent in utilising QOF in

this analysis include that no account is

taken of the population structure across

the four countries.Severity of disease

or co-morbidities is not considered,

all of which are contributory factors in

level and cost of prescribing. Although

QOF may be considered consistent in

deﬁnitions across the four countries; the

social and demographic characteristics

of the population differ widely as will the

recording and clinical behaviour of the

GPs.

3.25 We recognise that accepted research

shows there is additional health need

in Northern Ireland which may range

from 9 to 26 per cent. However, while

we acknowledge the Department’s

view that QOF should be interpreted

with caution

, recent data shows that

the prevalence of many of the main

diseases does not appear to be in line

with the general understanding of higher

health need here. Figure 10 shows the

prevalence of speciﬁc diseases

28 NAO, Healthcare Across the UK: A comparison of the NHS in England, Scotland, Wales and Northern Ireland.

29 Performance Review Report 2012-13,Pages 7 and 9, General Medical Services, HSC Board, 2013.

30 The Department considers that caution should be taken when interpreting QOF prevalence since the rates are simply the total

number of patients on the register, expressed as a proportion or percentage of the total number of patients registered with

the practice. They are not adjusted to account for patient age distribution or other factors that may differ between general

practices. Furthermore, although registers may be restricted (e.g. to only include persons over a speciﬁed age) the QOF

prevalence rate is based on the total number of persons registered with the practice (the practice list size) at one point in

time.

36 Primary Care Prescribing

Part Three:

Trends in General Practitioner (GP) Prescribing Practice

Average Level

in Great Britain

-1.75%

-1.25%

-0.75%

-0.25%

0.25%

Obesity

Atrial Fibrillation

Depression

Chronic Kidney Disease

Dementia

Heart Failure due to LVD (Note 2)

Heart Failure

Stroke

Mental Health

Hypothyroidism

Hypertension

Epilepsy

Diabetes

Heart Disease

COPD (Note 1)

Cancer

Asthma

Indicates higher prevalence of the disease in

Northern Ireland compared to Great Britain

Indicates lower prevalence of the disease in

Northern Ireland compared to Great Britain

Depression

Epilepsy

Dementia

Note 1: COPD - Chronic obstructive pulmonary disease Note 2: LVD - Left Ventricular Dysfunction

Figure 10: Comparison of disease prevalence in NI with the average level in the rest of the UK in March 2012

Source: The Department/NIAO

Primary Care Prescribing 37

and conditions here compared to the

average in other parts of the UK at

March 2012. Prevalence of epilepsy,

depression and dementia is higher

in Northern Ireland than the average

level in GB. However, for the majority

of categories, prevalence in NI is

considerably less than the average for

other parts of the UK.

3.26 On the basis of the data presented

in Figure 10, therefore, prevalence

of a condition does not seem to fully

explain the higher rates of prescribing

here. Despite the caveats footnoted

at paragraph 3.25, we consider that

estimates of disease prevalence rates

based on QOF data from GP practices

provides an additional source of

information which can help in providing

as complete a picture of prescribing

activity as possible, in order to identify

the opportunities to improve standards

and provide safer care as well as

improving efﬁciency and effectiveness.

In a period of unprecedented ﬁnancial

challenge, coupled with major

transformational change, we would

agree with the HSC Board (paragraph

3.23) that the use of QOF data could

be helpful in focusing attention around

optimising medicines use.

3.27 Information on long-standing illness and

disability (based on people’s subjective

assessments of their own health)

also

shows NI below the UK average – 18.4

per cent compared against 19.7 per

cent. The Department told us that the

use of patients’ subjective assessments

of their own health in reaching this

conclusion is inappropriate as the data

is unsuitable as a measure of need in this

context. Moreover, while the likelihood

is that people will suffer chronic illness

increases with age, the age distribution

of the population of NI reveals a

relatively smaller share of older citizens

than the rest of the UK (Figure 11).

31 The NI Statistics and Research Agency collects data relating to long standing illness and disability, based on people’s

subjective assessments of their own health. Independent healthcare providers would argue strongly that the incentives under

which they operate ensure that their activities are well aligned with the public interest. The results are contained in the

National Wellbeing Measures publication.

38 Primary Care Prescribing

Part Three:

Trends in General Practitioner (GP) Prescribing Practice

10%

15%

20%

25%

30%

2041203620332030202720242021201820152012

Percentage of population aged 65 and over

England

Northern Ireland

Scotland

Wales

Figure 11: Age distribution of the UK population – percentage of population aged 65 and over

Source: National Population Projections, 2012-based projections (Ofﬁce of National Statistics)

3.28 Overprescribing represents a waste

of resources. On the other hand,

under-prescribing can indicate unmet

need and potential future health

complications. In order to identify

the extent to which there may be

opportunities for improving the

value for money GPs get from their

prescribing, we recommend that the

HSC Board, along with GPs, should

use the streams of data on disease

prevalence, patients’ self assessments

and relative age distributions to

further explore the relationship

between prescribing rates and

relative healthcare need.

