Medicines optimisation in hospital and at the interface through effective commissioning: The role of a Commissioning Pharmacist

Transcription

1 Medicines optimisation in hospital and at the interface through effective commissioning: The role of a Commissioning Pharmacist Brigitte van der Zanden South West London Lead Commissioning Pharmacist South East Commissioning Support Unit

2 Commissioning pharmacist Introduction Roles and remit of commissioning pharmacists vary Based in CCGs, CSUs, hospital (NHS England Clinical Commissioning Pharmacists), NHS England, independent organisations (or a mixture) SWL perspective: Interface and Secondary Care Prescribing Support (ISPS) service 0.8WTE Lead commissioning pharmacist 1.0WTE Commissioning Support pharmacist Employed by South East CSU, providing service for 6 SWL CCGs

3 SWL Commissioning Pharmacist = SWL CCGs Population:1.6m Croydon CCG Kingston CCG Merton CCG Richmond CCG Sutton CCG Wandsworth CCG SWL hosted providers: Croydon Hospital St. George s Hospital Epsom & St. Helier Hospital Royal Marsden Hospital Kingston Hospital SWL and St. Georges Mental Health Trust 6 community services providers

4 What we will cover. Overview of NHS medicines commissioning arrangements and processes in England How can a Commissioning Pharmacist make a difference?- Practical examples of how to strengthen medicines commissioning and optimise medicines use in the NHS. Opportunities and barriers to optimise medicines use in hospital and at the interface from a Commissioning Pharmacist s perspective

5 Payment by Results NHS Plan (July 2000): from block / cost and volume to PbR National tariff of fixed prices for hospital procedures Aim: Improve efficiency, increase value for money, facilitate choice, enable service innovation and improvements in quality, and reduce waiting times. Healthcare Resource Group: cluster of diagnosis and procedure that consume the same level of resources. Reference cost: standard price for a particular procedure. Adjustments are made for market forces. Allows unbundling of treatment to enable different aspects of the treatment to be performed by different service providers PbR excluded drugs, devices, procedures

6 PbR excluded drugs High cost drugs not covered by the Tariff (annual list update by Monitor) (see Commissioners decide if commissioned (or not) and agree local price and arrangements for monitoring activity with providers Two main NHS commissioners: CCGs: Non-specialised services NHS England: Specialised services Manual for prescribed specialised services

7 SWL Commissioning Pharmacist Role Centralised, strategic pharmaceutical leadership to the South East CSU, on behalf of 6 SWL Clinical Commissioning Groups (CCGs) Facilitating collaborative working across the interface / in 2nd care Pharmaceutical advice and scrutiny for the contracting and procurement of commissioned services Ensure that clinical governance framework relating to pharmaceutical services and medicines use of commissioned service is in place QIPP (Quality, Innovation, Prevention, Productivity)

8 3 main areas: SWL Commissioning Pharmacist Role PbR excluded/high Cost drugs: Responsible for the development and implementation of a SWL Interface medicines management/prescribing strategy in relation to high cost drugs, NICE guidance and related areas, while promoting and supporting innovation and good practice in the hospital trusts and CCGs and ensuring value for money. Interface Support: Responsible for ensuring efficiencies and quality improvements gained through collaborative working across SWL are realised. Promote positive joint working and effective working relationships between key external agencies. Individual Funding Requests (IFR) Support: Responsible for ensuring that the IFR process is integrated into the commissioning cycle and the SWL medicines management strategy

9 PbR excluded drugs - SWL commissioning principles PbR excluded drugs are funded if: Commissioned by SWL CCGs Used as per NICE and/or local agreements Patients meet eligibility criteria submission of checklists (tick box forms) agreed with providers Clinical patient benefits (outcomes) reported by Trusts using continuation templates for on-going treatment Charged at the correct value as per contract : usually acquisition cost incorporating any relevant discounts

10 PbR excluded drugs- Process in SWL Clinical notification Clinician/nominated staff completes initial application or request for continuation on Blueteq (if funding period expired) Treatment can start Hospital pharmacy screen and approval Commissioning Pharmacist Approval by CSU high cost drug team for specified length of time (value) Blueteq identifies patients when reapproval is required Financial approval of submitted invoices Finance CSU receives patient level SLAM data Initial checks: MDS Value of SLAM vs SLAM PLD CCG misattribution Validation of HCD claims vs Blueteq & funding approval rules (incl ) HCD challenge report checked by pharmacist Challenge report to providers (directly and notification via contract management) Provider response to challenges & resolution Quarterly reconciliation exercise for unresolved challenges Updated challenge report

