Hospital Pharmacy Transformation Programme [HPTP] for Royal Surrey County Hospital NHS FT

Transcription

1 1. Executive Summary Hospital Pharmacy Programme [HPTP] for Royal Surrey County Hospital NHS FT Lord Carter s review of productivity and efficiency in acute hospitals included a review of hospital pharmacy and medicines optimisation through its NHS Procurement & Efficiency Board. Variations were found and a Hospital Pharmacy Programme (HPTP), led by NHS Improvement, has been established. It challenges acute Trusts and their hospital pharmacy departments to transform services by consists of the following work streams: a) Hospital Pharmacy Programme (HPTP) Planning & governance b) Core clinical pharmacy & infrastructure services c) Electronic Prescribing & Medicines Administration (EPMA) d) Accurate coding of medicines e) Top 10 drug saving opportunities (nationally) f) Medicines stock holding & supply chain The Main areas for consideration of service rationalisation at RSCH are: 1. Pharmacy department Core Clinical Pharmacy & Infrastructure Services 80% of pharmacists time should be spent on direct patient/safety related activities 7-day working Pharmacy on-call and out of hours service review 2. Pharmacy department Variable Infrastructure Services (Collaborative working with other Trusts) Pharmacy Procurement & Distribution Medicines Information & Joint Formulary services Education & Training Clinical Trials and R&D Wholesaler dealing to 3 rd parties 3. Trust EPMA 4. Trust accurate coding of medicines 5. RSCH Pharmacy Aseptic Manufacturing Unit (already in alignment with Carter principles) 6. RSCH Pharmacy Ltd (already in alignment with Carter principles) NHS Improvement has enabled hospitals to access benchmarking data via the designated Model Hospital Portal. The data available is continually being refreshed and will be used throughout the next three-years to track our progress. It makes various assumptions and it is important that this is contextualised correctly where RSCH does not fit the standard model assumed. Based on current data, RSCH is currently showing: A Positive low number for stock holding days Negative high cost base of medicines and pharmacy staff per Weighted Activity Unit (WAU is the normalising denominator used by NHS Improvement (but see below for RSCH local context). Negative low usage of the Summary Care Record (SCR) requires attention at Trust level Negative low utilisation of EPMA. (comments on these findings are made below (section 3)) It is envisaged that this programme will transform and optimise medicine use by reconfiguring pharmacy operations directly as well as those related to Pharmacy within the organisation. The efficiencies in 1

2 infrastructure will release staffing capacity for redeployment into front line clinical pharmacy services. Some of the opportunities for transformation will be driven by STP/Trust strategic plans and this will be incorporated into department and Trust business planning (See Appendix 1 attached Detailed hospital pharmacy transformation action plan). This paper is the Final HPTP plan for submission to NHS Improvement by 31 st March Thereafter, 6- monthly updates will be provided to the Trust Board until Carter Model Hospital Benchmarks & Metrics AAPT data: Pharmacist resource spent on direct patient and safety related activities: 62% (target 80%) Pharmacy Technician resource currently deployed on ward based activity: 55% (target 80%) Pharmacy Assistant time currently deployed on ward based activity: 20% (target 80%) From our own Trust data we know that we have: Positive low number of stock holding days (14.1). We are demonstrating a better figure than the Carter benchmark, which is 15 days. The screen shot from Model Hospital portal shows RSCH has a: Negative high cost base of medicines and pharmacy staff per Weighted Activity unit (WAU is the normalising denominator used by NHS Improvement). It is important to note that RSCH Pharmacy undertakes the buying of predominantly high cost drugs for its aseptic unit customers (four local acute hospitals). As only drug costs are taken into account in this calculation (and not the income associated with these costs) the Pharmacy Staff & Medicines Cost per WAU will appear falsely high]. We are working on the normalised figure for RSCH and will provide an update in the next report. Negative low usage of the Summary Care Record (SCR). The Trust use of SCR is reported as 18.8%, which is extremely low. Pharmacy staff have access to and are using the SCR but it is not clear how much they contribute to the overall 18.8% reported figure. The Pharmacy Department have lead the development of the use of SCR at the Trust, the Trust in general needs to work to improve this across all relevant disciplines. Negative low utilisation of EPMA (0%). The trust currently lacks a proper Electronic Health Record to which an EMPA system would have to be linked: an EPMA system would not derive the associated benefits if linked to OASIS. 2