39 Primary Care Prescribing

Part Four:

The Scope for more efﬁcient and effective prescribing

Part Four:

The Scope for more efﬁcient and effective prescribing

40 Primary Care Prescribing

Part Four:

The Scope for more efﬁcient and effective prescribing

4.1 While the prescribing of drugs in

primary care is a matter for GPs

independent clinical judgement, the

HSC Board can nonetheless seek to

inﬂuence the choices made by GPs

when prescribing, for example, between

different drugs that have the same

clinical effect but different prices. The

scope for savings in prescribing choices

arises because, for many conditions,

there are a range of drugs that could

be prescribed. When deciding to treat

a patient with medication, a doctor

will typically have a range of different

options to choose from. Frequently, the

cost of these varies considerably. It does

so for two main reasons:

• many drugs are available in both

branded and generic versions, the

latter generally being cheaper; and

• there may also be more than one

drug available for treating a given

medical condition, also at different

prices.

4.2 The management of spending on drugs

in primary care has generally improved

in recent years. For example, the HSC

Board provided us with details showing

annual GP prescribing efﬁciency savings

of £132 million in the four year period

to 2011-14 (Figure 12).

Figure 12: Annual Efﬁciency Targets and Achievement over the period from 2010-11 to 2013-2014

Year Efﬁciency Target

£ million

Efﬁciencies realised

£ million

(Under)/ Over

achievement

2010/11

£40 £26 (£14)

2011/12

£30 £40 £10

2012/13

£29 £34 £5

2013/14

£23 £32 £9

Total

£122 £132 £10

Note: These ﬁgures were calculated by the Department /HSC Board but were not validated as part of our review.

Source: Business Services Organisation

Primary Care Prescribing 41

32 In 2006 the Department launched the “Go Generic” campaign to increase public awareness of generic medicines and

advocate their use. In July 2006 the Department launched a new Prescribing Incentive Scheme (PIS) for GP practices which

included targets for generic dispensing. The PIS is no longer in operation.

33 Source: BSO.

34 By monitoring dispensing rates for generic drugs, NI is more closely identifying generic drug usage. Monitoring elsewhere

in the rest of the UK is based on prescribing levels which do not accurately reﬂect what was actually dispensed.

35 Generic Prescribing rates for NI are only available since April 2011. Since April 2011 BSO records items prescribed and

dispensed generically, previously it only recorded dispensed.

Primary Care Prescribing 41

The Department, HSC Board and GPs

are to be commended for the savings

generated from improving the rate of

generic prescribing

4.3 For many years the Department

and

the HSC Board have been encouraging

GPs to write prescriptions using a

drug’s chemical name, whether or

not the product in question is out of

patent. This is typically known as

‘generic prescribing’. When a branded

medicine’s patent expires, the generic

equivalents which appear on the market -

containing the same active ingredient(s) -

are usually cheaper. In 2013 the average

cost of a generic drug was around £4.21

whilst the average cost of a branded drug

was about £22.61

4.4 Generic dispensing rates have improved

considerably in NI over the past 10

years. In 2003-04, 41 per cent of items

dispensed were generic rather than

branded drugs. By March 2014, NI

generic prescribing rates had risen to 80

per cent and generic dispensing rates

had risen to 71 per cent. Figure 13

compares the generic rates in NI since

2003-04 against that elsewhere in the UK.

Financial

year

NI dispensing

rate %

NI’s prescribing

rate

England

Scotland

Wales

2003/04

41 - 78 79 76

2004/05

43 - 79 80 78

2005/06

46 - 80 81 80

2006/07

49 - 82 82 82

2007/08

53 - 83 82 84

2008/09

56 - 83 82 84

2009/10

58 - 83 82 84

2010/11

60 75 83 82 83

2011/12

64 78 83 83 83

2012/13

68 79 84 83 83

2013/14

71 80 84 83 83

Figure 13: Generic Prescribing Rates across the UK from 2003 to 2013

Source: The Department and the HSC Board

42 Primary Care Prescribing

Part Four:

The Scope for more efﬁcient and effective prescribing

4.5 The scope for achieving savings

from generic prescribing had been

highlighted in the past. For example, a

report published in 2005

outlined that

one of the main reasons for the higher

unit cost of prescriptions in NI (relative

to England) was the greater use of

branded drugs. The report stated that if

NI achieved the same generic rate as

England, costs could be reduced by 18

per cent, saving £55 million. A more

recent report, published in October

2012

, estimated that £129 million

savings could be generated in NI over

the 4 year period to 2015 through the

increased use of generic medicines.

The HSC Board estimate that currently

achievable savings from switching to

generic drugs are likely to be modest at

around £1.6 million when set against

the overall drugs bill as most of the

potential savings from generic switching

have already been made.

There is wide variation in the cost of

prescribing per head of population

across individual GP practices locally

4.6 While we recognise the progress that

has been made in how prescribing

costs have been controlled over recent

years, the Department and HSC

Board acknowledges that prescribing

costs per head of population here

are still higher than they should be

and are being addressed as part

of the efﬁciency agenda. Reducing

22 36

22 37

unwarranted variations in prescribing

activity and cost is one area where there

is potential to save on prescription costs.

