NHS DORSET CLINICAL COMMISSIONING GROUP 7.4 PRIMARY CARE COMMISSIONING COMMITTEE MEDICINES MANAGEMENT REPORT Date of the meeting 03/10/2018 Author Purpose of Report Recommendation Stakeholder Engagement Previous GB / Committee/s, Dates K Gough, Head of Medicines The purpose of this report is to update the Committee on medicines, prescribing and dispensing issues and the activity of the Medicines Optimisation Group. The Committee is asked to note the report. There are patient representatives on the Medicines Optimisation Group (MOG) and the GP prescribing leads for each locality are members of the MOG and work closely with the medicines team on prescribing issues. Parts of the report were presented to the Medicines Optimisation Group Monitoring and Assurance Summary This report links to the following Strategic Objectives Prevention at Scale Integrated Community and Primary Care Services One Acute Network Digitally Enabled Dorset Leading and Working Differently All three Domains of Quality (Safety, Quality, Patient Experience) Board Assurance Framework Risk Register Yes [e.g. ] Any action required? Yes No Detail in report Budgetary Impact Legal/Regulatory People/Staff Financial/Value for Money/Sustainability Information Management &Technology Equality Impact Assessment Freedom of Information I confirm that I have considered the implications of this report on each of the matters above, as indicated Initials: KMG 1
1. Introduction 7.4 1.1 This report set out some of the medicines optimisation work currently underway as well as drawing the committees attention to the Falsified Medicines Directive and the system leadership in Pharmacy programme that is underway. 2. Report 2.1 Medicines optimisation group: The next medicines optimisation group is on 19th September 2018 the minutes will come to the next meeting. 2.2 Falsified Medicines Directive (FMD): This is an EU directive which we understand will go ahead despite Brexit and will require medicines to be decommissioned before issue to a patient from 9th February 2018. NHSE/NHS Digital have been holding engagement event with pharmacy manufacturers, hospitals, community pharmacy and medical representative groups on this initiative for some time. 2.3 A consultation on some of the implementation aspects remains open until 23rd September https://www.gov.uk/government/consultations/implementing-safety-featuresunder-the-falsified-medicines-directive 2.4 Organisations including community pharmacies, hospital pharmacies and Dispensing doctors will be required to decommission products at the point of supply to a patient. Non Dispensing GP practices and Hospitals are classified as healthcare institutions in the regulations and will have to decommission medicines within their organisations. 2.5 Manufacturers are responsible for issuing packaging with 2d barcodes, and organisations undertaking decommissioning will have to have barcode scanners in place to decommission the medicines. It is understood that nationally, work is underway with system suppliers to ensure that the equipment is compatible and available. 2.6 The medicines team are receiving a number of enquiries about the FMD, however there is limited information available for the primary care setting. Dispensing Doctors are being referred to the dispensing Drs association as they have been party to the development, and it is anticipated that some of the activity will be subject to national contract negotiations with the contractor bodies. Following closure of the consultation on 23 rd Sept, the response should also clarify some aspects. Primary care prescribing 2.7 Locality prescribing visits have now taken place for most localities with the style of the meeting and venue varied to try and best suit the locality and support the practices. There has been a drive to encourage practices to work on prescribing both as part of a locality and as their individual practice needs. 2
2.8 The CCG Locality pharmacists have identified key areas for improvement and this has been shared at the meetings with the practices who in turn have worked on selecting actions that could make improvements and are important for their practice and locality. 2.9 At present we are on trajectory to deliver the savings plan for 2018/19, though there may be additional cost pressures in generic prices that will have an impact on the final outturn. Savings plan delivery to date is 1m. 2.10 In the savings plan, some of the largest savings are for price drops in products that had been forecast at the end of 2018/19 and we are now seeing the results of. This includes inhaler price drop saving 350K, 2017/18 savings still being delivered at of this 120K since Jan, other respiratory savings due to changing to lower priced inhalers, 390K, low value medicines 110K. 2.11 Other benchmarking measures: 2.12 Opioids High on high dose opioids ADQ/STAR PU CCG 7.13 v national 6.64 Items per 1000 patients CCG 1.58 v national 1.35 High on Oxycodone MR cost per 1000 STAR PU* CCG 8.1 v national 5.56 Good on opioid patches cost per 1000 STAR PU* CCG 13.03 v national 15.98 2.13 