Prescribing and Medicines Management

Transcription

1 Reporting Officer: Medical Director Board Meeting 3 May 2007 Agenda Item: 15 Prescribing and Medicines Management Key Issues and Actions Required The prescribing and medicines management strategy has been updated for and aims to support safe, effective and economic use of medicines across Neath Port Talbot within a system that facilitates maximum benefit and minimal risk for an individual patient and for the population as a whole. A number of initiatives have been established with the aim of continually improving and modernising the medicines management agenda. The Board is asked to consider the strategy, note progress on current initiatives and support the ongoing funding of Scriptswitch. Purpose This paper provides an update on key initiatives relating to prescribing and medicines management in Neath Port Talbot LHB and introduces the updated strategy for Prescribing strategy Vision and strategic aims The strategy aims to support safe, effective and economic use of medicines across Neath Port Talbot within a system that facilitates maximum benefit and minimal risk for an individual patient and for the population as a whole. Key to achieving these aims are: Promoting high quality cost effective prescribing The LHB has a responsibility to remain within the allocated prescribing budget while continuing to improve quality of prescribing and medicine s management. January 2007 prescribing figures indicate that the LHB is projecting a 3.4% ( 840K) underspend against an allocated budget of 24.8million. (These figures do not include adjustment for incentive scheme payments to practices and high cost drugs.) Neath Port Talbot LHB 1/6 LHB Board Meeting Prescribing and Medicines Management 3 May 2007

2 It has been demonstrated that improving quality whist reducing spend on medicines is achievable. These successes will be promoted by sharing good practice and developing innovative ways to improve medicines management. Working in partnership Good medicines management cannot be achieved without working in partnership with patients and across health and social care. Education Education of patients, carers, prescribers and other key stakeholders involved in medicines management is fundamental to improving quality and cost effectiveness. Minimisation of clinical risk Medicines use is associated with significant morbidity and mortality. This strategy aims to reduce risk through supporting appropriate medicines management. Appropriate support and resource allocation In order to ensure the delivery of this strategy, resources and support will be required. These will include appropriate prescribing budgets and incentives, accessible pharmaceutical advice, training packages and suitable enhanced services. National and local priorities National priorities will significantly shape the work of medicines management. These include NICE guidelines, National Service Frameworks, Healthcare standards, All Wales Medicines Strategy Group recommendations, national prescribing indicators, Welsh Health Circulars, extensions of prescribing rights, IT developments, the modernisation agenda and the General medical service and pharmacy contracts. In addition, specific local needs and priorities must be taken into account. Such local priorities include partnership working with secondary care and social services, the prescribing incentive scheme, target clinical areas such as hypnotics, NSAIDs and antibiotics, Scriptswitch, medicines management in care homes, improving cost effectiveness of dietetic prescribing and new models of working linking into developing local projects such as the Delivering Integrated Services project. Dynamic and flexible approach Within this three year strategy, specific priorities and deadlines may change as a result of unforeseen events both locally and nationally. It is therefore vital to take a dynamic and flexible approach which will adapt to emerging needs. Performance against All Wales high-level indicators High-level (national) prescribing indicators are used to monitor prescribing patterns across Wales and are linked with the SAFF. The LHB also has its own local indicators, which include additional factors to improve medicines management and is linked to prescribing incentive scheme. As previously highlighted, underspending practices tend to score more highly on prescribing quality indicators demonstrating that quality and cost effectiveness can go hand in hand. Neath Port Talbot LHB 2/6 LHB Board Meeting Prescribing and Medicines Management 3 May 2007

3 Details of the high level indicators for 2006/7 and the LHB s performance against each indicator based on data from December 06 is summarised in the table below. Indicator Percentage generic medicines prescribed target 78% Percentage inappropriate generic prescribing target 4% Hypnotics and anxiolytics DDS/1000 patients Co-proxamol cost per 1000 PUs NSAIDs DDDs per 1000 PUs Perform Comment ance LHB achieving 82% LHB achieving 2.4% Usage higher than average (deprivation affects this indicator). However, rate of prescribing is moving towards lower quartile Rate of prescribing significantly reduced (less than half national average) in line with guidance Usage higher than average (deprivation affects this indictor). However, rate of prescribing is moving towards lower quartile Key = target achieved = moving towards target (NB: LHB will achieve indicator if moving towards target) = moving away from target Core prescribing support A range of ongoing support activities are being provided as part of the LHB s work to improve medicines management. These activities include: Annual prescribing visits to each practice, with agreement of three prescribing actions for the year ahead, inline with the requirements of the GMS contract Prescribing Leads sessions and quarterly updates Training for practice staff via the repeat prescribing training packs In house practice support to targeted practices Regular prescribing newsletters and s Monitoring of prescribing patterns and performance with identification of outliers and open quarterly feedback to practices Incentives to change practice including the prescribing incentive scheme and open comparison of prescribing data Scriptswitch (see below) Scriptswitch Scriptswitch is an independently run software system designed as an innovative way to influence prescribing. The system is fundamentally a message service that Neath Port Talbot LHB 3/6 LHB Board Meeting Prescribing and Medicines Management 3 May 2007

