Hospital Pharmacy Transformation Plan

Hospital Pharmacy Transformation Plan Introduction In June 2014, Lord Carter of Coles was appointed to the position of Chair of a new NHS Procurement & Efficiency Board to direct the NHS Procurement & Efficiency Programme and its portfolio of projects. In accepting this new role Lord Carter stated his intent to include a review of hospital pharmacy and medicines optimisation in the work of the Board. Accordingly, in September 2014, Dr Keith Ridge, Chief Pharmaceutical Officer was invited to join the NHS Procurement & Efficiency Board and to chair the Hospital Pharmacy and Medicines Optimisation Project (HoPMOp). On 5 th February 2016, Lord Carter published his final report to the Secretary of State for Health identifying unwarranted variation across all of the main resource areas worth an estimated 5billion in terms of efficiency opportunity. Of this, the report stated that the NHS could save at least 800million through transforming hospital pharmacy services and medicines optimisation (by investing in medicines optimisation studies have shown that for every 1 invested in pharmacy services 3 is saved). It made eight recommendations at acute Trust, regional and national levels. All of the recommendations were accepted. Report recommendations Lord Carter s final report contained the following specific recommendations for transforming hospital pharmacy services and medicines optimisation which need to be implemented by NHS trusts. Recommendation 3: Trusts should, through the Hospital Pharmacy Transformation Programme (HPTP), develop plans by April 2017 to ensure hospital pharmacies achieve their benchmarks such as increasing pharmacist prescribers, e-prescribing and administration, accurate cost coding of medicines and consolidating stockholding, in agreement with NHS Improvement and NHS England by April 2020; so that their pharmacists and clinical pharmacy technicians spend more time on patientfacing medicines optimisation activities. The Directors of Pharmacy of Mid Cheshire NHS Foundation Trust, East Chehsire NHS Trust, Countess of Chester NHS Foundation Trust, Cheshire & Wirral Partnership NHS Foundation Trust and Wirral University Teaching Hospital NHS Foundation Trust have come together to work collaboratively to address the recommendations from Carter as well as scope out further collaborative projects which could benefit the local health economy (NB East Cheshire Trust is also currently exploring options with Greater Manchester in relation to pharmacy services). Current situation

The group of Trusts provide pharmacy services to acute and non-acute service users. A number of these services are similar and include dispensary services, aseptic services, procurement, homecare services, medicines information, formulary management and application and shared care pathway development as well as proactive direct clinical pharmacy support to service users and clinical staff. These services are key elements of the pharmacy service; this paper will evaluate these shared services to ascertain the potential for any collaboration. Collaboration will be of benefit where there is duplication of effort or economies of scale. For example if two hospitals process 100 prescriptions a day, 200 prescriptions per day will need to be processed. Savings will be only be available where there are efficiencies to be made. Options The following section lists the potential collaborative projects which have been highlighted by the Directors of Pharmacy. The individual sections include which Trusts currently provide the service, the scope of the potential collaboration and the risks and benefits of each collaborative project. 1. Inpatient dispensary services All 5 Trusts provide this service. CWP currently outsources this element of their inpatient service. Collaboration would entail provision of dispensary services from outside of the Trust either from a third party provider or a wholly owned subsidiary. Delayed doses (NPSA Alert) Increased length of stay Adverse impact on patient flow Increase in waste Increase in error rates Increased turnaround time for dispensing as clinical screen and dispensing would be provided separately No VAT cost savings as medicines are administered on site Inability to response to urgent requests for medicines Inability for outsourced pharmacy to stock all the medicines needed by the hospital pharmacy Reduced stock holding (one off saving) VAT savings from discharge medicines Clear KPIs could ensure medicines are dispensed in a timely manner and not omitted Limited scope for the acute Trusts to outsource their inpatient supply as patients require their medicines in a timely manner, acute Trusts stock 1000s of different medicines, there are no VAT saving on inpatient medicines and hospital pharmacies have access to hospital only contact prices (often cheaper than Drug Tariff prices). However CWP have successfully implemented this and there would be scope to evaluate an outsourced pharmacy managing the dispensing of discharge prescriptions.

