A meeting of the Governing Body of NHS Bromley Clinical Commissioning Group 16 November 2017

Transcription

1 A meeting of the Governing Body of NHS Bromley Clinical Commissioning Group 16 November 2017 ENCLOSURE 3 BUSINESS CASE AND SERVICE SPECIFICATIONS FOR THE MEDICINES OPTIMISATION SERVICE (MOS) AND TAILORED DISPENSING SERVICE (TDS) AUTHOR: Abigail Barry, Senior Prescribing Advisor (Interface) DIRECTOR RESPONSIBLE: Sonia Colwill, Director of Quality and Governance CLINICAL LEAD: Dr Chris Fatoyinbo SUMMARY: The contracts for both the MOS and the TDS are due to end at the beginning of June The business case for the re-commissioning of MOS and TDS is presented as one document due to codependencies and is attached alongside proposed service specifications. The service specifications are subject to minor changes. Appendices available electronically Appendix 1 Bromley MOS and TDS Business Case Appendix 2 Draft MOS Service Specification Appendix 3 Draft TDS Service Specification KEY ISSUES: The Bromley Medicines Optimisation Service (MOS) was commissioned in 2016 as a 2 year pilot to inform onward commissioning. This service receives referrals from health and social care professionals to assess and review patients who require support with their medicines, including a clinical pharmacist medication review element which was targeted in one ICN locality. The Oxleas pharmacy team was awarded the contract, with service delivery commencing in May The pilot evaluation report highlights the significant quality improvement and reduction in risk in relation to medicines for patients who have been assessed and reviewed by this service. During a 12 month period, MOS received 1328 referrals, of which 840 were seen for a first visit. The majority required clinical assessment with 2640 clinical interventions being made. 50% of patients were prescribed medicines associated with high risk of hospital admission, with 50% of these being considered at significant risk of harm i.e. approximately 160 patients. An independent panel met to review two groups of high risk patients identified by MOS, those taking high risk medicines associated with hospital admissions and those with significant 1

2 reconciliation errors post discharge. The likely improved clinical outcomes are documented within the business case as well as the significant financial savings, most especially in preventing hospital admissions (circa 354k). The Tailored Dispensing Service (TDS) was commissioned in 2014 from community pharmacy providers for the provision of dispensing adjustments/compliance aids following assessment by the Medicines Assessment and Support Service (MASS), then subsequently the MOS. There are approximately 2000 patients currently supported by TDS services. The contracts for both the MOS and the TDS are due to end at the beginning of June The business case for the re-commissioning of MOS and TDS is considered within this document as there are co-dependencies which require consideration. Recommendations To Governing Body Commission a substantive Medicines Optimisation service as a prime provider model to support mainly high risk/ vulnerable patients to get the best from their medicines whilst reducing avoidable harm from their medicines. Such a service has demonstrated value for money to the health economy. Consideration for service changes should reflect outcomes from the MOS pilot and stakeholder engagement. The service specification/ model has been reviewed with consideration of other similar services and in discussion with the current pilot provider. Re-commission the Tailored Dispensing Service using the Any Qualified Provider (AQP) approach, with additional service requirements which add clinical value to the patient s care alongside the dispensing adjustment. In the event of the commissioning of a substantive MOS and recommissioning TDS the following are applicable: Recommended Key Service Changes to MOS from the current pilot Increased clinical pharmacist resource to be available to all patients during business hours as well as scope additional cohort of patients, those over 70 with 2 or more unplanned admissions within the last 8 weeks. Remove the two levels of service (clinical or practical interventions) and replace with triage. Single timescale for acknowledging and acting on referrals to MOS i.e. urgent category removed, replaced with prioritisation. Routine annual reviews should be stopped due to lack of benefit shown in the pilot. Service changes in TDS aim to support patients long term and patients should be rereferred to MOS. Improved links with ICN MDTs. Recommended Key Service Changes to TDS Remove all dispensing adjustments from the tariff that have not been utilised or are no longer required. 2

3 Patients with capacity/carers should be asked which medicines are required before each repeat prescription request unless otherwise directed. When required medicines should only be requested and dispensed upon request from the patient or their representative. Significant interventions to be communicated to the patient s GP, recorded on the pharmacy patient medication record and reported along with invoice claims to the commissioner. Patients to be asked for unwanted medicines and/ or MCAs to be returned to the pharmacy (e.g. via the delivery driver) on a 3-6 monthly basis (timeframe TBC). The effectiveness of this intervention should be reviewed by the commissioner after a suitable timeframe. Delivery drivers to undertake level 2 safeguarding in addition to all CCG standard safeguarding requirements. Proposed service specifications for MOS and TDS are attached as appendices 2 and 3. The service specifications are subject to minor changes. Procurement for the TDS would follow an Any Qualified Provider (AQP) process. Procurement for MOS would follow an open tender procurement process. Anticipated Service Provision MOS As part of the mobilisation phase, the aim is explore improved referral routes from acute settings, this has the potential to increase the number of patients referred. It is anticipated that current inappropriate referral numbers could be reduced as currently 480 patients were not seen following triage. The contract for MOS is based on outcomes rather than a cost per patient basis, therefore currently the service commencing June 2018 is expected to annually receive approximately 1400 referrals, and visit approximately 850 patients. TDS In there were approximately 2050 patients receiving a TDS service. Although the growth rate has been slightly reduced and stabilised by the MOS service, for we would expect the TDS to be provided to approximately 2200 Bromley residents. Anticipated Contract Value and Length The proposed contract length for both MOS and TDS is 3 years, with the option to extend contracts by a further two years. The estimated annual contract value for MOS is 275,000. The estimated annual contract value for TDS is 350,000. (This contract value is an estimate and is based on activity levels within the current TDS. The actual annual contract value will be determined by the amount of activity undertaken and the number of claims submitted to the CCG). Market Engagement MOS A Prior information Notice (PIN) was published on contracts finder, which is accessible for all providers of NHS services. There have been 7 expressions of interest to date. A bidder 3

4 briefing event is planned for the end of November should procurement proceed. TDS A Prior information Notice (PIN) was published on contracts finder, which is accessible for all providers of NHS services. An engagement event took place and the timeline of procurement was adjusted in response with the aim to improve coverage of service and patient access. It was recognised that the procurement process has been strengthened and is now more rigorous since the previous TDS procurement, with particular reference to CCG governance assurances and thus additional support is being provided with an information portal and a further 2 bidder briefing events planned. Expressions of interest have been received from most of the existing providers (currently 35 providing TDS) as well as a few additional providers. There are currently 60 community pharmacies in the borough of Bromley. Key risks and how they will be mitigated Key risks and mitigations have been identified for these procurements. The project has a risk register which is reviewed regularly by the project team with support from the CCG s risk manager. These risks have been developed assuming Governing Body approval to proceed to the procurement stage i.e. these risks relate to the procurement and mobilisation processes. Risks are expected to be minimal with the procurement and mobilisation of the MOS service, subject to adequate CCG resources being available e.g. contract monitoring. The main risks identified for TDS which could lead to reduced service uptake are:- Providing evidence for CCG governance assurances within the application may be considered to be onerous Tariffs for provision of TDS items remains the same Increased quality outcome measures being introduced may be considered to increase workload. To support mitigation of these risks, we are liaising with the Local Pharmaceutical Committee (LPC) as well as providing supporting information and bidder events as above. Risks in relation to the decision not to commission one or both of these services are outlined within the business case options appraisal pages 11 to 13. Transitional and Mobilisation Issues MOS Transitional issues may occur if the MOS provider changes. These could include but would not be limited to:- Potential information governance issues regarding the transfer of patient data for the current active case load to a new provider. Transfer of data for historic patients should be unnecessary Workforce Issues. The TUPE request is being currently being processed by the existing provider Communication issues may arise between providers and patients or referrers with a changeover of provider. Contract monitoring should reduce this risk. 4

5 The main risks identified for MOS following mobilisation are: Lack of appropriately skilled workforce as it is a specialist pharmacy service. This was experienced with the service preceding the MOS. Invitation to Tender (ITT) questions aim to address this risk during bid evaluation. Increased number of referrals e.g. from the acute sector; because of increased GP understanding of the purpose of the service and increased awareness by the acute sector. The aim is to improve awareness gradually to allow scoping of benefit, working closely with the transfer of care bureau at the PRUH for example. Contract monitoring and evaluation during mobilisation will be more intensive and will facilitate management should this occur. TDS A lack of provider coverage across the CCG will result in reduced choice for patients as well as reduced capacity for new patients. A subsequent recruitment exercise could occur in this event If an incumbent TDS provider does not continue providing TDS, transition of patients to another provider would need consideration, resulting in potential service pressures and IG issues Increased requirements to demonstrate clinical outcomes as although the interventions may already be undertaken by some providers, recording and demonstrating these can be time intensive Some of the existing TDS providers are experiencing capacity saturation, this may also limit additional capacity for new patients Procurement timeline The two timelines run in tandem with one another up to the date of the Governing Body meeting for approval to proceed to the procurement phase. This reflects the interrelatedness of these services, which has been taken into consideration throughout the review phase. Further to Governing Body approval to proceed to the procurement phase, the timelines will diverge due to the different procurement approach taken for each service. Both timelines work towards the same service commencement date at the beginning of June Both services have been extended from the end of April 2018 until the beginning of June 2018 to accommodate these timelines, which was felt necessary by the project team in order to undertake the procurement and mobilisation processes. PROFESSIONAL INVOLVEMENT: Subject Matter Experts (SMEs) Procurement Advisor -Neil Lynch GP clinical lead - Dr Chris Fatoyinbo Communications and Engagement- Dave Moore Finance Lead Claire Goslitski Performance Lead Emeka Madueke 5

6 IM&T Lead Danny Crawford Contracts Lead Warren Galstin Infection Control Lead Esther Dias Safeguarding Lead Bob Parker Information Governance Lead Katie Nalkin, NEL CSU Medicines Management Karen Hong, Abigail Barry COMMITTEE INVOLVEMENT: Prescribing and Medicines Management Group (PMMG) July 2017, recommended to progress business cases for both MOS and TDS with modifications Clinical Executive Group July 2017, approved mandate to progress business cases for both MOS and TDS with modifications PMMG September 2017, approved recommendations within the business case for both MOS and TDS. Supported the proposed changes to the service specifications for both MOS and TDS. CEG October 2017, agreed to support the business case to progress to Governing Body on the 16th November Suggested greater identification of at-risk patients from hospital setting and increased awareness/referrals from community services. Stakeholder and Public Involvement/ Input: The review phase of this project has involved a significant amount of stakeholder engagement. The business case outlines, for MOS and for TDS, with whom we engaged, what the engagement consisted of, what was learned from the engagement, and how this shaped the project. For MOS, this included: A GP and practice staff survey GP cluster meetings engagement GP Academic Half Day PAG member focus group Engagement with pilot provider, including a service evaluation report and the expert case review panel For TDS, this included: GP cluster meetings engagement Patient surveys Provider engagement event with incumbent providers PAG member focus group 6