4 enables delivery of specific local messages to the GP at the point of prescribing with the aim of improving quality and cost effectiveness, managing entry of new drugs and linking to formulary implementation. Scriptswitch has been installed in eighteen practices in Neath Port Talbot since July 2006 with installation in a further three practices in March 2007 and plans to install in the remaining two practices by the end of The system is generally well accepted by practices and quarterly updates are made to the profile to ensure it is relevant and up to date. Costs for the first year are approximately 53K and projected savings by March 2007 approximately 140K. Given these results, ongoing funding for 2007/8 is strongly recommended and a three year contract (approximately 50K p.a.) offers preferential rates. Scriptswitch projected savings Vs Contract cost (NB. July 06 & March 07 are part months) 160, , , , , Cumulative Savings Installation cost 60, , , Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Month Improving cost effectiveness of oral nutritional supplements Due to a 13% increase in the prescribing costs on nutritional products and relatively high usage in Neath Port Talbot, it was agreed that measures should be put in place to ensure the appropriateness of initiation and continuation of oral nutritional supplements within Primary Care. Audits undertaken across the country have identified significant clinical and cost benefits resulting from careful initiation, monitoring and improved education of healthcare professionals and patients in this area of prescribing. In order to make progress in this area, dedicated dietician time was funded from the prescribing budget and a prescribing support dietician came into post in March 2007, initially for a period of three years. Progress and outcomes will be closely monitored. Improving medicines management in the domiciliary care setting In 2005, an initiative was funded via Wanless to improve medicines management in domiciliary care through joint working with social services. The aim is to Neath Port Talbot LHB 4/6 LHB Board Meeting Prescribing and Medicines Management 3 May 2007

5 improve medicines management for the users of Homecare services, ensuring that organisations comply with the National Minimum Standards for Domiciliary Care Agencies in Wales in administering medication and improving links between the Health and Social Care sectors. Initial progress was slow due to necessary culture changes and joint working to overcome barriers, but the following have been achieved to date: Agreement with the Unions on approached to medicines administration by carers Implementation of updated policies and procedures Training of over a thousand care staff from social services and the private sector Establishment of a local enhanced service with community pharmacists to provide medicines administration charts Appointment of a medicines management nurse to drive the initiative and visit patients with problems in their own homes However, while significant progress has now been made, the scheme has unearthed significant risks and capacity to deal with emerging needs and the backlog of patient referrals is currently insufficient. This has prompted initiation of a scoping exercise with planned anticipated development of a business case to increase funding and support to this key area. Improving medicines management in care homes The Commission for Social Inspection states that: homes are still not placing enough importance on this critical area of care with nearly half the care homes still not meeting the minimum standard relating to medication It also recommends that NHS primary care organisations should acknowledge and act on their responsibility to support health care provision within private and voluntary Care Homes and children s homes. In acknowledgement of this, and potential cost savings, the Board agreed to fund a Care home pharmacist who took up post in November Significant progress has already been made with respect to individual patient medication reviews and development of a local action plan to encourage all care homes to participate in improving standards for medicines management and minimising waste. Collaborative working with secondary care The Spoonful of sugar document from the audit commission reported that: 18% of prescribing is hospital initiated and 40% is strongly influenced by hospitals. It is therefore essential to work closely with secondary care to ensure a consistent approach to achieving the best from medicines across the whole health economy. An interface pharmacist and interface prescribing group are in place to support this approach. In addition, following a recent NLIAH Modernisation assessment (Spring 2006), a joint Designed for Improvement work plan has been produced, identifying Neath Port Talbot LHB 5/6 LHB Board Meeting Prescribing and Medicines Management 3 May 2007

6 priority prescribing areas for Bro Morgannwg Trust, Neath Port Talbot and Bridgend LHBs. Areas identified for joint working include, statin switches, cost effective ACE inhibitor choices, mental health prescribing, electronic discharge communication, formulary and shared care development Two successful changes recently achieved through joint working include the decrease in escitalopram due to promotion of more cost effective alternatives and an increase in percentage generic simvastatin as total statins. These two changes alone will release K p.a. CONCLUSIONS AND RECOMMENDATIONS The Board is asked to: Note the financial position, progress against high-level national prescribing indicators and current medicines management initiatives To consider and, if appropriate, approve the attached Prescribing and medicines management strategy for Consider the ongoing funding of Scriptswitch for a period of three years due to demonstrated quality and cost benefits. Impact Assessment Health Social Care and Wellbeing Resources Risk Equality The contents of this report demonstrate the ongoing work of the LHB to support continuous improvement in the quality and cost effectiveness of prescribing, which is recognised to be integral to improving health and wellbeing. Ongoing funding of the Scriptswitch initiative for a period of three years is approximately 150K, but savings anticipated to exceed this with the additional benefit of improved quality. Further work to evaluate the implications of risks identified across health and social care will be reported back to the Board. This work demonstrates the ongoing work of the LHB to manage the risks associated with prescribing and the actions being taken to minimise these risks through support, education and monitoring. There are no issues arising from this report. V:\LHB\Chief Executive (CE)\LHB Board\LHB Board Meeting Papers (CELHB 4)\2007\May 07\Finals\Prescribing and medicines managment march 07 V2.doc Neath Port Talbot LHB 6/6 LHB Board Meeting Prescribing and Medicines Management 3 May 2007