Given the factors set out in paragraph

3.2, the occurrence of some variation

is not only inevitable but, on occasion,

may also be necessary in terms of

clinical practice. Therefore, while it can

be difﬁcult to determine why variations in

prescribing patterns exist, unwarranted

variations in activity and expenditure are

causes for concern as they may reﬂect

differences in quality of care and may

lead to extra expense and potential

waste of resources.

4.7 Age and level of deprivation are two of

the principal determinants of the health

of any population. They affect both the

incidence of the disease (the number of

new cases that develop in a year) and

its prevalence (the number of people

who have a chronic disease at any point

in time).

4.8 Local data has been adjusted for,

among other things, social class and

age distribution using ‘prescribing units’

(PUs) to standardise GP caseloads so

that valid comparisons can be made. As

Figure 14 demonstrates, there can be a

substantial degree of variation between

GP practices after taking account of

population differences.

4.9 We recognise that BSO together with

GP practices have been working hard

to understand variation and to mitigate

unwarranted variation through the work

36 The Appleby Report examined the likely future resource requirements of the health & social care sector in Northern Ireland

and the scope for resources to be used more effectively.

37 The Ofﬁce of Health Economics for the Association of British Pharmaceutical Industries. UK NHS Medicines Bill projection

2012-15, Oct 2012.

Primary Care Prescribing 43

of MMAs (see paragraphs 3.10 to

3.12). The Department told us that in

the period 2010 to 2013 the range of

variation has reduced. However, Figure

14 shows that in 2013 there was a

variation of over 100 per cent between

the GP practice with the lowest cost

prescribing rate (£26,303) and that of

the highest cost practice (£55,501).

The differences in spending on GP

prescribing among practices here may

be due to differences in the amount of

prescribing; differences in the choice

of drugs prescribed and their cost; or a

mixture of both. The precise causes of

the variations require careful inspection

Figure 14: Cost per 1000 NI Prescribing Units by GP practices in NI (2013)

All GP Practices Mean

£0

£10,000

£20,000

£30,000

£40,000

£50,000

£60,000

351301251201151101511

£41,004

£26,303

£55,501

Source: BSO

to determine the extent to which they

represent good quality practice.

4.10 As the NI PU system normalises

prescribing data to enable a more

balanced comparison within prescribing,

this variation cannot reasonably be

explained by population differences. We

consider that this presents a signiﬁcant

opportunity for ﬁnancial savings for

the health and social care sector. For

example, if GP practices performing

above the average prescribing cost

brought their prescribing costs to that of

the average (£41,004), efﬁciencies of

around £19 million could be achieved.

44 Primary Care Prescribing

Part Four:

The Scope for more efﬁcient and effective prescribing

4.11 The Department has commented that

such an estimate is crude and does not

take into consideration the other factors

associated with prescribing, such as

access to other services; the impact of

cross-border workers; private healthcare.

The Department considers that there

will always be a degree of variability

between GP practices and therefore the

full quantum of such efﬁciencies will not

be realisable. Despite this, we consider

that a rolling target could be set to

minimise the level of variation between

GP practices. Further we consider that

there is scope to reduce the average

over time. For example, reducing the

average by 10 per cent over a three

year period would generate savings of

£54 million.

4.12 The Department told us that, while it

does not expect that all GP practices

should be at the mean, it accepts

that those with statistically signiﬁcant

variations (that is, beyond two standard

deviations of the mean) should be

investigated. The Department told us

that it does not accept the analysis

or conclusions in respect of the ﬁgure

of £54 million, as being deliverable

without further robust analysis.

There is scope to make further savings

from prescribing without affecting

patient care

4.14 Perhaps the most important dimension

in competition between medicines

is that of the relative effectiveness of

the drugs concerned. In principle, a

difference in price between two drugs is

understandable if the two products have

very different effects. However, when the

prices of prescription medicines do not

reﬂect their relative therapeutic beneﬁts,

the health and social care sector may

obtain poor value for money.

4.15 As outlined in paragraph 4.3, the

price at which branded medicines are

reimbursed does not change when they

come off-patent and generic substitutes

enter the market. In order to maximise the

savings available when generic substitute

drugs become available, therefore, it

is essential that the HSC Board has

arrangements in place to notify GPs well

in advance of patent expiry dates and to

provide them with clear guidance on the

recommended generic replacements.

4.16 We examined the scope for efﬁciency

improvements in three therapeutic

areas which account for a signiﬁcant

proportion of the prescribing budget:

Stomach Acid Treatments; Cholesterol-

controlling Treatments (statins); and

Depression Treatments. The drugs

discussed were chosen for illustrative

purposes to demonstrate the opportunity

costs of failing to prescribe more cost

effective alternatives.

4.13 We recommend that the HSC Board

and BSO continues to compare and

investigate the reasons for variations

that are statistically signiﬁcant in the

NI PU between GP practices to assist

in the identiﬁcation of opportunities for

achieving the potential saving levels

set out in paragraph 4.10.

Primary Care Prescribing 45

Earlier switching to cheaper generic

stomach acid treatments (Proton

Pump Inhibitors (PPI)) would have

resulted in additional efﬁciency

savings of £2.2 million in 2012 and

£1 million in 2013

4.17 Proton Pump Inhibitors (PPIs) reduce the

amount of acid made by the stomach.