Overall spend/items Av /Item high CCG 7.59 v national 7.28 Total per ASTRO PU good CCG 8.80 v national 9.49 Total Items per ASTRO PU good CCG 0.32 v national 0.36 2.14 Considerable work is underway with practices to identify high opiate prescribing and put in place management plans to get doses down to safe levels. There remain a number of outliers and these are challenged to engage with pain services and refer into the substance misuse services if appropriate. There are some challenges with the pain service and the level of specialist support available to practices when trying to reduce prescribing. Pharmacy integration Fund 2.15 The second wave of practices employing pharmacists as part of the pharmacy integration fund will soon begin to recruit and in other areas there continues to be interest in employing practice pharmacists. It is hoped that there will be increasing flexibility in the application and delivery process to allow for challenges in different areas. 3
2.16 The Dorset system has received funding for medicines optimisation in care homes (MOCH) and will soon be recruiting Care Homes Pharmacists and pharmacy technicians integrated into the integrated community and primary care development. Work is underway at the CCG to ensure that the reporting and quality measures can be delivered. There is a collaborative approach being taken to recruitment with partnerships being developed between the providers and community pharmacy in some areas and thus not destabilising any one sector. 2.17 The pharmacy integration fund has also provided money for urgent care pharmacists, and to date one has been recruited and will be working in the out of hours period to support the multidisciplinary team. 2.18 The fund has recently announced money to support pharmacy system leadership and Dorset is to be one of 7 sites in England to implement a pilot which will include developing pharmacy integration in system leadership and governance. Full details can be found: https://www.england.nhs.uk/publication/integrating-nhs-pharmacy-and-medicinesoptimisation-into-sustainability-and-transformation-partnerships-and-integrated-caresystems/ 2.19 Reporting on this will be through the Clinical Reference Group and one of the ICS portfolios. Antimicrobial stewardship & Quality Premium targets for 2018-19 2.20 The Quality Premium targets for 18-19 are the basis for the prescribing quality incentive scheme for GP practices in Dorset. 2.21 The targets are: A 30% reduction (or greater) in the number of trimethoprim items prescribed to patients aged 70 years or greater on baseline data (June15-May16) Items per STAR-PU must be equal to or below England 2013/14 mean performance value of 1.161 items per STAR-PU*. Additional reduction equal to or below 0.965 items per STAR-PU. This threshold is additional for 2018/19 2.22 At the 12 months ending June 2018, 78 practices were meeting the trimethoprim in over-70s target, according to in-house analysis of epact** data. The data from NHS England has not been updated since May but that shows the overall CCG target was at 15,038 compared to a target of 20,260 https://www.england.nhs.uk/publication/antibiotic-quality-premium-monitoringdashboard/ 2.23 At the end of June, 47 practices were already at or below the 0.965 items per STAR-PU target of 2018-9. Eighty-one practices were below the 1.161 target, meaning that 5 practices were not reaching either target according to in-house 4
analysis of epact data. The data from NHS England for May 2018 shows the overall CCG target was at 0.966. 2.24 GP locality prescribing leads and locality pharmacists are being encouraged to work together to support the small number of practices who find these targets challenging. 2.25 Over the counter medicines: A work plan is underway to implement NHS England guidance to reduce the prescribing of a set of over the counter medicines in primary care. This includes changes to the formulary, patient and public communication and an equality impact assessment. It is also expected that a range of gluten free foods will be blacklisted by the end of the calendar year. The Department of Health are currently consulting on the detail. 3. Conclusion 3.1 Falsified medicines directive will be implemented in the near future, once the last stage has been consulted upon. 3.2 The primary care prescribing budget continues to be a high priority to deliver savings and a locality approach supports the peer review and support needed to make changes. Savings are on-track. 3.3 The pharmacy integration fund is providing a range of opportunities to invest in pharmacy staff for new sectors and a collaborative approach to recruitment. 3.4 The Pharmacy System Leadership pilot will bring additional opportunities for the work in Dorset to be showcased. 3.5 Good progress is being made on antimicrobial stewardship and the delivery of national measures. Author s name and Title: Katherine Gough, Head of Medicines Optimisation Date: Sept 2018 Telephone Number: 01305 368946 Glossary *STAR PU is a prescribing measure **EPACT2 is a system that provides prescribing data 5