7 PRESCRIBING AND MEDICINES MANAGEMENT STRATEGY Policy author: Head of Prescribing and Medicines Management March

8 EXECUTIVE SUMMARY INTRODUCTION PROMOTING HIGH QUALITY COST EFFECTIVE PRESCRIBING MANAGING PRESCRIBING RESOURCES Managing prescribing budgets Identifying areas of prescribing growth Identifying areas of potential prescribing savings Planning and horizon scanning MANAGING PRESCRIBING QUALITY Implementation of national guidelines Medicines related audits Sharing best practice Overview of prescribing data to identify outliers Performance management through prescribing indicators WORKING IN PARTNERSHIP ENGAGING PRIMARY CARE PRESCRIBERS General practitioners Supplementary and independent prescribers EDUCATION AND TRAINING OF PRACTICE STAFF WORKING WITH SECONDARY CARE PATIENT AND PUBLIC INVOLVEMENT PHARMACEUTICAL INDUSTRY COMMUNITY PHARMACY Community Pharmacy Development CARE HOMES HEALTH AND SOCIAL CARE INTERFACE REGIONAL AND NATIONAL LINKS WITH OTHER MEDICINES MANAGERS WORKING WITH OTHER AGENCIES DEVELOPING IN LINE WITH NATIONAL PRIORITIES AND GUIDELINES NICE GUIDELINES AND HIGH COST DRUGS NATIONAL SERVICE FRAMEWORKS (NSFS) ALL WALES DIRECTIONS FROM THE ASSEMBLY All Wales Medicines Strategy Group (AWMSG) Welsh Health Circulars All Wales Prescribing indicators GP CONTRACT PATIENT GROUP DIRECTIONS (PGDS) AND PATIENT SPECIFIC DIRECTIONS (PSDS) TAKING ACCOUNT OF LOCAL NEEDS AND PRIORITIES PRESCRIBING INCENTIVE SCHEME Evolving Incentive Scheme improving quality and managing financial risk Criteria for spend, application and approval process SCRIPTSWITCH SPECIFIC TARGETED CLINICAL AREAS RISK MANAGEMENT RESPONSIVE AND REACTIVE TO UNPREDICTED EVENTS AND CHANGING NEEDS APPROPRIATE SUPPORT AND RESOURCE ALLOCATION STRATEGY IMPLEMENTATION AND CONCLUSION...46 REFERENCES...48 APPENDIX 1 LOCAL PRESCRIBING INDICATORS 2007/ APPENDIX 2 TARGETED CLINICAL AREAS 2007/

9 EXECUTIVE SUMMARY VISION AND STRATEGIC AIMS: To ensure the safe, effective and economic use of medicines across Neath Port Talbot, within a system that facilitates maximum benefit and minimal risk for an individual patient and for the population as a whole. Key to achieving these aims are: Promoting high quality cost effective prescribing The LHB has a responsibility to remain within the allocated prescribing budget while continuing to improve quality of prescribing and medicines management. It has been demonstrated that improving quality whist reducing spend on medicines is achievable. These successes will be promoted by sharing good practice and developing innovative ways to improve medicines management. Working in partnership Good medicines management cannot be achieved without working in partnership with patients and across health and social care. Education Education of patients, carers, prescribers and other key stakeholders involved in medicines management is fundamental to improving quality and cost effectiveness. Minimisation of clinical risk Medicines use is associated with significant morbidity and mortality. This strategy aims to reduce risk through supporting appropriate medicines management. Appropriate support and resource allocation In order to ensure the delivery of this strategy, resources and support are required. These will include appropriate prescribing budgets and incentives, accessible pharmaceutical advice, training packages and suitable enhanced services. National and local priorities National priorities will significantly shape work around medicines management. These include NICE guidelines, National Service Frameworks, Healthcare Standards, All Wales Medicines Strategy Group recommendations, Welsh Health Circulars, national prescribing indicators, extensions of prescribing rights, IT developments, the modernisation agenda and the General Medical Services and Community Pharmacy contracts. In addition, the specific local needs and priorities of Neath Port Talbot must be taken into account. Such local priorities include partnership working with secondary care and social services, the prescribing incentive scheme, specific clinical areas of concern (such as hypnotics and antibiotics), Scriptswitch, medicines management in care homes, improving cost effectiveness of dietetic prescribing and implementing new models of working by linking into developing local projects (such as the Delivering Integrated Services project- DIS). Dynamic and flexible approach Within this three year strategy, specific priorities and deadlines may change as a result of unforeseen events both locally and nationally. It is therefore vital to take a dynamic and flexible approach which will adapt to emerging needs. 3