Another option would be to send discharge prescriptions electronically to a patient s nominated community pharmacy; however the VAT savings this would generate would need to be off set with the community pharmacy dispensing fees. The group could share inpatient policies and SOPs to develop and improve current services. 2. Out-sourced outpatient pharmacy (wholly owned subsidiary/third party provider) Currently none of the 4 acute Trusts have this service, CWP has an outsourced third party provider (Lloyds Pharmacy) which dispenses outpatient, inpatient and discharge prescriptions. Collaboration would entail the formation of a wholly owned subsidiary (WOS) company which would manage the outpatient dispensing of medications, or a joint tender to outsource outpatient dispensing to a third party provider. Capital and revenue expense to allocate area for outsourced pharmacy Capital and revenue expense to set up subsidiary company NHS England and local commissioners may not enter into gain share agreements around VAT savings Improved patient experience VAT savings on dispensed medicines Increased capacity for inpatient activity Opportunity for using the WOS for other services such as estates. There would be scope to develop a collaborative subsidiary company by having one company which manages all the Trusts outpatient dispensing, working together to limit the costs of setting up individual WOS or jointly tendering for one supplier to provide outpatient dispensing services. 3. Aseptic services Currently the 4 acute providers have aseptic units. Three of which are MHRA licenced units. Collaboration would entail either: a. Aseptic units merging to provide 2-3 units over the foot print. b. Aseptic units reviewing their portfolio collaboratively to promote batch production of products required by local Trusts. This will make use of the current services and potentially release capacity. The increase in capacity could result in the closure of a unit or an opportunity to take on commercial work at a cheaper cost or to generate income Resilience of a service critical function if a unit goes down Investment costs into 2-3 aseptic units Economies of scale; savings from overheads, staffing costs, licence costs, quality assurance costs etc. organisations would share an aseptics unit. This would be aligned to the national and regional strategy for aseptic manufacture

Cost savings from merging units/collaboration of product portfolio Reduced future capital investment required Improved patient safety through the aseptic manufacture of high risk medicines which are currently manufactured at ward level. This would be possible if current capacity was increased. There would be scope to work collaboratively to develop a robust and cost-effective aseptic service for the group. 4. Procurement/stores and distribution Currently all acute Trusts manage medication procurement via a national and regional framework. Trusts purchase medicines locally through local wholesale dealers and other supply routes (CWP medicines are procured through Lloyd s pharmacy and based on drug tariff prices). Adherence to contract prices is measured and fed back to individual Trusts. Trusts are required to ensure the contract lines are manually changed when new contract prices are made available (nationally and regionally set). The processes in place to ensure hospital pharmacies access the best value contact price is well established. Collaboration would entail a Trust with a Wholesale Dealers Licence and a Home Office License (currently held by 2 Trusts and 1 Trust applying for a WDL and HOL) buying medicines and storing medicines on behalf of other Trusts. Trusts could collaborate by sharing a stock holding. This system could reduce the time taken to process invoices, maintain drug files, upload contract changes, address out of stock issues etc. Any shared stock holding collaboration would need the same IT system installed in each organisation. Risk to Trust with Wholesale Dealers Licence as the organisation will have an increased stock holding and increased risk of stock expiring Investment for the same IT system Cost savings where bulk discounts are available however this may be of limited financial value as the majority of contracts are mandatory and negotiated nationally and regionally. Time saving for each Trust from inputting contract changes, invoicing etc. Therapeutic tendering could result in cost savings through bulk buying (for example if the organisations agreed on one low molecular weight heparin then discounts could be available) There could be scope for this option but it would be dependent on any bulk discounts available and efficiencies to make cost savings. The shared stock holding could be evaluated to ascertain any time that could be saved. The group could also approach local commercial wholesalers to see if there is any scope to work collaboratively to set up a bulk store for the 5 Trusts. 5. Homecare services The 4 acute Trusts currently manage patients on homecare medicines. These services deliver the homecare medicines to the patient s home and are VAT free.