7 MANAGEMENT OF CONFLICTS OF INTEREST Nothing of note OUTCOME OF IMPACT ASSESSMENTS COMPLETED For this business case, assessments for equality, quality, privacy, and digital impacts were undertaken. The full impact assessments are included within the business case, and the main findings are summarised below. Equality Impact Assessment Of the 9 protected characteristics, two groups were found to be mostly affected by these services the elderly and those that consider themselves to have a disability. The current services have a positive impact on these groups, highlighted by a survey of current service users that provided data for the Equality Impact Assessment. Two significant findings of the survey are that 92.53% of respondents felt that the service helped to ensure they take their medicine, and 81.46% of respondents felt that they could not manage their medicines without these services. As the majority of respondents to the survey were 71 years old or older (76.33%) or considered themselves to have a disability (74.55%), the Equality Impact Assessment identified the services as having a positive impact on these groups. This positive impact will continue if the recommendation to continue commissioning the services is approved. These findings also align with the CCG s equality objective to improve access to healthcare for vulnerable groups. Of the remaining 7 protected characteristics, survey data are generally reflective of the Bromley demographic, and the decision to commission or decommission these services would not have a positive or negative impact on these groups. These 7 groups have therefore all been assigned neutral impact within the Equality Impact Assessment. It was also found that data related to the protected characteristics has not been routinely collected or monitored by the current services. A recommendation of the Equality Impact Assessment is that any future service providers continue to monitor data on the protected characteristics in order to identify where any changes may have a positive or negative impact on the protected characteristics groups. Providers will be expected to monitor data on all protected characteristics (not just age and disability) to ensure due regard is paid to any group that may be impacted by these services. Quality Impact Assessment: the MOS and the TDS have a positive impact on all areas of quality identified in the quality impact assessment. The recommendation to continue to commission both services supports the continuation of this positive impact on quality. The MOS panel review meeting provides supporting evidence for the clinical effectiveness of the service and the impacts the services can have on the wider health economy; patient experience/satisfaction (reported through patient surveys) is extremely high; and patient 7

8 safety is promoted and maintained through awareness and identification of safeguarding concerns during service visits. Privacy Impact Assessment: there are no planned or proposed changes to the services that would impact negatively on privacy. Some sensitive data related to protected characteristics were collected during the review process, via the patient and service user surveys, and all done anonymously. Data collected from providers for management and payment purposes is anonymised, and this will continue to be the case if the services are re-commissioned (no privacy impact). Three medium risks have been identified and these will be managed through the procurement and mobilisation processes. Digital Impact Assessment: the services have a medium dependence on IT and a low dependence on digitalisation, so the overall digital impact is not significant. The medium dependence on IT is determined by the need to ensure any new providers are enabled with an NHS.net address, providing a safe and secure means for the CCG to communicate with providers. Potential providers should be able to meet all other requirements for the services with minimal dependence on digitalisation or IT. RECOMMENDATIONS: The Governing Body is asked to approve the business case which recommends to: Commission a substantive Medicines Optimisation service to support mainly high risk/ vulnerable patients to get the best from their medicines whilst reducing avoidable harm from their medicines. Recommission the Tailored Dispensing Service with additional service requirements which add clinical value to the patient s care alongside the dispensing adjustment. Approve proceeding to the procurement phase for both services. The additional investment required by the CCG is circa 76k (see full financial overview) ACRONYMS A&E Accident and Emergency AQP Any Qualified Provider CEG Clinical Executive Group CP Community Pharmacist DBS Disclosure and Barring Service EA Equality Act GB Governing Body GP General Practitioner ICN Integrated Care Network IG Information Governance IM&T Information Management and Technology ITT Invitation To Tender LPC Local Pharmaceutical Committee MAR Medicines Administration Record 8

9 MASS MCA MDT MOS MRT MUR NMS PAG PIN PMMG PMR PNA SEL STP TDS WTE Medicines Assessment and Support Service Multi-compartment Compliance Aid Multi-disciplinary Team Medicines Optimisation Service Medical Response Team Medicines Use Review New Medicines Service Patient Advisory Group Prior Information Notice Prescribing and Medicines Management Group Patient Medication Record Pharmaceutical Needs Assessment South East London Sustainability and Transformation Programme Tailored Dispensing Service Whole Time Equivalent DIRECTOR CONTACT: Name: Sonia Colwill Post: Director of Quality & Governance Telephone: AUTHOR CONTACT: Name: Abigail Barry Post: Senior Prescribing Advisor (Interface) Telephone: GP CLINICAL LEAD: Name: Dr Chris Fatoyinbo Position: GP clinical lead 9

10 Bromley Medicines Optimisation Service and Tailored Dispensing Service Business Case November 2017 Author Abigail Barry Key Project Contacts Project Manager Abigail Barry, Karen Hong Lead Clinician - Dr Chris Fatoyinbo, Clinical lead; Dr Jan Wagstyl, Chair PMMG, Project Sponsor Sonia Colwill, Director of Quality and Governance Project Support Warren Galstin Project Mandate Subject Matter Experts Procurement Advisor Lead Communication and Engagement Finance Lead Performance Lead IM&T Lead Contracts Lead Infection Control Lead Safeguarding Lead Information Governance Lead (CSU) Medicines Management Lead Executive Summary The Bromley Medicines Optimisation Service (MOS) was commissioned in 2016 as a 2 year pilot to inform onward commissioning. This service receives referrals from health and social care professionals to assess and review patients who require support with their medicines, including a clinical pharmacist medication review element which was targeted in one ICN locality. The intention is to support all ICNs to reduce emergency admissions in these high risk patients by providing clinical pharmacist support within MOS across the CCG. The Oxleas pharmacy team was awarded the contract, with service delivery commencing in May An evaluation report on the service has been produced, which highlights the significant quality improvement and reduction in risk in relation to medicines for patients who have been assessed and reviewed by this service. An independent panel met to review two groups of high risk patients identified by MOS, those taking high risk medicines associated with hospital admissions and those with significant reconciliation errors post discharge. The likely improved clinical outcomes are documented within the business case as well as the significant financial savings. The impact of MOS could be considered in addition to those achieved by ICN MDTs as experience has shown that the issues identified by MOS are frequently not identified by existing systems or teams, although some overlap is acknowledged. The Tailored Dispensing Service (TDS) was commissioned in 2014 from community pharmacy providers for the provision of dispensing adjustments/compliance aids following assessment by the Medicines Assessment and Support Service (MASS), then subsequently the MOS. 1

11 The contracts for both the MOS and the TDS are due to end at the beginning of June The business case for the re-commissioning of MOS and TDS is considered within this document as there are co-dependencies which require consideration. Extensive stakeholder engagement has taken place and has shaped the re-commissioning of both services. This has included: - Attendance of GP cluster meetings by clinical commissioning GP and medicines management leads GP survey on MOS by CCG including academic half day attendance Patient survey on TDS Patient survey of MOS undertaken by MOS Patient Advisor Group TDS provider meeting/survey Committee Recommendations Bromley Prescribing and Medicines Management Group (PMMG) on 19 th July 2017 recommend Option 4 for onward commissioning Continue to commission both the MOS and TDS with review and modification of service specifications. Bromley Clinical Executive Committee (CEG) on 27 th July 2017 endorsed option 4 to proceed with the development of business cases for the re-commissioning of MOS and TDS services. PMMG September 2017, approved recommendations within the business case for both MOS and TDS. Supported the proposed changes to the service specifications for both MOS and TDS. CEG 12 th October 2017, agreed to support the business case to progress to Governing Body on the 16th November Suggested greater identification of at-risk patients from hospital setting and increased awareness/referrals from community services. Recommendations Commission a substantive Medicines Optimisation service to support mainly high risk/ vulnerable patients to get the best from their medicines whilst reducing avoidable harm from their medicines. Such a service has demonstrated value for money to the health economy. Consideration for service changes should reflect outcomes from the MOS pilot and stakeholder engagement. Recommission the Tailored Dispensing Service with additional service requirements which add clinical value to the patient s care alongside the dispensing adjustment. Recommended Key Service Changes to MOS from the current pilot 1. Increased clinical pharmacist resource to be available to all patients during business hours as well as scope additional cohort of patients, those over 70 with 2 or more unplanned admissions within the last 8 weeks. 2. Remove the two levels of service (clinical or practical interventions) and replace with triage. 3. Single timescale for acknowledging and acting on referrals to MOS i.e. urgent category removed, replaced with prioritisation. 2

12 4. Routine annual reviews should be stopped due to lack of benefit shown in the pilot. Service changes in TDS aim to support patients long term and patients should be rereferred to MOS. 5. Improved links with ICN MDTs. Recommended Key Service Changes to TDS 1. Remove all dispensing adjustments from the tariff that have not been utilised or are no longer required. 2. Patients with capacity/carers should be asked which medicines are required before each repeat prescription request unless otherwise directed. 3. When required medicines should only be requested and dispensed upon request from the patient or their representative. 4. Significant interventions to be communicated to the patient s GP, recorded on the pharmacy patient medication record and reported on claims to the commissioner. 5. Patients to be asked for unwanted medicines and/ or MCAs to be returned to the pharmacy (e.g. via the delivery driver) on a 3-6 monthly basis (timeframe TBC). The effectiveness should be reviewed by the commissioner after a suitable timeframe. 6. Drivers to undertake level 2 safeguarding in addition to all CCG safeguarding requirements. Contents of business case - Pages Content 3-5 Project rationale, background, aims and objectives 5-7 MOS model and care pathway 8-10 Outcomes from MOS pilot May May Business case options appraisal 13 Committee recommendations 13 Conclusions and recommendations Financial Overview Stakeholder engagement MOS Outline of recommendations for service changes to MOS Stakeholder engagement TDS 23 Outline of recommendations for service changes to TDS Quality Impact Assessment Equality Impact Assessment Privacy Impact Assessment Digital Impact Assessment Project Information Project rationale Between 30% and 50% of medicines prescribed for long-term conditions are not taken as intended. 1 Only 16% of patients who are prescribed a new medicine take it as prescribed, experience no problems and receive as much information as they need. Ten days after starting a medicine, almost a third of patients are already non-adherent of these 55% don t realise they are not taking their medicines correctly, whilst 45% are intentionally nonadherent million per year of medicines are wasted in primary care in the UK, of which 150 million could be avoidable 3 3