They are used to treat acid reﬂux

and treat and prevent ulcers of the

Figure 15: The number and cost of PPI prescribed since 2009

Spend (£ Million)

Number of Prescription Items (Thousand)

Spend Number of Prescription Items

£15m

£7.5m

20132012201120102000

500

1000

1500

2000

2500

Source: BSO

stomach and duodenum. They are also

prescribed to patients using non-steroidal

anti-inﬂammatory drugs.

4.18 Figure 15 shows that while the number

of PPIs prescribed here has increased

over the last ﬁve years, costs have

decreased substantially. However,

Figure 16 shows that NI is still some

way behind the rest of the UK in terms

of the cost of PPI treatments per head of

population.

46 Primary Care Prescribing

Part Four:

The Scope for more efﬁcient and effective prescribing

4.19 The higher cost per patient here reﬂects

the fact that GPs have tended to

prescribe lower volumes of a generic

PPI substitute compared to other UK

regions. Prior to 2002, PPI patients

were treated with one of a number

expired and a generic PPI, omeprazole,

became available. In NI, the majority

of patients who had been treated with

to omeprazole. However, few patients

who had traditionally been treated with

to omeprazole therefore a comparatively

greater proportion of patients in NI

continued to be treated with the branded

was £17.03 compared with £2.27 for

omeprazole.

4.20 Figure 17 shows that in NI in 2012,

48 per cent of the PPI spend related

to branded esomeprazole. Only 29

per cent related to, the much cheaper,

omeprazole. This is low compared

to the level of omeprazole spend in

other UK regions. Although NI GPs

Figure 16: Cost of PPI treatments per head of population in the UK over the 4 year period to 2013

£0

£1

£2

£3

£4

£5

£6

£7

£8

£9

Northern IrelandWalesScotlandEngland

2010

2012 20132011

£2.35

£3.85

£2.64

£4.14

Source: BSO

Primary Care Prescribing 47Primary Care Prescribing 47

prescribe more (low cost) omeprazole

than esomeprazole, the proportion

of esomeprazole prescribed in NI is

higher than any other region of the UK.

In 2012, the opportunity cost to local

health and social care services of not

prescribing omeprazole at a similar rate

as the rest of the UK was £2.2 million.

During 2013 the opportunity cost was

£1million.

Switching to less expensive statins

would have saved around £2.7 million

in 2012 and £2.5 million in 2013

4.21 Statins lower cholesterol and are one

of the classes of drugs employed to

treat cardiovascular disease - the single

greatest cause of death in the UK. High

levels of Low Density Lipoprotein (LDL) or

‘bad cholesterol’ are a well accepted

risk factor associated with the onset of

coronary heart disease. Statins have a

strong effect in reducing LDL cholesterol.

Figure 17: Comparison of the proportion of Omeprazole and Esomeprazole dispensed in the UK during 2012

based on Cost

10%

20%

30%

40%

50%

60%

Northern IrelandWalesScotlandEngland

Omeprazole (£2.27)

Esomeprazole (£17.03)

Source: BSO

48 Primary Care Prescribing

Part Four:

The Scope for more efﬁcient and effective prescribing

4.22 In an attempt to address rising rates of

cardiovascular disease the number of

statins prescribed by GPs has steadily

increased over the last number of years.

By moving from branded to generic

statins, the HSC Board has managed to

reduce unit costs (Figure 18). However,

while Figure 19 shows that the cost per

head of population has successfully been

reduced from £16 in 2010 to £5.32

in 2013, other regions of the UK have

fared even better: during 2013 Wales

spent £3.37 per head, Scotland £5.24

and England £2.88.

Figure 18: The number and cost of statins prescribed since 2009

Spend (£ Million)

Number of Prescribed Items (Thousand)

Spend Number of prescription items

35.10 35.76

33.77

23.17

14.64

20132012201120102009

1500

1600

1700

1800

1900

2000

Source: BSO

Primary Care Prescribing 49Primary Care Prescribing 49

4.23 As with PPIs (paragraphs 4.17 to 4.20),

analysis of the drugs dispensed across

the UK demonstrate that GPs here tend

to prescribe more expensive statins than

GPs elsewhere. In particular, GPs here

prescribe higher volumes of atorvastatin

and rosuvastatin. Prior to coming off

patent in May 2012, atorvastatin

cost £38 per pack and rosuvastatin

(which is not coming off patent until

2016) costs £32 per pack. By contrast

simvastatin and pravastatin (both

available generically since 2003) cost

approximately £2.20 per pack. Figure

20 compares the prescribing behaviour

of GPs here with their counterparts in

the rest of the UK and shows that, in

general, they prescribe larger volumes

of the more expensive statin drugs and

therefore incur higher unit costs.

