Medicines - achieving value and sustainability in prescribing: guidance

Achieving Value and Sustainability in Prescribing

Executive Summary

This guidance aims to reduce the use of low value medicines and ensure the effective use of medicines with limited clinical value throughout NHS Scotland. It also aims to ensure best value in the choice of blood glucose monitoring strips and insulin pen needles and to ensure the most effective use of antimicrobials (antibiotics) to minimise the risk of antimicrobial resistance. It provides guidance for NHS Health Boards and clinicians, to minimise the unwarranted variation in the prescribing of medicines and make the most efficient use of resources. It supports the principles of Realistic Medicine through shared decision making, encouraging medicine review, and ensuring medicines with low or limited value are not prescribed inappropriately.

This guidance was produced by an expert working group of the Value and Sustainability Prescribing Group and is predominately based on the NHS England policy guidance: Items which should not routinely be prescribed in primary care and the NHS Wales Medicines identified as low priority for funding in NHS Wales documents. It also includes items which have been requested by Health Boards within NHS Scotland.

Delivering value based health and care: a vision for Scotland defines

value-based health and care (VBH&C) as the equitable, sustainable, and transparent use of resources to achieve better outcomes and experiences for every person in Scotland. The aim is to reduce unwarranted variation and maximise the value of healthcare, to achieve the outcomes that matter to the individual and to lead to a more sustainable health care system. NHS Scotland has finite resources; therefore, it is important to ensure their optimal use to reduce waste, harm, and unwarranted variation.

Across Scotland there is significant variation in what is prescribed and to whom, and there are often more effective, safer, or cost-effective alternatives available. Good prescribing dictates that the choice of therapy should be made in discussion with the individual and on the basis of good clinical evidence of efficacy, safety, value and acceptability. It is good practice to prescribe the best value preparation available for the most appropriate duration, and to prescribe solid dosage forms where appropriate for cost, environmental and safety reasons. For example, effervescent analgesic preparations are high in salt content and often more expensive than standard tablets.

Cost-effectiveness of Diabetic Sundries

Included as a section in this guidance are insulin pen needles and blood glucose monitoring strips. Although clinically effective these have been included as they offer low value to the NHS above the cost limits stated as there are a variety of more cost-effective alternatives available.

Antimicrobial Stewardship

A further section of this guidance promotes the safe, effective and sustainable use of antimicrobials. Although antimicrobials are medicines of high clinical value they can be prescribed inappropriately, e.g. where not indicated (viral infection), or for longer than the recommended duration.

The aim of this section is to provide recommendations on the effective prescribing of antimicrobials. It complements the work of the Scottish Antimicrobial Prescribing Group (SAPG), who promote the safe and effective use of antimicrobials across hospital and community settings to improve antimicrobial stewardship and tackle the risks of antimicrobial resistance. It includes recommendations on the appropriate use of antibiotics, appropriate duration and advice on prescribing solid oral dosage forms instead of liquid or injectable preparations. These will minimise both environmental and financial cost.

Prescriber Responsibilities

Prescribers are encouraged to have due regard for this guidance when considering prescribing the items included. However, it does not remove the clinical discretion of the prescriber in discussing and agreeing the most suitable treatment for individuals in accordance with their professional duties and to minimise harm or unintended consequences. For example, this may include prescribing medications in the limited section where there are no suitable alternatives. A person-centred approach to care should be taken, with discussion of the risks and benefits of available treatment options. If the indication is outside the recommendations of the medicines marketing authorisation, this alters the prescriber’s professional responsibility and potential liability. The prescriber should be able to justify and feel competent in using this medicine, and also inform the patient or the patient’s carer that the prescribed medicine is unlicensed for this indication.