10 1. INTRODUCTION Prescribing presents both significant risk and opportunity to the Local Health Board, in terms of cost and patient care. Primary care drug prescribing accounts for 80% of the overall NHS drugs bill, 15-17% of the total budget for the Local Health Board (LHB), and approximately 10-15% of overall NHS expenditure. It is vital that this resource is used to the maximum benefit as a significant overspend on prescribing could potentially threaten other services. Medicines* have revolutionised health care and improved the lives of many, but they are also a source of morbidity and mortality. Medicines management is therefore crucial to maximise potential benefit and minimise risk from medicines use. Medicines management is a system of processes and behaviours that determine how medicines are used by patients and the NHS. Effective medicines management places the patient as the primary focus, thus delivering better targeted care and better informed individuals. It should: Improve health Improve patient care and satisfaction Make better use of professional skills Deliver effective clinical governance Improve Risk Management Maximise the use of resources available Morbidity and Mortality caused by Medicines It is thought that as many as half of all patients with chronic conditions end up using their medicines* in a way that is not fully effective. Medicines used inappropriately can cause harm. (National Service Framework for Older People. DH March 2001) Medication problems are implicated in 5-17% of hospital admissions and, while in hospital, 6-17% of older inpatients experience adverse drug reactions National Service Framework for Older People in Wales March 2006) For example, on average, prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) will cause 22 people in each primary care organisation to be admitted to hospital suffering from acute congestive heart failure each year. (Bandolier 79, September 2000) Medication errors have been estimated to cost the NHS 500 million a year in additional days spent in hospital. (Audit Commission, December 2001) A study conducted in two large hospitals, identified that 6.5% of admissions were related to an adverse drug reaction (ADR), with the ADR leading to the admission in 80% of cases. This accounted for 4% of hospital bed capacity. (BMJ July 2004) * For the purposes of this document the word medicine covers all prescribable and over the counter items which include dressings, appliances, inhalers, creams etc. 4

11 2. PROMOTING HIGH QUALITY COST EFFECTIVE PRESCRIBING Ensuring effective use of prescribing resources through promoting evidence based, cost effective medicines, planning, targeting and waste minimisation will ensure that more people, directly and indirectly, will benefit from the resources available. 2.1 Managing prescribing resources Managing prescribing budgets The LHB has a responsibility to remain within the allocated prescribing budget while continuing to improve quality of prescribing and medicines management. At the time of writing, latest available prescribing data relates to the quarter ending December 2006: Budget 2006/7: million Projected year end position Neath Port Talbot: 3.7% underspent (NB: These costs are before adjustments for high cost drugs and prescribing incentive scheme payments.) Trend since September 1999 is illustrated in graph 1. Graph 1 % Sep Neath Port Talbot LHB - Prescibing trend against budget September 1999-December 2006 Dec-99 Mar-00 Jun-00 Sep-00 Dec-00 Mar-01 Jun-01 Sep-01 Dec-01 Mar-02 Jun-02 Sep-02 Dec-02 Mar-03 Jun-03 Sep-03 Month Dec-03 Mar-04 Jun-04 Sep-04 Dec-04 Mar-05 Jun-05 Sep-05 Dec-05 Mar-06 Jun-06 Sep-06 Dec-06 5

12 Prescribing budget setting Allocation to Neath Port Talbot Local Health Board At a national level, prescribing budgets have been reduced due to the impact of cost savings from category M drugs, although increases in the cost of some high volume drugs have not been taken into account. This has added pressure on the prescribing budget in Neath Port Talbot along with the fact that national budget setting does not reflect local deprivation levels which are known to increase prescribing requirements. It is hoped that over the coming years, this situation will improve through the adoption of the needs-based Townsend Score allocation. Allocation within Neath Port Talbot Local Health Board Practice budgets are currently allocated on a weighted capitation basis, which takes into account age, sex, number of temporary residents, numbers in nursing and residential homes and a deprivation factor based on long term limiting illness. Prior to allocation, the budget is top-sliced to fund prescribing of agreed high cost drugs, out of hours drugs and prescribing support initiatives. Within Neath Port Talbot, there is considerable variation between practices, from 30% overspent to 25% underspent. The LHB medicines management team work closely with practices and prescribing data to understand these variances and promote change and improve quality where necessary. MANAGING PRESCRIBING BUDGETS ACTIONS AND TARGETS Overall objective: To remain within the allocated prescribing budget and ensure an appropriate allocation to practices. Prescribing budgets to be set for practices annually following notification of LHB allocation Prescribing budget to be closely monitored and forecasted throughout the year to feed into the overall LHB financial forecasting processes LHB medicines management team to continue to work with and incentivise practices and other partners to maintain a focus on cost effectiveness (See section 3) LHB medicines management team to identify and act on recognised cost saving opportunities Overall LHB position will continue to be reported to the Board, along with progress against prescribing initiatives and other significant medicines management information Annual review of the effectiveness of top-sliced elements such as high cost drugs, prescribing support, out of hours drugs, incentive schemes etc. Development of closer working between LHB finance and medicines management teams with respect to budget management and planning for prescribing cost pressures Exploration of different budget setting methodologies as they become available 6