Figure 19: Cost of Statins per head of population in the UK over the 4 year period to 2013

£0

£2

£4

£6

£8

£10

£12

£14

£16

Northern IrelandWalesScotlandEngland

2010

2012 20132011

£2.88

£5.24

£3.37

£5.32

Source: BSO

50 Primary Care Prescribing

Part Four:

The Scope for more efﬁcient and effective prescribing

38 Statins for the prevention of cardiovascular disease, NICE, January 2006.

4.24 In the absence of strong evidence that

other statins achieve a better reduction in

cardiovascular related deaths and illness

in large populations than simvastatin,

the fact that GPs here tend to favour

the prescription of more expensive

equivalents has a major budgetary

impact.

4.25 Evidence on the comparative efﬁcacy of

statins was produced by the National

Institute for Health and Care Excellence

(NICE) in 2006

. In summary, this

guidance recommended the use of a

statin of lowest cost and at that time, this

was simvastatin. In September 2011,

The Scottish Medicines Consortium

advised prescribers that rosuvastatin was

not recommended within Scotland for

the prevention of cardiovascular events.

In November 2011, the All Wales

22 38

Figure 20: Comparison of the use of statins in the UK during 2012

10%

20%

30%

40%

50%

60%

70%

80%

Northern IrelandWalesScotlandEngland

Generic Statin (£2.20)

Branded Statin (£35)

75%

25%

69%

31%

73%

27%

59%

41%

Note The cost ﬁgure represent the average cost of statins during 2012

Source: BSO

Primary Care Prescribing 51Primary Care Prescribing 51

39 Lipid modiﬁcation: cardiovascular risk assessment and the modiﬁcation of blood lipids for the primary and secondary

prevention of cardiovascular disease, NICE, July 2014.

Medicines Strategy Group directed

that rosuvastatin was not recommended

for preventing major cardiovascular

events in patients with a high risk as

the clinical and cost effectiveness

evidence provided was not sufﬁcient

to recommend it. Until April 2014, in

Northern Ireland there was no body

specifying what medicines ought to

be or not be prescribed resulting in a

higher proportion of the more expensive

drugs being prescribed. Since this

time though, the HSC Board has

put in place the NI Formulary and a

‘Managed Entry’ process to deal with

new medicines.

4.26 Atorvastatin is now available

generically and now costs less than

10 per cent of the branded version.

The NICE Clinical Guidance has

recently been updated

and it now

recommends the use of atorvastatin.

However, it has been apparent that

GPs here have been prescribing

comparatively more expensive

equivalents that have a major

budgetary impact. In 2012, the

opportunity cost to local health and

social care services of not prescribing

simvastatin at a similar rate as the rest

of the UK was £2.7 million. The total

opportunity cost for not prescribing all

statins at similar proportions to the rest of

the UK was £4 million and during 2013

was £2.5 million.

Earlier switching to alternative generic

drugs in the treatment of depression

would have resulted in additional

efﬁciency savings of £2.7 million in

2012 and £1.6 million in 2013

4.27 QOF data (see paragraph 3.24)

shows a slightly higher prevalence of

depression in NI than other UK regions

(see Figure 21). Therefore it is expected

that NI will spend slightly more per

capita on this type of medication.

However, as previously noted, the

Department considers that QOF data is

unsuitable as a reliable measure of need

in this context.

Figure 21: UK Disease Prevalence (as a % of GP Registered Population) Comparison March 2012

Disease Area NI England Scotland Wales

Conditions for

Depression

Screening

7.1% Not available 7.8% 8.2%

Diagnosis of

Depression

9.6% 9.2% 9.0% 9.5%

Source: DHSSPS

52 Primary Care Prescribing

Part Four:

The Scope for more efﬁcient and effective prescribing

Figure 22: The volume and cost of anti-depressants prescribed in NI since 2009

Spend (£ Million)

Number of Presscritpion Items (Thousand)

Spend Number of prescription items

£0

£2

£4

£6

£8

£10

£12

£14

£16

£18

£20

20132012201120102009

500

1000

1500

2000

2500

3000

Source: HSC Board

4.28 The volume of anti-depressant

prescribing here has been steadily

increasing over recent years. The cost of

anti-depressants fell considerably during

2012 but rose again slightly in 2013

(see Figure 22). Figure 23 illustrates

that NI has consistently had signiﬁcantly

higher anti-depressant prescribing costs

per capita than other UK regions.

Primary Care Prescribing 53

4.29 Comparison with the rest of the UK

shows that in Northern Ireland there

was a lower proportion of generic

treatments being prescribed for

depression which would, in part,

explain the higher cost per head.

In particular, escitalopram, one of

the more expensive treatments for

depression, is used more widely here

than any other region of the UK.

During 2012 prescribing costs per

head of population was £1.71 here

compared with £0.41 in Scotland

and £0.26 in Wales.

Figure 23: The cost of anti-depressant prescribing per head of population in the UK over the

4 year period to 2013

£0

£2

£4

£6

£8

£10

£12

Northern IrelandWalesScotlandEngland

2010

2012 20132011

£5.27

£5.55

£6.58

£8.61

Source: HSC Board

4.30 While research suggests that there may

be some slight differences between

escitalopram and close equivalents

(which may make a difference in

how the medicines work), the drug

citalopram is regarded as a close

comparator. However, the price of

these two drugs varies considerably.