Collaboration could be achieved by bringing the homecare activity back in-house and using a wholly owned subsidiary (WOS) to dispense the medicines. This could either be a WOS at each Trust or managed by a central WOS providing the dispensing service for each Trust. See option 2 above. Other areas of collaboration could be a common IT system for managing (prescribing, invoice reconciliation etc.) home care medicines. Cost savings could be made through a joint procurement of a fit for purpose IT system. Capital expense to allocate area for outsourced pharmacy Capital expense to set up subsidiary company Resilience issue if only one Trust provided this service Patient satisfaction if the Trusts decide not to offer a delivery service and ask patients to collect their medicines from the WOS pharmacy Able to continue with VAT free medicines Improve governance as will be managed within the NHS (no need to consent patients/data sharing agreements etc.) Reduce the time taken to process home care medicines (currently prescriptions, invoices and delivery notes need to be reconciled against purchase orders) Improvements in patient safety as homecare medicine will form part of the patient s electronic medication record. There would be scope for this option following the formulation of WOSs. 6. Medicines Information (MI) Currently 4 of the Trusts provide an in-house medicines information service. However, the small numbers of pharmacists providing the medicines information service have another specialist role, for example MI and Critical Care Pharmacist. The MI element of their role takes up around 50% of their time. The Trusts also operate a patient help line via their MI pharmacist. A collaborative approach could be achieved by having a central hub for all the MI queries and patient help line questions to be directed to. Risk Disruption to established staffing structure if MI element was removed Need for the MI hub to have access to all Trusts patient records, formularies and pathways. The MI hub team would also need to have a broad clinical specialism in various therapeutic areas to be confident in answering a variety of different queries. Loss of in-house education and training for all pharmacy staff in answering MI queries (a key skill for junior pharmacy staff which would need to be provided either by the hub or a dedicated training session) Cost of setting up and hosting the MI hub De-skill pharmacists/technicians in answering queries Cost savings through staff and individual Trust subscription fees to MI resources

There could be an option to look at an acute MI hub and a mental health MI hub (with Merseycare, CWP & 5-Boroughs) and an oncology MI hub (CCC). This approach could be viable; however the group suggests that this be evaluated when an MI pharmacist post comes vacant. (NB this was evaluated at one Trust and a potential cost saving of 10k between 2 Trusts was highlighted, however the cost to train the junior pharmacist workforce in MI would need to be weighed against any saving). 7. Formulary management and application Currently each Trust has an internal Medicines Management committee: MCHFT has a Joint medicines Management group (hosted by MCHFT and CCG reps invited), a new medicines sub group (ECNT, MCHFT and CCGs) and an area prescribing committee (ECNT, MCHFT, CCGs). ECT has a Medicines Management Group which has representation from the CCG medicines management team. ECT are also part of the local area prescribing committee and its new medicines sub-group COCH has internal MM committee (D&T), cross sector NICE, New Drugs and Formulary Committee and overarching APC for more strategic issues. The Wirral Heath economy has a joint Drug and Therapeutics Panel which provides the holistic management of the entry of new drugs across the health economy and approves medicines optimisation policies and procedures. CWP has an internal medicines management group (MMG) for discussing all internal medicines management issues, it then has several sub-groups that report into the MMG; they are the PGD sub-group, the medicines safety subgroup and the interface group (this is made up of primary care reps from the CCGs & CSU) discussions are had that affect primary care but the CWP meeting cannot make decisions on behalf of the CCGs, any recommendations made are then taken back to the various Area Prescribing committees(apcs) or an equivalent CCG governance group for a decision. Collaboration would entail the 5 Trusts having the same formulary and the same application process for a medicine to be added to the formulary. NICE Technology Appraisals (TAs) would be implemented over a number of Trusts with common pathways. Challenges around 8 organisations agreeing on adding a medicine to a joint formulary and agreeing a pathway. However there is national plan to move towards Regional Medicines Optimisation Committees which will have an impact on Trust level medicines management committees. Timeliness of 8 organisations managing the introduction of new medicines or new guidelines Local ownership works well and is well adhered to in some Trusts. Reduction in work load for individual Trusts as they currently manage their own formulary (Trusts employ medicines management and medicines optimisation pharmacists to manage their individual formularies and work up new medication requests etc.)

