Medicines Medicines Optimisation n Strategy 2016/2020
Contents Document Information Document location : This document is only valid on the day it was printed. Authorship: This document has been prepared by: Name Designation Organisation Kate Needham Head of Medicines NHS North Derbyshire CCG Management Revision history: The current version of this document supersedes all previous versions. Revision date Summary of changes Version Approvals: This document requires the following approvals: Name Signature Date taken NDCCG Governing Body Approved 25 th April Assurance Committee 2016 Version V1 Distribution: This document has been distributed to: Recipient Date of Issue Version Date for review: Date of review Name Designation and Organisation Page 1 of 30
Contents Section One The Purpose of this Document... 3 1.1 What is the Medicines Optimisation Strategy?... 3 Section Two Our Clinical Commissioning Group... 6 2.1 Who We Are... 6 2.2 Our Values... 9 2.3 Our Vision... 9 2.4 Our Mission... 9 2.5 Our Commitment to You... 10 2.6 Our Guiding Principles... 10 Section Three North Derbyshire CCG Strategic Vision... 12 Section Four Objectives... 13 4.1 How Medicines Management Supports the CCG s Corporate Objectives... 13 4.2 Medicines Management Objectives... 15 4.3 Delivery, Reporting and Review... 16 4.4 Assurance... 17 Section Five References... 19 Section Six Appendices... 20 Appendix 1 Medicines Management Work Plan 2016 17... 20 Appendix 2 Medicines Management Work Plan 2016-2020... 24 Appendix 3 CCG Reporting Structure... 29 Appendix 4 Team Structure and Lead Roles... 30 Page 2 of 30
Section One The Purpose of this Document 1.1 What is the Medicines Optimisation Strategy? Executive Summary Robust and efficient management of medicines is crucial to fulfilling the clinical, financial and corporate responsibilities of NHS North Derbyshire Clinical Commissioning Group (CCG) and to the delivery of the CCG s Strategic Objectives. This Medicines Optimisation Strategy and its supporting plans and work programmes are aligned to the North Derbyshire CCG Strategic Vision and define the overarching aims and objectives for the delivery of robust and efficient medicines management functions. Background Medicines have a major role in maintaining health, preventing illness, relieving symptoms, managing chronic conditions and curing disease and remain the most common therapeutic intervention in healthcare. The investment in use of medicines for patients must achieve optimal outcomes and the right patients should get the right choice of evidence based cost effective medicine at the right time. The medicines management team delivers this through optimising the use of medicines for patients to ensure maximum health gain is realised from the prescribing budget spend. The medicines management team continually strive to improve the safety and quality of prescribing and delivers statutory responsibilities on behalf of the CCG including the safer management of controlled drugs. What is Medicines Optimisation? Medicines Optimisation is used to describe a patient focused approach to achieving the best outcomes from medicines. It requires multidisciplinary working and partnership between health professionals and patients and results in patients getting the right choice of medicine, at the right time and in the right place which maximises health outcomes from prescribed medicines. Medicines optimisation looks at how patients use medicines over time. It may involve stopping some medicines as well as starting others, and considers opportunities for lifestyle changes and nonmedical therapies to reduce the need for medicines. By improving safety, adherence to Page 3 of 30
treatment and reducing waste the medicines optimisation approach will help to ensure that by working together we support patients to get the best outcomes from their medicines. The Royal Pharmaceutical Society of Great Britain has established four guiding principles to support medicines optimisation (8) and a model of medicines optimisation: Model of Medicines Optimisation Patientcentred approach Principle 1. Aim to understand the patient s experience. To ensure the best possible outcomes from medicines, there is an ongoing, open dialogue with the patient and/or their carer about the patient s choice and experience of using medicines to manage their condition; recognising that the patient s experience may change over time even if the medicines do not. Principle 2. Evidence based choice of medicines. Ensure that the most appropriate choice of clinically and cost effective medicines (informed by the best available evidence base) are made that can best meet the needs of the patient. Principle 3. Ensure medicines use is as safe as possible. The safe use of medicines is the responsibility of all professionals, healthcare organisations and patients, and should be discussed with patients and/or their carers. Safety covers all aspects of medicines usage, including unwanted effects, interactions, safe processes and systems, and effective communication between professionals. Page 4 of 30
Principle 4. Make medicines optimisation part of routine practice. Health professionals routinely discuss with each other and with patients and/or their carers how to get the best outcomes from medicines throughout the patient s care. Vision Delivering medicines optimisation for all our patients. Mission statement Maximising health outcomes for all our patients by delivering safe, cost-effective, evidence based, patient-centred prescribing and medicines use. Page 5 of 30
Section Two Our Clinical Commissioning Group 2.1 Who We Are The core role of our CCG is to use the resources we have to commission (procure and contract for) health care which provides high quality, safe and effective care to meet the health needs of the population we serve. The Clinical Commissioning Group Governing Body is chaired by a GP and includes two additional GP s, three lay members, a Chief Nurse, a specialist doctor from outside the area, an Accountable Officer and a Chief Finance Officer. The constitution we have agreed with our member practices sets out how we will work within the following areas: The governing structure (including the Governing Body membership and sub-committees) The roles and responsibilities of the Governing Body members and member practices Standards of business conduct The NHS North Derbyshire Clinical Commissioning Group (NDCCG) comprises of 36 member practices with a registered population of 288,000 and covers five geographical localities, Chesterfield, Dronfield, High Peak, North East and North Dales. Page 6 of 30