13 2.1.2 Identifying areas of prescribing growth Best practice in some areas of prescribing will undoubtedly result in increased costs. These areas include National Institute for Clinical Excellence (NICE) and All Wales Medicines Strategy Group (AWMSG) guidance, National service frameworks (NSFs), the Quality and Outcomes framework (QOF) of the General Medical Services (GMS) contract and the removal of the prescription charge from April 2007 However, even in these areas of anticipated growth, costs can be managed through: Appropriate targeting of medicines to patients who benefit most Use of evidence based, cost effective drugs first line An example of this is the prescribing of statins, where use of the most cost effective statin first line accounts for savings of 200K- 300K per annum Identifying areas of potential prescribing savings There is also scope for savings, some of which have been highlighted in the Audit Commission report on Primary Care Prescribing (see link below) F8572/Prescribing-bulletin_web.pdf These include: Reduction in waste and overuse of medicines Wastage and over reliance on unnecessary medicines is a significant issue both locally and nationally. The LHB aims to minimise waste through a range of initiatives including patient information, community pharmacy audits and improved medicines ordering systems. Appropriate choice of medicines Promoting evidence based, cost effective medicines first line and moving to more cost effective options which do not compromise patient care, can have a significant impact on prescribing costs. For example, many newer, more expensive drugs lack evidence of any advantage over existing therapies but may be heavily promoted both to professionals by pharmaceutical representatives and advertising, and to the general public via media exposure. Access to independent information on the place of new therapies is important to ensure that the most appropriate medicines are used. Promoting the appropriate use of generic rather than branded medicines remains important to ensure cost effectiveness. However, the following issues complicate generic use and cost savings in some circumstances: A growing list of inappropriate generics Pharmaceutical industry s patent dodging tactics Availability of branded generics The LHB generic prescribing rate is currently 82% which meets the national target of 78% or above. 7

14 2.1.4 Planning and horizon scanning In order to effectively manage prescribing, it important to plan for the future and anticipate likely changes in prescribing patterns. The LHB will work with the Trust/LHB Interface Pharmacist to horizon scan and plan for the introduction of new drugs (including those awaiting NICE guidance). It is also necessary to horizon scan for any other change which could influence prescribing practice/spend e.g. NSFs, GMS contract Quality and Outcomes framework, Drug Tariff and the Pharmaceutical Industry Marketing Strategies and the availability of free prescriptions. MANAGING PRESCRIBING RESOURCES ACTIONS AND TARGETS Overall objectives To ensure the prescribing resources are used in the most effective way to benefit more patients. Ensure targeted and cost effective use of medicines in areas of anticipated high growth, whilst reducing waste and inappropriate prescribing (through mechanisms outlined in Section 3 and 4) Maintain LHB Generic rate target of > 78% (national target) Work with Interface Pharmacist to plan and horizon scan 2.2 Managing prescribing quality Prescribing is a complex science and art and as such it is difficult to measure against the concept of quality. However, through prescribing data we can achieve a two dimensional view of prescribing patterns and compare these against some simple markers, such as prescribing indicators. In the future, with improved IT, clinical audit, prevalence data and referral patterns, it will be possible to judge quality more appropriately in a three dimensional manner which will link prescribing with indications and diagnosis. Key areas for consideration in prescribing quality include: Implementation of national guidelines NICE National Service Frameworks National Patient Safety Agency All Wales Medicines Strategy Group (AWMSG) Medicines related audits Annual audits are agreed during prescribing visits to each practice Annual audit is agreed as part of the pharmacy contract 8

15 2.2.3 Sharing best practice Open sharing of prescribing data has been in place for a number of years Medicines management collaborative approach is used to share best practice and promote positive changes Sharing of drug related incidents is used as a learning tool Overview of prescribing data to identify outliers Data analysis is undertaken on a quarterly basis following receipt of data with more detailed analysis during annual prescribing visiting process. This includes a systematic quarterly review for high use of controlled drugs Performance management through prescribing indicators National prescribing indicators measure LHB prescribing performance in key areas, are reviewed annually and are linked with the SaFF. At the time of writing, the indicators for 2007/8 are: Generic rate Inappropriate generic rate Percentage simvastatin as total statins prescribed NSAIDs Hypnotics and Anxiolytics Details of these indictors can be found on the following link: Performance for December 2006 shows that the NPT LHB has reached the target for two of the indicators and moving towards target in the other three, showing that good progress is being made. Local prescribing indicators are developed annually in collaboration with the prescribing leads. These include the high level indicators along with other areas of local priority, including audit, training and development. See Appendix 1 for local and national indicators 2007/8 Performance against local quality indicators is linked with the prescribing incentive scheme which rewards practices for high quality cost effective prescribing. Analysis confirms that underspending practices tend to score higher against the locally agreed prescribing quality indicators (See graph 1 below). 9

