Wales Audit Office Primary Care Prescribing Review Update Against Action Plan WAO reviewed primary care prescribing In November 2012 and developed a report which was published in December 2013. It is recognised that whilst the report focuses on GP (primary care) prescribing, which is where the majority of prescribing costs fall, the influences on that prescribing are complex (e.g. secondary care influence recommendations and initiations) and a whole system/university Health Board (UHB) approach and action plan is required in order to effect sustainable change. An action plan which recognised improvements made in the period Nov 12 to Dec 13 went to HSMB in January 2014. This is a further update to October 2014. WAO Primary Care Prescribing Action Plan Update against actions APPENDIX I WAO Recommendation Action taken to date/actions to implement Responsibilities Timescales Develop and implement a clear strategic framework for primary care medicines management, setting out, amongst other things: a medium to long-term vision and objectives for service provision; a direction for the integration of prescribing and medicines management services; links to its wider strategic objectives; Divisional structure has been replaced with a Clinical Board (CB) structure. The prescribing team is now managed within Primary, Community & Intermediate Care (PCIC) Clinical Board. All clinical boards are in the process of developing integrated medium term plans for 2015/16. PCIC Clinical Board will develop a primary care medicines management strategy, which will have a wider remit than savings plans alone, as part of that process and will take it through the corporate Medicines Management Group in order to obtain approval with other clinical boards. This Clinical Board Directors; Clinical Board s; Corporate Medicines Management Group; End of January 2015 Review Updates Against Action Plan 1 of 8-18 November 2014
an approach that further strengthens alignment with, and supports the delivery of, national policies; and an approach for the reduction of waste, including effective monitoring. plan will enable short and long term objectives to be articulated and enable integration of the PCIC medicines management strategy to the wider strategy for primary care services, in order to provide synergy and efficiency. Each Clinical Board now has a Medicines Management Group (feeding into the corporate Medicines Management Group (cmmg) there is primary care representation on each of those boards to ensure that impact of any decisions on medicines & prescribing practice or pathways in primary care is considered in advance of decisions being made. PCIC Clinical Board also have a MMG which meets regularly and is attended by the Community Directors. Clinical Board MMGs and continuous There has been increased focus on using medicines in the most cost effective way and in the past eighteen months prescribing pathways have been developed in high cost areas to ensure maximum efficiency and prudent prescribing. This multidisciplinary integrated approach, localising national guidance, will ensure that there is agreement to and adherence to prescribing messages across the interface and into primary care. Both primary and secondary care clinicians and pharmacists are involved in the development of these pathways. Pathways developed so far in this way include COPD, Asthma, Diabetes, Overactive Bladder, and Ocular Lubricants. Application of those pathways will identify and address areas of variation in practice (both primary and secondary care) which will in turn improve cmmg CB MMGs and continuous Review Updates Against Action Plan 2 of 8-18 November 2014
cost-effectiveness, drive down waste and ensure a focus on quality. Development of an approach for the reduction of waste will be an action for all Clinical Board MMGs to consider. In primary care waste is being addressed through the prescribing pathway work (using an expensive medicine where an equally effective less costly one is available is waste), polypharmacy work in GMS contract, identification and management of variance in prescribing in individual GP practices by prescribing advisors, GP prescribing meetings in every practice with a prescribing advisor alone and also with a community director/ prescribing advisor pair, Therapeutic leads educational sessions, inhaler technique training session with each (67) GP practice, upkeep of scriptswitch profile & extension to GP practices with previously non-compatible clinical systems, waste reduction scheme in Vale Locality, switching programmes in primary care. Activity in primary care is monitored through prescribing data. Audit of managed repeat prescribing processes in community pharmacy to be repeated. Further actions, including extending polypharmacy work to be developed within pcic MM strategy. Prepare ready for 2015-16 financial year. Ensure that longer-term objectives are clearly prioritised within annual work programmes for primary care prescribing and medicines Prescribing advisors are identified to support the development and implementation of pathway work across the UHB as well as to implement shorter term work plans. PCIC MM Strategy will include long term objectives within Director, PCIC CB Review Updates Against Action Plan 3 of 8-18 November 2014
management teams. work programme. Ensure that meaningful patient and stakeholder engagement is an integral part of the development of a strategic approach to primary care prescribing and medicines management. MMG (held monthly) is well attended by Community Directors (GP leads); this forum is used to test out approaches and ensure that GPs, as stakeholders, are fully involved in prescribing strategy development. MMG PCIC senior staff attend various forums that enable stakeholder engagement e.g. practice nurses, district nurses, community resource teams, and voluntary sector organisations. The Expert Patient Programme provides feedback to the CB on issues and is used for gaining input to approach and testing ideas. PCIC Senior Team A meeting will be held with CHC to discuss the feasibility of including medicines management related questions in the CHC annual practice visit during which patient feedback is sought. January 2015 Further develop its performance dashboard to include key indicators directly relating to performance in primary care medicines management. Prescribing performance is considered at PCIC Service Development Group each month financial information is presented monthly and performance against National prescribing indicators is provided quarterly. PCIC Senior Team Review Updates Against Action Plan 4 of 8-18 November 2014