The list below details the commissioning responsibilities of our clinical commissioning group. This list has been determined by the Department of health 1 and shows the statutory responsibility of our organisation to commission the following health services for patients registered with our member practices and for patients unregistered however present within our geographical area: Since the 1 st of April 2015 the CCG has expanded its role in primary care commissioning under fully delegated authority from NHS England. Co-commissioning of Primary Care will assist in ensuring whole system integration to support the delivery of a single out of hospital health and well-being network. Co-Commissioning will enable the CCG to increase the scale and scope of Primary Care focusing on quality improvement, long term sustainability and local values. Co-commissioning offers the flexibility and opportunity for the CCG to develop alternative local approaches to Primary Care delivery and provision in North 1 The Functions of Clinical Commissioning Groups. Department of Health (2012) http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_134569.pdf [accessed 10/8/12] Page 7 of 30
Derbyshire. Co-Commissioning of Primary Medical Services supports the progression of particular aspects of the CCG objectives as outlined in the five year strategic plan. Responsibilities of primary care co commissioning include: Review, planning and procurement of primary care services in the North Derbyshire CCG, under delegated authority from NHS England. Promote increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers. Carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act, including: GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract); Newly designed enhanced services ( Direct Enhanced Services ) Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF); Decision making on whether to establish new GP practices in an area; Approving practice mergers; and Making decisions on discretionary payment (e.g., returner/retainer schemes). The CCG will also carry out the following activities: To plan, including needs assessment, primary [medical] care services in the North Derbyshire CCG geographical area; To undertake reviews of primary [medical] care services in the North Derbyshire CCG geographical area; To co-ordinate a common approach to the commissioning of primary care services generally; To manage the budget for commissioning of primary [medical] care services in the North Derbyshire CCG geographical area. Page 8 of 30
2.2 Our Values Our values, as determined by our member practices, define our culture and will shape our decision making. They are: We have identified four key values from our word cloud and have defined the following values statements: Patient-focus - Putting patients at the centre of all we do Integrity - Being honest, fair and open Courage - Being empowered to make positive change Responsiveness - Working together, committed to delivery 2.3 Our Vision Our vision is to work in partnership to deliver a patient centred, Clinically led, evidence based approach to service commissioning Our Vision Our Values Our Mission 2.4 Our Mission Our mission is to improve the health and wellbeing of our population by commissioning high quality services through effective use of our resources Our commitment to you Our Guiding Principles Page 9 of 30
2.5 Our Commitment to You We will behave with integrity, energy and enthusiasm. Our drive is to deliver improvements through innovation and the empowerment of individuals; be that patient, partner or colleague. 2.6 Our Guiding Principles We actively seek feedback from our patients, our members, our partner colleagues and the general public both to help us plan services and monitor the performance of the services we commission. At all times we are working across the North Derbyshire health community to engage with our patients, staff and the general public with regard to both the changes taking place in the NHS, the current challenges we face and how we need to approach the difficult decisions we need to make. The feedback we receive continues to shape our guiding principles and will be used as a basis to guide our decision making on behalf of our population. All services will be person centred We will work in partnership with people needing care and their families and carers to provide care as close to the person s home as possible, and when appropriate support them to access the right care away from home. Care will be provided flexibly We will listen to and understand the person s complete needs and meet them by using all services and resources available. We will ensure that we will co-ordinate care across health, social care and voluntary services to ensure people receive the right care from the right service at the right time. Assumptions will be challenged We will have the courage to make changes for the better that will improve the patient experience and obtain the best value for money. We will embrace innovation and find new approaches to care based on sound evidence. We will commit to monitoring and publishing patient experience data to be accountable to those who use our services. Page 10 of 30
People will be treated with dignity and respect We respect and value the people who use and work in health and social care services in Derbyshire and we will invest resources to support the health and well-being of our communities. We will plan and deliver services partnership We will actively seek and listen to the views of people who use and work in health and social care in Derbyshire so that we can plan and deliver services in partnership and be accountable to them. Healthy lifestyles will be promoted We will support people to help them to make an informed choice about lifestyle and services and identify and provide extra support for those who need and want to make positive lifestyle changes. The CCG is currently leading a transformation programme 21 st Century #JoinedUpCare which is a collaboration between eight key providers across North Derbyshire including health and social care with the aim of finding new ways of working to improve services and ensure financial balance for the population of North Derbyshire. The partnership is working to ensure the demands of a growing elderly population, with long-term complex illness and multiple conditions can be met, breaking down barriers to make sure patients receive not just high-quality clinical care, but wellorganised care that enables a great patient experience. Page 11 of 30
