|Control of medicines use at University College London Hospitals Trust (UCLH)
Drug and Therapeutics Committees are an important source of independent medicines information and prescribing guidance and control. Such Committees include representatives from all groups involved in prescribing, including representatives from local PCTs and at UCLH there is also a lay member.
The Committee evaluates applications submitted by consultants or other prescribers to include new drugs on the local formulary by examining clinical trials and other evidence relating to the medicines. Information on efficacy, safety, cost and ease of use are considered, according to a hierarchy of evidence. A decision is made to accept the application, decline it or request further information. Guidance on dose and duration of treatment is given. This information is invaluable, particularly because doctors are usually unaware that the licensing process does not consider the comparative efficacy of drugs.
At UCLH - where the Drug and Therapeutics Committee is known as the Use of Medicines Committee (UMC) - approximately 50% of applications are accepted. The onus is on the applicant to provide information, although the pharmacist will check that a comprehensive data set has been provided. The Hospital Management Board ratifies decisions.
Advice given by the UMC may be more stringent than NICE guidance. The line taken by UCLH on the prescribing of COX-2 inhibitors, for example, was much more restrictive than that of NICE, and preceded the NICE advice by several months. The Committee produced a leaflet on COX-2 inhibitors, explaining the decision on recommended prescribing limitations. As a result, prescribing levels, particularly in the local PCTs (primary care being a strong driver for the use of COX-2 inhibitors), was lower than the national average.
Unusual prescribing patterns, or sudden changes in prescribing rates of particular medicines, may not be immediately identified and addressed by UMCs, however. It seemed anomalous that the electronic production of prescriptions that is in place in most PCTs is not present in hospitals and that there is no centralised record of drugs prescribed and dispensed in hospitals.
Although all NHS trusts are required to have a Drug and Therapeutics Committee (or equivalent), there is no standard structure, membership, processes, powers or terms of reference. The UCLH UMC counts clinical pharmacologists and specialist pharmacists among its members. However, this is not true for many such committees, particularly in small trusts with limited clinical pharmacology and pharmacy support. Furthermore, many PCTs do not have medicines management committees with the scope and influence of secondary care trusts' Drug and Therapeutics Committees.