3 3. HPTP Plan Summary Pharmacy Department Core Clinical & Infrastructure Services 80% of pharmacy staff resource should be spent on direct patient and safety related activities. Currently, we are operating well below this target. A full workforce review has been started to enable workforce alignment in this direction. This is being facilitated by Nikki Hill in HR and the aim is to develop a robust workforce strategy for pharmacy. There needs to be some discussion regarding the exclusion of OPD (RSCH Pharmacy LTD) staff from this metric and reallocation of Aseptic Unit staff to the end user. These changes would result in an improvement in this metric. To support numbers of staff involved in direct patient care, we also have plans to integrate our pharmacy in-patient dispensary service (and staff) directly into the pharmacy clinical services team. This will support clinical activities such as medicines reconciliation on admission and to facilitate timely discharge, through better use of staffing resources. We will further train assistants to support dispensary activities (e.g. labelling, dispensing, POD checking etc), and technicians to cover all prescription final checking functions and work alongside pharmacists in all clinical areas. We aim to implement Band 6-7 progression posts for Pharmacists, to support training and development and aid recruitment and retention. We would also like to implement Band 6/7 rotations that include primary care, namely GPs, but also which include collaborative working with ASPH and Epsom Hospitals (which fall within our STP). Our Band 7 pharmacists will routinely work towards becoming independent prescribers and so become proactive in the support of TTO management and thus also facilitate timely discharge. The difficulty in recruiting band 7 staff across the SEC region is being discussed with HEEKSS. We will work with HEEKSS who commission places for independent prescriber training to ensure that our requirements are met. Addition of a prescribing qualification into the current Foundation Pharmacist programme should ensure that we have adequate independent pharmacist prescribers (IPPs) in future. We are working closely with our Trust NMP lead to actively ensure Pharmacy and Pharmacists are an integral part of the Trusts NMP strategy and funding is set aside for this each year. Deployment of IPP s in the Emergency Department working alongside a GP has good scope. In addition to this, we will need to review current working shifts and staff rotas to understand how 7-day pharmacy working can be implemented safely and effectively to provide adequate pharmacy support to Trust clinical services. This will stimulate a natural review of the pharmacy on-call and out of hours service. Pharmacy Department Variable Infrastructure Services We are collaborating with the pharmacy department at ASPH (both previously as part of merger discussions and more recently through Carter activities) and have begun to scope opportunities for rationalising Pharmacy Variable Infrastructure Services at both Trusts. This includes: A combined pharmacy procurement & distribution function (includes stock holding, supply chain & drug saving opportunities) A single Medicines Information Service Joint Formulary services (with G&W and NW Surrey CCG also & includes drug saving opportunities) A combined Education & Training team An integrated Clinical Trials and R&D team with joint trial activity Wholesaler dealing to 3 rd parties from a single site, and the revoking of our license. The HPTP provides the correct opportunity and platform to implement collaborative working. 3

4 Our stockholding days are currently below the required target at 14.1 days and we are working towards 5 daily deliveries by reviewing our ordering patterns and working to rationalise our suppliers. Out of stock items and drug cost from different suppliers based on CSU contracting are impacting factors on achieving this. There is conflict between having a low number of deliveries and a low stockholding, the consequences of which may adversely affect patients i.e. more out of stock situations. A consolidated store/procurement hub with ASPH/EPsom in the future (or alternative collaborative arrangements) will help to rationalise this. Our e-ordering rate is at 66% via Powergate but this figure is 95%+ of those we can order from electronically. Pressure on individual suppliers will be required to support this. Our e-invoicing rate is 0% - We are unable to tackle this at present as the issue lies within Trust IT/Finance infrastructure. We have plans to introduce e-invoicing with or without a pharmacy system upgrade. A known issue is that not all of our suppliers [to be quantified] support e-invoicing so we would like that escalated to NHS Improvement for ongoing support. Trust EPMA Timescale: Trust EHR dependent, but approximately 2 years A robust EHR and EPMA system would greatly increase safety, quality and efficiency within the pharmacy department, release pharmacy staff time and allow patient targeted care. The Pharmacy Dept has been engaging with Trust IT, the Trust Digital Hospital Lead (DMD) and has started to engage with epma providers to better understand how epma should be implemented following the implementation of a proper Trust EHR system. We are also working collaboratively with ASPH on this. The Trust has timescales of approximately two years for the roll out of epma. To date, we have implemented the Aria system for chemotherapy prescribing this is an on-going project and requirements are continuously changing. This system is being used in partnership with the surrounding hospitals for whom RSCH also provides chemotherapy. In addition to these core activities, as a Trust we need to encourage non-pharmacy clinical staff to access Summary Care Records, enable electronic ordering from ward to dispensary, and transfer paper-based ordering and invoicing to electronic systems. This will streamline processes and generate significant time efficiencies. Trust Accurate Coding of Medicines Timescale: Sept 2017 The current management of this data is under review in the Trust as the EPR is not sensitive enough to pull all the required data as a standard data set. The drugs are coded within the Pharmacy system but thiss exists as a single point of failure. The increasing need for clinical data to be merged with the drug data is an ongoing issue. The Trust has therefore set-up a task and finish group, lead by the Deputy Director of Finance & Chief Pharmacist, and includes all relevant stakeholders, to look at this in more detail. SnoMed codes, as part of DM+D, are being integrated into Trust information systems and JAC at present. The aim is to produce a resilient system that meets Trust and Commissioner needs, both now and in the future. RSCH Pharmacy Ltd Timescale: Sept 2017 Our subsidiary pharmacy company is currently in its 3 rd year of trading and provides a dedicated pharmacy service to Trust out-patients, including some enhanced services. There is a plan to further expand the subsidiary s activity and footprint to include oncology out-patients, hospital discharge prescriptions and to re-patriate our current 3 rd party homecare provider supply. This will continue to generate operational and financial efficiencies for the Trust and its Commissioners. 4