13 Relating to the rising incidence of co-morbidities, the King s Fund 4 reported issues of problematic polypharmacy and the importance of improved medicines optimisation for the individual patient and the wider health economy. 5% to 8% of unplanned hospital admissions are due to medication issues, this figure can increase to 17% in the over 65s 4, 5 When patients move between care settings is a time of significant risk, patients medicines will be unintentionally altered, leading to adverse drug events and hospital readmissions 6. The National Patient Safety Agency (NPSA) have reported that between 30 and 70% of patients have either an error or an unintentional change to their medicines when their care is transferred 7 References: 1. National Institute for Health and Clinical Excellence. Medicines adherence. Involving patients in decisions about prescribed medicines and supporting adherence. NICE Clinical Guideline Royal Pharmaceutical Society. Medicines Optimisation: Helping patients to make the most of medicines. Good practice guidance for healthcare professionals in England. May York Health Economics Consortium and The School of Pharmacy, University of London. Evaluation of the Scale, Causes and Costs of Waste Medicines icines_waste_nov_2010.pdf 4. The King s Fund. Polypharmacy and medicines optimisation: Making it safe and sound cy-and-medicines-optimisation-kingsfund-nov13.pdf 5. Frontier Economics Ltd. Exploring the costs of unsafe are in the NHS A report prepared for the Department of Health. October National Institute for Health and Clinical Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE Guideline Royal Pharmaceutical Society. Keeping patients safe when they transfer between care providers getting the medicine right. Good practice guidance for healthcare professions. July transfer-of-care-10pp-professional-guidance---final-final.pdf Project Background and Identified Need The Bromley Medicines Optimisation Service (MOS) pilot was commissioned from May 2016 till April 2018 to inform onward commissioning as it was recognised that previous services did not fulfil requirements. The aim of the Medicines Optimisation Service (MOS) was to build upon the practical support organised by MASS and add the skills of a clinical pharmacist to the team. Interventions could therefore be more individualised and incorporate clinical as well as practical considerations. 4

14 Fewer patients referred to MOS received a MCA, and of those that did, a substantial number met criteria for receiving a dispensing adjustment under the Equality Act (EA). Spend on TDS has plateaued and over time could start to fall. MOS includes individual patient assessment with a clinical review as applicable to identify issues and appropriate personalised intervention. This will result in reduced inappropriate use of MCAs and associated costs and improved patient outcomes as can be demonstrated within this business case. The contract for the TDS service ends simultaneously and therefore this business case discusses options for the re-commissioning of both services as the outcomes could be considered interdependent. Project Description Project aims Increased patient understanding of their medicines Empowering the patient to be able to make informed choices regarding their medication regimen Individual clinical medication review as applicable Rationalisation of medication regimen Reduced pill burden for individuals Improved adherence leading to o less medicines waste o less adverse effects, o improved clinical outcomes from their medicines o reduced GP appointments/ home visits for medicines-related issues. o reduced number of visits by carers to administer medicines o reduced costs and adverse effects from medicines stopped o reduced inappropriate use of MCAs, workforce capacity issues as well as increased clinical risk and associated costs o avoidance of A&E attendances and/or admissions (see section on the independent MOS panel assessment) Improved communication with acute hospital professionals (e.g. pharmacists and transfer of care bureau) in order to support appropriate high-risk patients with their medicines post-discharge and reduce risk of readmission due to medication issues. Referrals received from a range of health and social care professionals to ensure appropriate patients are supported. Description of Current Medicines Optimisation Service MOS currently operates as follows: 1. A referral to the service is made by a GP, or other member of health or social care staff. Referrals were either for a clinical review or practical intervention, in addition to referrers differentiated urgent from non-urgent. 2. The referral is screened to determine whether a visit is required or a solution to the presenting problem can be found in another way. 5

15 3. Those patients requiring a visit are seen at home by a pharmacy technician or pharmacist (depending on complexity) and an assessment completed to identify and understand medicines-related problems (both practical and clinical) in the context of the available background information (recent GP consultations, diagnosis etc). 4. Practical support with taking medicines is recommended such as large print labels, easy open bottles, reminder charts and MCAs with a clinical medication review undertaken by a pharmacist where necessary. This involves recommendations such as simplifying the medication regimen, switching to better tolerated medicines or stopping medicines that the patient was clearly unwilling to take. 5. Recommendations are made to resolve problems. As far as is possible, these recommendations are based on an assessment of the patient s ability to use the recommended dispensing adjustment taking into account patient s views. 6. The MOS clinician liaises with those involved in the care of the patient (prescriber/pharmacist, formal or informal care workers, community matrons) as required so that recommendations can be considered and implemented. 7. The patient is followed up within 6 weeks to ensure that the identified medicines-related issues have been resolved. If not, steps 5 7 are repeated. 8. An annual review is undertaken for each patient to identify any changing needs. When a patient requires an auxiliary aid, the MOS team assesses the patient s status with respect to the Equality Act 2010a (EA) and refers the patient to their usual community pharmacist. When a patient is considered to meet EA criteria, the patient s usual community pharmacist provides the auxiliary aid as part of the national pharmacy contractual arrangements. When a patient is not considered to have met EA criteria, the patient s usual community pharmacist provides the MOS recommended auxiliary aid as part of the TDS. The TDS service thus providers for those that do not meet the Equality Act criteria but still have a need for support in managing their medicines. The Equality Act 2010 (EA) provides that a person must not be treated in a discriminatory way because of a protected characteristic by service providers (including providers of goods, services and facilities) when that person requires their service. A disability would constitute a protected characteristic identified in the Equality Act. A person has a disability for the purposes of the Act if he or she has a physical or mental impairment and the impairment has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. 6

16 Service model and care pathway Referral from health/social care Initial triage and contact/assessment Trigger questions: - Access to medicines - Adherence (intentional VS non-intentional) - Side effects/poor outcomes Medication assessment/review - Domicillary visit undertaken by pharmacy technician or clinical pharmacist - Care plan agreed Liaise with GP, CP and others to coordinate implementation of care plan - Refer for appropriate support Implementation of adherence support Liaise with appropriate services e.g. - Community pharmacy support* - Social services care package - District nursing - Other carers/family *Community pharmacy support includes: - Usual essential/advanced services e.g. MUR, NMS, compliance aids/ adjustments for EA patients - TDS patients e.g. MAR charts, compliance aids for non-ea patients - Ongoing monitoring, information and support Review within 6 weeks to ensure care plan implemented - Follow up of care plan - Liaise with CP for ongoing support in accordance with care plan - Arrange further follow-up/review as appropriate - Telephone support to relevant health care professionals as appropriate CP - Community Pharmacist MUR - Medicines Use Review NMS - New Medicine Service EA - Equality Act (formerly Disability Discrimination Act) TDS - Tailored Dispensing Service MAR - Medicines Administration Record 7

17 OUTCOMES FROM MOS PILOT MAY MAY 2017 During a 12 month period, approximately 1328 referrals were made to MOS. 480 patients did not have or require a first visit, for example alternative support could be offered through a community pharmacy or the patient declined the service or refused staff entry to their property. Reducing this cohort referred would improve efficiencies of MOS. For the 840 patients seen for a first visit, the following outcomes were achieved:- Clinical outcomes 2640 interventions were recommended relating to medication i.e. multiple interventions were made for individual patients. The vast majority had a clinical assessment which required a clinical intervention 50% of patients seen by MOS were prescribed medicines known to be associated with high risk of hospital admission; 50% of these were considered to be at significant risk of harm. Data to evaluate the service was collected within the first year of the pilot. Data for different patient cohorts was collected within randomly selected months to minimise impact on the service. An independent panel met in September 2017 including doctors and pharmacists from secondary and primary care. They assessed the likely impact that the MOS service had on the outcome of two groups of patients as well as the likely outcome if the patient had not been referred to MOS. 1) Over a one month period with 76 first appointments, 40 patients were prescribed high risk medicines. 18 of which were assessed as being at significant risk of harm and these were all reviewed by the panel. Examples of issues identified a) CCF; symptomatic ankle oedema. Only takes morning diuretic due to urinary frequency. Patient stopped taking digoxin (though still prescribed) and prescribed indomethacin (known to exacerbate CCF) b) RA: prescribed prednisolone 10mg/day which specialist cannot reduce without flare up, however was only taking average of 1/3 daily sulfasalazine dose. Often forgot PPI. c) Several admissions for falls. Patient continued to take Lisinopril which GP had stopped (normotensive). Large supply of BuTrans found in home as no longer used but still ordered. d) CVA; mental health Clopidogrel not added to repeat medication list following discharge. Quetiapine replaced by clopixol depot, however quetiapine remained on repeat. e) Diabetes: GP stopped naproxen due to CKD/poorly controlled diabetes. Patient continued to take supply of naproxen from a relative. Was not using insulin due to injection pain and boils. 8

18 2. Over a one month period with 66 first appointments, 26 (40%) had recently been discharged from hospital. 11 (42%) had interface problems identified and these were all reviewed by the panel. Examples of issues identified a) Fluid Overload HF: Furosemide increased to 40mg BD, patient continued old dose of 20mg BD b) Patient was using up old medicines after discharge despite numerous changes c) Numerous admissions: Nicorandil omitted during in-patient and patient was readmitted post discharge with chest pain. Subsequent admission: Warfarin noted to be on repeat prescription, supplied and given on discharge despite no GP record of ever being prescribed. Isosorbide mononitrate started by hospital but not on repeat medication at GP surgery. d) UTI: Prescribed prophylaxis nitrofurantoin for chronic UTIs by GP, ciprofloxacin given during admission however no record of nitrofurantoin which was continued by GP post discharge. e) Urinary retention: Fesoterodine changed to solifenacin in hospital but both remained on GP repeat prescription. Outcomes The independent panel concluded that the intervention from MOS could be divided into three categories - preventing significant ill health (serious outcome likely if intervention had not occurred) - resolving poor quality of care (e.g. due to poor reconciliation processes; poor communication or human error) - improved the quality of care (i.e. no harm was likely without the intervention, however improvements to care could be achieved through medicines optimisation) Although it is challenging to demonstrate direct impact, these are all likely to increase health and social care costs due to increased morbidity. Examples of harm avoided included admission or re-admission due to worsening heart failure or CKD with fluid overload Cardiovascular event e.g. angina or MI Vascular event such as VTE/CVA gastric bleed fall, possible fracture mental health crisis epileptic seizure The panel debated the likely outcome should MOS not have intervened. These fell into five main categories:- i. Intervention unlikely (within the near future) ii. GP or MRT visit iii. A&E attendance iv. A&E attendance plus admission v. Increased Pressure on Health and Social care 9

19 Extrapolating the patients reviewed by the independent panel, the annual impact of MOS Cohort of Patients Assessed by MOS Panel High Risk Medicines Annual Patients identified at risk Annual Patients requiring interventi on 442/ /442 11/199 Impact of MOS Intervention Prevented significant ill effects (6%) Resolved poor quality care 100 /199 (50%) Improved quality of care 88 /199 (44%) Likely Outcome Without MOS Intervention Interven GP or tion MRT unlikely Visit(s) 23/199 (12%) 66 /199 (33%) A&E Attendance Plus Admission 88 /199 (44%) Increased Pressure on Health and Social Care 22 /199 (11%) Reconcili ation issues at discharge 336/ /336 26/141 (18%) 90/141 (64%) 26/141 (18%) 51/141 (36%) 51/141 (36%) 26/141 (18%) 13/141 (9%) Annual total affected patients from the above 2 risk groups This highlights the substantial role MOS currently have regarding resolving poor/sub optimal care. Further work regarding preventing such implications is required as the implications are relevant to patients outside of this service. Additional outcomes presented within the pilot review Based on a sample month, 10% had their dosage frequency reduced i.e. reduced pill burden. Evidence supports an improved clinical outcome for such interventions by improving the control of underlying conditions. o In 17% of patients, there was a reduction in medicine-related risk, reducing likelihood of harm which has subsequent financial impact o In 17% of patients there was reduced waste. o In 17% of patients, care needs were reduced. MCAs are recommended in approximately 630 patients (75%) however 271 (43%) were provided under the Equality Act (EA). Before the MOS service, the number of MCAs started under the EA were minimal. In addition to direct cost savings, it represents a learning opportunity for the application of the EA by community pharmacy to all applicable patients which would not only reduce medicine related costs but result in a significant cost saving in associated ill health costs. This includes a benefit to EA patients that have not accessed the MOS service, as TDS pharmacists are better placed to apply the EA criteria and provide support as appropriate. 10

