Commissioning of products: medical ethics Yvette Perston Colorectal CNS QEHB
Scottish Government NHS UK structure Pop 5.3M 13B 14 local NHS Boards Plan commission & deliver services Welsh Assembly Pop 3.2M 6.5B 7 Local Health Boards Responsible for all health services in area Northern Ireland Pop 1.8M 4.3B 5 local commissioning groups Fully integrated Health & Social Care Service
Pop 50M 100B NHS England Health & Social Care Act (2012) Clinically led commissioning 211 CCGs 65M Average pop 250,000 Healthcare market competition Increase pt choice Services from many providers Includes voluntary & private sector
Right to treatment? Human Rights Act (1998) Right to life (Article 2) State must act reasonably in allocating resources Right to respect for private life (Article 8) Breaches Balance must be between interests of community & individual Discrimination due to age (Article 2) Discrimination due to gender (Article 14)
Patient Choice (Choice Framework, 2014) Legal rights GP Acute care consultant led team Changing hospitals Who carries out specialist tests Treatment in another European countrysw
Other Choices not legal right Services provided in community Depends on CCG decisions Choosing to have a personal health budget Legal right to ask Take part in health research
When not offered choice Complain to GP Complain to CCG Complain to Monitor enquiries@monitor.gov.uk Complain to Parliamentary and Health Service Ombudsman www.ombudsman.org.uk NHS complaints advocacy service www.healthwatch.co.uk
Quality, Innovation, Productivity & Prevention Programme (QIPP)(2013) Efficiency savings of 20bn by 2015 To tackle rising costs Increased elderly Long-term conditions Economic down turn Improving quality Use of new technology New ways of working
QIPP Aims Productivity reduce variation in spend, all in line with most efficient Quality improve outcomes, reduce variation in outcomes Innovation cost effective techniques, pathways, procedures Prevention self management, health education
Monitor Sector regulator for health services England Issues licenses to NHS-funded providers Responsibility for national pricing & tariff Aids commissioners to ensure services continue Procurement choice & competition operate
Commissioners Role Cheap effective patient pathways Rationalise services Offering care in cheaper location Improving prevention Improving outcomes Efficiency savings Quality gains Resource allocation
Medicines Management Service Provide CCGs with advice Cost effective Improve outcomes Reduce wastage Encourage self management long term conditions
Commissioning Clinicians input Commissioners need to be aware of clinical problem Essential elements required for quality service Cost effective cheaper is not always better! Awareness of local health demographics Require service level agreements from all providers Defined deliverables Standards of care Audit outcomes Quality measures
Cost Why is Commissioning Important? Birmingham 2.25M stoma products (2013) Midlands 62.8M Initiation prescriptions multiple sources GPs unsure of Type Quantities Frequency Retrospective prescriptions Additions following sampling Inappropriate products
Case Study Joan, 72yrs APR & permanent colostomy for Ca 2009 Closed one piece appliance x2 daily Adhesive remover & deodorant Died 2014 relatives returned unused stock 12 boxes (unopened) closed pouches 20 deodorants & 25 adhesive removers Total cost approx. 1265
National Sources of Guidance Patients, Industry & Professionals Forum (PIPS) National group for Stoma & Continence Care Stoma prescribing guidelines Expected usage pouches ASCN Stoma Care Nursing Standards Useful guide for commissioners Same format as NICE Evidence based Audit templates
NHS PrescQIPP NHS programme working with CCGs Prescribing advice Medicines Optimisation Projects to deliver QIPP Stoma & continence tool kit Appliances only 67% total spend Accessories Categorised by usage
Solutions Local formulary Local policy Local guidelines Expected average quantities Responsibilities of all involved Tool kit What accessories are for Expected quantities Most cost effective available Review of ostomate by SCN if outside guidance
Solutions?Annual review by SCN Clinical review when usage outside normal AURs provided by supplier Nurse prescribing by CNS Scotland Rotherham?budget Resources
Stoma Care Scotland (2006 onwards) Abolition of company nurses incl sponsorship Unitary funding regime for all contractors Service standards for all contractors Optional national hospital formulary Other products available pt need Procurement of samples in acute care Specific procedure before adding items to prescription Regular care review by CNS pt choice Aim CNS = prescriber of products
Case Study - John 57 yr old care worker Urge & passive FI Daily accidents (Vaisey 24) Rectal washouts x3 weekly No accidents GP refused permission to prescribe Monthly cost irrigation 100
Case Study - John No longer works Cost to wider society Alternative colostomy Cost of surgery 4000+ Monthly cost approx. 170 Psychological cost Patient choice??
The four principles of biomedical ethics Respect for autonomy Enabling individuals to make informed choices Beneficence Risks vs benefits Non maleficence Avoiding harm Justice fairness
Biomedical Ethics Maximum advantage to maximum no of patients Decisions to fund treatment should be made on Clinical effectiveness Cost effectiveness
Ethical Frameworks the four Quadrant approach (Jonsen et al, 1992) Indications for medical intervention Diagnosis, options for treatment Preferences of patient Quality of life Contextual features Religion, culture, legal factors
NMC Code (2015) Prescribing and Medicines Management Prescribe, dispense & administer within competence Prescribe medicine or treatment with knowledge of pts needs Check treatment is compatible with other care (including over the counter) Comply with appropriate guidance
NMC code 2015 Revalidation against code (Dec 15) Personalised & person-centred care Evidence based care Implement equality Manage resources effectively Act as patient s advocate Ensure patient choice Be impartial
Thank you for listening