PUs were developed to take account of the greater need of elderly patients for medication when reporting prescribing performance at both practice and Health Authority (HA) level. Patients aged 65 and over are counted as three prescribing units and patients under 65 and temporary residents as one.

Introduced in 1993 as a more sophisticated weighting system than PUs, with a greater number of age bands. In the light of further research the weightings of the age bands were adjusted in 1997. These are known as ASTRO(97)-PUs.

The ASTRO-PU weightings for patients in Residential Homes are twice the value of the corresponding patients in their own home, and for Nursing Homes, three times the value.

ASTRO-PUs are devised from the total of all drug costs. STAR-PUs have been developed along similar lines but based on costs within therapeutic groups. STAR(97)-PUs have been developed for the eight leading therapeutic groups, i.e. gastrointestinal, cardiovascular, respiratory, central nervous system, infection, endocrine, musculoskeletal and skin, which together account for 85% of prescribing in England. The weightings are based on cost rather than on the number of prescription items.

A system developed and maintained by the World Health Organisation (WHO). Each drug is given a value that represents the assumed average maintenance dose per day for a drug used for its main indication in adults. The DDD is a unit of measurement, not a recommended dose, and may not be a real dose.

Whereas the DDD is defined by international prescribing habits, the ADQ is based upon the prescribing behaviour within England. It represents the assumed average maintenance dose per day for a drug used for its main indication in adults. The ADQ is an analytical unit used to compare treatment activity, and not a recommended dose.

A unit of measurement which is the assumed average maintenance dose per month for a drug used for its main indication in adults.

Average daily amount actually prescribed by a specified group of prescribers. Difficult to determine using Prescription Pricing Authority (PPA) data alone as the duration of each item is not available. Therefore, need to use sample databases, such as the General Practice Research Database, which contain this information. The PDD is an analytical unit, and may not be a real dose.

A single entry on a prescription form. This can be for a single tablet or many tablets. Items are not a good indicator of total use unless total amounts are also being considered. Counting of items can be of great value in measuring the frequency of prescribing and this is relevant to treatments given largely, or entirely, in courses, e.g. antibiotics and immunisations.

The Jarman underprivileged area (UPA) score is used in the NHS for planning and to weight capitation payments to General Practitioners (GPs). It is readily available by electoral ward from the public health common dataset. The score is the weighted total of eight transformed and standardised census variables and can be used to rank areas in order of deprivation; a score of 0 is the mean for England.

The eight variables are the ward percentages of elderly people living alone; households with children under five years; one parent families; unskilled manual workers; unemployed people; overcrowded households; residents who have changed address in the previous year; and head of household born in the new commonwealth. An area with a larger score is more deprived than one with a lower (including a negative) score.

A measure of deprivation based upon claims for exemption from the prescription charge on the grounds of low income.

Measure of deprivation that is the largest single predictor, after age and sex profile, of difference between drug expenditure between HAs. It accounts for about 57% of the observed difference. Based upon those reporting themselves as `off work' because of permanent sickness. It is a direct measure of morbidity.

This index of deprivation is based on car ownership, unemployment, overcrowded housing, and housing tenure and reflects levels of material deprivation.

As a result of workshops held for medical and pharmaceutical advisers the following Prescribing Toolkit reports were developed by the PPA:

Top 40 drugs by size of potential saving at national level.

Top 30 drugs by size of potential saving at HA level.

Top 20 drugs by size of potential saving at practice level.

Currently seven performance indicators are contained within the Toolkit:

Expenditure on drugs of limited clinical value (as defined by the Audit Commission).

Expenditure on premium priced products - modified release (all systems of sustained release).

Expenditure on premium priced preparations - combination products.

Benzodiazepines - DDDs per CNS STAR-PU.

Cost per DDD - inhaled corticosteroids.

DDDs for inhaled corticosteroids per respiratory STAR-PU.

Percentage generic items.

Additional indicators introduced in 1998 are:

DDDs per STAR-PU for oral NSAIDs.