Figure 24 shows that a higher

proportion of (the more expensive)

escitalopram is prescribed in NI than

in the rest of the UK. In 2012, the

opportunity cost to local health and

social care services of not prescribing

54 Primary Care Prescribing

Part Four:

The Scope for more efﬁcient and effective prescribing

citalopram at a similar rate as the

rest of the UK was £2.7 million. The

opportunity cost in 2013 due to

Northern Ireland prescribing patterns for

anti-depressant medication not being

similar to those in the rest of the UK was

£1.6 million.

4.31 It should be noted that the HSC Board

has advised that simply switching from

a branded medicine to a different

medicine that is available as a generic

needs to be managed carefully. Given

that the two medicines cited here are

being used for depression and other

mental health issues, the HSC Board has

advised that such changes need to be

worked through very carefully.

Figure 24: Comparison of the proportionate use of Escitalopram and Citalopram in the UK

countries in 2012

10%

20%

30%

40%

50%

60%

Northern IrelandWalesScotlandEngland

Escitalopram

Citalopram

51%

46%

57%

10%

38%

Source: BSO

Primary Care Prescribing 55

40 Pregabalin became available as a generic in October 2013.

Primary Care Prescribing 55

More money is spent prescribing

Pregablin in NI than on any other

drug. Pregablin is more frequently

prescribed in NI than elsewhere in

the UK

4.32 Pregabalin

is a medicine used to

treat epilepsy, neuropathic pain and

generalised anxiety disorder. As an

analgesic it works by reducing the

volume of pain signals sent to the brain

from damaged nerves. It can have a

euphoric effect on patients and cases of

abuse and misuse have been reported.

4.33 Figure 25 shows a steep rise in the

volume of pregabalin prescribed

over the last six years and despite a

slowing down of expenditure over

this period, pregabalin currently costs

the prescribing budget £17 million

a year (see Figure 25). This level of

expenditure is higher than any other

single medicine prescribed by GPs.

Pregablin is also more frequently

prescribed in NI than in the rest of

the UK. Figure 26 shows that, during

2013, £9.43 was spent on pregabalin

per head of population here compared

to approximately £4 per head in the

rest of the UK .

Figure 25: The number and cost of Pregabalin since 2009

Spend (£ Million)

Number of Prescription Items (Thousand)

Spend Number of prescription items

20132012201120102009

100

150

200

250

300

Source: HSC Board

56 Primary Care Prescribing

Part Four:

The Scope for more efﬁcient and effective prescribing

Figure 26: The cost of Pregabalin per head of population in the UK over the period 2010-2013

£0

£1

£2

£3

£4

£5

£6

£7

£8

£9

£10

Northern IrelandWalesScotlandEngland

2010

2012 20132011

£3.98

£3.78

£4.51

£9.43

Source: HSC Board

4.34 NICE initially recommended

pregabalin (or amitriptyline) as a ﬁrst-

line treatment in its early guidance on

the pharmacological management

of neuropathic pain published in

2010. But within 18 months withdrew

this recommendation. Guidance

subsequently published in 2013 is that

pregabalin is one of three drugs to be

considered in ﬁrst line treatment.

4.35 Given the additional cost incurred

by prescribing pregabalin, and the

potential for it to be ‘abused’, it is

not clear why pregablin is so heavily

prescribed in Northern Ireland. In 2013,

the opportunity cost to local health and

social care services of not prescribing

pregablin at a similar rate as the rest of

the UK was £9.7 million. During 2012

it was £8.5 million.

Primary Care Prescribing 57Primary Care Prescribing 57

4.38 We acknowledge that GPs have

succeeded in generating signiﬁcant

savings in prescribing costs over

recent years by moving from branded

to generic drugs. However, it is clear

also, from the variations we have

found between prescribing practice

here and the rest of the UK, that there

is potential to increase the quantum

of savings even further by focusing on

conditions where there are suitable

drugs available at differing prices. For

instance, on the small range of drugs

we have examined in paragraphs

4.17 to 4.36 we have calculated

that the opportunity cost to health

and social care services here of not

prescribing in a more cost effective

way was over £17 million in 2012

and £15 million in 2013.

4.36 BSO monitors the level of pregabalin

use in NI. In view of its concerns

that usage in NI is higher than is

necessary, it has set a target to

reduce total pregabalin spend by

approximately £1million during 2014.

BSO anticipates that MMAs will play

a signiﬁcant role in ensuring this target

is achieved.

4.37 We note that the HSC Board has

set a target to reduce usage of

pregabalin in NI by £1 million during

2014. However, in our view, this

target is not sufﬁciently challenging.

We consider that, with the assistance

of MMAs, GP practices in NI

could move much more quickly to

prescribing levels elsewhere in the

UK.

4.39 An integrated approach,

encompassing all stakeholders,

is needed to optimise the use of

clinically-appropriate and cost-

effective medicines. It is essential the

HSC Board continues to build on the

work it has been undertaking in the

promotion of efﬁcient prescribing.

Appendices:

60 Primary Care Prescribing

Appendix 1

Generic Drug Categories (paragraph 2.12)

Deﬁnition Price Basis

Category A

Drugs which are readily

available.

