Oxfordshire Primary Care Commissioning Committee

Transcription

1 Oxfordshire Clinical Commissioning Group Oxfordshire Primary Care Commissioning Committee Date of Meeting: 6 March 2018 Paper No: 6 Title of Paper: Prescribing Incentive Scheme Proposal Paper is for: (please delete tick as appropriate) Discussion Decision Information Purpose and Executive Summary: The attached paper is being presented to OCCG executive on 27 February 2018 to gain feedback on the proposed Prescribing Incentive scheme. However due to the timing of OPCCC it has not been possible to update the paper following OCCG Executive and instead feedback will be provide verbally. The paper describes the four proposed elements of the scheme. To note: the following abbreviations have been used in the paper YTD year to date QP quality premium UTI urinary tract infection AKI acute kidney injury EPACT2 electronic prescribing and cost IRT integrated respiratory team COPD chronic obstructive pulmonary disease BB beta blockers STAR PU - Specific Therapeutic group Age-sex Related Prescribing Units DAMN diuretics/acei/arbs/metformin/nsaids ACEi angiotensin converting enzyme inhibitors ARB angiotensin II receptor blockers NSAIDs non steroidal anti-inflammatory drugs Financial Implications of Paper: The maximum county payment for the scheme will be approximately 600k which will be offset by savings on the prescribing budget. For it is expected that the maximum payment will be 0.80/patient/practice assuming all elements are achieved based on January 2109 practice list size The views of the Director of Finance will be reflected in the feedback from OCCG Executive. Action Required: The OPCCC is asked: Page 1 of 7

2 to consider the proposed Prescribing Incentive Scheme for approve for use in OCCG Priorities Supported (please delete tick as appropriate) Operational Delivery Transforming Health and Care Devolution and Integration Empowering Patients Engaging Communities System Leadership Equality Analysis Outcome: The proposed model of prescribing budget setting will take into account deprivation Link to Risk: AF26 Delivery of Primary Care Services, Lead Pharmacist for Medicines Optimisation Clinical / Executive Lead: Diane Hedges, Chief Operating Officer Date of Paper: February 2018 Page 2 of 7

3 Prescribing Incentive Scheme, Proposal Oxfordshire Clinical Commissioning Group 1.0 Aim To outline the proposed OCCG Prescribing Incentive Scheme, , for consideration and seek support from OCCG Executive. Key points The prescribing incentive scheme is designed to increase value for money by improving the quality and cost effectiveness of primary care prescribing. For a number of years the use of the incentive scheme has proved an effective way of incentivising practices to make efficiencies to realise benefits for patient care scheme is designed to align with key priorities. The scheme offers maximum achievable payment of 0.80 per patient A national Prescqipp budget setting model (appendix 1) provides greater confidence in realistic and achievable budgets. The introduction of epact2 and EMIS Enterprise Search and Report provide greater opportunity to identify meaningful priorities and monitor more accurately Potential savings areas are currently being finalised to offer priority options for practice work and aid budget achievement (element 1). These will be available in the annual OCCG Prescribing Report which will be discussed at practice meetings 2.0 Background 2.1 Prescribing Incentive Schemes have been successfully implemented in Oxfordshire for many years. Their purpose is to encourage and reward medicines optimisation, cost-effective and high quality prescribing. Success of previous schemes has resulted in reliable savings for OCCG and underspend against the overall primary care prescribing budget. The scheme has also led to closer working relationships between OCCG and GP practices resulting in high levels of overall engagement. Achievement of the scheme provides practice funds to directly benefit patients. 2.2 Oxfordshire compares well nationally with respect to cost-effective primary care prescribing. Based on the most recent epact data (November 2017) Oxfordshire cost per ASTRO-PU* is 2.97 YTD. This places Oxfordshire in the best 10% nationally, while the mean is 3.56 (STP average 3.05). However consideration of the most recent 3 months data shows us below the 10% threshold and therefore there is a need to maintain, and further embed, our current level of success. 1