5 RSCH Pharmacy Aseptic & Manufacturing Unit Timescale: April 2018 The Pharmacy department aseptic manufacturing unit already operates in line with Carter recommendations. Being a tertiary referral cancer centre, we currently manufacture and supply chemotherapy to our own patients as well as those at 4 local acute Trusts i.e. the resources have already been centralised. Continual growth in activity without adequate investment, has shifted the focus to internal activity over external activity in recent years. However, this has been addressed recently and through appropriate management systems and recruitment. This will enable a return to a full stable Carter model. We need to look at how the resources (drug cost and staff) are allocated in the Model Hospital data the current position results in RSCH numbers being skewed. Overall, we envisage there will be project costs related to the implementation of the HPTP and it would be prudent to secure funding via the 2-year HPTP CQUIN funds. 4. Risks and mitigations Risk Potential investment required for implementation of 7 day working & OOH review Variable Infrastructure Consolidation Continual, effective engagement with ASPH & Epsom epma dependencies & implementation costs RSCH Pharmacy Ltd RSCH Aseptic & Manufacturing Unit 2-year CQUIN enabling funds [total c 140k] may not be accessible Mitigation Include and secure as part of 2017/18 Business plan. review and staff consultation. Continual, effective staff engagement Series of staff de-briefs planned throughout the year. Close HR engagement required as well as Trust Execs. We have plans to introduce electronic invoicing with or without a pharmacy system upgrade. A known issue is that not all of our suppliers [to be quantified] support e-invoicing so we would like that escalated to NHS Improvement Effective engagement with Epsom Hospital is required. The respective chief pharmacists have been in dialogue for some months and the second tier of pharmacy management have now also made contact with respective counterparts. Develop a good working relationship with the recently appointed Chief Pharmacist at ASPH. Visibility & understanding of Trust EHR Road Map and timescales HPTP leads to liaise with local and national networks to gain NHS Improvement engagement to resolve the funding gap Close engagement and good communication with Company Board Integration of St.Lukes oncology and IP dispensary teams and activity into the Out Patient clinical team will change the dynamics of the RSCH Ltd service. Partnership working arrangements with NHSE need to be agreed and implemented. Dialogue in situ at present. STP geography means that current collaborators may move to other partnerships resulting in the potential destabilisation of services. A current lack of clarity in some STP arrangements is unhelpful at this stage. Director of Finance & Information to continue dialogue with commissioners and flag to NHS Improvement via regular reports 5

6 5. Issues and mitigations Issue New [substantive] ASPH Chief Pharmacist in Jan 2017 Epson Hospital involvement in collaborative work RSCH Pharmacy Ltd Mitigation Active engagement required Active engagement required Active engagement with Commissioners required Royal Surrey County Hospital Acting Chief Pharmacist Moiz Hameed March