NIC per DDD for oral NSAIDs.

DDDs per STAR-PU for ulcer healing drugs.

NIC per DDD for ulcer healing drugs.

Items per STAR-PU for antibacterials.

NIC per Item for antibacterials.

Number of months of treatment of HRT per woman aged 45-64.

Average cost per month for HRT treatment (NIC/ASTROPU).

http://www.ppa.nhs.uk (via NHSnet)

Removal of an amount of money from a budget before it is allocated generally to individual budget headings. Acts as a pool for related purposes, e.g. incentives and contingencies.

Budgets that are allocated for a single financial year. Not usually used to fund posts, as continued funding can not be guaranteed from one year to the next.

Funds that are received into budgets year on year. Staff salaries are usually remunerated from recurrent funds.

Slippage is the amount of money remaining within a budgetary heading because the intended spend occurred later in the financial year than planned. Therefore only part, if any, of the expected costs for that year are incurred. Slippage is often used as a source of non-recurrent funds.

Used for resource allocation. It represents the number of patients in a population adjusted to take account of various factors, e.g. age, sex, residency status and morbidity.

Budget of limited amount locally; size of budget determined centrally.

Budget not limited locally within a HA but limited within a central DoH budget. The NHS has a financial target within which it has to operate. Overspending was dealt with centrally by the DoH until the introduction of unified budgets, which means that the financial risk is now handled at a more local level.

Strategies by which budgets are used to maximal effect and the impact of any overspend by unforeseen cost pressures is minimised or removed completely (see also clinical risk management).

Basic price of a drug, i.e. the price listed in the Drug Tariff. Used in PACT reports and other analyses to present the prescribing patterns of GPs, PCGs and HAs.

NIC standardises cost throughout prescribing nationally. The NIC of any prescribed item is the same whoever the prescriber may be.

Closer to the true price paid by the National Health Service (NHS). This takes into account NIC minus the discount dispensers are assumed to have received from their suppliers plus container fees.

The discount calculation in PMD (formerly IPS) takes into account discounts across all dispensers. Community pharmacists are assumed to receive a discount from their suppliers. The discount factor assumed for individual pharmacies varies according to the number of items they dispense. However, for the purposes of GP, PCG and HA prescribing budgets and statements, a national average discount percentage is used, based on the total discount calculated.

Similar discounts exist for dispensing practices.

The prices of drugs bought by hospitals or Trusts are determined by negotiation. In some instances this is done by the pharmaceutical company and the hospital pharmaceutical-purchasing manager or by the NHS Supplies Authority on behalf of the hospital. Deals are normally based on bulk purchase. Drug companies can provide items as `loss leaders' to promote that product's use in primary care once initiated in hospital.

In the past, the promise of exclusivity (i.e. an arrangement in which no similar drug produced by a competitor would be stocked) was occasionally used to reduce contract price. Now, however, these linked deals are contrary to European Union regulations.

Reward improvements in patient care and health outcome and link them to clinical governance.

Be internally aligned to avoid the creation of perverse behaviours within the health system (i.e. avoid the possibility that health bodies appear to be performing well while shifting costs or activity between different bodies/budgets).

To reward those PCGs (and their constituent practices) who take on greater levels of responsibility and undertake it in a clinically and cost effective manner.

To operate at the point at which decisions are taken (i.e. reflect the alignment of clinical and financial responsibility).

To reward performance based on achieving higher quality care, effective clinical practice and best value for the resource available. PCGs should ensure any incentive payments to practices are consistent with this principle to ensure surpluses are not generated at the expense of effective patient care.

To operate in an integrated fashion with the local clinical governance arrangements and alongside the incentive arrangements in the other sectors of the new NHS.

To ensure a coherent package of measures designed to reward performance that delivers improved care, and better and more equitable health outcomes for patients.

To ensure the appropriate balance between generating rewards for the effective development of services within the PCG overall and the improvement of services at practice level.