16 Neath/Port Talbot LHB Prescribing indicator scores (%) - March % NPT GP NPT GP NPT GP NPT GP NPT GP NPT GP NPT GP NPT GP NPT GP % over/under allocated prescribing >10% over 0-10% over 0-10% under >10% under NPT GP NPT GP NPT GP Practice NPT GP NPT GP NPT GP NPT GP NPT GP NPT GP NPT GP NPT GP NPT GP NPT GP NPT GP PRESCRIBING QUALITY INDICATORS ACTIONS AND TARGETS Overall objective: To develop useful and meaningful tools to enable the monitoring of overall prescribing quality Maintain focus on high level prescribing quality indicators, through a range of prescribing initiatives, clinical audit, GMS contract prescribing actions and links with the incentive scheme. Annual review of local prescribing indicators in collaboration with GP Prescribing Leads Provide quarterly feedback on practice performance against quality indicators to the GP Prescribing Leads (open sharing of other practice performance is included) Continue to include quality performance indicators as a key part of any prescribing incentive schemes Use developing clinical audit packages to create more sophisticated prescribing quality indicators 1 0

17 3. WORKING IN PARTNERSHIP The All Wales Healthcare Standards are devised to: promote care based on shared values that can be adopted universally, ensuring that quality services are patient and user centred and provided equitably, robustly and ethically across the full breadth of services we provide, no matter what the setting Adopting a whole systems approach is vital to improving medicines management. The diagram below gives an indication of some of the factors which influence prescribing and medicines management. 1 1

18 3.1 Engaging primary care prescribers The bulk of prescribers in primary care are general practitioners. However, due to changes in the legislation enabling nurse prescribing, supplementary prescribing and most recently independent prescribing, the number and type of prescribers is set to increase and the impact of this on overall prescribing will need to be closely monitored General practitioners In Neath Port Talbot, there are approximately 80 GP prescribers. Principle factors, which have been found to change prescribing habits locally, are: Pharmaceutical industry Secondary care prescribing Patient demand Incentives Active prescribing lead Open comparisons of performance National/local guidelines and evidence base Pharmaceutical advice Education and awareness Audit Principal factors which are barriers to change include: Established and engrained habits Lack of time or resources Lack of incentives Secondary care prescribing Lack of cohesion within the practice Patient demand It is important to create a culture, which supports prescribers to review and change their prescribing where this is appropriate. Prescribing infrastructure which promotes good medicines management will be promoted and supported by the LHB. This includes: Regular face to face medication review Active prescribing leads Protected time to work on medicines management Development of repeat prescribing policies Regular practice meetings which include medicines management issues Active use of development of care pathways including shared care and enhanced services Education and training Patient information on prescribing to reduce inappropriate demand 1 2

19 Engaging and influencing GP prescribers-where are we now? Generally, the GPs in Neath Port Talbot are responsive to advice and incentives. In addition to national influencing (e.g. journals, guidelines, pharmaceutical industry etc.) there are currently a number of direct mechanisms in place at a local level aimed at positively influencing GP prescribing for the benefit of the NHS. They include: Annual prescribing visits The LHB prescribing team visits each practice at least annually to provide a practice specific overview of prescribing compared with the LHB and the rest of Wales. During this visit, three prescribing actions are agreed with the practice as part of the quality and outcomes framework of the General Medical Services Contract (GMS). Achievement of these actions is monitored. The prescribing leads initiative - A nominated practice prescribing lead is supported to attend quarterly updates on prescribing and medicines management issues. The scheme also enables GPs protected time in practice to work on prescribing issues. The quarterly meetings provide a means of sharing good practice in a peer support group, with the aim that this information is shared back at the practice and any suggested changes implemented. Areas focused on with the prescribing leads have subsequently demonstrated positive changes in prescribing data. Prescribing indicators and performance comparisons Performance against LHB agreed prescribing quality indicators are sent to the prescribing leads on a quarterly basis and are linked in with the prescribing incentive scheme. An open culture of information sharing exists within the prescribing leads network and this has been a key driver towards affecting change. Prescribing incentives The prescribing incentive scheme has been key to improving the quality and cost effectiveness of prescribing in Neath Port Talbot. Supplementary schemes have also been established where there has been a requirement to target specific issues and these have also proved successful (e.g. nitrate initiative). Scriptswitch - Scriptswitch is an independently run software system which was implemented in compatible practices in July 2006 as an innovative way to influence prescribing. The system is fundamentally a message service that enables delivery of specific information to the GP at the point of prescribing. These messages are developed and updated locally with the aim of improving quality and cost effectiveness and raise awareness regarding local initiatives, guidelines etc. Scriptswitch has been well accepted and initial analysis is demonstrating good results. Formulary and shared care development - A web based joint formulary with Bro-Morgannwg Trust and Bridgend LHB is currently under development. It includes a Traffic light system for drugs, highlighting those which should only be prescribed in secondary care (RED), and those which can be prescribed in primary care where there are shared care protocols to support this (AMBER 1 and 2). Methods for effective implementation in primary care are currently being evaluated. Prescribing newsletters and s - Prescribing newsletters highlight local prescribing and medicines management issues and are sent to all GPs and pharmacists and where appropriate, other groups including nursing and secondary care staff. In addition, regular s are sent to the prescribing leads group with important medicines related information. Over the coming years, greater use will be made of electronic presentation and transmission of information, with posting of 1 3