11 2015/16 PBR Exclusions Funding Application for Abatacept, Adalimumab, Certolizumab, Etanercept, Golimumab, Infliximab or Tocilizumab for Rheumatoid Arthritis First line biologic drug (includes post-adverse event with 1 st line biologic treatment within 6 months of initiation) (South West London version 1 pending confirmation of other participating CCGs outside SWL): Last updated 01/04/2015) Before providing patient identifiable data on this form, please confirm that the patient (or in the case of a minor or vulnerable adult with the parent/legal guardian/carer) has given appropriate explicit consent for sensitive personal information on this form to be passed to the CCG and/or CSU for processing this funding request and validating subsequent invoices. Consent given: Yes Patient NHS No. Trust: GP Name: Patient Hospital No: Patient s birth year: (yyyy) Consultant Making Request: GP code /Practice code: Confirm patient status: (* select 1 option) NHS Private Overseas Consultant Contact Details: GP Post code: Please indicate whether patient meets the following NICE criteria 1. Patient is aged 18 years or over 2. Does patient have active rheumatoid arthritis with DAS28 score >5.1, confirmed on at least 2 occasions 1 month apart (before starting biologic treatment)? Please tick Yes Yes No No Only fully completed forms will be accepted by CCGs/CSUs for consideration. If the answer to any of these questions is NO, please consider if there are patient Please give scores: Score 1 Date: Score 2 Date: specific exceptional clinical circumstances 3. Before starting biologic treatment, patient has not responded to at least 2 disease-modifying antirheumatic drugs, including methotrexate (unless contraindicated) or has had an adverse event to a CCG approved first-line biologic drug. A trial of DMARD is defined as being normally of 6 months, with 2 months at standard dose, unless significant toxicity has limited the dose or duration of treatment. Provide details: Yes No demonstrated. If so, a full individual funding request (IFR) form will need to be completed. This may be obtained from the named contact at the relevant CCG/CSU/Trust. Please refer to the Start date Stop date Treatment Reason for stopping individual CCG IFR policy for further details. 4. Tick applicable statement:: Yes No This is the patient s first biologic drug for rheumatoid arthritis OR CCG approved 1 st line biologic drug treatment had to be stopped due to an adverse event within 6 months of initiation. Provide brief details: 5. Licensed dose and frequency of requested biologic drug will be used? Yes No 6. Treatment choice will be the drug with the least acquisition cost Yes No 7. Please specify Abatacept IV (go to 10) Abatacept SC (go to 10) Adalimumab (go to 13 ) which drug is Certolizumab (go to 9) Etanercept (go to 13 ) Golimumab (go to 11) requested? Infliximab (go to 8) Tocilizumab IV (go to 10) Tocilizumab SC (go to 10) 8. Remsima is the preferred Infliximab brand for all London Trusts. Please specify Infliximab brand to be prescribed: Remsima (biosimilar) Inflectra (biosimilar) Remicade Please provide valid reason, if not using preferred biosimilar. (then go to 12) 9. The manufacturer will provide the first 12 weeks of certolizumab pegol free of charge (go to 13) Yes No 10. For Abatacept or Tocilizumab, the manufacturer will provide the drug at the discount agreed by NICE as part of the patient access scheme? Note: Full list price will not be Yes No reimbursed (go to 12) 11. For Golimumab, the manufacturer will provide the 100mg dose at the same cost as the 50mg (go to 12) Yes No Contact details: Form completed by: Phone: Date of completion: Additional Information: Patient weight (if used for drug dosing): Drug dose + frequency: Please note: CCGs only fund licensed doses. Do not exceed licensed dose or frequency. kg

12 Continuation notification I understand that funding will only be re-approved if there is an adequate response at 6 months (12 weeks for certolizumab). An adequate response is classed as an improvement in current DAS28 score by 1.2 compared to baseline with an absence of severe drug toxicity. This should be monitored every 6 months and treatment withdrawn if not maintained. I herewith provide you with the requested information to apply for further funding: Measurement At baseline (before starting any biologic) Current DAS28 score Date: Date: Improvement in DAS score 1. Is there an improvement in current DAS28 score by 1.2 compared to baseline? 2. Patient has not experienced malignancy, severe drug related toxicity, pregnancy, severe intercurrent infection? (yes= no experiences) Yes Yes (did not experience this) 3. Please provide up-to-date weight if required for dosing. Weight : kg 4. Infliximab only: Remsima is the preferred Infliximab brand in all London Trusts. Please provide valid reason if preferred biosimilar is not being prescribed. No No 5. What is acquisition cost of drug including VAT (if applicable)? /month A new application is required for: Repeat treatment with the same agent because improved DAS28 scores deteriorated when treatment was stopped. Please provide history before treatment with biologic was started and also additional information (score on stopping and current score) in additional information box. Note: Funding will only be re-approved if the patient has shown an improvement of scores