4 Oxfordshire number of items (prescriptions) per 1000 ASTRO-PU YTD is also lower than the national mean ( v 118) but falls short of the top 10% threshold (84). The STP average is This suggests further scope for improvement. (Benchmarking data sourced from PrescQipp February 2018.) * ASTRO-PUs are used to weight prescribing information to allow information users to compare prescribing in different practices based on individual practice populations. The weighting is applied based on the practice populations for age, sex and patients aged Conditions of practice participation in the scheme 3.1 Inclusion is automatic for all Oxfordshire practices in the scheme 3.2 Table 1 Conditions required for participation. Condition Detail Annual Prescribing Meeting with the CCG s Prescribing Advisors in the spring/summer 2018 Use of ScriptSwitch for all prescribers Discuss the priorities and opportunities at the practice for the year and agree an approach to scheme achievement. It is expected that all practice clinical staff and, ideally, local Community Pharmacists will be invited to this meeting. Demonstrate its use through switches being made. This is a useful tool for making cost savings in prescribing as well as informing prescribers about quality issues 4.0 Content and detail of Scheme 4.1 The scheme will run from 1 st April 2018 to 31 st March Practices are encouraged to work towards achievement of all four elements however payment will only be triggered if the practice achieve element 1 target at year end. If successful, payment will be made for all other element targets which are met (see tables 2 and 3). Elements 1 to 3 are strictly defined, but the Quality Prescribing element 4 offers a number of options to meet the needs and capacity of individual practices. 4.2 All reviews/work are required to be completed within the year and submission of audit results must be made to the Medicines Optimisation Team by 30th April Where available, audit templates provided by the Medicines Optimisation Team must be used to ensure consistency of approach. 4.3 It is proposed that the budget achievement element is considered to be set as a locality target. This will share the risk amongst the practices and encourage engagement across the locality. The use of the Prescqipp budget setting model offers greater confidence in accurate and fair budget allocation at practice level and should therefore reassure at locality level. 2

5 Table 2 Cost/waste savings elements Elements Target Costeffectiveness 1 Prescribing within spend must fall within the allocated practice/locality budget allocation budget Detail Use of national tool for budget setting (appendix 1) Proposal that this be at locality level. 2 Repeat Prescribing. It is estimated that up to 10% of all prescribed medicines are not used properly and medicines worth 4% of the national drug budget are disposed of annually. For OCCG, this could equate to 3.4M. Each practice to review their current repeat prescribing policy and update as needed (CCG to provide a template where required) Submit an audit review of a sample of patients (totaling 0.5% of the practice population) to check for good practice in handling repeat prescriptions At least two practice staff members (inc. one admin member and one prescriber) to attend a training event at the CCG (e-learning course available also) Practices will be invited to take part in a project to review repeat prescribing processes, the aim of which would be to reduce unnecessary waste in prescribing both in terms of actual medicines prescribed as well as the time spent in managing repeat prescriptions. As a result, it is anticipated that; patient care will be improved, by optimising medicines use, and time will be saved, as a result of reviewing and improving processes. The Medicines Optimisation Team will support practices in reviewing their repeat prescribing policies and processes including improving repeat prescribing in care homes (in line with NICE Guidelines on managing medicines in care homes). 3

6 Table 3 Quality elements Elements - Quality Target 3 Antibacterial Antimicrobial items per STAR PU to be below 0.52 (the Prescribing. Two parts OCCG average for Q3 and Q4 2016/17) PLUS high risk for which payment is antimicrobial items (cephalosporins, quinolones and coamoxiclav) as a % of all antimicrobial items to be < 10% achieved separately. These may require (in line with the national target). This target will be updating when QP measured using total figures for Q3 and Q4 (i.e. Oct is confirmed Mar 2019). Antimicrobial prescribing in UTI (In line with the Quality Premium 2018/19): Trimethoprim items prescribed to patients aged 70 or over: target a 30% (or greater) reduction compared with practice baseline Jan-Dec 16. This target will be measured using figures for Quality prescribing. Choice of one topic for audit as agreed at Annual Prescribing Meeting (alternative options available in annual prescribing report) Audit 0.5% of practice population (to be agreed) Reduction in opioid prescribing in non-end of life care Polypharmacy. epact2 dashboards indicate particular scope for improvement in meds likely to cause AKI (DAMN drug combinations) particularly over 65s. Heart failure. RightCare shows lower levels of ACE/ARB + BB prescribing v peer CCGs. NICE suggest readmission cost of 1.7k to 3.7k per patient Respiratory: COPD or asthma inhaler reviews. This supports development of OCCG IRT project. Detail In line with national policy and the Quality Premium, we are continuing to promote good antimicrobial stewardship and, therefore, include this element in the incentive scheme again. The aim will be to: improve the quality of antimicrobial prescribing through the promotion of self-care and management of minor infections, the use of back up prescriptions or no prescribing strategies, and education for both patients and clinicians reduce the incidence of Health Care Associated Infections (HCAIs) e.g. C.difficile by decreasing the prescribing of high risk, broad spectrum antibiotics e.g. cephalosporins, quinolones and co-amoxiclav reduce the incidence of E.Coli bacteraemia by reducing the prescribing of trimethoprim for urinary tract infections. Resources available to follow Audit of patients on 8+ meds using the Prescribing Rationalisation Clinical Tool and potentially also monitor any changes using epact 2 (i.e. average number of items) Prescqipp polypharmacy e-learning courses and bulletin available. Audit patients with heart failure and ensure dosage titration is optimised. pathway Review respiratory patients to optimise inhaler use, device and technique. In line with COPD / asthma guidance 4

