El outsourcing y la ventaja competitiva empresarial de la experiencia se corrobora la implicancia del Outsourcing en la Ventaja

The Audit Commission was set up by the Government in the eaiiy 1980s to audit and assess whether local authorities were delivering value for money. The Commission was to promote economy, efficiency and effectiveness. The Govermnents white paper on the NHS published in 1989 amiounced that the Audit Conmiission was to talce on the external audit of the health service. The responsibility began on 1st October, 1990 (Smith, 1990). The Audit Commission uses 3 criteria in deciding which issues to study, these are:-

1. The issue must cany substantial financial costs, 2. There is an opportunity to achieve improvements, and 3. There is the possibility of change, (Smith, 1990).

The NHS drugs budget fulfils all 3 criteria and as the laigest proportion of the NHS dmgs budget is accounted for by medicines prescribed by GPs it is not surprising that this became the focus of an Audit Commission evaluation.

A report of the GP study (Audit Commission, 1994) stated that more rational prescribing by GP's would lead to better quality caie for patients and to major economies in drug expenditme. It was suggested that a saving of £425 million would be made thioughout England and Wales if all doctors were to prescribe in a cost-effective manner similai* to those GP practices classed as 'good' prescribers in the evaluation. The report identified opportunities which could lead to better patient caie and more effective use of NHS resom'ces. One of the areas of patient care identified which required increased drug expenditme was that of the preventative treatment of astlima. It was estimated that if all GP's were to increase their prescribing of inlialed steroids for preventative treatment to 50% of the prescribed bronchodilator rate, then drug expenditme would increase by £75 million. However, it was considered that it would be cheaper for the NHS as a whole as fewer patients would be admitted to hospital with severe astlima attacks or complications. Each year 2,000 people die in the UK as a result of an asthma

attack, of which 80% aie avoidable. It was also felt that there was a general under diagnosis of clnonic conditions which if reversed would have additional prescribing resomce implications (Audit Commission, 1994). Table 2.3 summaiises the opportunities for rationalising resources as identified by the Audit Commission.

Table 2.3 Opportunities for more rational prescribing with implications for resources (from Audit Commission, 1994)

Opportunity for modification Resource implication (compared to 'good' prescribers)

Over prescribed drugs £295 million saving Less prescribing of drugs of limited therapeutic

value

£45 million saving Substitution of alternative drugs £25 million saving More generic prescribing £50 million saving More selective use of expensive formulations £30 million saving

More inlialed steroids for astlima £75 million spending increase Additional prescribing resulting from a reduction

in the under-diagnosis of cln onic

£ not estimated

Hospital/GP interface and cost-shifting

GP prescribing is influenced by medicines initiated in hospital or recommended when patients are referred to hospitals for an opinion. The frill expenditme implications are difficult to quantify (Audit Commission, 1994). There aie two reasons why hospital doctors prescribing behaviour should initiate more prescribing, and more expensive prescribing amongst GP's than is necessary. Firstly, drugs may be available at a lower price in hospitals tlian in the FHS (primaiy care) sector. The drug companies offer 'loss-leaders' to hospital pharmacies at an artificially low price so that the drug replaces others, which aie often cheaper in the primary caie sector, in the hospital formulary. Because hospitals aie cash limited there has been a strong incentive to persuade their doctors to prescribe the cheapest, clinically appropriate dmgs. Formulaiies are used to limit or guide their choice. By offering 'loss-leaders' the drug companies

are attempting to get then products initiated by the hospital based doctors (Wolfson et al, 1983). When a patient goes to the GP for Huilier prescriptions it is very difficult for the GP to change the prescription even if there is a cheaper and equally effective alternative as the patient sees the consultant as the ultimate decision nialcer on therapy (Health Committee, 1994). Lower hospital drug prices may also result from hospitals using their position as bulk puichasers to negotiate lower prices. Wliichever way the hospital drug price is lowered, the drug company will attempt to recoup lost profit' by raising the price of their dmgs in the prhnary caie sector (Wolfson et al, 1983). Secondly, hospital drugs budgets aie cash limited whereas those of FHSAs aie not. Although fundholders have specific budgets, the majority of GP's (non-frmdholders) are subject to looser financial limits in their spending on medicines. They do have taiget budgets but as already explained there is a contingency budget for overspends This has provided an incentive to the hospitals to shift prescribing on to FHSA's in order to remain within their budgets. The lack of a unified system of funding between the primaiy caie sector and the secondary care sector has led to a cost-shifting approach. Many drugs initially prescribed for patients by hospital doctors ai'e continued for some yeai's after dischaige. The authors of one study (Jackson, 1993) estimated that between 15 to 20% of GP prescribing is hospital initiated; in total 40% may be strongly influenced by hospitals, since a GP's choices of drugs when prescribing for their own patients aie also likely to be guided by local consultants. In addition to the ubiquitous di'Ugs, GP's have been increasingly called upon to prescribe expensive specialist drugs to tieat more exotic conditions that until recently would have been treated by hospital doctors. These include treatments for infertility, growth deficiency, malignant disease and HIV; also drugs used as adjuncts to organ transplantation, cancer chemotherapy and home dialysis. Nationally, such 'high-tech' drugs, normally prescribed only imder specialist supervision, now represent 4% of GP prescribing expenditure, although there are big local variations (Audit Commission, 1994). GP expenditure on these drugs rose by 20.5% between 1991/92 and 1992/93. The Audit Commission (1994) recommended that the FHSA and DHA should jointly agree with the medical professions the circumstances in which such expensive drugs should be provided

on tlie NHS and who should be responsible for tlie cost. It was considered that GP's should not be asked to malce political decisions on an ad-hoc basis. A flulher recommendation by the Audit Commission (1994) was for the prices at which drugs aie reimbursed in the commmiity to be talcen into consideration when agreeing regional purchasing contracts and when compiling and reviewing hospital formularies. Formulaiies should distinguish di'ugs considered suitable for routine prescribing by GP's from those intended primarily for specialist hospital use and that both sets of drug prices, hospital and commmiity, should be shown. The Audit Commission report frequently referred to the need for cost-effective prescribing and considered that 'FHSAs should continue to foster the realisation that prescribing decisions must be taken within the context o f the overall resources available to the NHS'.

The reconmiendations of the Audit Commission aie not mneasonable and can be practically put into operation. The inclusion of GP's and FHSA medical advisers on the drugs and therapeutics committees of major hospitals aie a useful way of ensming that commmiity interests are represented in hospital decisions about inclusion of new drugs in formulaiies or about prescribing responsibilities. Smrey is one FHSA that has promoted the formation of a joint co-ordinating committee on which all hospital miits in its area are represented and which talces the lead on issues of common interest to the commmiity (Jackson, 1993). However, joint general practice/liospital formularies are tliiii on tlie gromid, a survey of acute general hospitals in the UK found that although 90% had a formulary, less than 4% operated a joint one (Joshi et al, 1994). The Grampian formulaiy, which was completed in 1992 (Ferrow et al, 1996), was one of the first reported joint general practice/liospital formularies and although compliance with the formulary by Grampian GPs is volimtary, it appeal's to be worldng quite well. A recent smvey (Ferrow et al, 1996) showed 84% of drugs being prescribed to patients admitted to local hospitals were joint formulary items. All Scottish Health Boaids were supposed to implement joint formulaiies by the end of 1995 but it is difficult to assess whether this has actually happened because the only published paper advertising this event is the one for Grampian region (Ferrow et al, 1996).