20 documents on LHB intranet website and use of for communications with community pharmacists. Working within practices - Work is undertaken by the LHB medicines management team within targeted practices to support change. The Audit Commission Report Primary Care Prescribing- A bulletin for Primary Care Trusts states: Experience has shown that face to face contact with GPs (and other prescribers) for example through practice visits and working directly with practices to improve prescribing are the most effective methods of delivering change. Prescribing Advisers need to organise their work in a way that maximises the amount of time they can spend doing these things. (NB: Some practices currently choose to employ pharmacists on a sessional basis through prescribing savings) The report also highlights the importance of skill mix within the LHB medicines management team so that clinical skills are used most effectively. The efforts of the entire team need to be directed towards those actions that will demonstrably lead to change. There will be an ongoing review to ensure that the Medicines Management Team is using its resources and skills efficiently. Medicines Management Collaborative (MMC) - The Medicines Management Collaborative Wales was a 20 month initiative which began in July 2004 and was directed and facilitated by the National Leadership and Innovation Agency for Healthcare. The overall goal of the programme was to help optimise prescribing whilst improving the experiences and outcomes for patients, wherever medicines are involved. The MMC provided a useful focus to develop local medicines management work with some key successes. For example, the development and implementation of repeat prescribing training packs for prescription clerks in practices; a demonstrated decrease in sleeping tablets prescribing along with the development of an associated patient leaflet; and a demonstrated reduction in proportion of prescriptions without clear instructions. The collaborative framework has been used to develop service improvement programmes throughout the UK via the NHS Modernisation Agency, National Primary Care Development Team and National Prescribing Centre in England and the National Leadership and Innovations Agency for Healthcare (formerly Innovations in Care) in Wales. Training on collaborative methodology has been useful to identify further areas of work and will be used in the future to continue improving medicines management. 1 4

21 ENGAGING AND INFLUENCING GP PRESCRIBERS ACTIONS AND TARGETS : Overall objective: To ensure prescribers have appropriate information and feedback regarding prescribing and medicines management and that action is taken to change practice where necessary. Continuation of annual prescribing visits linked with GMS contract. Continue development and feedback of prescribing indicators within a culture of openness and sharing Review and continue appropriate prescribing incentives Review and continue the Prescribing Leads initiative, including the quarterly meetings Continue and develop prescribing newsletters and timely relevant s Focus and prioritise sessional work within practices Update and review use of Scriptswitch software to optimise effect on prescribing Develop and implement the joint formulary to optimise effect on prescribing Use the collaborative methodology to share best practice and improve medicines management Develop LHB website to include more information for prescribers & other health professionals Supplementary and independent prescribers In 2000 nurse prescribing was introduced in Wales, initially for district nurses and health visitors who can prescribe from a limited list. Since that time, this list has been extended and nurses and pharmacists have been trained as supplementary prescribers, with training recently initiated for independent prescribers. While the overall impact of these groups on prescribing is still relatively small, growth is anticipated and appropriate monitoring and support for these prescribers will be increasingly important. 1 5