20 Business Case Option Appraisal Option 1 Commission the MOS only and decommission the TDS. Most areas do not commission a separate service to fund provision of compliance aids over and above the community pharmacy contractual framework. Pros Financial saving of the TDS activity c. 324K. Assessment by MOS of practical need and clinical medication review for patients who have difficulty managing their medicines in the community will continue across the borough, with an improvement in quality and reduction in risk. Patients supported to self-manage their medicines. Reduction in medicines waste. Relieve pressure on primary, secondary and social care. The scope of MOS can be developed further to integrate with ICNs e.g. those with frequent hospital admissions. Cons Without the TDS, there would be no funded route for provision of compliance aids for patients who do not fall within EA criteria. The continued supply of MCAs would most likely result in increased pressure on primary care to issue 7 day prescriptions. This would add clinical risk and increase workload. - 7 day prescriptions will incur additional dispensing fees across the health economy. Based on comparative data with 2 neighbouring boroughs, the calculated cost pressure for Bromley prescribing would range between 473,000 and 1,227,392. (The CCG with the lower cost pressure has undertaken extensive work to limit 7 day prescribing) The current TDS caseload of approximately 2000 patients would need to be managed Option 2 Commission the TDS only and decommission the MOS. A number of areas commission medicines optimisation services in the community providing clinical medication review for vulnerable/complex patients. TDS providers do not provide any clinical medication review, it is predominantly a supply function. There are currently 36 community pharmacies across Bromley who provide the TDS, with good geographical coverage across the borough. There are also some community pharmacies who are not currently TDS providers who provide MCAs i.e. without CCG funding. Pros Financial saving of the MOS, c. 275K. Patients who do not fall within EA criteria will have a funded route to receive compliance aids, potentially relieving pressure on health and social care Cons Without MOS, the need to review these patients and their medicines would increase pressure on primary care. Most of the referrals come from primary care and are elderly housebound patients. Increase in GP appointments or home visits/ MRT which has workload and workforce implications locally. Increased hospital admissions circa 354k and social care packages circa 42k. Re-procurement of the TDS could increase costs, if providers who previously provided MCAs outside of the service become part of the TDS Without MOS to direct patients to receive compliance aids in accordance with the essential services of the pharmacy contract, there is an additional potential cost pressure of 39k, if these patients were funded by the TDS route. With current MOS, annual growth of MCAs supplied by TDS is negligible. Previously growth was significant, thus the saving of 65k in reduced MCAs first year of MASS would present as cost pressure year on year. 11

21 Option 3 Decommission both MOS and TDS. MOS currently receives approximately 1300 referrals each year, mostly from primary care. Of those patients seen by MOS, approximately 45% of these patients are referred on to a TDS provider to receive a dispensing adjustment. MCAs are recommended for approximately 75% of patients being assessed. 57% of these are provided under the TDS, while the remaining 43% fall within Equality Act criteria (formerly DDA) and therefore receive provision as part of the community pharmacy contractual framework essential services. Pros A financial saving of c. 599K the current service costs for MOS are 275K and TDS activity at 324K Cons Without the TDS, there would be no funded route for provision of compliance aids for patients who do not fall within EA criteria. This may result in increased pressure on primary care e.g. to issue 7 day prescriptions to support funding for MCA provision. This would add clinical risk and increase workload. Based on comparative data with 2 neighbouring boroughs, this cost pressure could range between 473,000 and 1,227,392 for Bromley prescribing. Without MOS, the need to review these patients and their medicines would increase pressure on primary care. Most of the referrals come from primary care and are elderly housebound patients. Increase in GP appointments or home visits/ MRT which has workload and workforce implications locally. Increased hospital admissions 354k and social care packages 42k. The current TDS caseload of approximately 2000 would need to be managed. Loss of savings to the health economy due to reduced need to access other services Option 4 Continue to commission both the MOS and TDS with modifications to the service specifications. If both services were to be commissioned, some minor variations to the service specifications would be required based on the findings of the MOS pilot and engagement process. Pros Assessment of practical need and clinical medication review for patients who have difficulty managing their medicines in the community will continue across the borough, with an improvement in quality and reduction in risk. Patients supported to self-manage their medicines. Reduction in medicines waste. Relieve pressure on primary, secondary and social care. Reduced GP/MRT home visits which currently present significant workforce problems. Patients who do not fall within EA criteria will have a funded route to receive compliance aids. 12 Cons Expanding the clinical medication review element across the borough will increase the overall cost of the service by 50k/annum. Re-procurement of the TDS will open up the market to community pharmacies who previously provided a service unfunded

22 - Reduced clinical risk and workload implications of 7 day prescribing - Financial savings for the health economy of potential 7 day dispensing fees of 473,000 to 1,227,392 Financial savings to the health economy due to reduced demand on other health and social care services. -Circa 354k savings in reduced hospital admissions. -Further significant savings likely from the additional cohort of high risk patients to be scoped who have frequent unplanned admissions Committee Recommendations Bromley Prescribing and Medicines Management Group (PMMG) on 19 th July 2017 recommend Option 4 for onward commissioning Continue to commission both the MOS and TDS with review and modification of service specifications. Bromley Clinical Executive Committee (CEG) on 27 th July 2017 endorsed option 4 to proceed with the development of business cases for the re-commissioning of MOS and TDS services. Bromley Prescribing and Medicines Management Group 27 th September Approved recommendations within the business case for both MOS and TDS. Supported the proposed changes to the service specifications for both MOS and TDS. Conclusion and Recommendations Commission a substantive Medicines Optimisation service to support mainly vulnerable patients to get the best from their medicines whilst reducing avoidable harm from their medicines. Such a service has demonstrated value for money to the health economy. Consideration for service changes should reflect outcomes from the MOS pilot and stakeholder engagement. Recommission the Tailored Dispensing Service with additional service requirements which add clinical value to the patient s care alongside the dispensing adjustment. Current MOS Staffing model Current staffing model includes very senior manager oversight/service development, senior pharmacist service management, with a mixture of clinical pharmacists and technicians delivering the service, supported by administration. Proposed Staffing Model Funding for the pilot included 1.2WTE clinical pharmacists to cover one ICN. The current MOS provider has been providing a significant amount of additional clinical pharmacist time at their own cost to support the whole service which was soon identified as being required. They have estimated that a further 0.8 WTE 8a clinical pharmacist would be required to maintain the outcomes demonstrated in addition to scoping an additional cohort of high risk patients. 13

23 Financial Overview Both TDS and MOS have been commissioned by NHS Bromley CCG for some years. The following summary gives a breakdown of cost efficiencies already being achieved due to these services, which if decommissioned would result in additional costs being incurred. Description Option 1 - Commission MOS Only 000's Option 2 - Commissio n TDS Only 000's Option 3 - Decommissio n both MOS and TDS 000's Option 4 - Commissio n both MOS and TDS (investment) 000's Increase in MCA Use 65 Formal Carer Waste Increase Non Identification Under Equality Act 39 Increased Acute Admissions NHSE Pharmacy Contract - 7 Day Prescribing (average used) Investment in TDS/MOS 76 Sub-total Cost Impact , MOS (225) (225) TDS (324) (324) Sub-total Cost Savings (324) (225) (549) 0 Total Cost Impact/(Savings) Detail of Financials within the Summary TDS Annual Costs and Activity Trends Year Claims 000's MDS TDS Total Value 000's Claims 000's Value 000's Claims 000's Value 000's Annual Cost +/- 000's % Growth in Total Number of Claims Comments 2013/ / % Implementation of TDS and MOS 2015/ % Annual Growth 2016/ % Annual Growth 2017/18 Inc. Growth % Trend applied to provide FOT 2018/19 Inc. Growth % Trend applied to provide FOT 14

24 Required Investment Service 17/18 Budget 000's Investment 000's Budget Required 000's Comments TDS Expected 18/19 Outturn including Growth MOS Investment to cover 3 ICN's Total Cost of Reduced Dosage Frequency Description 000's Comments Reduced Waste 30 Annualised Cost Identified by MOS Service Formal Carers patients x 3,011 (annual cost as per Lewisham MOS) Total 72 Estimated Cost of Pharmacy Professional Fees Organisation NHS Bromley CCG Registered Patients 000's Number of Items Per Patient NHS Bromley CCG Professional Fee Per Item Total Cost (AxBxC) 000's NHS Bromley CCG 16/17 Annual Professional Fees 000's Estimated Level of Savings Being Experienced (D-E) 000's A B C D E F CCG A No Service 344, ,256 4,029 1,227 CCG B Partial Service 344, ,502 4, The annual cost of professional fees paid as part of the Global Sum within the Pharmacy Contract of two CCG s with very similar patient demographics were compared to Bromley CCG to identify potential increased cost of 7 day prescribing if either or both services were decommissioned. The consequence of stopping the service would be to increase the cost of the Pharmacy Contract commissioned by NHSE. Estimated Cost of Possible A&E Admissions Primary Diagnosis Total Patients Assessed by MOS Panel Prorated to Total Service Cost of an A&E Attendance + MFF Average Cost of Admission (ICD10) Total Estimated Cost of A&E plus Admission 000's CCF or Heart Failure ,104 99,426 Gastric Bleed ,032 37,497 Fall or Fracture ,704 79,356 CKD ,248 79,911 MH Crisis ,932 Epileptic Fit ,529 31,766 Cardiovascular Event ,318 Total ,206 15

25 Stakeholder Views, Summary of Engagement MOS GP/practice staff survey: What we did: A survey was designed to gather GP and practice staff feedback on the MOS service. The survey asked about the types of medicines management problems they ve encountered; whether they re aware of and have referred to MOS; if not, why not; and if so their feedback and suggested improvements. What we learnt: For every type of medicines management/adherence issue suggested, the majority of GPs reported having encountered these issues at least occasionally and more often than not GPs reported having encountered these issues frequently or very frequently There is a general awareness of the service, with 97.14% of respondents stating they are aware of the service. The service is also referred into by the majority of respondents 84.85% However, even though GPs are aware of and make referrals into the service, feedback indicates GPs are not always aware of the purpose and remit of the service. For instance, Not helpful when I and patient and family have identified need for dosette and MOS decline it e.g. carers involved. Comments such as this suggest the MOS continues to be viewed as a gateway to attaining a dosette box More generally, the survey also received comments such as Want to know what services you provide now so that I can use more for my patients also indicating a general need for GPs to be further informed on the purpose and remit of service. Feedback on the whole was positive, with 100% of GPs that have used the service stating they are either extremely likely or likely to recommend the service to a colleague. Comments received support this, with GPs responding positively to the service s speed, use for patient, and use for primary care More than ¾ of GPs surveyed either agree or strongly agree with and implement recommendations made by MOS Suggested improvements (where suggested by multiple respondents) include o MOS to undertake medication reviews (it is unclear whether this is suggested as GPs are unaware of the medication reviews already undertaken by MOS, or whether it is suggested that MOS undertake medication reviews with a wider scope that is not currently covered by MOS) o Longer-term follow-ups o Liaise with hospital and/or have a hospital base to review patients predischarge to help with medicines reconciliations o Phone calls to the referrer if MOS is unsure that information received is correct or complete How has this shaped the procurement process: MOS to constantly promote and re-enforce the aims and remit of service to all stakeholders All stakeholders should refrain from pre-empting assessment outcomes especially informing patients they are going to be provided with a dosette box. Evidence that MCAs improve outcomes for patients is weak and can increase risk is some patients. Communications between primary care, secondary care, pharmacists, and service users often increases risks of error with associated poorer outcomes for the patient. Systems for improvements between hospital and community pharmacy are being explored across SEL. Community pharmacy access to local care records may improve this, however there remains a continued need for better communication 16