7 Appendix 1 HPTP in detail Project Activity Plan Workstream Milestone Programme Design Influencing Commissioners Programme Architecture Steering Group Established Determine Benefits Activity Design workstreams and prioritise, taking into account review of pharmacy Determine membership, finalise ToRs, set meeting dates Resources - estimate investments (staff, technology, other) Financials - best guess gross savings Financials - determine and document methodology for determining and tracking savings Financials - validate targets (gross and net) Start/Due Date 31-Jan Jan Jan Jan Feb Feb-17 Owners Assign owners - workstreams and projects Engagement PID Finalised Implement Identify Leads Complete negotiations Revisit savings Fees & Drug Costs Develop stakeholder engagement plan Engage with stakeholders to underpin implementation PID - initial draft completed PID - Gateway review PID - Finalise PID Brief dispensary and ward based pharmacists on schemes and ensure that responsibilities and timescales of delivery have been understood Track implementation against programme and workstream milestones Identify Pharmacy, Contracting and Finance Lead to negotiate with commissioners Develop negotiation strategy; one for NHSE; one for CCGs Schedule meetings (anticipated minimum 2 will be required) & meet with NHSE Schedule meetings (anticipated minimum 2 will be required) and meet with CCG(s) - potentially via Joint programme Revisit savings targets for relevant schemes to reflect outcome of negotiations; and develop milestone plans Dispensing & homecare fees for non-pbr medicines - establish systems and processes for invoicing commissioners (NHSE / CCG) Dispensing fees and reimbursement of drugs costs for hospital only and shared care medicines; SPT to identify relevant medicines, calculate the value of drugs to be reimbursed and show as target in plan 17-Mar Jan Feb Mar-17 Ongoing 10-Feb Feb-17 7

8 Establish systems for tracking transactions (for fees) and tracking spend (drug cost reimbursement); invoice monthly Ongoing Medicines Optimisation (MO) Leads & Engagement - All MO workstreams Reviews and Identify pharmacy leads for each scheme Identify clinical leads for each scheme Define and meet with stakeholders (Divisions, Specialties, Clinical, Non-clinical etc) for each scheme (refer to CIP Summary Sheet) Inhaler review: scope review to include: Inhaler dispensing policy for inpatients when on nebulised treatment; review of TTO packs (started 2016/17); Joint CCG / Trust review of inhaled ICS / LABA / LAMA for COPD (potentially as part of the Joint Formulary work) - requires CCG liaison Biosimilar Insulin Glargine (BIG): Amend JAC minimum order levels for standard insulin glargine to run down stocks Thyrotropin: Amend JAC minimum order levels and start to run down stocks Ciclosporin 1% EDs - Identify patients suitable for transfer to GP for prescribing & support specialties with communications to GPs & "go live" Dalteparin (c/f from 2016/17) - develop shared care guideline based on CCG compromise position Midodrine (new 17/18) - develop information sheet Aprepitant - identify opportunities (e.g. review prescriber trends; identify regimens where aprepitant used as "rescue" before other options") & engage with clinicians to discuss alternatives (where clinically indicated) Biosimilar Insulin Glargine (BIG): Engage with clinicians and specialist nurses to ensure momentum in switching is maintained Biosimilar Insulin Glargine (BIG): Brief ward pharmacists and dispensary staff with a view to challenging prescriptions for standard insulin glargine; track from Apr 17 [Inpatients - promote change where patient is admitted as a result of diabetic control] 24-Feb Mar Mar Mar-17 Thyrotropin: Redefine pathway to indicate that it is the referring Trust's responsibility to supply and administer thyrotrophin as part of the patient workup; secure approval via appropriate Trust committees Thyrotropin: Retrospective analysis of post codes to identify "out of area patients" i.e. those referred by more distant Trusts; reassess saving based on this analysis 8

9 Controls Controls Reviews and Thyrotropin: Engage with referring Trusts to ensure awareness of new pathway (SASH aware and on board) Formulary implementation - address miscoding of non-formulary medicines to obtain an accurate baseline for spend and KPI tracking Non PBR (PBRX) medicines - address miscoding of PBR and Non-PBR medicines Rifaxamin (c/f from 2016/17) - identify patients to transfer and support specialty with communications to GP (includes understanding why scheme did not deliver in 2016/17) Pain: run down Lyrica stocks; purchase generic; review minimum reorder levels on JAC Aprepitant - amend regimens; "go live" and track implementation from April Thyrotropin: "Go Live" and track from Apr 17 Dexamethasone: Price reduction for standard product (2mg / Liquid from March); product range (standard, soluble, liquid and pre-packs) and strengths (500mcg, 2mg, 4mg, 8mg); agree where soluble preparations will be 1st line e.g. regimens which require large doses of dexamethasone Dexamethasone: Logistics: Amend JAC minimum order levels; if applicable, update ward stock lists and issue communications to staff (to highlight different strengths which will be stocked); enablement policy (switching dose form / dose optimisation without reference to clinicians); brief ward and dispensary staff (only switch in-patients if no PODs). "Go live" from April 17 and track DOACs: New contract prices from April update JAC. Track from April 17 Pain: Check Trust guidelines and amend (if necessary) to gabapentin 1st line; pregabalin 2nd line; dose optimisation from Apr 17; use generic from July 1; submit to DTC, PCN & MOG (as required) for approval Fulvestrant: Engage with Divisional leads and clinicians to agree strategy of "no new patients"; "review existing patients and stop wherever possible (particularly where no evidence of benefit)" Rituximab 100mg & 500mg: Review spurious issues to cost centres other than oncology and Medicines and Access; address inappropriate use; ensure expenditure is recovered from commissioners 16-Jun Apr Apr Apr Apr Apr Apr-17 9