Standardised formulary over a larger footprint would reduce challenges/uncertainty from commissioners when medicines are prescribed off formulary All organisations would be able to contribute to an agreed formulary Fewer meetings for staff to attend This approach could be viable if there was support from all the stake holder organisations. The introduction of the Regional Medicines Optimisation Committees could lead to wider collaboration. CWP currently have an agreed mental health formulary across the Wirral and Cheshire footprint. This could be expanded upon to cover physical health medicines. In essence the group could have one Area Prescribing Committee (APC) for the footprint with some sub-groups working to the APC for the work plan. 8. Shared care agreements Each Trust formulates its own shared care agreements (SCAs) with their local commissioners. Collaboration would entail the 5 Trusts producing collaborative SCAs which could be used over a wider foot print. The rationalisation of established SCAs and development of new SCAs would help to standardise the medications offered through SCAs. Challenges around 8 organisations agreeing on adding a SCA pathway Timeliness of 8 organisations agreeing a SCA. Organisations with extensive shared care agreements may be asked to reduce to align with those where a more cautious approach to shared care is taken, this could result in a cost pressure for secondary care. Helps to address public perception of postcode prescribing Is beneficial if service users transition across different organisations Reduction in work load for individual Trusts to manage their Own SCAs Standardised SCAs over a larger footprint would reduce challenges/uncertainty from GPs when asked to enter into a SCA. All organisations would be able to contribute to an agreed program of SCAs. This approach could be viable if there was support from all the stake holder organisations including primary care. 9. Pre-packing/manufacturing units All the Trusts purchase over labelled medicines (medicines which are pre-labelled so can be dispensed from ward/treatment area level) from a pre-packing unit. Each Trust sources the required product with best price from numerous pre-packing units in the UK. Collaboration could occur if the group worked with Trusts with a manufacturing unit (currently ECNT has a manufacturing unit) to develop a portfolio of over labelled products which would be purchased by the group. This could offer savings through assured business and economies of scale.

Resilience of supply chain if manufacturing unit goes down Loss of business for other NHS manufacturing units de-stabilisation of the market Cost savings (high volume, low mark-up) Timely receipt of product from point of order as delivery is within the local area This collaborative project could be viable but will be dependent on the product lines and quantities required by the group of Trusts. It would also be dependent on the capacity in the single manufacturing unit. Other opportunities Community pharmacy post discharge follow ups Community pharmacy offer a New Medication Use Review to patients who are commenced on certain new medications, they can also offer general Medication Use Reviews (MURs) to patients who require one. There are currently two IT systems that allow hospital pharmacies to refer eligible patients to their local pharmacy following discharge from hospital for a medication use review. Collaboration around this initiative would entail the group of Trusts deciding upon which system best suits our needs and purchasing this together. There is scope to progress this option as there is evidence that referring a patient for a medication review following discharge can improve patient adherence and understanding of their medication and subsequently reduce the risk of readmission for those with long term conditions. As of September 2016 each Trust has expressed an interested in being involved in an NHS England funded project to introduce an electronic referral to community pharmacy (ercp) scheme. Additional work load for ward based pharmacy staff Requirement for portable tablets to enable prompt referral to community pharmacy (following consent from a patient at the bed side) Improvements in patient care, patient experience and patient education and training around their medicines Potential reductions in readmission rates Potential reduction in medication related adverse events Improved patient self-care Reduction in unwanted medicines waste Education and training Each Trust delivers its own tailored medicines management training to their Trust staff (nurses, medical staff etc.). There could be scope to develop a shared medicines management training programme which is an e-learning package applicable to staff working in the collaboration. These packages could be tailored to various staff groups.

Each Trust also delivers education and training to pharmacy students, preregistration pharmacists and pharmacy technicians and diploma students (there is some shared training through pre-registration pharmacist study days). There could be collaboration with this, although any changes with the current system should be risk assessed against the changes happening with the Pharmacy Undergraduate training programme. There could be scoped to collaborate on patient counselling initiatives such as counselling videos and patient information documents. Work force planning Trusts could work together to support education and training in and exposure to specialist areas of pharmacy. Currently specialist services are struggling to recruit pharmacists; this could be supported by offering a rotation of pre-registration pharmacy students or diploma pharmacists through pharmacy specialities. By doing so would raise awareness of the speciality and encourage trainees and younger pharmacists to consider such specialist areas at a later date in their career. Reciprocal arrangements would also be beneficial for pharmacists in all speciality areas to have refresher hands-on sessions in various specialities to keep up their clinical skills in those disciplines. MCHFT 80% of the pharmacy workforce at ward-level MCHFT was the first hospital in the North West to employ a pharmacy technician to administer medications to inpatients. This pilot has been successfully implemented and will be expanded to other wards in the hospital. MCHFT has two specific roles for non-medical prescribers. This will increase by one in 2017 and a business case is being submitted to increase this further. Electronic prescribing MCHFT currently has an electronic discharge system and an electronic chemotherapy prescribing system. The Trust is working up the specification for an inpatient electronic prescribing and administration system as part of the IT forward plan. Accurate coding for medicines Accurate cost coding is managed through the Ascribe dispensing system and Define software solution. There is work ongoing to ensure dm&d compliance through these systems. Consolidation of stock holding is being reviewed as described by the collaboration and in line with the Specialist Pharmacy Service (SPS) A National Approach to Medicines Procurement: A contribution to local Carter responses.