13 PbR excluded drugs- findings Do Trust really follow NICE guidance? E.g. DAS28 scores not always measured or recorded in RA in some Trusts Over-ordering: Adalimumab overdose (weekly doses instead of 2 weekly) Rituximab: waste due to patient DNA Insulin pump: excessive use of consumables without hospital knowledge Wet-AMD: continuation of treatment despite decline in BCVA Growth hormone: use outside commissioning agreements Invoice charges exceeding acquisition cost / double charging for same patient Charges for deceased patients NHS England and CCG misattributions Funding not approved /no notification submitted

14 PbR excluded drugs Month 1-9 (2014/15): Total charges: 17.7million Challenges/queries: 8.36million Conservative estimate of likelihood of successful challenges: 1.48million Accepted by Trusts: 386k Challenges removed: 806k Outstanding challenges used for year-end deals: 7.1million 8.3% inappropriate charging (if monitored for several years) Helps providers and commissioners with audit/reporting

15 Interface support South West London Medicines Commissioning Group Members: all SWL CCGs, hospital providers, community services providers Interface Prescribing Policy (in contracts) Annual provider reports: Is interface prescribing policy being implemented? Shared care Prescribing Guidelines & Hospital or Specialist only drug list Consistency across SWL scope for error in GP practices Cross fertilisation of good practices that improves patient experience e.g. safe SC methotrexate shared care prescribing Systematic joint decision making process to decide best place of prescribing Commissioning principles for PbR excluded drugs/devices (in contracts)

16 Interface Support South West London Medicines Commissioning Group Other: Joint bidding for resources or sourcing of SWL wide priority workstreams Medicines incidents: quarterly reporting and review across SWL reporting and learning from medication errors (building on CCG Quality premium 14/15) Horizon scanning to inform budget setting process Other contractual levers: CQUIN, KPI, Information Schedule

17 Individual Funding Requests Considered by CCGs (3 panels across SWL) Commissioning pharmacists advise: Whether a drug is commissioned by NHSE or CCG Whether a drug should be dealt with as an IFR or can be processed as a PbR excluded drug Clarify commissioning arrangements for drugs both within and outside SWL Identification of repeated requests (service developments) Trigger for care pathway reviews

18 Care Pathway Review - Ophthalmology Wet-AMD Recommendations Aflibercept preferred choice: less frequent administration and follow ups (note subsequent change in SPC ranibizumab): Better for patients cost for commissioners Inappropriate administration charges Variation betw providers: day case (~ 450) vs outpatient ratio (~ 168) : range 0.5%-56% cost for commissioners One stop clinics vs separate review and treat appointments Better for patients cost for commissioners Explore using community clinics

19 Care Pathway review - Rheumatology (on-going) Approach: Analysis of IFRs processed in SWL to identify any unmet need Analyse biologics expenditure and the choice of biologics locally Analyse and benchmark activity charges for SWL Trusts Seek suggestions from local Trusts Review care pathways in place in other regions Review of evidence base to support any suggested deviations from the NICE treatment pathways in use.

20 Care Pathway Review - Rheumatology (on-going) Early findings: Drug administration costs varies between providers: to be reviewed with contract management and providers NICE advocates use of least costly biologic first line: Preferences vary between providers- scope for optimisation ( saving per patient per year if using 2 lower cost agents instead of currently preferred agents) Tocilizumab/abatacept: can patients on IV therapy be changed to SC? Do we get rebates on golimumab for patients who are not responding? Relatively high use of rituximab for RA and golimumab for Psoriatic Arthritis in one provider requires review

21 Care Pathways Review - Rheumatology (on-going) Early findings: Analysis of IFRs: RA (35), Psoriatic arthritis (9); Ankylosing spondylitis (5) (19 months) Local Trusts want to change NICE care pathway Review of evidence base Pre-biologics optimisation: Is NICE CG79 and EULAR 2013 implemented? Review NICE treatment pathway and amend as appropriate Consider piloting anti-tnf drug level monitoring service to optimise patient outcomes

22 Opportunities: Opportunities and barriers Focus on outcomes rather than inputs: Use objective clinical response measures to ensure use of high cost drugs is appropriate Benchmarking identify outliers / areas for improvement Linking medicines use to activity data focus on efficiencies in treatment pathway (not just cost of medicine) Commissioning pharmacists can optimise medicines by linking intelligence from: clinicians - contract management-finance activity data-ccgs Barriers: NICE- single rather than multiple technology appraisals- (national pathways rather than lots of local ones) Regulatory Cross border issues (different priorities)

23 Any questions? For more information: Acknowledgements: Chief Pharmacists from Croydon CCG, Kingston CCG, Merton CCG, Richmond CCG, Sutton CCG and Wandsworth CCG SWL Commissioning Support Pharmacist