Education And Debate

Transferring the costs of expensive treatments from secondary to primary care

BMJ 1995; 310 doi: (Published 25 February 1995) Cite this as: BMJ 1995;310:509
  1. B J Crump, director of public healtha,
  2. R Panton, professor of pharmacyb,
  3. M F Drummond, professor of economicsc,
  4. M Marchment, chief executived,
  5. R A Hawkes, general practitionere
  1. a South Birmingham Health Authority, Birmingham B15 3DP
  2. b Keele University, Keele, Newcastle under Lyme, Staffordshire ST5 5BC
  3. c University of York, York YO1 5DD
  4. d Premier Health Trust, Burton on Trent, Staffordshire DE14 2AU
  5. e Tamworth, Staffordshire B79 7JN
  1. Correspondence to: Dr Crump.
  • Accepted 30 December 1994

General practitioners, especially fundholders, are becoming increasingly concerned about being asked to prescribe treatments for their patients that are outside their therapeutic experience. They are concerned about the clinical responsibility for such prescribing and the effects on their budgets. In some specialties transferring the costs of expensive treatments from secondary to primary care (cost shifting) has become partly institutionalised because of the separate sources of funding for drugs prescribed in the two sectors. With increased efforts to control the rising costs of the drugs budget and the emergence of new expensive treatments, cost shifting will be a challenge to clinicians and purchasers as they strive for rational, cost effective prescribing. A review of the funding mechanisms for drugs prescribing and of the relation between the licensing process and the decision to support the use of a treatment in primary or secondary care is needed.

For many years hospital doctors have worked to strictly cash limited budgets, but only with the introduction of fundholding have some general practitioners had cash limited drug budgets. Since the introduction of prescribing analysis and cost (PACT) data general practitioners have become more aware of the unit cost of individual drugs and begun to identify the extent to which prescribing initiated by hospital consultants has affected their overall budget. These factors have led some general practitioners to become increasingly concerned at being asked to write prescriptions for particular treatments when they have not been part of the decision making for their use and when clinical monitoring continues at the hospital.

In some areas of care, such as the management of chronic renal failure, transferring the cost of prescribing from cash limited hospital budgets to the primary care prescribing budget (cost shifting) has become partly institutionalised. In this and other therapeutic areas shared care protocols have been …

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