10 Controls Controls Controls Waste Non PBR (PBRX) medicines - site visit to Frimley to review Extended Bluteq system and to understand how non-pbr medicines have been managed more effectively. Business case to purchase Extended Bluteq Pain: Enablement policy - to allow pharmacists to dose optimise and switch to generic without contacting prescriber Pain: Brief ward pharmacists, dispensary staff to promote dose optimisation and challenge 1st line pregabalin (from Apr 17) and to switch to generic from July 17 [only where no PODs for inpatients]. Track from Apr 17 Submit shared care guidelines (Dalteparin) & information sheets (midodrine) to PCN, MOG & DTC for approval by 31 May 17 Volatile Liquid Anaesthetics (VLAs) - develop guidelines for isoflurane as 1st line agent for induction, but highlighting where sevoflurane may be more clinically appropriate; and submit to Theatre Clinical Risk Group for approval (Dr Justin Kirk- Bayley to use Chair's Action for DTC) Fulvestrant: Identify "high" prescribers and tackle via Divisional structure; escalate to Meds Mgt Steering Group where there is resistance to change Non PBR (PBRX) medicines - clinically led scheme. Undertake a systematic review of processes from the decision to prescribe, seeking approval, securing approval, prescribing, appropriate follow up (for continuation of funding and treatment) and processes for invoicing. To include a "reconciliation exercise" to determine what proportion of current expenditure on non- PBR medicines is recovered; identifying patients / medicines where monies haven't been recovered; and identifying specialties and/or medicines which are routinely started without the appropriate authorisation being in place Non PBR (PBRX) medicines - consider the role of IPPs in supporting specialties with high risk medicines and high use of non-pbr medicines at Pharmacy Away Session; review how existing teams can be used to implement and develop business case to address gaps Reduce Pharmaceutical Waste: Consider pharmacy led top up for all clinical areas at Pharmacy Away session; consider how this can be delivered from within existing resource or feed into business case for redesigned team 03-May May-17 10

11 Waste Waste Waste Controls Reduce drug write offs - undertake root cause analysis for write offs in 2016/17 and develop action plan based on findings (to include review of JAC minimum order levels, effective horizon scanning, participating "rebate schemes" (e.g. as offered by NHSE) Reduce drug write offs - aseptics: institute pre-manufacture checks of raw materials for particles; and work with QA to undertake root cause analysis e.g. operators and other factors which may contribute to high rate of particulate matter; develop action plan for implementation. Ensure all procedures document required changes Reduce drug write offs - aseptics: move away from manual ordering to JAC automatic ordering via minimum stock levels. Consider higher graded, dedicated resource (band 4 or 5); ensure that all stock used for aseptic manufacturer is processed daily; develop standard operating procedures; Chilworth Day unit to continue to prepare all calcium folinate Formulary implementation - strengthen processes to ensure appropriate use and reporting of pink forms (DTC to consider trends not "monthly snapshots"; develop escalation procedure to flag inappropriate use / abuse of pink forms to Divisional structure; investigate if pink form can be come electronic; reduce no. of forms before formulary request is triggered) Dalteparin - Identify patients suitable for transfer to GP for prescribing & support specialties with communications to GPs Midodrine - Identify patients suitable for transfer to GP for prescribing & support specialties with communications to GPs VLAs - review minimum reorder levels on JAC; increase isoflurane and reduce sevoflurane Fulvestrant: Amend JAC minimum order levels; start to run down stocks Adjust JAC minimum order levels for dalteparin, midodrine and ciclosporin 1% EDs to reflect anticipated lower usage by RSCH Inhaler review: establish "task and finish group" to undertake review - aim for completion (including guidelines, approvals by DTC, PCN, MOG) 01-Jun Jun Jun Jun Jun Jun Jun-17 11