Section Three North Derbyshire CCG Strategic Vision NORTH DERBYSHIRE CCG STRATEGIC VISION Work together across health, social care, housing, voluntary sector and with the public itself to enable people to retain independence supported by their local community. When publicly funded services are required they will be responsive, safe, caring and provide a good experience of care still within the local community in the majority of cases. Where exceptionally people need to access more specialised services outside of their community this will happen easily and they will be supported to return to their local community as quickly as possible. 2014/15 CORPORATE OBJECTIVES Maximise the health and wellbeing of the North Derbyshire population Reduce inequalities and unwarranted clinical variation Balance good governance with innovative working and decision making within the CCG Reduce unnecessary expenditure To put quality at the heart of all services we commission ensuring patient safety, clinical effectiveness and improving patient experience To develop our organisational capability and ensure that our behaviours are consistent with our values and guiding principles Listen to what our patients and public tell us, acting on what they tell us and engaging them fully in all aspects of service redesign WHAT WILL THIS MEAN FOR OUR PATIENTS? Services will feel seamless and coordinated this means that transfers between Where possible the individual will be cared for in their own home or as close to home care settings/organisations will be minimal and not obvious to the patient as their condition allows. The patient will be treated as an individual, will be supported to live independently Where acute need or specialism is required it will take place as quickly and safely as and encouraged to manage their own condition as far as possible. possible. Any care required will be discussed and agreed in partnership with the individual. Fundamentally the needs and wishes of the individual will be at the centre of care delivery and planning at all times. Strategic Aim One Transform Primary Care Having high quality and equitable primary care that works seamlessly with all aspects of the system is central to the CCG s strategic vision. Improving health outcomes and significantly reducing inequalities remain a key focus as does access, clinical effectiveness and patient experience. We will continue to support local practices to maintain and improve the quality of primary care provision for patients and have a broad range of primary and community care services provided at General Practice level through a lead provider model which supports improved access through flexible models of care. Strategic Aim Two Develop integrated models of care Strategic Aim Three Redesign urgent and emergency care Our aim is to develop integrated, patient focused health and social care fit for the 21st century. An initial focus will be on developing integrated pathways of care for the frail and elderly, children and young people and people with mental health or learning disabilities. Our vision for those people with urgent but non-life threatening needs is to provide highly responsive, effective and personalised services outside of hospital and as close to people s homes as possible thereby significantly reducing emergency activity in the hospital setting. For those with more serious or life threatening emergency needs we will ensure they are treated in centres with the very best expertise and facilities in order to reduce risk and maximise their chances of survival and a good recovery. Strategic Aim Four Improve the management of long term conditions Strategic Aim Five Focus on prevention/ self management The aim for long term conditions/planned care in North Derbyshire is that more patients will be diagnosed earlier meaning better, more cost effective treatment and better management of their illness. Patients and carers will feel informed, supported and confident in managing their conditions effectively with better access to patient education programmes. Improved information and education will lead to better awareness of conditions and their symptoms across the population. Services will be more integrated and centred around the patient. Use of telehealth and telemedicine will be available to support those patients for whom this approach is appropriate and who want it. Clinicians and healthcare professionals within primary, secondary and community care will have increased skills, capacity and capability in supporting people with long term conditions. The CCG s aim is to work in partnership with Public Health and other partners on a range of measures that will improve lifestyle choices, prevent the development of chronic conditions and ensure earlier diagnosis. This will be further supported by developing community resilience and capacity to enable people to manage their own condition and retain independence for as long as possible. Strategic Aim Six Review the productivity of elective care Working in partnership with providers and Clinical Strategic Networks the CCG will significantly improve the productivity of our providers over the next 5 years so that existing activity levels can be delivered with better outcomes and less resource.
Section Four Objectives 4.1 How Medicines Management Supports the CCG s Corporate Objectives The medicines management team supports the CCG deliver its corporate objectives: Corporate objective Maximise the health and wellbeing of the North Derbyshire population Balance good governance with innovative working and decision making within the CCG To put quality at the heart of all services we commission ensuring patient safety, clinical effectiveness and improving patient experience To develop our organisational capability and ensure that our behaviours are consistent with our values and guiding principles Reduce inequalities and unwarranted clinical variation Medicines Management team role: Support the development and implementation at practice level of Derbyshire wide prescribing guidelines, shared care, and other prescribing guidance to deliver cost effective, evidence based healthcare. Improve the safety and quality of prescribing across the practices and commissioned services including the CCG requirements for the safer management of controlled drugs. Improve the safety and quality of prescribing, and cost effectiveness of prescribed medicines through work with practices including specific safety audits and other practice work. Work with commissioned services to improve whole health economy cost effectiveness and safety through close partnership working and contractual levers. For all transformational change, projects, and changes in service the Medicines in Commissioning Checklist must be completed to assess any impact on prescribing costs and ensure safe, effective, affordable services are commissioned in line with legislation. Continually develop, train, support and educate members of the medicines management team to further develop the service provided to membership practices. Produce and review prescribing indicators, and other data sets to understand clinical variation across the CCG practices. To discuss variation with practices through annual prescribing reviews, and provide audits, education and support to practices to reduce unwarranted clinical variation in prescribing. Work with the CCG and membership practices to develop an escalation policy to support the CCG to effectively manage inappropriate prescribing. Work practices and commissioned services to reduce inappropriate use of antibiotics.
