May 2012 The NHS medicines bill for 2010 was 12.9 billion, of which secondary care costs accounted for 32%. Prescribing inflation in 2010 ran at 4.8% and it is estimated that around 14% of total CCG budgets will be spent on medicines. However, medicines optimisation is more than just about costs. Its focus is the use of medicines by patients (adherence) and the role that evidence-based prescribing has in supporting new care pathways and treatment models to improve patient outcomes. Excellent progress has been made over the last 15 years in improving prescribing efficiency and safety but optimising medicines by CCGs will be a key component of their success as organisations and to the patients they serve. This toolkit supports CCGs in their journey towards authorisation, focusing on one of the major elements of healthcare expenditure prescribing and the essential associated medicines management and optimisation functions that underpin its safe, effective and financial management. In July 2011 the National Prescribing Centre (NPC) published An Organisational Competency Framework to Ensure the Effective Delivery of Medicines Management Functions and Responsibilities, http://bit.ly/jknroa. Provided by NICE, the document supports emerging CCGs and their development regarding medicines management and optimisation. In this toolkit each of the NPC indicators that underpin the six overarching competencies is allocated to one of the six CCG domains central to the authorisation process. Alongside each competency statement are one or more suggestions for the type of evidence the CCG should have, or be developing, to demonstrate it is meeting that competency and therefore supporting the overall aims of the domain in which it sits. www.pcc-cic.org.uk PCC May 2012 1
Domain 1 Clinical focus a strong clinical and multi-professional focus, which bring real added value A great CCG will have a clinical perspective threaded through everything it does, which puts quality at its heart and a real focus on outcomes. It will have significant engagement from its constituent practices as well as widespread involvement of all other clinical colleagues: clinicians providing health services locally including secondary care, community and mental health, those providing services to people with learning disabilities, public health experts, and social care colleagues. It will communicate a clear vision of the improvements it is seeking to make in the health of the locality, including population health. NPC indicators 14. Understands the structure and functions of all agencies/services contributing to health improvement and the impact on patients and their medicines as they move through care interfaces 17. Works with all stakeholders to ensure the safe transfer of medicines and information when patients cross interfaces of care CCG evidence examples Engagement with other agencies, membership of committees, working groups Engagement with community pharmacy, LPCs Examples of joint working eg social services, care agencies Description of networks Transfer of care policies, projects, agreements Engagement with secondary care, community services, social care, community pharmacy, mental health, hospice. Shared care agreements and processes Medicines reconciliation implementation New medicines service/medicines use review implementation Waste reduction projects Green bag projects or equivalents www.pcc-cic.org.uk PCC May 2012 2
21. Establishes and maintains a full understanding of current and future health needs and service requirements involving medicines 22. Where there is discretion to commission locallyenhanced services involving medicines, does this equitably based on patient need 24. Involves medicines management expertise at the start of and throughout the development of commissioning specifications and services (or changes to existing services) 25. Ensures that the commissioning outcomes framework, indicators and commissioning guidelines (developed by NICE for the National Commissioning Board) inform the commissioning and management of services using medicines 35. Understands the legislation and systems governing the purchasing, prescribing, administration, supply and disposal of medicines, and their impact on how services can be developed and delivered 36. Accesses and interprets horizon scanning information for new medicines to identify future trends in medicines usage; for example, to forecast budget expenditure, redesign services Joint strategic needs assessment (JSNA) Pharmaceutical needs assessment (PNAs) Links with health and wellbeing boards Commission services of senior pharmacist job description or service level agreement (SLA) with a provider service Examples of local enhanced services (LES) particularly linked with JSNAs and so on Inclusion of pharmacists in pathways redesign and commissioning of new services examples of working groups, active consideration given to medicines access and use Inclusion of relevant performance management indicators and reporting functions into SLAs, LES agreements and so on Secondary care CQUINs (Commissioning for Quality and Innovation) Organisational structure showing medicines management personnel Or www.pcc-cic.org.uk PCC May 2012 3
or develop commissioning agreements 37. Has the skills necessary to access and use quality summaries of evidence to help shape and inform local decision-making processes 38. Knows how to interpret, and where appropriate challenge, the evidence-base underpinning the use of medicines 39. Recognises the need to access clinical knowledge and skills where needed 40. Has appropriate pharmaceutical knowledge, knows how to assess pharmaceutical need, and understands pharmaceutical public health 41. Has an overview of the implications of IT developments on service delivery relating to medicines through, for example, electronic prescription services, electronic transmission of prescriptions and GP clinical systems 43. Understands the role and functions of NICE, the NHS Commissioning Board, Monitor and the Care Quality Commission (CQC) relating to GP consortia and the cost-effective use of resources, with a focus on medicines 46. Understands how health and social care professionals working with medicines are trained, their skill base and how their competence is maintained and developed Links with social services departments www.pcc-cic.org.uk PCC May 2012 4