Weighted average of the

prices listed by the following

manufacturers and suppliers:

AAH, Alliance Healthcare

(Distribution) Ltd, Teva UK

and Actavis.

Category B

Drugs whose usage has

declined over time.

Price lists from the following

manufacturers or suppliers

are considered strictly in the

following order: Alliance

Healthcare (Distribution) Ltd,

AAH, UCB Pharma and

Thornton & Ross.

The Tariff price is the list price

for the item is that quoted by

the ﬁrst manufacturer or

supplier.

Category C

Drugs which are not readily

available as a generic.

Based on the price of

a particular proprietary

product, or as listed by the

manufacturer or, as the case

may be, supplier.

Category E

Extemporaneously prepared

items, made up of two or

more products listed elsewhere

in the Tariff.

The Tariff price is the sum

of the Tariff prices of the

components.

Category M

Drugs which are readily

available.

The Tariff price is set by the

Department of Health based

on information submitted

by manufacturers under

Scheme M

41 Scheme M is a voluntary scheme for generic manufactures which is designed to assist the Department of Health, England

gather information to support the revision of Category M prices.

Primary Care Prescribing 61

Appendix 2

Legal challenge to new Drug Tariff (paragraph 2.19)

The PCC sought to have the

Department’s decision to introduce the

new Drug Tariff in Northern Ireland

judicially reviewed in 2010. The legal

challenge brought by the PCC was

successful.

In January 2010 the lawfulness of the Department’s

arrangements for remunerating community

pharmacies for dispensing drugs was the subject

of a High Court Judicial Review. The legal

challenge was brought by the Pharmaceutical

Contractors Committee (the PCC)

and two

companies which own and operate community

pharmacies in Northern Ireland.

The judge concluded that the 1994 agreement

to follow the Scottish Drug Tariff (which was

based on the English Drug Tariff) reﬂected the

view of the Department and the PCC that it fairly

remunerated pharmacists. He noted that by 2001,

the Department had become concerned that

the remuneration being provided to pharmacists

was excessive. However, he considered that the

Department’s decision to make a compensatory

payment of over £6 million in 2006-07 was

evidence that it accepted that the revised

arrangements did not fairly reimburse pharmacists.

The judge considered that once it became

apparent to the Department that the Drug Tariff was

not fulﬁlling its statutory purpose, it had a legal

obligation to resolve the situation. While accepting

that the Department took steps to remedy the

position, the judge was critical of the Department

for failing to calculate and offer a compensatory

amount for the 2007-08 and 2008-09 ﬁnancial

years.

42 On 15 June 2005, the Pharmaceutical Contractors Committee (PCC) became a Company Limited by guarantee.

On 24 March 2011, the company changes its name to Community Pharmacy NI (CPNI) to reﬂect and represent its

expanded remit.

43 The CPNI represents all of Northern Ireland’s community pharmacy contractors negotiations on services, the pharmacy

contract and remuneration and reimbursement with the Health and Social Care Board (HSCB) and the Department of

Health, Social Services and Public Safety (DHSSPS).

The judge ruled that the failure to reach agreement

with the PCC did not excuse the Department from

its obligation to provide reasonable remuneration

to pharmacists (for past and future periods).

Concluding that the Department was continuing to

fail in complying with its statutory obligations, he

declared that the arrangements at that time were

unlawful.

The 2010 Judicial Review led to extensive

negotiations between the Community Pharmacy

Northern Ireland (CPNI)

and the Department. This

resulted in the signing of a provisional agreement

in July 2010. The provisional agreement provided

for interim, non-recurrent monthly payments to

contractors from 1 April 2010 to 31 March

2011. The agreement highlighted that it was

incumbent on all relevant parties to work to have a

fair and reasonable remuneration model in place

by 31 March 2011. Finally it was made clear that

if agreement could not be reached the Department

would be legally obliged to implement a fair and

reasonable solution.

No agreement could be reached and, on 1 April

2011, following consultation on the outcome

of an external review of community pharmacy

remuneration in NI which recommended the

introduction of the English Drug Tariff in NI, the

Department introduced a revised Drug Tariff. In

December 2011, the CPNI brought a second

judicial challenge against the Department.

62 Primary Care Prescribing

Appendix 2

Legal challenge to new Drug Tariff (paragraph 2.19)

44 NI - True Costs of NHS Pharmacy, The Tribal Report, 13 January 2011.

The CPNI sought a second Judicial

Review of the Department’s decisions

when it unilaterally introduced a

revised Drug tariff in 2011. This

second legal challenge brought by

PCC was also successful.

The Department, having an awareness of the

importance of obtaining access to reliable and

up-to-date market information employed an external

consultant

to provide advice. The consultant was

tasked with developing a methodology, model and

working prototype:

• to support the development and

ongoing maintenance of a new NI

Drug tariff which could be adapted

or reviewed to reﬂect changing

circumstances; and

• to support the assessment of the

return on investment required by

community pharmacists to achieve

fair and reasonable funding for

the delivery of their NHS service

contract.

In October 2010, the consultant reported that any

amended NI Drug Tariff should adopt the English

model as a reference source. It acknowledged

that the model would require adjustment to reﬂect

the different conditions in Northern Ireland and

highlighted that there were various areas were

Northern Ireland-speciﬁc data would need to

be gathered in order that appropriate, informed

adjustments could be made.