26 between health care professionals. Consideration to be given on how to undertake longer-term patient follow-ups. The MOS pilot has demonstrated that annual reviews by MOS are not cost-effective. Patients can be re-referred to MOS at any point when need is identified by any suitable referrer. To capture patient s changing needs proactively, the service spec for TDS has been amended to include 3-6 monthly returns of dosette boxes in order to hopefully review adherence. The success of this should be reviewed. In addition we are hoping that NHSe will authorise annual telephone MURs to be completed for TDS patients. Where recommendations made to GPs are not implemented, feedback on reasons for this would be beneficial, however recognised as time consuming. However periodic peer review from a lead GP could improve communication/recommendations from MOS and could be considered. Alternatively, MOS could work more closely with 2 GP practices to optimise recommendations and process. These suggestions could be scoped during the remaining 6 months of the MOS pilot. GP engagement What we did: GP clinical lead and medicines management leads attended Orpington, Unity and Bromley cluster meetings. An overview of the MOS pilot report was presented whilst encouraging an open forum for feedback on the current service as well as views regarding the onward commissioning of the service. What we learnt: Feedback MOS seen as a gatekeeper for MCAs by some, however upon receiving examples of clinical interventions undertaken, nearly all GPs agreed that the added clinical value was clear for this vulnerable group of patients. Concern was raised where MCAs were not initiated when they had asked for one. Added value of an independent assessment of adherence within a patient s home, pulling all strands together, including the patient s view on their medicines and actual behaviour. Little time to achieve this within GP practice. Felt to be a responsive and timely service Some criticism regarding increased workload to review patients following MOS intervention e.g. a home visit may sometimes be required to follow up clinical issues identified by the MOS team. Views regarding onward commissioning of MOS All GPs supportive of the re-commissioning of the MOS service Improved links at the point of discharge from hospitals (missed opportunities and timeliness of referral) Co-commissioning with Local Authority/ usage of Better Care Fund regarding optimising medicines for patients with formal care packages including those in extra care housing or care homes. This should include reducing pill burden, reducing frequency of administration to match care packages and upskilling care staff regarding medicine administration. Could housebound respiratory patients be a focus (especially COPD), as inhaler technique often poor and leads to increased morbidity and hospital admissions? Medicines reconciliation has become a significant role for MOS however should there be more cost-effective systems to improve this which include patients not seen by MOS? 17

27 How has this shaped the procurement process: Continued education of referrers e.g. GPs and CPs regarding the role of MCAs in managing this patient group is required during mobilisation and throughout service provision. Review linking MOS service to ICN clinical pharmacists in practice after the ICN pharmacist pilot has been completed. Improve links between MOS service and those leading the discharge process at the PRUH. To include ward pharmacists and medics. Progress co-commissioning agenda with LA, especially regarding better care fund. This is unlikely to result in change for the current procurement process, however could be explored in future. COPD patients with poor adherence are currently included within the service spec, however an increased role could be explored. Medicines reconciliation is currently included within the workplan of the ICN pharmacist pilot and therefore systems to improve the governance surrounding this will be explored via this pilot. PAG consultation:- What we did: Held a meeting with 4 PAG members. Gave an overview of service and suggested changes. Asked for views. What we learnt: MOS is not known about by all relevant stakeholders which could prejudice some groups of patients. How can we increase the number of patients feeling they can be more transparent regarding their wishes for their medicine regimens? (felt many patients hide the fact that they do not take their medicines as the doctor prescribes) How has this shaped the procurement process: Service specs for both services include communication strategies both on mobilisation and throughout the service provision. Prescribing which takes into account patient preferences and opinions should be the norm, however it is recognised that this continues to present challenges, especially in acute settings. Beyond the scope of this service, however any potential improvements could be explored as part of the service. Medicines Use Reviews ask patients about their individual regimens and make recommendations to their GP accordingly. Outline of recommendations for Medicines Optimisation Service changes 1. The MOS was commissioned to pilot clinical medication review by a pharmacist in one ICN locality only. It was quickly identified however that the majority of patients required this and therefore the service have been providing clinical medication reviews to all eligible patients across the 3 ICNs at their own cost from other departments. In addition, referrals were categorised into clinical and non-clinical, however it was soon realised, that most required a clinical intervention. Therefore the workforce identified to effectively deliver this ongoing service has been increased by 0.8 WTE band 8 clinical pharmacists. This increase will also include the scoping of an additional cohort of patients, those over 70 with 2 or more unplanned admissions within the last 8 weeks. A clinical pharmacist should be available during all business hours. 18

28 2. The pilot service had two levels of referral, one for practical assessment, the other for a clinical assessment. As MOS is predominantly seen as a gatekeeper for MCAs, most referrals simply involved requests for MCAs to be commenced. However clinical interventions were required in the majority of cases and therefore it is proposed to not separate type of referrals, but have a triage system upon receipt of a referral. 3. There should be a single timescale for acknowledging and acting on referrals to MOS i.e. urgent category removed. The MOS team should contact each patient as soon as possible after referral and prioritise visits. 4. Routine annual reviews should be stopped due to lack of benefit shown in the pilot. Service changes in TDS aim to support patients long term and patients should be rereferred to MOS should any significant changes occur that cannot be managed outside of MOS. 5. As Integrated Care Networks are developed in Bromley, the service provider will work closely as part of these networks, ensuring that patient care and communication is integrated with other appropriate providers. This includes working towards access and integration of care records with primary care. 19

29 Summary of stakeholder engagement for Tailored Dispensing Service GP cluster engagement What we did: Sought views from GP cluster meetings regarding feedback on current service in addition to views regarding the onward commissioning of TDS What we learnt: GPs generally supportive of the continuation of TDS GPs raised concerns that the alternative to funding TDS would be a significant increase on the pressure to supply 7 day prescriptions, which currently are mainly only requested for high risk patients e.g. where diversion is a risk. This would increase clinical risk, workload for GPs and costs. GPs recognised the significant support for vulnerable, high risk patients that some community pharmacies provide on top of TDS contractual requirements. Community pharmacies (CPs) should request the return of MCAs before delivering new ones. CPs should check that a patient requires their medicines monthly before requesting repeats Concern was raised that CPs often request MCAs and if MOS do not initiate, GPs feel caught in the middle. The financial incentives for CPs to increase number of MCAs was raised as a concern. How has this shaped the procurement process: CCG policy regarding 7 day prescriptions will remain as it is (high risk patients only, where clinical rationale is clear) Incorporate a periodic (3-6 monthly?) return of medicines into the TDS service spec with commissioner review impact after appropriate time period. CPs to only order when required medication when requested by the patient, unless otherwise advised. CPs to ask patients with capacity or carers where known every month if all repeat medication is required. CPs and GPs should be communicated to clearly regarding rationale for not initiating a MCA. A consistent message from TDS providers and practices to patients is important and will be re-iterated during mobilisation. Patient Survey Results What we did: Survey sent to all TDS patients via their provider. 180 responses in the first month were considered for this overview. 75% of returns were from service users; 25% from carers/ family/ friends What we learnt: 99% of respondents stated they were happy with the current TDS 90% stated that the dosing adjustment offered was a MCA 92% of all patients stated that the dosing adjustment helped them to take their medicines 81% stated they could not manage without their dosing adjustment Feedback, three themes emerged Communication between GPs and community pharmacists (CP) required improvement e.g. regarding medicine changes or recent hospital admissions 20

30 Communication from the CP to the patient could be improved e.g. regarding phoning to assure medicines are due to be delivered and then phoning ahead of delivery. Medicines outside of the MCAs continue to be accumulated and cause confusion. How has this shaped the procurement process: SEL medicines optimisation STP are considering options regarding communication between hospital and community pharmacists regarding discharge medicines Mobilisation of service should include promotion of improved communication between GPs and CPs as well as ongoing dialogue and feedback between providers. TDS patients could be a topic to discuss during CP and GP annual meeting (could be stipulated if the meetings are funded within the CCG prescribing incentive scheme in future years.) TDS to ask patients or carers what medicines they require before ordering, which will in addition inform patients that their repeat delivery is due soon. TDS to remind patients in advance when their medicines are due for delivery MOS to ensure that medicines are only left out of MCAs where there are no alternative options. TDS to only order when required medicines on request Provider Engagement What we did: Held a meeting with a group of TDS providers, MOS leads, CCG contracting and medicines management to seek views on current service and scope ideas for the onward commissioning of the service. What we learnt: Hospitals continue to ask Community Pharmacy (CP) to provide emergency MCAs, sometimes without prescriptions, and often ahead of discharge. Subsequently the patient is not discharged and time/drugs are wasted. Communication regarding discharge medication to CPs is poor and not timely, resulting in potential errors or delays in implementing changes. TDS providers tend to increase the level of scrutiny for TDS patients as they tend to be high risk with often minimal capacity to control their repeats/ medication. Drivers tend to receive comments or feedback from patients, which is then feedback to the CP Capacity issues to provide MCAs has arisen from some providers resulting in patients having to change pharmacy. MAR charts and large print labels cannot be supplied by all providers Improved understanding regarding EA criteria however the pressure of increased volume strains an already fragile system. Currently drugs are returned via the driver for high risk patients only. Whilst capacity does not exist to do this for all patients, a system of periodic review of returned medicines could trigger communication back to GP or a re-referral to MOS. A MOS helpline to discuss cases CPs could assist with rather than refer to MOS. Implementation of a central communication system (e.g. PharmaOutcomes) between hospitals, CPs and CCGs would improve TDS Permit telephone MURs for TDS patients to facilitate review CPs often intervene to optimise medicines or discuss concerns with the patient s GP, however this is not currently captured with respect to adding clinical value to the supply service of TDS. How has this shaped the procurement process: Systems such as PharmaOutcomes are being considered under the SEL STP footprint as apply to whole of SEL and involve significant changes within acute trusts 21