12 Controls Controls Waste Waste Non PBR (PBRX) medicines - strengthen systems and processes taking into account findings of the systematic review. Includes working with specialty teams to ensure robust systems are in place with respect to applying for funding and managing follow ups. Institute regular contact between pharmacy, contracting and finance to ensure seamless process to managing non- PBR medicines Establish systems to ensure timely transfer of new patients (Dalteparin after 2 months; other medicines after 1 month) VLAs - Engage with anaesthetists and Operating Department Assistants - principle is that trolleys are loaded with isoflurane routinely in the am; and a clinical decision is required to switch to sevoflurane Inhaler review: calculate financial impact - to include risk/benefit share with the CCG Inhaler review: amend formulary; review JAC minimum stock levels, update enablement policy ready for "go live"; brief dispensary and ward pharmacists Rituximab 100mg & 500mg: Engage with clinicians & nursing staff in relevant specialties (oncology, acute medicine - rheumatology) and agree principle of wholesale switch and method Rituximab 100mg & 500mg: Submit application to DTC for "approval in principle" to switch to biosimilar Rituximab 100mg & 500mg: Update regimens on Aria; prepare brand specific worksheets (once SPCs available); undertake stability reviews ecabinets and eordering: Develop business case for the roll out of ecabinets and eordering in clinical areas with high medicine spend i.e. Theatres, ICU and A&E Reduce Pharmaceutical Waste: Institute rolling programme of ward / clinical area stock list review and return of non-stock & overstocked medicines to pharmacy (and return on JAC). Initial review, of all wards and clinical areas to be completed by 30 June 17 Reduce Pharmaceutical Waste: Return all RSCH "individually dispensed medicines" and TTOs, which have not been issued to patients at the point of discharge to pharmacy and return on JAC "Go live" i.e. existing patients transferred (Dalteparin, Midodrine) 30-Jun Jul-17 12

13 Controls Controls Controls VLAs - "go live" - pharmacy presence in theatres first thing in the morning for a few days to influence implementation; track implementation Fulvestrant: Amend regimens and protocols when all clinicians are on board; "Go Live" 3 July and track Dexamethasone: Amend Aria regimens to reflect strength of dexamethasone which will be used by end of Jul (or sooner) - track as above Inhaler review: "Go live" and track from July Homecare medicines - secure agreement in principle for a gain share for savings associated with reducing prescription length and contacting patient to determine if a supply is required (refer to "Influencing Commissioners"). If agreed, develop plan and determine savings - aim for plan in place by July ecabinets and eordering: Develop plan for roll out to clinical areas (prioritise according to "ease of implementation"; may need support from Estates and IT) - aim for "go live" in Sept 17 Track implementation monthly - from Apr 17 (Rifaxamin, Ciclsoporin 1% eye drops) and from July 17 (Midodrine, Dalteparin) New contract prices: Review contract prices quarterly. Identify medicines for new switches and calculate savings associated with price reductions. Feed into programme and develop project mandates or PIDs as required Carter Top 10 medicines: Develop processes to formally "receive" top 10 medicines; secure DTC / Meds Mgt Steering Group approval; develop medicine specific plans and savings. Build into programme Formulary implementation - implement chapter by chapter; includes clinical engagement, uploading onto online formulary; costing implications (savings and cost pressures - feeding into the negotiation strategy); briefing dispensary and ward staff; enablement policy; and tracking VLAs - Flow rates - ensure all theatres are equipped with equipment to ensure very low flow rates are used DOACs: primary / secondary review of DOACs and LMWT - place in therapy, preferred choice; update Trust formulary and guidelines DOACs: Recalculate savings once outcome of review known; and set implementation date Jul Jul Jul Jul Jul Sep-17 Ongoing Ongoing Ongoing Ongoing from July 17