To be simple to operate.

To be sufficiently attractive to health professionals and PCG members to provide motivation to perform well.

To reward good performance at practice level even if the PCG performance overall is poor (recognising that without such performance the overall PCG performance would be worse).

To allow year-on-year improvements in practice performance to be rewarded.

To provide incentives for good performers to help poorer performers improve.

Part 1 NHS services/monies

See Hospital & Community Health Services.

Part 2 NHS services/monies

See Family Health Services.

Quality improvement processes (e.g. clinical audit) are in place and integrated with the quality programme for the organisation as a whole.

Leadership skills are developed at clinical team level.

Evidence-based practice is in day-to-day use with the infrastructure to support it.

Good practice, ideas and innovations (which have been evaluated) are systematically disseminated both within and outside the organisation

Clinical risk reduction programmes are in place.

Adverse events are detected, openly investigated and learning applied.

Lessons for clinical practice are systematically learned from the input of patients.

Problems of poor clinical performance are recognised at an early stage and dealt with, both to prevent harm to patients and to improve the practitioner's development.

All professional development programmes reflect the principles of clinical governance.

The quality of data gathered to monitor clinical care is of a high standard.

www.nhs-fraud.org.uk (General Public)

www.fraud.exec.nhs.uk (NHS Customers via NHSnet)

To `encourage in the United Kingdom, the efficient and competitive development and supply of medicines to the pharmaceutical markets in this and other countries'.

Promotion

Information

Research and development

Manufacture and distribution

Administration.

Information on Medicines: by helping to co-ordinate the provision of effective information on medicines and prescribing related issues to audiences including HAs and their prescribing advisers and GPs. The information is disseminated through various NPC publications such as MeReC Bulletins and Briefings; Connect newsletters; Information Resource documents; New Drugs in Clinical Development and New Medicines on the Market Bulletins (in collaboration with the Drug Information Pharmacists Group, DIPG)

Training and Education: by delivering a co-ordinated programme of events aimed at supporting prescribing advisers and other senior HA professionals and managers; PCG leads, managers and advisers; GPs and other relevant professionals across the NHS. This is achieved through targeted therapeutic workshops, day seminars and national conferences.

Dissemination of Good Practice: by ensuring that HAs, advisers, PCGs and through them their GPs, have a clear understanding of how the wider prescribing agenda is developing and what information and support on evidence-based healthcare, clinical effectiveness and medicine use is potentially of value to the NHS both locally and nationally. This work builds on the HA prescribing initiative database now available, password protected for HA use, on the NPC's web site. Other relevant NPC publications include - `Medicines and the NHS: a guide for Directors' and `GP Prescribing Support: a resource document and guide for the new NHS'. See below for details of the NPC website.

Information Technology: by helping in the development of information systems related to prescribing, and by assessing the potential of new and emerging technologies to aid the work of HAs, advisers, PCGs, Trusts and GPs. The NPC's work builds on developments such as the `Toolkit' initiative produced in collaboration with the PPA and Prescribing Support Unit (PSU), the Hospital Prescribing Information Project and the ePACT training programme.

Informing Research and Initiatives: by continuing to keep HAs, advisers and other relevant NHS staff informed of key information emerging from both the NHS Research and Development, and Health Technology Assessment initiatives.

http://www.npc.co.uk (Internet)

http://nww.npc.ppa.nhs.uk (NHSnet)

Examination, investigation and pricing of prescriptions dispensed in England.

Calculation of reimbursements due to dispensing contractors in the primary care sector and payments to pharmacy contractors.

Prompt and regular provision of information analysing costs and prescribing trends of GPs.

Compilation, publication and distribution on a monthly basis of the Drug Tariff.

Administration of the NHS Low Income Scheme Index.

Investigation in the primary prescribing sector of fraud by patients and contractors, including the promotion of fraud awareness and prevention.

http://www.ppa.nhs.uk (NHSnet)

http://www.ppa.org.uk/

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