Corporate objective Reduce unnecessary expenditure Medicines Management team role: Deliver cost savings through medication reviews, therapeutic switches, audit, education and supporting practices to initiate the most cost effective therapies at the point of prescribing (through use of OptimiseRx, clinical systems and education). Work with commissioned services to provide assurance of cost effective, appropriate prescribing in line with local and national guidance including high cost drugs and uptake of biosimilars. Consider alternative procurement options where financial savings may be realised ensuring quality services are delivered. Work to reduce waste. Work to support CCG Right Care programme of work. Work with federations to support delivery of improved medicines management. Listen to what our patients and public tell us, acting on what they tell us and engaging them fully in all aspects of service redesign Undertake an annual survey with practices to obtain feedback on the service provided and act on this feedback to continually improve the service. The effective and efficient use of medicines underpin the delivery of the CCGs strategic priorities and supports the numerous projects including 21 st Century #JoinedUpCare, work streams and the commissioning of services that aim to improve health, quality and outcomes. As greater integration occurs across the north of Derbyshire, through 21st Century Healthcare, high quality medicines optimisation support to commissioners and providers of health and social care is fundamental to ensure that the patient remains at the centre of all decisions, and that commissioning decisions are aware of the impact the decisions will make on prescribing costs. Within the key aims of the transformation agenda it is likely that considerable investment will be required in primary care prescribing to prevent disease, complications or exacerbations of long term conditions and deliver best health outcomes for all our patients. There are likely to be increasingly complex and costly prescribing in primary care to deliver care closer to home during the delivery of this strategy. The optimisation of medicines will be a key enabler in delivery of transformation for the CCGs. Page 14 of 30
The NHS Outcomes framework (9) Medicines Optimisation Strategy has five outcome domains which underpin the work of the Preventing people from dying prematurely Enhancing quality of life for people with long term conditions Helping people to recover form episodes of ill health or following injury Ensuring people have a positive experience of care Treating and caring for people in a safe environment and protecting them from avoidable harm 4.2 Medicines Management Objectives 1. Promote evidence based, clinical and cost effective use of medicines supporting prescribers to make evidence based, cost effective choices at the point of prescribing 2. Provide medicines management leadership and expertise for commissioning of services to ensure safe, effective, affordable services are commissioned in line with legislation 3. Provide oversight, governance and assurance of safe, effective and affordable medicines usage 4. Lead the interpretation and implementation of national policy and guidance relating to medicines management 5. Ensure the CCG meets its key national and local performance targets relating to medicines including delivery of QIPP targets 6. Implement effective systems and processes to assist in the management of the financial, clinical and corporate risks associated with medicines 7. Deliver appropriate specialist medicines management support to improve prescribing safety and reduce unwarranted clinical variation 8. Work in partnership with practices and commissioned services to promote continual improvement in the optimisation of medicines use across North Derbyshire CCG Page 15 of 30
A Derbyshire wide Medicines Optimisation Strategy is currently in development which is in line with the footprint for the NHS Sustainability and Transformation Plans this has identified six key priority areas: Workforce how we better develop a pharmacist and pharmacy technician workforce across Derbyshire Patients managing their own medicines including supporting patients with better medicines adherence, improving the use of self-management plans and reducing medicines waste Medicines safety including reducing medicines harms, appropriate antimicrobial prescribing, care homes Medicines related outcomes how do we measure this both clinically and financially as impact is often greater than medicine savings Transfer of care including improved communications, particularly around medicines and medicines reconciliation Cost effective prescribing including robust governance structures for decisions about medicines, cost effective prescribing / prescribing budgets for each organisation. The priorities are aligned to the key priorities for the CCG and therefore the Derbyshire wide Medicines Optimisation Strategy will help the CCG deliver this Medicines Optimisation Strategy through focussing on medicines safety, cost effectiveness, achieved health outcomes and well developed pharmacy workforce. 4.3 Delivery, Reporting and Review The medicines management functions are delivered by a team of pharmacists, technicians, and administration support as shown in Appendix 1. The delivery of the strategic medicines management aims and objectives is outlined in the medicines management work plan 2016-2020, with a detailed core work plan for 16-17. Progress against delivery will be reported and monitored through the Prescribing Sub Group, which reports to the Governing Body Assurance Group. Page 16 of 30