7 Enablers 5.1 There are a number of resources and sources of support for practices. The CCG will provide all practices with an Annual Report of detailed prescribing information and data, identifying any areas where there may be potential savings or quality improvements. There will continue to be a dedicated scheme webpage providing resources; relevant protocols and audit templates, system searches, patient leaflets etc. The Prescribing Dashboard will be aligned to monitor scheme elements where appropriate, providing useful progress and benchmarking information. The CCG s Prescribing Advisers and wider Medicines Optimisation Team will support practice-based work on prescribing throughout the year. OCCG.medicines@nhs.net immediate access to Medicines Optimisation Team advice. Funding 6.1 The scheme will be funded through a top slice from the prescribing budget. 6.2 The scheme maximum payment level was set at 0.80 per patient. Current Oxfordshire population at January 2018 is 742,391 suggesting a maximum county payment of approximately 594k. However, Oxfordshire population continues to grow (+1.6% from April 2017 to January 2018), but not all practices achieve all elements and some practices fail to claim. Work continues to identify areas for potential savings which could be over 4m. Experience indicates that practice level work tends to release approximately a third of potential savings initiated. Other inyear projects, savings initiatives and opportunities will augment the annual savings potential further. Therefore there is continuing scope to further increase potential efficiencies, despite uncertainty of national pressures for next year. Continued incentive scheme opportunities also retain ongoing engagement of Oxfordshire prescribers with all medicines optimisation initiatives. 6.3 The prescribing budget allocation has yet to be confirmed. The GP practice element of the budget for was 84,682,783. Therefore the potential total payment to practices as outlined above would represent approximately 0.7% of the GP practice prescribing budget. Payment 7.1 The Medicines Optimisation Programme Board (appendix 2) will consider representations for exceptionality (evidence required), or other significant factors, from practices for achievement adjustments and will have the power to adjust payments due. The maximum payment available will be 0.80 per patient (using practice population at January 2019). 5

8 Table 4 Element 1: Prescribing within budget allocation Element 2: Repeat prescribing Element 3a: Antibacterial items per STAR PU PLUS % high risk antimicrobials Element 3b: Prescribing in UTI Element 4: Quality prescribing Total 0.20 (25%) per registered patient 0.20 (25%) per registered patient 0.10(12.5%) per registered patient 0.10 (12.5%) per registered patient 0.20 (25%) per registered patient 0.80 per registered patient Practice use of scheme payment 8.1 All payments received from the scheme must go into practice funds, and not to individuals, for the benefit of patients of the practice. 9.0 Conclusion 9.1 Oxfordshire incentive schemes have reliably delivered savings as well as encouraging wider engagement between practices and OCCG. The proposed scheme provides a number of elements to ensure all practices have fair opportunity to participate and achieve payment. The Medicines Optimisation Team provides a high level of resources and support to the scheme as well as the wider prescribing agenda. There remains scope for continued savings and cost avoidance despite considerable uncertainty due to national pressures OCCG Executive consideration of: Seek feedback on: Achievement gateway for budget achievement at locality level. The scheme format combining cost and quality elements The proposed maximum payment per patient under the scheme as Heather Motion Lead for Medicines Optimisation February

9 Appendix 1: Prescqipp Prescribing Budget Setting Tool This tool considers Historic spend Populations Cost based ASTRO-PU Care home patients Deprivation, /English_Indices_of_Deprivation_2015_-_Statistical_Release.pdf Prescribing needs allocation, Appendix 2: Medicines Optimisation Programme Board Membership The Medicines Optimisation Programme Board will comprise the following members: Clinical Lead for Medicines Optimisation (Chair) Head of Urgent Care and Medicines Optimisation Lead Pharmacists for Medicine Optimisation (3) Medicines Optimisation Pharmacists (3) Prescribing Analyst (vacancy currently supported by temporary dedicated Prescribing Adviser role) CCG Finance Lead CSU Management Accountant Programme Management Office representative as appropriate Declarations of interest are sought at the beginning of all meetings. Where conflicts of interest occur when the Board considers decisions regarding Prescribing Incentive Scheme achievement, the relevant Board member is excluded from the discussion and decision process. 7