Monday, 1 November 2010

Committee for Responsible and Appropriate Prescribing (CRAP)

I was going to continue my blog exploring what other gems are hidden away in the white paper but I’ve changed my mind (its my blog and I can do that). In the news today it was announced that the National Institute for Clinical Excellence is to be stripped of its power to decide on which new drugs get the nod for NHS prescribing.

Instead that dubious honour will be given to GPs. So in addition to looking after their own patients, managing the practice, juggling the budget for the NHS as a whole they will now take on this role too. NICE will be relegated to giving out advice about drugs and creating guidelines (a bit like the Drug and Therapeutics Bulletin does).

NICE was independent of government influence and made decisions based on a combination of the clinical effectiveness of a drug and its overall cost. NICE got in trouble after patient groups (more often than not funded by drug companies) and the media would criticise them for not recommending drugs that it deemed to be clinically ineffective or of marginal benefit but v.expensive. It’s a tricky thing that I don’t think the public fully appreciates. The NHS is not a bottomless pit of cash. It has a finite drug budget – once gone then that’s it. The overall NHS budget for the next year has been increased to 0.5% but taking into account the annual inflation of NHS costs that amounts to about a 5% cut. Not only that but the government expects the NHS to find £20bn in efficiency savings over the next 4 years.

NICE was created, in part, to get rid of a postcode lottery of drug prescribing. Some PCTs would approve expensive treatments, some wouldn’t. NICE created a level evidence-based playing field that everyone could stick too. Doctors like having an independent body we could turn to that offered expert opinion on new drugs (even if it was a bit slow at times). Now various GP prescribing groups up and down the country will have to take on the role of evaluating drugs and deciding what’s allowed and what’s not. Should a patient get drug X that costs £20k per year and might increase life expectancy by 4months or should 1000 patients get drug Y that costs £20 per year that reduces the risk of heart disease? What do you say to patient(s) you decline? What do GPs say to the lobby groups that will no doubt start nagging them about some new fancy experimental drug? What do GPs do when the media paints them as fat cat GPs not allowing drugs as they are penny-pinching? How will GPs feel when the government blames them for spiraling NHS budget costs?

GPs will have to form committees to decide which new drugs get the nod or not. I suggest it’s called the Committee for Responsible and Appropriate Prescribing (CRAP). Of course there wouldn’t be a national one (otherwise why get rid of NICE’s powers) so no big CRAP. Instead there will be lots of regional ones – lots of little CRAPs. Which GPs will want to be in the CRAP? Will patients understand the CRAP rulings? It feels like GPs have been given more crap then they can possibly handle. I’m trying to recall the all the health economics training I got as a GP. Oh that’s right, there isn’t any.

Perhaps I am being a tad negative. GPs could with their new powers get rid of a lot of duplication in prescribing. For example funding for one or two types of a class of drug rather than several, or cutting funding for isomerised versions of drugs. I wonder what would happen if a CRAP group wanted to allow prescribing of Heroin?

The degree of change going on the NHS is quite staggering considering the government said that they wanted a hands off approach to the NHS originally. It was a scary enough prospect considering becoming a GP partner and managing my own practice and small budget. Now being expected to sort out the NHS budget and take over the role of NICE is quite frankly terrifying. I think I’ll stick to being a locum for the time being.

Actually on second thoughts any GP involved in a CRAP will no doubt get some hefty backhanders from drug companies so its not all bad…


  1. Brilliant! Getting rid of NICE makes no sense to me apart from fitting with laissez-faire end of NHS.

  2. Lunacy. Where did the idea GPs should run everything in the NHS come from in the first place? What was so wrong that it all ne3eeded devolving to people who dont want the job?

  3. The idea you have proposed in the post seems to be practical if implemented with proper rules and regulations. Meanwhile Appraisal for Doctors is already here to keep a check and balance on the practice of doctors.