THE PRESCRIBING ADVISERS in Primary care represent one of the industry’s biggest challenges. In the second part of this topic, Omar Ali explores some key aspects on the agendas of prescrib-ing advisers and how this affects interactions with the pharmaceutical industry. This article gives examples of The Good, The Bad and the Ugly, joint working, pharma relations and key agendas are explored. Omar also asks the question: Why do some pharmaceuti-cal advisers have a no-see policy ?

Key Agendas
Pharmaceutical Advisers broadly speaking have three agendas that drive their main activities:

• Prescribing Cost – Containment within the Drug Budget
• Evidence Based Prescribing
• Clinical Risk Management in Prescribing

Whilst each of the agendas are driven from key-government documents, the cost-containment is the direct measure of the Prescribing Adviser’s abil-ity to exert control, influence and accountability of his/her activities. Let’s take a closer look at each agenda…

AGENDA 1: Prescribing Cost – Containment within the Drug Budget
ACTIVITIES DRIVEN BY AGENDA 1
• Financial planning of drug budget
• Listing and targeting Top 10 expenditures (absolute cost terms) Listing and targeting Top 10 rate of increasing expenditures (in cost relative terms)
• Horizon Scanning of New Drugs & Managed Entry of Molecules at Launch (often in an attempt to pre-empt or neutralise marketing campaigns)
• Therapeutic Swaps of given classes (PPIs, CCBs, Inhaled Steroids) where it is felt significant patient numbers may be treated with a differ-ent agent within a class at a significant cost reduction.
• Scanning therapeutic classes which are under national priority for cost-reduction or improved cost-effective prescribing (ie) The DoH website encourages Prescribing Advisers to nationally target and prevent overuse of : antibiotics, SSRIs, Sartans:ACEI ratio, PPIs
• Securing Funding for NICE drugs. Rejecting funding for NICE drugs not being used within NICE guidance (ie) monoclonal antibodies, tenecteplase

AGENDA 2: Evidence Based Prescribing
ACTIVITIES DRIVEN BY AGENDA 2
• As there is much prescribing that is NOT evidence based, and given the fact there are not many pharmacists per PCT, to try and keep all prescribing evidence based is almost impossible
• SO – we target evidence based prescribing in those areas which are EXPENSIVE !
• Example : ALLHAT STUDY : Reinforcing bendrofluazide is 16x cheaper than amlodipine. The company line is that amlodipine is as effec-tive as bendrofluzide. Data is the same. Message is different.

Example : INHALED STEROIDS : Reinforcing BTS Guidelines and that combined steroids/beta-agonist is not step 1 or 2! Company lines vary but there is a feeling (right or wrong) that some companies encourage combination products earlier in disease and also that high dose steroids are over marketed. Probably not true but the perception is there without question.

• Practice Guidelines : PCT Formularies are rife now, with incentives and guidance and even some very heavy handed clinical governance rods to beat the GPs with!

AGENDA 3: Clinical Risk Management in Prescribing
ACTIVITIES DRIVEN BY AGENDA 3
• Even the most evidence based cost effective drugs will have elements of clinical risk

Example : infliximab requires concurrent treat-ment with methotrexate. In many cases, the methotrexate is not being monitored, neither is the liver function or the full blood counts. Consultants are too busy to recall them and GPs complain it is too specialised to follow up. Interestingly, a new agent from Abbott Labora-tories may be the answer for these rheumatoid patients…

Example: The glitazones have been well promoted, understood and are being prescribed. However, GPs are generally reluctant to initiate therapy. So despite prescribing power in primary care and all the budgets based at the PCT, unless diabetologists are starting, monitoring and following up patients, only those GPs with specialist interest in glitazones are initiating therapy. As they cost £27-£57 per patient per month you may find prescribing advisers toler-ating their use but they certainly won’t be encouraging their GPs to use them. Here the PCT adviser may use an evidence based argu-ment to stop the use of an expensive drug

WHY DON’T SOME PHARMACEUTICAL ADVISERS SEE REPRESENTATIVES FROM THE INDUSTRY?
REASONS THEY WILL GIVE…
• “The data supplied by a representative is biased.” It is a company’s job to promote its product in the best light.
• “I haven’t got time.” Representatives must remember that they are paid to see customers. I am not paid to see members of the industry. So my ‘job description’ and ‘timetable’ will not allow for this unless I decide to do so.
• “The industry is just in it for the money.” Many companies are tailoring their activities with the intention of really looking at the NHS and what is required with a view to joint part-nerships. Having said that, most representatives are not bonused on relationships with customers but are bonused on sales (RSA, Market Share, % target)
• “Decision Makers are best kept at an arms distance from the Drug Industry.” Current debate of the day. Please read NO FREE LUNCHES BMJ May 2003. The whole issue is dedicated to this statement. It seems the USA, UK and much of Europe is asking this same question in different ways …

THE REAL REASONS WE DO NOT SEE REPRESENTATIVES !!!
As a prescribing adviser, if I look down on my PCT with a helicopter view, how do I see the Pharma-cuetical Industry? If they were all radioactively labelled, I would see hundreds of little ‘green ants’ running around from practice to practice, seeing GPs and telling them ‘what to prescribe’.

As a prescribing adviser, if I look with my own PCT what is MY JOB? I am effectively a lone ant (with 1 or 2 helper ants), running around from practice to practice, seeing GPs and telling them ‘what to pre-scribe’

CAN YOU SEE THE PROBLEM? WE DO THE SAME THING, WE ARE COMPETING DIRECTLY
This is different from your relationships with any of your other customers, and it is why Pharmaceutical Advisers and Pharmaceutical Representatives will always have a tenuous relationship.