22 ENGAGING AND INFLUENCING NON GP PRESCRIBERS ACTIONS AND TARGETS Overall objectives: To ensure implementation and integration of non GP prescribers and provide appropriate monitoring and feedback Implementation of independent prescribing in collaboration with the Welsh Assembly Government and local universities Continue to provide education, support and feedback to the nurse prescribers group and the undergraduate university course Closely monitor available prescribing trends, providing feedback to individuals once this level of data becomes available Encourage practices to engage with their nurse prescribers, including them in practice meetings, formulary choices, repeat prescribing policies and joint monitoring of their prescribing 3.2 Education and training of practice staff Practice staff, including non-prescribing nurses, practice managers and practice repeat prescribing clerks, are closely involved in prescribing and medicines management in various ways. Practice nurses Medicines management role: Having key roles in disease management and other clinics, practice nurses often recommend initiation or changes of prescription to prescribers and provide information to patients on their medicines and other health issues as well as identifying and flagging medicines related problems. Furthermore, an increasing role in medication review is highlighted for practice nurses in the GP contract. Progress to date: Support and education from the LHB has included sessions on medicines management and adverse drug reaction reporting via the yellow card scheme, patient group directions, critical appraisal and also specific clinical areas such as asthma devices and cardiac drugs. Practice managers Medicines management role: Practice managers have an increasing role in the development of practice policies, including repeat prescribing polices, overseeing and auditing their implementation and training staff to undertake repeat prescribing duties. Progress to date: Support and education from the LHB has included educational sessions on medicines management and development of repeat prescribing policies Repeat prescribing clerks Medicines management role: Production and monitoring of repeat prescriptions and the provision of information to patients regarding the repeat prescribing process, ideally positions the clerks to aid in, highlighting errors, ensuring medication review and reducing wastage through discouraging over ordering. Progress to date: As part of the Medicines Management Collaborative work, repeat prescribing training packs have been developed for practice staff and have since been used in other LHBs. The packs are designed in workbook style and include, 1 6

23 basic, standard and advanced levels to be undertaken in house with the aid of a designated mentor. Following the successful pilot and feedback, the packs were rolled out across all Practices in 2005/6 and linked to the local prescribing indicators and incentive scheme. 87% of practices used the training packs with positive feedback in this first year. The packs were updated in October 2006 and ongoing reviews of content and usage will be made. EDUCATION AND TRAINING OF PRACTICE STAFF ACTIONS AND TARGETS Overall objective To train all members of the practice team regarding their role in medicines management Nurses: Ongoing general training on prescribing and medicines management issues are required. 2007/8 Explore the feasibility of developing medication review training for practice nurses. Practice managers: Ongoing training on general issues including repeat prescribing policies, use of training packs for practice staff, pharmaceutical issues relating to implementation of the new GP contract. Practice staff: Use of training packs included in prescribing indicators linked to incentive schemes Review and updates to repeat prescribing training packs 3.3 Working with secondary care Secondary care has a significant impact on the prescribing in primary care. The Spoonful of sugar document from the Audit Commission recently reported 18% of prescribing is hospital initiated and 40% is strongly influenced by hospitals and Three out of four GPs surveyed said that their local hospital did not take account of the impact on primary care when new medicines were introduced. It is therefore essential to work closely with secondary care to ensure a consistent approach to achieving the best from medicines across the whole health economy. This requires commitment from the most senior management and clinical directors of the Trust to work closely with the LHB to introduce and monitor effective joint policies and systems for prescribing in both sectors and across the interface. Neath Port Talbot LHB interfaces mainly with Bro-Morgannwg and Swansea Trusts. Prescribing work with Swansea Trust is facilitated through close links with the Swansea LHB prescribing team and interface pharmacist. Mechanisms for working with Bro-Morgannwg Trust include: 1 7

24 Interface Prescribing Strategy Group This group was established in 2003 with membership from Bro Morgannwg NHS Trust, Neath Port Talbot, Vale and Bridgend LHBs and includes, pharmacist, doctor and finance representatives. Examples of key areas of work include: Formulary development Development of care pathways including shared care Development of clinical guidelines with a focus on medicines Identification and implementation of measures to improve cost effectiveness of prescribing across the health economy Identification and implementation of measures to improve communication across the interface Monitoring and audit of prescribing initiatives, formulary and guideline implementation Interface Pharmacist Post This post is a joint appointment working across Bro Morgannwg Trust, Bridgend and Neath Port Talbot LHBs and supports the work of the Interface Prescribing Strategy Group with particular emphasis on: Horizon scanning for the NICE forward program, and other high cost new drugs to determine the likely financial impact Interface Formulary development and management Decision making support to the Interface Prescribing Strategy Group to facilitate managed entry of new drugs. Joint Interface Formulary The joint interface formulary is under development and its introduction, which includes a traffic light and managed entry system, has the potential to benefit all partners, with the promotion of evidence based cost effective first line choices. Prescribing Messages to secondary care prescribers Wherever possible the prescribing messages, indicators and newsletters will be shared with groups such as the Vocational Training Scheme Registrars, Non- Principals Group, Hospital Doctors, supplementary and independent Prescribers etc. Areas for joint working Following the NLIAH Modernisation assessment in spring 2006, a joint Designed for Improvement workplan has been produced, to identify priority prescribing areas for the Bro Morgannwg Trust, Neath Port Talbot and Bridgend LHBs. Areas identified for joint working include: Statin drug switches Cost effective ACE inhibitor choices Drug choices & clinical pharmacy input to Mental health Electronic Discharge Communication which Informing Healthcare is taking forward nationally in addition to local solutions being sought, building on the work carried out under the Electronic Discharge Project. Shared Care Several shared care protocols have been developed over recent years, some of which have been linked to enhanced services and payments under the GMS contract. Shared care drugs will be colour coded in the developing formulary as 1 8