Domain 2 Engagement meaningful engagement with patients, carers and their communities CCGs need to show how they will include patients, carers, public, communities of interest and geography, health and wellbeing boards and local authorities. They should have mechanisms for gaining a broad range of views, then analyse and act on these. It should be evident how the views of individual patients are translated into commissioning decisions and how the voice of each practice population will be sought and acted upon. CCGs need to promote shared decision-making with patients about their care. NPC indicators 2. Fulfils the requirements of the NHS constitution regarding patients access to medicines 3. Has clear and accessible processes for prioritising investment in healthcare interventions and services that involve medicines CCG evidence examples Local decision making (LDM) processes Area prescribing committees (APCs) terms of reference, minutes Individual funding request (IFR) processes Appeals process LDM processes APCs terms or reference, minutes. IFR processes 4. Gives the public and patients the opportunity to help shape services and local systems that use medicines, in the context of using NHS resources most effectively 13. Engages fully with local health and wellbeing boards, Healthwatch Membership lists of key groups Patient and public involvement in APCs, medicines management committees Patient engagement with IFR processes Patient reference groups or equivalents Use of GP patient involvement groups www.pcc-cic.org.uk PCC May 2012 5
bodies, patient participation groups and community partners 23. Understands what patients want and need from services involving/using medicines 26. Ensures that service specifications support providers to engage with patients to help them obtain the most benefit from their medicines, minimise the risk of harm medicines wastage Plans around health and wellbeing involvement Engagement with local pharmaceutical committees (LPC), responses to pharmaceutical needs assessment consultations (PNA), action plans from PSQs and community pharmacies, expert patient groups Lay representatives on key medicines groups Key clauses in SLAs, contracts and so on Medicines-related performance indicators quality and financial indicators www.pcc-cic.org.uk PCC May 2012 6
Domain 3 QIPP Clear and credible plans that continue to deliver the QIPP challenge within financial resources, in line with national requirements and local joint health and wellbeing strategies. CCGs should have a credible plan for how they will continue to deliver the local QIPP challenge for their health system, and meet the NHS constitution requirements. These plans will set out how the CCG will take responsibility for service transformation that will improve outcomes, quality and productivity, while reducing unwarranted variation and tackling inequalities within the financial allocation. NPC indicators 5. Effectively manages the entry of new medicines, or new indications for existing medicines, into the health and social care economy 7. Delivers the quality, innovation, productivity and prevention (QIPP) agenda relating to prescribing, medicines usage and procurement CCG evidence examples LDM processes APC terms of reference Medicines management committees terms of reference Joint working with local acute and mental health trusts local drug and therapeutic committees Job descriptions of MM staff, GP prescribing lead Plans, progress, outcomes on NPC QIPP indicators and comparators Prescribing incentive schemes QOF MM indicators MM projects relevant to QIPP Benchmarking and RAG reporting Secondary care CQUINs Waste reduction projects: Green bags, care home reviews, media campaigns www.pcc-cic.org.uk PCC May 2012 7
8. Has robust mechanisms for managing the risks associated with medicines (clinical, safety, financial and reputational) 18. Understands, develops and works with local contractor services to optimise medicines usage, for example, dispensing practices, community pharmacy, dentistry and ophthalmology services, and appliance contractors 20. Gives proper consideration to working in partnership with commercial organisations (such as pharmaceutical companies) to improve outcomes for patients 27. Identifies and accesses prescribing data and interprets it to plan for, monitor, audit and manage medicines usage and expenditure 28. Challenges inappropriate variation in practice in medicines use and shares and promotes good practice 30. Encourages and supports reporting of, and shared learning from, serious incidents and near misses Clinical effectiveness and safety groups or equivalent Incident reporting processes Performance management around prescribing quality and financial indicators and measures Professional performance management processes Links with LPC, LDC, LOC Supporting implementation of new medicine service (NMS) and medicines use reviews (MURs) Community pharmacist member of CCG board or intention for advisory capacity Policy for joint working with the pharmaceutical industry in line with current guidelines Examples of joint working and outcomes epact reports Prescribing reports Prescribing software support systems Availability of data analyst resource Quality-based performance indicators Use of indicators as performance management tool in poor performance management Sharing of information between all practices No blame culture Serious incident policy Use of root cause analysis in investigating incidents Reporting policies and processes Shared learning newsletters www.pcc-cic.org.uk PCC May 2012 8
33. Monitors medicines usage, using quality markers and key performance indicators and feeds back to providers Prescribing/ePACT reports QIPP indicators progress Practice reports Notes and actions from meetings Use of prescribing software support systems www.pcc-cic.org.uk PCC May 2012 9
Domain 4 Proper constitutional and governance arrangements with the capacity and capability to deliver all their duties and responsibilities, including financial control, as well as efficiently commission all services for which they are responsible CCGs need the capacity and capability to carry out their corporate and commissioning responsibilities. This means they must be properly constituted with all the right governance arrangements. They must be able to deliver all their statutory functions, strategic oversight, financial control and probity, as well as driving quality, encouraging innovation and managing risk NPC indicators 2. Fulfils the requirements of the NHS constitution regarding patients access to medicines 3. Has clear and accessible processes for prioritising investment in healthcare interventions and services that involve medicines 6. Has systems that comply with statutory regulations and can stand up to legal challenge CCG evidence examples Local decision making (LDM) processes Area prescribing committees (APCs) terms or reference, minutes Individual funding request (IFR) processes Appeals process NICE implementation processes LDM processes transparent, documented, accessible APCs terms or reference, minutes. IFR processes Appeals process LDM processes transparent, documented, accessible APCs terms or reference, minutes. IFR processes Appeals process Controlled drug management Accountable officer role (statutory requirement) www.pcc-cic.org.uk PCC May 2012 10