14 Alternative Supply Arrangements Waste Rituximab 100mg & 500mg: Once product launch date is known, amend JAC minimum order levels and start to run down stocks Rituximab 100mg & 500mg: Following launch, liaise with clinicians and nursing staff responsible for administration to agree implementation date (existing stocks to be used up first) Recover aseptics write off expenditure: Progress formal complaint and, if required, institute legal proceedings against BD to recover the costs of waste aseptic medicines which occurred as a direct result of a faulty batch of syringes. Ensure legal proceedings kicked off by May 17 Reduce Outpatient prescribing: RSCH Pharmacy Ltd and Satellite Pharmacy (until transfer of medicines to RSCH Pharmacy Ltd) to rigorously enforce policy of restricting outpatient dispensing to medicines associated with the consultation; and to check with patients if a supply is actually needed. Includes escalation to new Divisions if prescriber is consistently prescribing outside of the policy (need to set threshold) TTOs - Elective patients (phase 1) - Update medicines policy to reflect new policy (new medicines only prescribed and dispensed for admissions <48 hours) and pharmacy to ensure that minimum 7 days provided at discharge (TTO will only be dispensed if patient has <7 days on PODS or one stop medicines); develop SOPs to set out approach to implementation TTOs - Elective patients (phase 1) - Patient letters confirming date of surgery to include a statement that routine medicines will not be dispensed at discharge and that further advice on OTC medicines to have "in stock" at home will be provided at the pre-assessment appointment TTOs - Elective patients (phase 1) - Develop patient information leaflet to be handed to the patient at the surgical preassessment appointment. This will allow clinician / nursing staff at pre-assessment to complete a "medicines to keep in stock at home" section TTOs - Elective patients (phase 1) - Communicate new policy to clinicians; brief ward pharmacists to clinically screen TTOs against drug chart but to only supply new medicines. Pain relief only to be supplied if patient does not have stocks at home 03-Apr May-17 14

15 Reduce Outpatient prescribing: Confirm scope as urgent ("define", hospital only, shared care before transfer. Update outpatient prescribing policy and seek approval from DTC Reduce Outpatient prescribing: Short term: Develop & Issue communication to all prescribers reinforcing that outpatient prescribing should be restricted to new medicines relating to the consultation; Long term (including in the same communication) to reinforce new policy - include link to policy document Reduce Outpatient prescribing: Develop communication for GPs - perhaps adapting the current outpatient prescription into a letter which can either be forwarded to GP (via the daily pathology collection) or handed to the GP by the patient (in a sealed envelope). Communication needs to clearly state that a prescription is not required urgently and up to XX days is required by the GP practice to process the request Reduce Outpatient prescribing: Outpatient appointment letters to include a paragraph or an information leaflet which advises patients that they will not routinely be prescribed medicines following an outpatient consultation; and that a communication will be sent to the GP within XX days of their appointment Reduce Outpatient prescribing: map processes which will need to be in place to ensure transformational change is in place TTOs - Non-elective patients (phase 2) - Update medicines policy to reflect new policy (new medicines only prescribed and dispensed for admissions <48 hours) and pharmacy to ensure that minimum 7 days provided at discharge (TTO will only be dispensed if patient has <7 days on PODS or one stop medicines); develop SOPs to set out approach to implementation TTOs - Non-elective patients (phase 2) - Prioritise specialties for implementation (starting with lower risk) Reduce Outpatient prescribing: "Go live" on new outpatient policy; track from July 17 TTOs - Elective patients (phase 2) - Communicate new policy to clinicians (on a specialty by specialty basis); brief ward pharmacists to clinically screen TTOs against drug chart but to only supply new medicines. Feeds: Pharmacy to cease procurement and supply of dietetic products. Budget to be transferred to dietitians; Supply via Catering () Jun Jun Jul-17

16 Outsource Outsource Outsource Outsource Outsource Outsource Outsource Outsource Outsource Radiological Products: Pharmacy to cease procurement and supply of nonprescription only contrast media; transfer to radiology St Luke's Dispensing: Update proposal, preferred options and recost to transfer St Luke's dispensing to RSCH Pharmacy Ltd St Luke's Dispensing: St Luke's Dispensing: St Luke's Dispensing: TTOs: TTOs: TTOs: TTOs: Establish governance arrangements to ensure that VAT only reclaimed for TTOs issued at the point of discharge TTOs: Innovative Recruitment: Design and build online diagnostic surveys for pharmacy staff and wider trust to explore options for innovative recruitment and wider Trust roles (also feeds into the workforce transformation workstream); and go live Innovative Recruitment: Analyse results of survey to identify themes; prepare slide deck for workshop Innovative Recruitment: Pharmacy workforce away day to explore options for dual banding, apprentices etc Stop External Services: Give notice on Virgin clinical contract and redeploy pharmacist and technician into delivering RSCH clinical service w/c 6 March Mar Mar-17 Shared Services - Shared MI service with ASPH (RSCH to Host): Determine how requirement will be staffed (including patient helpline on 5 days a week; assess full costs associated with hosting the service; agree realistic charge for the service with ASPH; finalise gross and net revenue Stop External Services: Transfer of HIV service to Central North West London is confirmed from 1 April. Innovative Recruitment: Feed options into short term workforce redesign strategy; evaluate the extent to which workforce solutions can be met from within the existing establishment funding; prepare business case if required Innovative Recruitment: Seek approval to recruit for positions which do not require additional funding; prepare job descriptions; initiate recruitment process Apr 17 16