4.4 Assurance The National Medicines and Prescribing Centre, (NICE) produced An organisational competency framework to ensure the effective delivery of medicines management functions and responsibilities, (2011), covering the skills and competencies needed in order to fulfil the CCG responsibilities for medicines management. To deliver effective medicines management, a commissioning organisation is required to demonstrate that it: 1. Has a strategic overview through leadership and a clearly communicated strategy for optimising the use and management of medicines in a health economy, 2. Establishes effective partnerships by linking with local, regional and national partner organisations to ensure a coordinated approach to medicines usage across health and social care 3. Commissions services that optimise the use of medicines i.e. when commissioning services or redesigning pathways, the CCG recognises the potential that optimising medicines usage has to improve patient outcomes and increase productivity 4. Provides medicines oversight where the CCG Board provides oversight, governance and assurance of safe, effective and affordable medicines usage in provider services 5. Has medicines expertise where the CCG has access to the full range of skills, expertise and knowledge necessary to deliver the safe, legal and effective use of medicines across the healthcare economy in order to improve patients outcomes 6. Supports and develops people through ensuring that staff who work in medicines management roles are competent, supported and developed. Page 17 of 30
The CCG is able to demonstrate these organisational medicines management competencies through the implementation of this Medicines Optimisation Strategy, its supporting plans and associated work plans. Page 18 of 30
Section Five References Royal Pharmaceutical Society. Medicines Optimisation: Helping patients to make the most of medicines Good practice guidance for healthcare professionals in England May 2013 https://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-oftheir-medicines.pdf The NHS Outcomes Framework. NHS England 2014 www.gov.uk Page 19 of 30
Section Six Appendices Appendix 1 Medicines Management Work Plan 2016 17 Annual Practice Prescribing Review all practices to have an annual prescribing review meeting to discuss practice prescribing performance and agree work to be done for the next year by the core medicines management team, additional medicines management support (where relevant) and the practice. PINCER all practices to be offered the opportunity to take part in the rollout of the PINCER study (A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis) to improve the quality and cost effectiveness of prescribing in primary care. Prescribing Information Information to be sent regularly to practices to support Medicines Optimisation and reducing unwarranted clinical variation: Controlled drug monitoring data periodically Non medical prescriber controlled drug prescribing reports Antibiotic performance information quarterly with C difficile information included every 6 months Annual Prescribing Indicator information Quarterly PrescQIPP DROP list information (Drugs to Review for Optimised Prescribing) Eclipse reports Medicines Management Team reports used routinely to support medicines optimisation at practices: Specials report Items > 500 Unspecified items Medicines Management Team to send quarterly information to community pharmacies and dispensing practices to enable review of out of pocket expenses. Page 20 of 30
OptimiseRx The medicines management team will continue to develop and support practices to use OptimiseRx, to deliver prescribing advice at the point of prescribing to support implementation of national and local guidance, safety advice and deliver improved safety, quality and cost effectiveness of prescribing. OptimiseRx practice level reports will be provided to Prescribing Leads at the quarterly meeting and discussed at the annual prescribing review meetings. Medicines Management QIPP 2016/17 CCG wide switches to be offered to all GP practices: Routine core work Specials Items > 500 Unspecified drugs Ticagrelor stop dates Pregabalin dose optimisation Controlled drug monitoring Big wins Red drugs, Black Drugs Bulk switches Oilatum emollient to LPL 63.4%. Zero AQS, aqueous cream, E45 cream/lotion, Aquamax to Epimax tottle Metformin MR to Sukkarto (check availability) Audit sheet switches or reviews Fentanyl patch to Fencino/Matrifen/Mezolar Matrix brand prescribing Daily tadalafil to as required sildenafil As required tadalafil, vardenafil or avanafil to as required sildenafil Doxazosin MR to plain Carbocysteine liquid to sachets Diltiazem 60mg MR tablets to Tildiem brand Page 21 of 30
Audit of bath & shower emollient preparations. Omega-3 audit Pregabalin dose optimisation Chronic antibacterial review prophylaxis for UTI Nitrofurantoin 50mg and 100mg capsules to tablets (on repeat for UTI prohylaxis at night) Chronic antibacterial review acne/rosacea prescribing Stoma audit (liaise with stoma nurses CRHFT) Continence audit (liaise with Helen Greaves) Generic LABA/ICS to brand Clenil 250/salmeterol 25 Evohaler to Fostair 100/6 asthma or COPD Clenil 200/salmeterol 25 Evohaler to Fostair 100/6 asthma or COPD QVAR 100/salmeterol 25 Evohaler to Fostair 100/6 asthma or COPD Sirdupla/Seretide 100/25 to Fostair 100/6 asthma or COPD Sirdupla/Seretide 250/25 to Fostair 200/6 - asthma Seretide and generic fluticasone 500/salmeterol 50 Accuhaler to AirFluSal Forspiro (fluticasone 500/salmeterol 50) COPD Tramadol MR to cost effective MR Practice specific switches or reviews to be offered to practice with high spend: Audit sheet switches or reviews Ezetimibe audit Rosuvastatin audit Pregabalin review review of efficacy Mirabegron review whether first or 2 nd line agents appropriate and prescribed; whether recent safety advice regarding use in hypertension and BP monitoring is being followed. Solifenacin review - whether first or 2nd line agents appropriate and prescribed; whether dose can be reduced or stopped to reduce anticholinegic burden in high risk patients. Non-staple gluten free products Lidocaine plaster review (who is initiating and why) Fentanyl immediate release review (who is initiating and why) Over ordering of inhalers audits. Over ordering of GTN sprays Perindapril arginine to erbumine Page 22 of 30