31 in staffing and IT. Consider incorporating support role of TDS in service spec of MOS service alongside continued education regarding EA. Drivers to be included in level 2 safeguarding as well as technicians and pharmacists. Include authorisation for telephone MURs for TDS patients in the service spec (subject to NHSe approval). Include quarterly or 6 monthly returns of patient s medicines to monitor concordance. Link one with annual MUR. Feedback to GP and/or MOS Interventions undertaken should be fed back to the patient s GP and recorded on the patient s patient medication record (PMR) within the pharmacy. Interventions undertaken since the last submission for each TDS patient. Wider TDS provider engagement What we did: Sent a survey to all TDS providers asking for feedback and views regarding onward commissioning What we learnt: Feedback yet to be received How has this shaped the procurement process: N/A PAG consultation:- What we did: Held a meeting with 4 PAG members. Gave an overview of service and suggested changes. Asked for views. What we learnt: Important that patients understand that medicines are being asked to be returned to the pharmacy periodically to monitor adherence as they will most likely be reluctant. Is it legal to ask them to sign an agreement to do so at the commencement of service? The lack of Bromley CPs being able to access appropriate records of patient s medicines, including post discharge (e.g. through local care records) is of concern considering their vital role in medicines reconciliation and medicines optimisation. How has this shaped the procurement process: The legality of asking patients to sign that they will return medicines as requested by the pharmacy is being investigated. Service leaflets will include this change as well as verbal messages to re-enforce. IT solutions are being progressed both through SEL STP and digital programmes, however CP access remains limited. Beyond the scope of this project but acknowledge the implications. 22

32 Outline of recommendations for The Tailored Dispensing Service changes 1. Remove all dispensing adjustments from the tariff that have not been utilised or are no longer required 2. Patients with capacity/carers should be asked which medicines are required before each repeat prescription request unless otherwise directed 3. When required medicines should only be requested and dispensed upon request from the patient or their representative 4. Significant interventions to be communicated to the patient s GP, recorded on the pharmacy patient medication record and reported on claims to the commissioner. 5. Patients to be asked for unwanted medicines and/ or MCAs to be returned to the pharmacy (e.g. via the delivery driver) on a 3-6 monthly basis (timeframe TBC). The effectiveness should be reviewed by the commissioner after a suitable timeframe 6. Drivers to undertake level 2 safeguarding in addition to all CCG safeguarding requirements. 23

33 Impact Assessments Assessments for Quality, Equality, Privacy and Digital impacts have been undertaken, jointly, for both the Medicines Optimisation Service and the Tailored Dispensing Service. These are laid on the following pages. 24

34 Quality Impact Assessment for the Medicines Optimisation Service and Tailored Dispensing Service This tool involves an initial assessment (Stage 1) to quantify potential impacts (positive or negative) on quality from any proposal to change the way services are commissioned and/or delivered. Where potential impacts are identified they should be risk assessed using the risk scoring matrix to reach a total risk score. (ref) Quality is described in 6 areas, each of which must be assessed at Stage 1. Where a potentially negative risk score is identified and is greater than (>) 8 this indicates that a more detailed assessment is required in this area. All QIAs scoring a negative impact of >8 must go on to a detailed assessment at Stage 2. Quality Impact Assessment: Stage 1 The following tool will require judgement against the 6 areas of risk in relation to Quality using the Guidance Tools above. Each proposal will need to be assessed for positive/negative impacts. Where negative impacts score >8 is identified in any area this will result in the need to then undertake a more detailed QIA. This will be supported by the Governance team. Title for Project Business Case for Medicines Optimisation Service and Tailored Dispensing Service Project Lead Abigail Barry Brief Description of Project Clinical Lead Dr Chris Fatoyinbo The Bromley Medicines Optimisation Service (MOS) was commissioned in 2016 as a 2 year pilot to inform onward commissioning. This service receives referrals from health and social care professionals to assess and review patients who require support with their medicines, including a clinical pharmacist medication review element which was targeted in one Integrated Care Network locality. The Oxleas pharmacy team was awarded the contract, with service delivery commencing in May The Tailored Dispensing Service (TDS) was commissioned in 2014 from community pharmacy providers for the provision of dispensing adjustments/compliance aids following assessment by MOS. TDS is provided by 36 pharmacists across Bromley, who issue a dispensing adjustment at the time of dispensing the prescription. The contracts for both the MOS and the TDS are due to end at the end of April Options for onward commissioning have been discussed at the Prescribing and Medicines Management Group and the Clinical Executive Group, with the recommendation to continue commissioning both of these services. The CCG is now reviewing these services in preparation for a procurement process. 25

35 Answer positive/negative (P/N) in each area. If N then score the impact/likelihood/total in the appropriate box. Area of Quality P/N Impact Likelihood Score Full Assessment Required >8 score Patient Experience P N/A N/A N/A N/A Patient Safety P N/A N/A N/A N/A Clinical Outcomes/Effectiveness P N/A N/A N/A N/A Access/Waiting Times P N/A N/A N/A N/A Impact on organisations/wider health P N/A N/A N/A N/A economy Workforce/Staff P N/A N/A N/A N/A Further Comments As the business case makes a recommendation to continue to commission both the MOS and TDS services, and the service models will not change significantly from the current provision, the impact for each area is considered to be positive inasmuch as there is a lack of a negative impact. I.e. the services are already having a positive impact. This is evident in the following areas: - Clinical outcomes/effectiveness: a panel meeting, consisting of a GP, consultant geriatricians, and pharmacists, was held to review outcomes and effectiveness of the MOS service. The panel reviewed 29 cases and agreed that, without MOS intervention, 9 of these would have resulted in an A&E attendance and admission, 10 would have resulted in one or more GP visit, and 3 would have resulted in increased pressure on health and social care over time. This demonstrated the effectiveness of the MOS service and the positive impact this service can have on patients and other healthcare organisations - Patient experience: 99.46% of service users have reported that they are satisfied with the current TDS service (193 respondents as of 26/09/2017). Both the MOS and TDS services decrease the social cost of healthcare for patient and their families are carers as an increase in compliance with medication will reduce unnecessary visits to GPs and pharmacists. Improved medication compliance will also reduce the likelihood of an exacerbation in the patient s condition, potentially avoiding a visit and admission to A&E - Patient safety: the MOS service, through visiting patients at home, is able to pick up and appropriately act on a number of safety and 26

36 safeguarding issues that would not have been identified without a home visit and may not necessarily be related to the reason for referral (may not be related to the patient s medication compliance issues). For instance, in one of the cases reviewed by the MOS panel, the MOS team had safeguarding concerns during the service visit and these concerns were raised with the care agency and the patient s GP. This concern may otherwise have been left unaddressed. The aim of both of the services is to improve medicines optimisation and compliance which improves patient safety through a reduction in potential harm caused by non-compliance - Access and waiting times: a recent survey (Aug17-date) of current TDS service users notes that 76.79% of respondents are aged 71 years old or older % of respondents consider themselves to have a disability. This patient cohort therefore has difficulty attending clinics. The MOS service is a domiciliary service, providing home visits, and the TDS service delivers medications to the patient s home; both services have a positive impact on access to healthcare for these patients. There is also a wider positive impact on access to services for patients that meet Equality Act requirements, as the MOS service educates TDS providers on how to undertake Equality Act assessments and on which patients fall under the Equality Act. This has a positive impact on the wider patient population as TDS providers will be more able to identify Equality Act patients that are out of scope for MOS. - Impact on other organisations/wider health economy: improved medicines compliance has a positive impact on the wider health economy by reducing the burden on primary and secondary care where GP appointments and A&E attendances may have been caused by an issue related to non-compliance with medicine plans. These impacts on other organisation and the wider health economy were also demonstrated by the MOS panel (noted above). These impacts will continue with the new services. Conversely, the decision to decommission these services would have a negative impact for reasons that mirror those outlined above. (Survey data are accurate as of 26/09/2017 survey is ongoing with responses still being received, so figures are subject to change) 27

37 Bromley CCG Equality Impact Assessment Title of policy or project: Name and role of officer/s completing the assessment: Business Case for Medicines Optimisation Service and Tailored Dispensing Service Warren Galstin, Contract Support Manager Date of assessment: 13/09/2017 Type of EIA undertaken: Screening EIA (section 1&2 only) Please refer to the EIA guidance and EIA Flowchart to help in completing the following sections. SCREENING (Sections 1&2 only) 1. Outline Give a brief summary of your policy or project What is the purpose of the policy/project In what context will it operate Who is it intended to benefit What results are intended Why is it needed Are there any implications for partners, or national or regional policy The Bromley Medicines Optimisation Service (MOS) was commissioned in 2016 as a 2 year pilot to inform onward commissioning. This service receives referrals from health and social care professionals to assess and review patients who require support with their medicines, including a clinical pharmacist medication review element which was targeted in one Integrated Care Network locality. The Oxleas pharmacy team was awarded the contract, with service delivery commencing in May The Tailored Dispensing Service (TDS) was commissioned in 2014 from community pharmacy providers for the provision of dispensing adjustments/compliance aids following assessment by MOS. TDS is provided by 36 pharmacists across Bromley, who issue a dispensing adjustment at the time of dispensing the prescription. The contracts for both the MOS and the TDS are due to end at the end of April Options for onward commissioning have been discussed at the Prescribing and Medicines Management Group and the Clinical Executive Group, with the recommendation to continue commissioning both of these services. The CCG is now reviewing these services in preparation for a procurement process. 28

38 Identifying impact: Positive Impact: will actively promote or improve equality of opportunity; Neutral Impact: where there are no notable consequences for any group; Negative Impact: negative or adverse impact causes disadvantage or exclusion. If such an impact is identified, the EIA should ensure, that as far as possible, it is either justified, eliminated, minimised or counter balanced by other measures. This may result in a full EIA process. 2. What impact have you identified for the all of the protected groups? Positive Impact Neutral impact Negative impact What evidence base was used to determine impact? A recent survey (Aug17-date) of current TDS service users notes that 76.33% of respondents are aged 71 years old or older % of respondents consider themselves to have a disability. On this basis, these two groups will be impacted by any change in service provision. Link to CCG Equality Objectives? Improving access to healthcare for vulnerable groups Age With 92.53% of respondents stating that the service helped to ensure they take their medicines, and 81.46% feeling they could not manage without the service, the removal or decommissioning of the TDS service would have a negative impact on these groups. The proposal is to continue to commission this service, and thereby 29

39 2. What impact have you identified for the all of the protected groups? Positive Impact Neutral impact Negative impact What evidence base was used to determine impact? Link to CCG Equality Objectives? Disability continue to have a positive impact on these two groups. The TDS service is accessed via referral from MOS only and so it can be assumed that the MOS service has a similar patient cohort that would be affected by changes to service provision. Typically, referral into MOS is made for elderly and disabled people that have difficulty taking medicines or are not compliant with their medicines. As MOS is a domiciliary service, it actively promotes equality of opportunity for these groups by providing a service in their own which they would otherwise not be able to access. Improving access to healthcare for vulnerable groups (Survey data are accurate as of 21/09/2017 survey is ongoing with responses still being received, so figures are subject to change) For the below 7 protected characteristics, data from the TDS survey has been provided for information. This demonstrates that due regard has been paid to these characteristics by monitoring this information. The data are generally reflective of the Bromley demographic, with the exception of Pregnancy and Maternity which is reflective of this patient cohort s age. The decision to commission or decommission the MOS and TDS services would not have a positive or negative impact on these groups and they have therefore all been assigned neutral impact. Providers will be expected to continue to monitor data on protected characteristics, as a minimum through annual patient surveys. If monitoring indicates a move away from trends that reflect Bromley s demographic, further consideration will be given to how these characteristics could be impacted by changes to these services. Gender reassignment Patients were asked whether they have been through or intend to 30