17 Aseptic Dispensing & Manufacturing CIPs & (1) Aseptics Aseptics Aseptic Dispensing & Manufacturing Aseptics Aseptics Shared Services - Procurement: Liaise with ASPH regarding options for shared procurement team; and explore ASPH appetite for a partnership as one of the options for transformation workstream (Procurement and Supply Chain) External QA: Recruit to permanent QA position or identify an alternative, and lower cost, external provider. Track target from April; Track Stretch target from September (if milestone successfully delivered) St Luke's Dispensary Staff: Redeploy staff (either TUPE into RSCH Pharmacy Ltd) or offer alternative RSCH role (will require consultation); pharmacy and finance to model benefits of transferring dispensing to RSCH Pharmacy Ltd - this will influence whether or not the is a saving to RSCH from staff TUPE KSS Pharmacy Apprenticeship programme: KSS Pharmacy Apprenticeship programme: KSS Pharmacy Apprenticeship programme: Apprenticeship Programme: Consider the role of apprentices at the Pharmacy Away and liaise with Nikki Hill re: bidding for funding Apprenticeship Programme: Apprenticeship Programme: Identify leading practice to inform options for the future model of service provision Develop options for future model and draft skeleton business case Aseptic Sales: Assess the current costs of running the aseptic unit (including increased QA and impact of write offs) and assess the current margin on external sales; if margin is low and below the current Trust minimum, then either increase the charge to external customers OR Trust to make a strategic decision on whether or not to continue Develop full business case and submit for consideration and approval of preferred model Define and meet with stakeholders (Divisions, cancer service, clinical, nonclinical staff, procurement, partners etc) 07-Aug Mar Mar-17 Ongoing Aseptic Dispensing & Manufacturing Procurement Tariff: Re-model chemotherapy procurement tariff, taking into account the current costs of running the aseptic unit (as above); RSCH to use output to make a decision on whether or not to 17

18 renegotiate with NHSE (2) Procurement and Supply Chain (3) Alternative Dispensing Models (4) Integrated Medicines Optimisation (MO) Enabler 1 Enabler 2 Automation Aseptics Alternative Supply Alternative Supply Alternative Supply Alternative Supply Alternative Supply Integrated MO Integrated MO Integrated MO Integrated MO Develop PID to underpin implementation of preferred model Identify leading practice to inform options for the future model of service provision Develop options for future model(s) and draft skeleton business case Develop full business case and submit for consideration and approval of preferred model Define and meet with internal and external stakeholders Develop PID to underpin implementation of preferred model Discuss with CCG the appropriateness of transferring this opportunity to the Joint Programme Learn from leading practice (invite to scoping meeting if feasible) and build into options for service models Set up initial scoping meeting with Surrey Heartlands partners Agree scope (STP priorities, RSCH priorities, leading practice elsewhere) and process to take forward 30-Mar Mar-17 Ongoing 22-Mar Mar-17 Integrated MO Identify organisational leads Integrated MO Develop business case Integrated MO Develop PID Automation Automation Automation Strategy: Develop draft long term pharmacy workforce strategy, consulting with key stakeholders within the Trust on short and long term options Business case: Prepare business case Develop PID Extended Bluteq: Prepare business case for purchase of extended bluteq Aseptic Labelling Software: Review options and prepare business case for new software to facilitate labelling of medicines within the aseptic suite ecabinets: Develop business case for (i) ecabinets for A&E, ITU and Theatres; and (ii) ecabinets and electronic registers for CDs 31-Jul Aug-17 17/04/17 18

19 CQUINs Automation Automation Automation Automation CQUINs Extended Bluteq: Purchase and arrange training sessions for pharmacy, contracting, finance, clinical teams who need to seek funding for non-pbr medicines Refer to Pharmacy Software: Develop business case if decision is made to adopt this system to support the integrated medicines optimisation transformation scheme ecabinets: Develop business case for roll-out of ecabinets Trust wide Electronic Prescribing and Administration: Business case will be required if timescale can be brought forward from 2019/20 Determine where pharmacy responsibility for CQUIN delivery will sit; develop milestones for implementation if required 19