Having considered the evidence the judge

concluded that:

• the Department failed to carry

out sufﬁcient consultation and

investigation to enable it to compile

and publish a Drug tariff which

complied with statutory objectives,

including the objective of ensuring

fair and reasonable remuneration for

pharmacists, in particular, it failed to

carry out any costs surveys or any

margins survey, or to use available

alternative powers to establish key

information about the costs and

proﬁts of pharmacy business in

Northern Ireland;

• the respondents failed to carry

out sufﬁcient consultation and

investigation to enable them to

identify the need for (and arrange

for the implementation of) any

necessary adjustments to the English

Tariff model in light of conditions in

Northern Ireland, with the objective

of ensuring fair and reasonable

remuneration for pharmacists here;

and

• the Department erred in failing

to carry out a Regulatory Impact

Assessment (RIA) and that error

constituted a breach of the

applicant’s legitimate expectation that

an RIA would be conducted in the

present case and resulted in potential

loss of relevant information.

Primary Care Prescribing 63

In summary the legal challenge brought by the

CPNI was successful. While the judicial review

clariﬁed the Department’s statutory obligation to

provide fair and reasonable reimbursement and

remuneration, the judge did not quash the extant

NI Drug Tariff (as requested by the CPNI) or

impose any ﬁnancial penalty on the Department.

As a consequence of the second Judicial Review,

the Department was required to conduct a Cost of

Service Inquiry and an On-going Margins Survey

for NI. These exercises are on-going.

The Department and CPNI agreed an interim

ﬁnancial arrangements covering the two year

period to 31 March 2013. Agreement was also

reached that no RIA was required for this period.

The NI Drug Tariff continues to reﬂect

reimbursement costs in England and Wales and

is key to ensuring that the cost of medicines in NI

is not excessive (compared to other UK regions).

The application of English Tariff prices supports the

current policy position that NI is part of a UK-wide

Drugs Markets with access to the same medicine

prices as the rest of the UK.

Community Pharmacists received

£6 million compensation in 2006-

07. Additional non-recurrent

remuneration of some £40 million

was paid to community pharmacists

over the period 2007 to 2011.

Since the implementation of Category M in NI

in 2006, CPCs have received £6 million in

compensation in recognition that the revised

arrangements have resulted in lower reimbursement

rates for community pharmacists. Additional non-

recurrent remuneration of some £40 million was

paid to community pharmacists as part of an

agreed interim position covering the period 2007

to 2011.

Further agreement was reached following the

outcome of the second judicial review. On the eve

of an Appeal Hearing, community pharmacists

agreed to participate in the Cost of Service

Inquiry and the On-going Margins Survey and

waived the need for the Department to produce an

RIA. Elements of the funding provided under this

further agreement remain subject to retrospective

clawback subject to the outcome of the on-going

reviews.

Additional Payments to Pharmacy Contractors over

the period 2006 to 2013

Year Additional

Payments

(£ million)

2006-07 6

2007-08 to 2010-11 40

Total 46

Source : DHSSPS

64 Primary Care Prescribing

NIAO Reports 2013-2014

Title Date Published

2013

Department for Regional Development: Review of an Investigation

of a Whistleblower Complaint 12 February 2013

Improving Literacy and Numeracy Achievement in Schools 19 February 2013

General Report on the Health and Social Care Sector by the Comptroller

and Auditor General for Northern Ireland 5 March 2013

Northern Ireland Water’s Response to a Suspected Fraud 12 March 2013

Department of Culture, Arts and Leisure: Management of

Major Capital Projects 22 March 2013

Sickness Absence in the Northern Ireland Public Sector 23 April 2013

Review of Continuous Improvement Arrangements in Policing 3 September 2013

The Agri-Food and Biosciences Institute (AFBI) 12 September 2013

Tackling Social Housing Tenancy Fraud in Northern Ireland 24 September 2013

Account NI: Review of a Public Sector Financial Shared Service Centre 1 October 2013

DOE Planning: Review of Counter Fraud Arrangements 15 October 2013

Financial Auditing & Reporting 2013 5 November 2013

The exercise by local government auditors of their functions in the

year to 31 March 2013 19 November 2013

Department for Regional Development: Archaeological Claims Settlement 3 December 2013

Sport NI’s Project Management and Oversight of the St Colman’s Project 10 December 2013

2014

The Future Impact of Borrowing and Private Finance Initiative Commitments 14 January 2014

Improving Pupil Attendance: Follow-Up Report 25 February 2014

Belfast Metropolitan College’s Titanic Quarter PPP Project 25 March 2014

Safer Births: Using Information to Improve Quality 29 April 2014

Continuous Improvement Arrangements in Policing 6 May 2014

Improving Social Housing through Stock Transfer 3 June 2014

Managing and Protecting Funds Held in Court 1 July 2014

Modernising beneﬁt delivery in the Social Security Agency’s

local ofﬁce network 11 November 2014

Local Government Auditor’s Report - 2014 18 November 2014

Primary Care Prescribing 67

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