Practices with additional medicines management support to work on agreed CCG priorities including medication reviews and medicines optimisation of appropriate patients e.g. care home patients, housebound patients, polypharmacy patients, frail elderly, following hospital discharge. Prescribing Leads Meetings Quarterly Prescribing Leads meetings will be held to support two way discussion between the CCG and practices in relation to prescribing to support delivery of the medicines management strategy at practice level. Page 23 of 30
Appendix 2 Medicines Management Work Plan 2016-2020 (will be reviewed and updated on an ongoing basis) Principle = 1 = Aim to understand the patient s experience, 2 = Evidence based choice of medicines, 3 = Ensure medicines use is as safe as possible, 4 = Make medicines optimisation part of routine practice Objective Action MO Principle Responsible Lead Responsible member(s) of staff Timescale Empowering patients to get the most from their medicines encouraging patients to be actively involved in their medicines, including only ordering the medicines they require. Encouraging patients to access services available to support their medicine use including practice medication review and long term condition reviews. Community pharmacy New Medicines Service (NMS), Medicines Use Review (MUR), patient counselling and support. Dispensing practices dispensing review of the use of medicines (DRUMs). Providing a supportive environment for patients to discuss their medicines adherence, aims for treatment and take an active role in their decisions regarding treatment. Encouraging prescribers to improve the quality of medication reviews building on the PrescQIPP award winning Reducing Inappropriate Polypharmacy practice education sessions to encourage better recording and discussion with the patient/carer of aims of prescription, consideration before adding Medicines waste campaign targeting patients and carers Medicines waste campaign promoting New Medicines Service and Medicines Use Reviews and Dispensing Review of the Use of Medicines. Patient information regarding community pharmacy services available to support medicines optimisation and use of resources Patient information regarding GP medication reviews Self care campaign to support prescribers to reduce prescribing of products patients could self care with. Joint QUEST session for HCCG and NDCCG localities on medicines waste, deprescribing, starting to raise awareness with all staff on prescription costs and waste. 4 Helen Gregory Helen Gregory and David Brown 4 Helen Gregory Helen Gregory and David 1, 3, 4 Helen Gregory Helen Gregory and David Brown 1, 3, 4 Helen Gregory Helen Gregory and David Brown 2, 4 Jon Vinson Jon Vinson and David Brown 4 Maxine North Maxine North and Helen Gregory Ongoing May-June 16 Jan Mar 17 Oct Dec 16 Jun Sep 16 Ongoing Page 24 of 30
medicines to repeat prescription, regular review of outcomes from prescribed medicines involving the patient in deprescribing decisions when the risks of treatment outweigh the benefit or the desired aims from prescribing have not been realised. Encouraging all staff involved in patients care to discuss medicines adherence, to help support patients medicines taking, switch to alternative medicines where appropriate or stop prescribing medicines that are currently not taken. Educating and supporting prescription clerks and practice staff to improve repeat prescribing systems, and reduce system waste e.g. inhalers that should last 2 months being ordered monthly. The aim is to reduce over ordering of medicines which will improve patient safety and reduce waste. Improve medicines use in care homes - continue to provide medicines management audits and waste audits in all care homes, providing support to improve the safe effective use of medicines in care homes, encouraging staff to discuss with the prescriber medicines issues e.g. patient no longer requires medicine. Prioritise additional medicines management support to review and improve cost effective medicines use in care homes. Develop practice resources for supporting improved patient outcomes from prescribed medicines and improved adherence conversations with patients during medication reviews Develop plan to deliver education sessions for prescription clerks and practice administration staff. Develop resources to support prescription clerks reduce waste medicines. Provide education sessions at joint QUEST sessions, locality sessions to empower staff to reduce waste medicines and improve practice repeat prescribing systems. Where issues have been identified, review and improve practice repeat prescribing processes to reduce waste medicines Medicines waste audit to be completed in all homes, and reaudited. Develop information to support homes to reduce medicines waste. All homes to be encouraged to take control of medicines ordering process and checking prescriptions to reduce wasted medicines. Medicines management audit to be delivered in all homes, with action plans for improvements where needed. Work to reduce inappropriate prescribing of feeds, stoma, continence and other non-medicine items. Work to improve compliance with continence formulary 1, 4 Helen Gregory Helen Gregory Apr Jun 17 4 Helen Gregory Helen Gregory April Jun 16 4 Helen Gregory Helen Gregory July-Sep 16 4 Helen Gregory Helen Gregory Oct 16 onwards 4 Helen Gregory Helen Gregory Oct 16 onwards 3, 4 Jon Vinson Sian Burleigh Ongoing 3, 4 Jon Vinson Sian Burleigh Sep Dec 16 3, 4 Jon Vinson Sian Burleigh Sep 16 Mar17 3, 4 Jon Vinson Sian Burleigh Ongoing 3, 4 Jon Vinson Sian Burleigh April 16 Mar 17 3, 4 Jon Vinson Sian Burleigh April 16- Mar 17 Page 25 of 30