40 2. What impact have you identified for the all of the protected groups? Positive Impact Neutral impact Negative impact What evidence base was used to determine impact? Link to CCG Equality Objectives? undergo a gender reassignment process: Yes: 0.68% No: 97.96% Prefer not to say: 1.36% Marriage and civil partnership Patients were asked their marital status: Single: 11.98% Married: 40.12% Civil partnership: 0.60% Divorced / person whose civil partnership has been dissolved: 4.79% Widowed / surviving civil partner: 38.92% Separated: 2.99% Prefer not to say: 0.60% Pregnancy and maternity Patients were asked if they were pregnant or had given birth in the last 26 weeks: Yes: 0.00% No: % Prefer not to say: 0.00% Race Patients were asked their race: 31

41 2. What impact have you identified for the all of the protected groups? Positive Impact Neutral impact Negative impact What evidence base was used to determine impact? Link to CCG Equality Objectives? Welsh/English/Scottish/Northern Irish/ British: 92.81% Irish: 1.80% Gypsy or Irish Traveller: 0.60% Other white background: 1.20% Mixed white and black Caribbean: 0.60% Other Asian background: 1.20% Black or black British African: 1.20% Turkish: 0.60% Other white background responses noted were French-English and Norwegian. (Other races/ethnicities not listed here as nil response) Religion or belief Patients were asked their religious belief: No religion: 14.55% Christian: 78.79% Catholic: 2.42% Buddhist: 0.61% Hindu: 0.61% Jewish: 0.00% Muslim: 1.21% Sikh: 0.00% Prefer not to say: 1.82% Other religions or beliefs noted were Salvation Army and humanist secular. 32

42 2. What impact have you identified for the all of the protected groups? Positive Impact Neutral impact Negative impact What evidence base was used to determine impact? Link to CCG Equality Objectives? Patients were asked their sex: Sex Male: 41.88% Female: 57.50% Intersex: 0.63% Prefer not to say: 0.00% Patients were asked their sexual orientation: Sexual orientation Heterosexual / straight: 96.79% Lesbian: 0.00% Gay: 0.00% Bisexual: 0.64% Other: 0.00% Prefer not to say: 2.56% 33

43 Privacy Impact Assessment Questionnaire This PIA questionnaire must be completed wherever there is a change to an existing process or service, or a new process or information asset is introduced that is likely to involve a new use or significantly changes the way in which personal data is handled or processed. Work stream: Business Case for Medicines Optimisation Service and Tailored Dispensing Service Work stream Lead Name Abigail Barry Designation Senior Prescribing Advisor Telephone Abigail.barry@nhs.net Overview: (Summary of the project) The Bromley Medicines Optimisation Service (MOS) was commissioned in 2016 as a 2 year pilot to inform onward commissioning. This service receives referrals from health and social care professionals to assess and review patients who require support with their medicines, including a clinical pharmacist medication review element which was targeted in one Integrated Care Network locality. The Oxleas pharmacy team was awarded the contract, with service delivery commencing in May The Tailored Dispensing Service (TDS) was commissioned in 2014 from community pharmacy providers for the provision of dispensing adjustments/compliance aids following assessment by MOS. TDS is provided by 36 pharmacists across Bromley, who issue a dispensing adjustment at the time of dispensing the prescription. Implementation Date: October 2017 The contracts for both the MOS and the TDS are due to end at the end of April Options for onward commissioning have been discussed at the Prescribing and Medicines Management Group and the Clinical Executive Group, with the recommendation to continue commissioning both of these services. The CCG is now reviewing these services in preparation for a procurement process.

44 1. Screening questions Q Category Screening question Yes/No 1.1 Technolo gy Does the project introduce new or additional information technologies that can substantially reveal an individual s identity and has the potential to affect that person s privacy? No 1.2 Technolo gy Does the project introduce new or additional information technologies that can substantially reveal business sensitive information, specifically: have a high impact on the business, whether within a single function or across the whole business? 1.3 Identity Does the project involve new identifiers, re-use or existing identifiers e.g. NHS or NI number, or will use intrusive identification or identity management processes? 1.4 Identity Might the project have the effect of denying anonymity and pseudonymity, or converting transactions that could previously be conducted anonymously or pseudonymously into identified transactions? 1.5 Multiple organisa tions Does the project involve multiple organisations, whether they are public sector agencies i.e. joined up government initiatives or private sector organisations e.g. outsourced service providers or business partners? No No No Yes multiple providers Q Category Screening question Yes/No 1.6 Data Does the project involve new process or significantly change the way in which personal and/or business sensitive data is handled? No 1.7 Data Does the project involve new or significantly changed handling of a considerable amount of personal and/or business sensitive data about each individual in a database? 1.8 Data Does the project involve new or significantly change handling of personal data about a large number of individuals? 1.9 Data Does the project involve new or significantly changed consolidation, inter-linking, cross referencing or matching of personal and/or business sensitive data from multiple sources? 1.10 Data Will the personal data be processed out of the U.K? No 1.11 Exemptions and Exceptions 1.12 Exemptions and Exceptions 1.13 Exemptions and Exceptions Does the project relate to data processing which is in any way exempt from legislative privacy protections? Does the project s justification include significant contributions to public security and measures? Does the project involve systematic disclosure of personal data to, or access by, third parties that are not subject to comparable privacy regulation? No No No No No No

45 The purpose of this assessment is to confirm that privacy laws and information governance standards are being complied with, or highlights problems that need to be addressed. It also aims to prevent problems arising at a later stage which might impede the progress or success of the project. Answering Yes to any of the screening questions above represents a potential IG risk factor please proceed and complete the next section.

46 2. Privacy Impact Assessment 2.1 Is this a new or changed use of personal and/or business sensitive information that is already collected? See note 3 for guidance New/Changed No 2.2 What data will be collected? Personal Confidential Data Administration data Forename Surname DoB Age Gender Address Postcode NHS No Another unique identifier (please specify) Other data (Please state): Sensitive data Racial or ethnic origin Political opinion Religious belief Trade Union membership Physical or mental health or condition Sexual life Commission or alleged commission of an offence Proceedings for any offence committed or alleged Will the dataset include clinical data? (please include) Will the dataset include financial data? Description of other data collected No No Yes/No Sensitive data race or ethnic origin, religious belief, sexual orientation, and physical or mental health condition were collected as part of the CCG s equality duty when collecting feedback from patients and service users on the current services. Surveys are submitted anonymously. Business sensitive data Financial Local Contract conditions (National contract conditions are in the Public domain)

47 Decisions impacting: One or more business function N Yes/No Across the organisation N Description of other data collected 2.3 List of organisations involved in processing the data? If yes, list below Yes/No Name Data Controller (DC) or Data Processor (DP)? Y Completed and compliant with the IG Toolkit 1 Bromley CCG DC and DP Y Oxleas NHS FT DC and DP Y Community pharmacists various providers DC and DP Yes/No Required to carry out selfassessments of their compliance against IG requirements 2.4. Has a data flow mapping exercise been undertaken? If yes, please provide a copy, if no, please undertake see Note 4 for guidance 2.5 Does the Work involve employing contractors external to the Organisation? If yes, provide a copy of the confidentiality agreement or contract? No Yes/No No Yes / No

48 2.6 Describe in as much detail why this information is being collected/used? Data are currently collected from the incumbent providers for contract management and payment purposes. The new services will continue to provide the same information to the CCG for these purposes. Other than data collected through surveys, as noted in section 2.2, no additional data are being collected for this project other than the data already reported to the CCG by the incumbent providers. Data received from providers for monitoring/management of this service are in anonymised format. 2.7 Will the information be collected electronically, on paper or both? Electronic 2.8 Where will the information will be stored: Paper On the CCG s Q drive. Access is restricted to CCG colleagues working on the project. 2.9 Will this information being shared outside the organisations listed above in question 3? If yes, describe who and why: Yes/No No 2.10 Is there an ability to audit access to the information? Yes 2.11 What roles will have access to the information? (list individuals or staff groups) Access will be provided to CCG employees as and where appropriate and only where required for project purposes. Abigail Barry (Senior Prescribing Advisor), Karen Hong (Head of Medicines Management), and Warren Galstin (Contract Support Manager) all have access to the area of the Q drive where the data are stored What security and audit measures have been implemented to secure access to and limit use of personal identifiable and/or business sensitive information? Username and password Smartcard key to locked filing cabinet/room Secure 1x Token Access Restricted access to Network Files Other: Provide a Description Below: 2.12 Is Mandatory Staff Training in place for the following? Yes/No Dates Data Collection: Use of the System or Service: All CCG colleagues involved in the project are compliant with

49 Collecting Consent: CCG mandatory training on information governance Information Governance: 2.13 Are there any new or additional reporting requirements for this project? What roles will be able to run reports? The project doesn t involve running of reports, other than the production of the business case. No What roles will receive the report or where will it be published? Project team, CCG s Clinical Executive Group, Governing Body and Prescribing and Medicines Management Group Will the reports be in person-identifiable, pseudonymised or anonymised format? 2.14 Reports will not contain person-identifiable data. Where personal information is used, for example the business case may contain case studies of patients that have used the services, these will be reported in an anonymised format. Will the reports be in business sensitive or redacted format (removing anything which is sensitive) format? All reports will remove business sensitive data. Governing Body reports that contain business sensitive data will be reported to the Governing Body in private only, with redacted versions presented to the Governing Body in public. Awards of contracts will be made publicly. If this new/revised function should stop, are there plans in place for how the information will be retained / archived/ transferred or disposed of? 2.15 Have any Information Governance risks been identified relating to this project? (if Yes the Yes final section will need to be completed) 2.16 Are individuals informed about the proposed uses of their personal data? Yes 2.17 Are arrangements in place for recognising and responding to requests for access to personal Yes data? 2.18 Will individuals be asked for consent for their information to be collected and/or shared? If no, list the reason for not gaining consent e.g. relying on an existing agreement, consent is implied, he project has s251 approval or other : Yes Information Governance Risk Identified and Actions required: Risk High/Low Action Timescale Data may be generated for Bromley CCG which relates to less than 10 individuals which could lead to identification. Patients are not effectively informed if a new prime Medium Medium Any data generated which relates to less than 10 individuals must be suppressed. Ensure fair processing notices are updated if a new provider is Agreed prior to project implementation Prior to the start of the new Yes/No Yes NHS contract

50 provider is appointed. appointed. contract. Bidding organisations are not IG toolkit compliant Medium All bidding organisations will be required to be IG toolkit compliant in order to be awarded a contract as part of the procurement Agreed as part of the procurement