8. Has robust mechanisms for managing the risks associated with medicines (clinical, safety, financial and reputational) 19. Has governance processes in place, and codes of conduct that set out how consortia commission or interact with commercial bodies (relating to medicines), and monitors them 27. Identifies and accesses prescribing data and interprets it to plan for, monitor, audit and manage medicines usage and expenditure 29. Has integrated clinical and corporate governance, providing assurance of control and safety in the use of medicines (for example through policies, training and audit) 31. Ensures the safe management of controlled drugs in line with regulations 32. Identifies, and has mechanisms for the management of, unsafe or poor practice, and shares the learning from any investigations Clinical effectiveness and safety groups or equivalent Incident reporting processes Performance management around quality and financial indicators and measures NICE/NPSA implementation processes and assurances Controlled drug management/accountable officer role Medicines management financial expertise Policy for joint working with pharmaceutical industry Policy for corporate sponsorship Register of conflicts of interest epact reports Prescribing reports Prescribing software support systems Organisational structure identifying clear links and lines of accountability for key groups and committees eg clinical governance, medicines management, safety and effectiveness Appointment of controlled drugs accountable officer Membership of CD local intelligence network Contractual assurance around CD management Reporting around prescribing and incidents Prescribing quality performance indicators Prescribing reviews of prescribers undergoing performance review MM input into performance reviews www.pcc-cic.org.uk PCC May 2012 11
Domain 5 Collaborative arrangements for commissioning with other CCGs, local authorities and the NHS Commissioning Board as well as the appropriate external commissioning support CCGs need robust arrangements for working with other CCGs to commission key services across wider geographies and play their part in major service reconfiguration. They need credible commissioning support arrangements in place to ensure robust commissioning and economies of scale NPC indicators 1. Has a clear leadership role for medicines management linked to senior colleagues in all partner organisations and provider services 5. Effectively manages the entry of new medicines, or new indications for existing medicines, into the health and social care economy 9. Has a consistent approach to medicines across services, whether commissioned directly by GP consortia or by other organisations supporting GP consortia CCG evidence examples federation arrangements JD for senior medicines management adviser to CCG Organisational structure linking MM functions and staff to other organisations LDM processes, APCs Medicines management committees terms of reference Joint working with local acute and mental health trusts Job descriptions of MM staff, GP prescribing lead Drug and therapeutics committee involvement Standard contracts and performance indicators for all commissioned providers www.pcc-cic.org.uk PCC May 2012 12
12. Partners and plans effectively with local authorities, other GP consortia and the NHS Commissioning Board Commissioning support services (CSS) arrangements 15. With partner organisations, uses local decision making groups to make evidence-informed decisions about the effective use of medicines APC terms of reference Drug and therapeutics committee involvement 16. Works with other consortia to identify where collaboration and decision-making on a wider footprint may be appropriate 34. Shares and routinely benchmarks medicines related performance against other commissioners or service providers federation arrangements CSS arrangements Monitoring and benchmarking indicators Performance management process www.pcc-cic.org.uk PCC May 2012 13
Domain 6 Great leaders who individually and collectively can make a real difference Together, CCG leaders must be able to lead health commissioning for their population and drive transformational change to deliver improved outcomes. They need individual clinical leaders who can drive change, and a culture that distributes leadership throughout the organisation. All those on the governing body will need the right skills NPC indicators 10. Knows how medicines are priced, funding allocated, how the financial flows through the NHS are structured, and how this impacts on budgets across the health and social care economy 11. Supports national policy development and implementation regarding medicines and unplanned emerging issues 42. Understands the structure and functions of the NHS, how they are evolving and their implications for service delivery 44. Ensures clear professional and managerial accountability within the organisation for all medicines management roles and responsibilities CCG evidence examples Expertise available to CCG through federation, CSS, employed medicines management professionals Responses to issues like pandemic flu, QIPP plans, antibiotic prescribing, meeting the objectives of the operating framework Engagement with workforce development teams/deanery Organisational structures and clear lines of accountability Board member with responsibility Terms of reference from subcommittees and clear mandates for action www.pcc-cic.org.uk PCC May 2012 14
45. Recruits and retains, or accesses, the appropriate skill mix that takes account of emerging roles and organisations Expertise available to CCG through federation, CSS, employed medicines management professionals 47. Contributes to future workforce planning and development initiatives 48. Supports and helps develop clinical and professional leadership networks for medicines management Engagement with workforce development teams/deanery Workforce development plans Engagement and development of local professional networks (LPNs) www.pcc-cic.org.uk PCC May 2012 15