Reduce inappropriate antimicrobial prescribing to reduce incidents of healthcare acquired infection and take action against antimicrobial resistance. Antibiotic formulary adherence supported through education, audits, quarterly prescribing data, OptimiseRx, formulary messages, across all providers where relevant. Quarterly information to be provided to each GP practice to help support reduction in inappropriate prescribing Antimicrobial prescribing to be discussed with each practice individually at the annual prescribing review, identifying outlying prescribing and individualised action plan for each practice which could include medicines audit, education or other tailored support. 2, 3, 4 Jon Vinson Jane Bell Cheryl Davison 2, 3, 4 Jon Vinson Jon Vinson Maxine North Ongoing Ongoing Focusing on medicines safety a derbyshire wide medicines safety group will be established to improve safety, learning and reduce incidents and errors in relation to medicines. The use of OptimiseRx software will support practices to identify prescribing safety issues e.g. prescribing without appropriate monitoring. The medicines management team will be supporting the PINCER study role out throughout 2016 to reduce inappropriate prescribing. Prescribe cost effectively providing annual prescribing reviews, support and education to prescribers and point of prescribing support using OptimiseRx to encourage cost effective prescribing, and prescribing in line with local guidelines and traffic lights. Focussing on Encourage all members of the CCG including practice staff to become antibiotic guardians. Use of CQUINs to reduce inappropriate prescribing of antibiotics. Implement OptimiseRx in practices to support safer prescribing Build on indicators within OptimiseRx to improve safety of prescribing, and specifically consider additional indicators following medicines related incidents. Develop a Derbyshire wide medicines safety network to implement the work required of the Medicines Safety Officer and Medical Device Safety Officer role. Implement PINCER trial as part of the AHSN role out across the East Midlands. Rerun PINCER indicators on a 6-monthly basis as part of the PINCER trial rollout across the East Midlands Provide each practice with an Annual prescribing review where an agreed action plan of work related to improving the safety, cost effectiveness and outcomes from prescribed medicines will be agreed. 4 Jon Vinson Jon Vinson Ongoing 3, 4 Jon Vinson Jon Vinson Ongoing 3 Jon Vinson Jon Vinson Ongoing 3, 4 Jon Vinson Jon Vinson Ongoing 3, 4 Kate Needham Kate Needham Sep 16 1, 2, 3, 4 Maxine North Maxine North Helen Gregory 1, 2, 3, 4 Helen Gregory Medicines Management Technicians 2, 3, 4 Maxine North Maxine North Jon Vinson Feb 16 Sep 16 Ongoing Sep 16 June 16 onwards Page 26 of 30
reducing waste medicines, medicines optimisation and appropriate cost saving switches and medication reviews will deliver cost effective prescribing. However there are very limited patent expiry generic savings until later 2017 which will put considerable pressure on primary care prescribing costs. Rebates are in place to provide delivery against QIPP, along with practice prescribing switches, medication review, and other work. This work will support reduction in inappropriate clinical variation. Assurance that high cost PbRe drugs are used in line with national and local commissioning policy the use of Blueteq software will enable linking of invoices with patient criteria to provide assurance that patients are being treated in line with policy. The Blueteq information will provide opportunities to plan and predict impact of future NICE guidance and also opportunities to review and identify potential cost saving, this will support better financial planning of this activity. Consider and implement effective procurement options for non practice led prescribing where appropriate - to improve cost effectiveness, quality of care and outcomes for patients. Medicines management technicians to implement agreed prescribing switches Medicines management additional support to implement agreed work including medication review of priority groups of patients. Provide education to practices through joint quest sessions, individual practice education sessions and other sessions. Develop a CCG medicines management education plan. 2, 3, 4 Helen Gregory Medicines Management Technicians 1, 2, 3, 4 Maxine North Practice Support Pharmacists June 16 onwards Apr 16 onwards 2, 3, 4 Jon Vinson Jon Vinson Apr 16 onwards 2 Jon Vinson Jon Vinson Sep 16 Produce annual prescribing indicators for practices. 