51 Bromley CCG Digital Impact Assessment Project Name: Name and role of officer/s completing the assessment: Business Case for Medicines Optimisation Service and Tailored Dispensing Service Warren Galstin, Contract Support Manager Date of assessment: 15/09/2017 Analysis / Design Initiation Delivery Close Down Review / Lessons Project Stage: Learned Anticipated date IT / Digital solution(s) is required May 2018 Project Budget: MOS: 275,000 per annum TDS: 324,000 per annum No specific budget for the procurement project Has a funding source been secured? Has a specific amount been set aside for IT / Digitisation? Yes (for the service provision) NO Source of funding: CCG Further Details: N/A List key beneficiaries (Stakeholders): Health Social Care Third Sector Patients Public Other Specify: Informal carers

52 Information Governance Has a Privacy Impact Assessment been completed? YES Please include PIA with this form PIA is in draft stage currently being reviewed by CSU information governance colleagues. Outline Give a brief summary What is the purpose of the Project In what context will it operate What results are intended Why is it needed Is there are current provider of the service? The Bromley Medicines Optimisation Service (MOS) was commissioned in 2016 as a 2 year pilot to inform onward commissioning. This service receives referrals from health and social care professionals to assess and review patients who require support with their medicines, including a clinical pharmacist medication review element which was targeted in one Integrated Care Network locality. The Oxleas pharmacy team was awarded the contract, with service delivery commencing in May The Tailored Dispensing Service (TDS) was commissioned in 2014 from community pharmacy providers for the provision of dispensing adjustments/compliance aids following assessment by MOS. TDS is provided by 36 pharmacists across Bromley, who issue a dispensing adjustment at the time of dispensing the prescription. The contracts for both the MOS and the TDS are due to end at the end of April Options for onward commissioning have been discussed at the Prescribing and Medicines Management Group and the Clinical Executive Group, with the recommendation to continue commissioning both of these services. The CCG is now reviewing these services in preparation for a procurement process.

53 Anticipated dependency on IT (explanation) High: requires new devices and operating systems/solutions, network, telecoms, accounts, software, training, project management etc Medium: expansion of existing IT to cover the project; Low: minimal change in IT provision as it is already in place Anticipated dependency on digitalisation (explanation) High: Project is fully dependent on digital solutions; Medium: Digital solutions are required to enable / enhance the Project; Low: minimal dependency on digitalisation (in place or due to nature of the project IT and Digital Dependency Anticipated dependency on IT (use above explanation as a guide) Low Medium High What assumptions / evidence have been used to allocate this score? Source of any external references NB: the below considerations are in relation to the delivery of these services (as opposed to the procurement project to establish these services). New providers will require an NHS.net address for secure communication with the CCG Based on experience from working on the current service, community pharmacists may require IT support to help them meet the CCG s reporting requirements for payment and contract monitoring. E.g. some pharmacists work on old versions of Microsoft which are not compatible with the spreadsheets the CCG asks providers to use to report on the service. Anticipated dependency on digitalisation (use above explanation as a guide) Anticipated benefits to be enabled Providers should be able to meet the CCG s requirements for these services with minimal dependency on digitalisation. There is a certain level of digitalisation required e.g. being able to access the Shared Care Record. However these services don t have any additional digital requirements List benefits (example): Safety Describe how this is to be enabled (example): Communication through nhs.net accounts is a safer way to communicate with providers

54 Productivity If community pharmacists are using Microsoft software compatible with the CCG s software, reporting on activity, KPI monitoring, and invoicing the CCG will be more efficient for both the providers and the CCG Questions Briefly Outline any concerns / questions This will ensure that any assessment can address queries upfront or take them on-board for further analysis Nil

55

56 Medicines Optimisation Service (MOS) Service Specification Service Specification No. Number 2 Service Commissioner Lead Provider Lead Period Medicines Optimisation Service Date of Review September 2017 Karen Hong, Head of Medicines Management Abigail Barry, Senior Prescribing Adviser 3 years (with option of 2 year extension) 1. Population Needs Background a. National/local context and evidence base Getting the most from medicines for both patients and the NHS is becoming increasingly important as more people are taking more medicines, this will lead to improved quality of life and better clinical outcomes. Medicines prevent, treat or manage many illnesses or conditions and are the most common intervention in healthcare. However, it has been estimated that between 30% and 50% of medicines prescribed for long-term conditions are not taken as intended 1 and the number of people with long-term conditions continues to grow rapidly. Relating to the increasing incidence of co-morbidities, the King s Fund 2 reported issues of problematic polypharmacy and the importance of improved medicines optimisation for the individual patient and the wider health economy. Only 16% of patients who are prescribed a new medicine take it as prescribed, experience no problems and receive as much information as they need. Ten days after starting a medicine, almost a third of patients are already non-adherent of these 55% don t realise they are not taking their medicines correctly, whilst 45% are intentionally non-adherent. 3 Management of patient safety and risk with medicines is another important factor, a report commissioned by the Department of Health 4 found that 5% to 8% of unplanned hospital admissions are due to medication issues, this figure can increase to 17% in the over 65s 2. A time of significant risk that has been highlighted is when patients move between care settings, patients medicines will be unintentionally altered, leading to adverse drug events and hospital readmissions 5. The National Patient Safety Agency (NPSA) have reported that between 30 and 70% of patients have either an error or an unintentional change to their medicines when their care is transferred 6. Furthermore, it is estimated that around 300 million per year of medicines are wasted in primary care in the UK, of which 150 million could be avoidable 7. With the 2014/15 primary care drug spend estimated to be over 8 billion in England (NHS Business Services Authority) and over 43 million in Bromley, suboptimal use of medicines will not only lead to poor patient outcomes, but also represents a significant economic challenge. References: 1. National Institute for Health and Clinical Excellence. Medicines adherence. Involving patients in decisions about prescribed medicines and supporting adherence. NICE Clinical Guideline

57 2. The King s Fund. Polypharmacy and medicines optimisation: Making it safe and sound cy-and-medicines-optimisation-kingsfund-nov13.pdf 3. Royal Pharmaceutical Society. Medicines Optimisation: Helping patients to make the most of medicines. Good practice guidance for healthcare professionals in England. May Frontier Economics Ltd. Exploring the costs of unsafe are in the NHS A report prepared for the Department of Health. October National Institute for Health and Clinical Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE Guideline Royal Pharmaceutical Society. Keeping patients safe when they transfer between care providers getting the medicine right. Good practice guidance for healthcare professions. July transfer-of-care-10pp-professional-guidance---final-final.pdf 7. York Health Economics Consortium and The School of Pharmacy, University of London. Evaluation of the Scale, Causes and Costs of Waste Medicines icines_waste_nov_2010.pdf 2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators Domain 1 Preventing people from dying prematurely x Domain 2 Enhancing quality of life for people with long-term x conditions Domain 3 Helping people to recover from episodes of illhealth x or following injury Domain 4 Ensuring people have a positive experience of x care Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm x 2.2 Local defined outcomes Improved access to support options for patients with their medicines Improved clinical outcomes for patients from their medicines Reduced medicines waste Reduced adverse drug events Reduced hospital admissions Reduce inappropriate use of multi-compartment compliance aids (MCAs) Reduced care needs/ independence maintained Reduced harm from medicines 2

58 3. Scope 3.1 Aims and objectives of service Aim: To support patients living in the community to access and use their medicines appropriately, thereby enabling them to manage their medicines better, support self-management and independence, reduce medicines-related harm or hospital admissions, improve health outcomes and reduce medicines waste. Objectives: To support patients to manage their own medicines and maintain independence To improve patients understanding of their medicines and improve adherence To provide clinical medication review to patients identified as having a medicinesrelated problem To reduce the number of inappropriate drugs prescribed using evidence-based tools To reduce the number of adverse drug events experienced To reduce medicines waste To work collaboratively with other health and social care professionals to support and implement personalised tailored interventions for individual patient needs To work with the CCG and social care to develop and implement guidance/policies on medicines administration support To reduce the risks of harm caused by medicine regimens or inadvertent reconciliation errors. 3.2 Service description/care pathway The service will build upon the Medicines Optimisation Service (MOS) pilot, which ran between May 2016 and April A review of this service was conducted in 2017, which identified opportunities to optimise the service and made a few key recommendations. The service provider will receive referrals from health and social care professionals for adults identified as requiring support with their medicines. Direct self-referral from patients and their informal carers is not currently considered appropriate, however can be achieved through a health or social care professional in order to ensure appropriate information is received. As Integrated Care Networks are developed in Bromley, the service provider will work closely as part of these networks, ensuring that patient care and communication is integrated with other appropriate providers. This includes working towards access and integration of care records with primary care. There will be a single point of electronic referral. Upon receipt and acknowledgement, referrals should be triaged in order to allow prioritisation. All referrals should be assessed for the requirement of a comprehensive clinical medication review at the most relevant time for that individual. Clinical medication review may be defined as a structured, critical examination of a patient s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medication related problems and reducing waste. (Room for Review: A guide to medication review: the agenda for patients, practitioners and managers. Task Force on Medicines Partnership and The National Collaborative medicines Management Services Programme. 2002) 3

59 Good collaboration with other health/social care professionals and services e.g. the voluntary sector will be essential to ensure implementation of some interventions. The Provider will develop a communications strategy to raise awareness of the service and ensure that relevant health/social care professionals and patients understand the aims of the service and how it will be delivered. The provider will engage with the local authority and commissioners to explore additional services which would better support patients with formal care packages and in formal care settings e.g. extra care housing or care homes. The provider will engage with commissioners to explore additional services which better support other identified high-risk patients currently not included within the service specification. Proposed Staffing Model The MOS provider will include very senior pharmacist/manager oversight and strategic leadership. In addition, senior pharmacist oversight of the service is required. The service must include appropriate skill mix of technicians and clinical pharmacists. A suitably experienced/skilled clinical pharmacist should be available during all operating hours of MOS to provide medication review and clinical advice as is appropriate to the service. 4

60 Service model and care pathway Referral from health/social care Initial triage and contact/assessment Trigger questions: - Access to medicines - Adherence (intentional VS non-intentional) - Side effects/poor outcomes Medication assessment/review - Domicillary visit undertaken by pharmacy technician or clinical pharmacist - Care plan agreed Liaise with GP, CP and others to coordinate implementation of care plan - Refer for appropriate support Implementation of adherence support Liaise with appropriate services e.g. - Community pharmacy support* - Social services care package - District nursing - Other carers/family Review within 6 weeks to ensure care plan implemented - Follow up of care plan - Liaise with CP for ongoing support in accordance with care plan - Arrange further follow-up/review as appropriate - Telephone support to relevant health care professionals as appropriate *Community pharmacy support includes: - Usual essential/advanced services e.g. MUR, NMS, compliance aids/ adjustments for EA patients - TDS patients e.g. MAR charts, compliance aids for non-ea patients - Ongoing monitoring, information and support CP - Community Pharmacist MUR - Medicines Use Review NMS - New Medicine Service EA - Equality Act (formerly Disability Discrimination Act) TDS - Tailored Dispensing Service MAR - Medicines Administration Record 5