Establish clear prescribing and medicines management plans for the interface between secondary and primary care to: ensure routine monitoring and robust challenge of prescribing recommendations across the interface; further strengthen mechanisms to support GPs in their responses to secondary care prescribing recommendations; ensure effective influencing by senior clinical staff with regard to the prescribing behaviour of secondary care colleagues; raise awareness amongst secondary care clinicians of the potential cost and wider impact of their prescribing recommendations on primary care, and of unilateral decision making; improve the quality of discharge communications; and identify and pursue opportunities for prescribing and medicines management The process previously developed by PCIC to capture and feedback, to secondary care colleagues, inappropriate prescribing requests to GPs, has been amended so that it is reported into the respective clinical board MMG for discussion and challenge as well as to the individual clinician. The form has been posted on the intranet for easy access by GPs, and pathways and prescribing newsletters and advice is posted on a PCIC prescribing page. A project providing feedback on prescribing to junior doctors is being developed and implemented in secondary care. Medicines Transcribing and Electronic Discharge (MTED) is in process of being implemented across the UHB which will improve communication of discharge information. See previous info re pathway development and cross representation on clinical board MMGs PCIC Prescribing Advisors CB s CB Directors Enabling Medicines Management II (EMM) Project Informatics Services E- Communications Project Board UHB Currently ongoing Review Updates Against Action Plan 5 of 8-18 November 2014
staff, and other clinicians, to work across the interface to reinforce effective prescribing between secondary and primary care. Using the findings from the snapshot diary exercise, ensure that prescribing support resources are being used to best effect by: optimising the proportion of work taking place directly with individual prescribers and general practices; building capacity for data analysis, to support the locality teams; organising the activities of prescribing support teams to enable them to undertake more education and one-toone sessions with GPs; and setting clear longer-term objectives for the work of prescribing support staff. Amalgamated diary snapshot was analysed by staff group to determine and consider activity by grade/role, within current staff resources noted as being lowest in Wales. Skill mix has been reviewed to maximise time in practices by prescribing advisors, current staff shortages and difficulties in recruitment to be resolved. Business case to be developed as part of PCIC MM Strategy and IMPT to increase support in GP practices and across Localities. Available levers will continue to be used to increase the number of GP educational/development meetings with advisors, including an additional meeting with community director in attendance. E.g. Medicines Management Incentive Schemes and GMS QOF actions All prescribing team staff have personal objectives aligned with the objectives of the team as a whole. This includes, going forward, the pathway work described previously and longer term objectives will be included in the PCIC MM Strategy. CB Director PCIC; CB PCIC, Personal Appraisal and Development Review Process all line managers December 2014 Review Updates Against Action Plan 6 of 8-18 November 2014
Strengthen current arrangements for the Medicines Management Group (MMG) by: setting out a forward programme for the Group; improving secondary care consultant representation on the Group; and considering routine reports on formulary compliance to help to understand and manage the reasons for non-complaint prescribing. The membership and timing of the corporate medicines management group has been reviewed in light of clinical boards being set up with their own medicines management groups and aligned with HSMB meetings to facilitate and maximise secondary care clinical representation. Work streams, part of the Leaner and Fitter, Enabling Medicines Management project, looking at strengthening the formulary and communicating it effectively took place in 2013. cmmg EMM Project Group Improve information available to prescribers by: developing an electronic online version of the local formulary; and ensuring a consistent format and content for SCAs, and making them easily accessible online. The Inform formulary is available in an online platform. There are links to the good prescribing guide and other national guidance from the formulary. The Good Prescribing Guide is also available electronically now. The shared care committee is now a sub-committee of the cmmg. Shared Care Protocols are being transferred to a drug specific format as they come up for review (as opposed to indication specific). Shared Care Committee Address each of the specific opportunities highlighted in this report to improve the quality, safety and economy of primary care prescribing. Each opportunity highlighted was reviewed as part of preparation for the PCIC IBP 2014; feasibility and ease of attainment were considered. Some were included as work streams in the PCIC IBP Completed Review Updates Against Action Plan 7 of 8-18 November 2014
(which may require engagement of or action by other clinical boards), some will be addressed via alternative routes e.g. Medicine Management Incentive Scheme, Scriptswitch software message. Completed The same process will be in place for the PCIC IMTP 2015/16. PCIC Medicines Management & Senior Team End of January 2015 Strengthen the approach to increasing rates of generic prescribing. Much work has been done to encourage generic prescribing so much so that generic prescribing rates are no longer monitored as a national indicator. In order to identify surgeries where practice has slipped (as opposed to patients intolerant of alternative) a piece of work was undertaken in the top 20 brand prescribing practices to switch appropriate patients to generic; 340 patients were switched. PCIC Medicines Management Team Completed Scriptswitch profile was reviewed to ensure all brands within WAO brand basket have a message attached to switch patients to a generic alternative in order to remind prescribers. Ensure regular reporting to the Board of clear performance information in relation to primary care prescribing. Performance reporting, by CB, to UHB Board is via the monthly executive performance review. CB s senior teams Review Updates Against Action Plan 8 of 8-18 November 2014