2, 3, 4 Maxine North Denise Shaw April 16 and annually Produce regular quarterly prescribing reports for practices to identify changes in prescribing and opportunities for savings. All rheumatology patients to be on the Blueteq system by April 16. Agree ophthalmology forms for Blueteq and include them on the system. All ophthalmology patients to be on the Blueteq system Agree gastroenterology forms for Blueteq and include them on the system. All gastroenterology patients to be on the Blueteq system Ongoing process to develop forms for Blueteq for CCG commissioned High Cost drugs and for anonymised patients to be included on the system Identify spend by each area of non GP led prescribing area 2 Kate Needham Denise Shaw Jane Bell Quarterly 2 Kate Needham Sadaf Qureshi April 16 2 Kate Needham Sadaf Qureshi Sep 16 2 Kate Needham Sadaf Qureshi Mar 17 2 Kate Needham Sadaf Qureshi April 16 2 Kate Needham Sadaf Qureshi Sep 16 2 Kate Needham Sadaf Qureshi Ongoing 2 Kate Needham Kate Needham June 16 Prioritise areas for procurement priority 2 Kate Needham Kate Needham Sep 16 Include procurement options in work plan in order 2 Kate Needham Kate Needham Dec 16 of priority based on cost savings and improved health outcomes for patients. Continence prescribing review and savings opportunities 4 Kate Needham Kate Needham 16-17 Page 27 of 30
Improve transfer of prescribing across interfaces this will reduce risk (e.g. medicines stopped or continued inappropriately), improve medicines safety (e.g. reduce dosing errors due to inaccurate or unclear discharge information), and improve medicines optimisation. Practices will be encouraged to use the PrescQIPP award winning GP portal to resolve and identify prescribing issues at the interface between Chesterfield Royal Hospital Foundation Trust and practices. Woundcare prescribing review and savings opportunities Stoma prescribing review and savings opportunities Gluten Free prescribing review and savings opportunities Promote use of the GP portal at Chesterfield Royal Hospital Foundation Trust to resolve individual issues and identify themes and trends of issues for commissioning discussions and service improvements. 4 Kate Needham Kate Needham 16-17 4 Kate Needham Kate Needham 17-18 4 Jon Vinson Jon Vinson 16-17 3 Kate Needham Kate Needham Ongoing Ensuring effective medicines commissioning all commissioning decisions to complete the Medicines Commissioning Checklist to ensure effective medicines commissioning in all pathways, decommissioning decisions, commissioning decisions and commissioning changes. Agree Medicines Commissioning Checklist Kate Needham Kate Needham April 16 Include checklist in NDCCG and HCCG process for Kate Needham Kate Needham June 16 commissioning. Medicines Management team to work with commissioners to complete section 2 of the checklist where the answer is yes to any of the section 1 questions. Kate Needham Kate Needham June 16 onwards Page 28 of 30
Appendix 3 CCG Reporting Structure Page 29 of 30
Appendix 4 Team Structure and Lead Roles Jayne Stringfellow Chief Nurse and Quality Officer Kate Needham Head of Medicines Management (Lead areas include High Cost drugs, Chesterfield Royal Hospital Foundation Trust, procurement, out of hours, QIPP delivery, controlled drugs, medicines safety, Prescribing Sub Group, Joint Area Prescribing Committee) Maxine North Lead Medicines Management Pharmacist (Lead areas include practice level work, practice QIPP delivery, Prescribing Leads meetings, Sheffield Acute Trust, Hardwick CCG, deprescribing) Jane Bell Senior Project Support Officer (Lead areas include controlled drug monitoring, production of regular epact information, Eclipse reports) Cheryl Davison Administrative Support (Lead areas include administration support for the medicines management team) Jon Vinson Lead Medicines Management Pharmacist (Lead areas include education, training, antibiotics, care homes and social care, Stockport Acute Trust, OptimiseRx, projects, community pharmacy, NICE Associate, map of medicine) Bob Whitehouse, Carmen Villegas-Galvez, Mary-Jane Sagar, Vacancy Practice Support Pharmacists (Lead areas include supporting practices to improve the safety, quality and cost effectiveness of prescribing prioritising high risk patients for review) Karen Barker QIPP pharmacist (Lead areas include Hardwick CCG delivering and achieving QIPP through improving the safety, quality and cost effectiveness of prescribing and reducing waste) Sian Burleigh Care Home Medicines Management Technician (Lead areas include care home medication waste, safety and quality work and social care) Helen Gregory Lead Medicines Management Technician (Lead areas include practice level technician work, delivering QIPP, improving safety and quality of prescribing, project work, receptionist and prescription clerk training, project work including waste, practice system formulary, Patient Participation Group work) Mary Aldred, Carla Peacock, Marie Dixon, Emily Doherty, Alison Clarey, Vacancy Medicines Management Technicians (Core practice work) (Lead areas include delivering core practice medicines management work to practices to support delivering QIPP, auditing at practice level to improve the safety, quality and cost effectiveness of prescribing) (Mary also provides a medication review role to support patients identified by practices, pharmacies or social services to assess their needs and support medicines compliance) Kerry Coles, Denise Shaw, Caroline Taylor, Annette Farrow, Andrea Wass, Emily Doherty, Vacancy Medicines Management Technicians (Additional practice work) (Lead areas include delivering additional medicines management support to practices to improve the safety quality and cost effectiveness of prescribing providing prereviews of high risk patients for an independent prescriber to review) (Kerry has lead role for GP clinical system formulary, Denise for epact, sharepoint, Eclipse and Emis Web, Andrea for SystmOne TPP) Marie Miles QIPP Technician (Lead areas include Hardwick CCG delivering and achieving QIPP through improving the safety, quality and cost effectiveness of prescribing and reducing waste) Page 30 of 30