Download Medicines Optimisation Strategy 2016-20

Medicines Optimisation
Strategy 2016-20
“Given that medicines remain the most common therapeutic intervention
in healthcare, and colleagues in research and the broad pharmaceutical
industry have worked hard to discover and develop safe and effective
medicines, we must all work even harder together to ensure that
individual patients and society gets as much value out of that effort as
possible, and resources are used wisely and effectively.”
Medicines Optimisation: Helping patients to make the most of medicines
Good practice guidance for healthcare professionals in England
Sir Bruce Keogh National Medical Director NHS England
Jane Cummings Chief Nursing Officer England
Dr Keith Ridge Chief Pharmaceutical Officer
May 2013
Medicines Optimisation Strategy 2016-20
Page 2 of 29
Contents
1
Executive Summary
4
2
Background
2.1 National Drivers
6
7
2.2 Local Drivers
8
2.3 B&NES Medicines Use
11
3
Our Approach to Medicines Optimisation
13
4
Our Priorities
4.1 Operating Plan
15
26
5
Workforce
27
6
Conclusion
28
Appendix 1: Plan on a Page
Medicines Optimisation Strategy 2016 -2020
29
3
1. Executive Summary
Bath and North East Somerset broadly has a healthy population but it does have areas of
deprivation and areas of clinical challenge where the CCG could improve outcomes for its
residents.
There has been a long culture of good medicines management over the years in BaNES.
Current use of medicines benchmarks well. In more recent years our GP practices have
engaged well with a range of activities with embedded practice pharmacists helping to
deliver good medicines optimisation.
The current financial climate is challenging for the NHS with significant pressures on the
health and social care system through a combination of:
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Demographics – increase in over 85s
New technologies and medicines
Diseases of modern lifestyles
Consumer expectations
Optimising medicines use to support a sustainable system and give the best value has
never been more important.
This strategy set out five key approaches to medicine optimisation for BaNES:
1. We will support local decision making to commission safe, effective and evidencebased medicines use within pathways
2. We will promote a safety culture around medicines use including effective use of
national and local reporting systems to report and learn from medication safety
incidents
3. We will maximise care gains across health and social care by innovative
management of medicines at the best obtainable value
4. We will support workforce development activity to create a sustainable healthcare
system with particular emphasis on the pharmacy workforce and medication review
5. We will use clinical audit , education and quality improvement to improve safe
and effective care and reduce variation in health outcomes
Medicines Optimisation Strategy 2016-20
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Through consultation with the CCG Board, our patient public involvement group “Your
Health Your Voice” and with the Medicines Team we have identified ten top priorities
which are aligned to both the CCG and National priorities.
This strategy set out ten key priorities for the next four years.
The priorities are:
1.
Diabetes Care – optimise the medicines we use
2.
Frail Elderly - commission clinical pharmacy medicines reviews for all frail elderly
3.
Antimicrobial Stewardship – lead a collaborative and work programme to support
this national priority
4.
Improving Value from our Medicines - ensuring maximum benefit from investment
through a focus on outcomes
5.
Musculoskeletal - support the review of rheumatology and pain medicines pathways
6.
Workforce development - maximise the use of pharmacy staff in the health
community
7.
Acute Kidney Injury – implement the national programme for primary care Acute
Kidney Injury and optimise management of patients with Chronic Kidney Disease
8.
Stroke Prevention and VTE – optimise the medicines we use
9.
Safer Care Culture – establish a local reporting and learning culture in primary care
including use of the National Reporting and Learning System (NRLS) GP eForm
10. Mental Health – optimise the medicines we use for this vulnerable group
Medicines Optimisation Strategy 2016 -2020
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2. Background
Medicines are the most common intervention and biggest cost after staff in healthcare.
Getting the most from medicines for both patients and the NHS is becoming increasingly
important as more people are taking more medicines. Medicines prevent, treat or manage
many illnesses or conditions.
This section of the report sets out some key national and local policy drivers and data
about BaNES medicines use that provides the context for the CCG’s medicines
optimisation strategy.
There are a number of concerns about England’s use of medicines:

30-50%* of medicines are not taken as intended and patients have insufficient
information to support taking medicines
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5-8%* of hospital admissions are due to preventable adverse reactions to
medicines
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Medication errors have risen as a proportion of all errors reported from 8.19% to
11.02% from 2005 to 2010

Medication wastage in England per year is approximately £300 million of which 50%
is estimated to be preventable
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There is a real threat to healthcare from antibiotic resistance
*Range comes from different studies in the literature
Medicines Optimisation Strategy 2016-20
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2.1 National Policy Drivers
There are many National Policy drivers that should impact on a CCG medicines strategy.
Table 1 highlights some of the key drivers and outline the potential impact for the CCG
Medicines strategy.
Driver
NHS
Five
Forward View
Impact for medicines strategy
prevention of disease and public health
optimisation of medicines use to improved efficiency,
reduced demand and reduced demand
Year


2016/17
NHS
Planning Guidance

help deliver the must dos: financial balance, sustainable
quality general practice, improved access to A&E
NHS
Outcomes
Framework
(Domains)
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safe use of medicines (4 and 5)
evidence based use of medicines (1, 2 and 3)
equality and access to medicines (1, 2, 3 and 4)
patients experience with their medicines ( 1, 2, 3, 4 and 5)
NHS Constitution
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the right to receive treatment that is appropriate
the right to drugs that have been recommended by NICE
the right to expect local decisions on funding of drugs
the right to an explanation when NHS decides not to fund
Royal
Pharmaceutical
Society:
Medicines
Optimisation
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aim to understand the patient experience
evidence based choice of medicines
ensure medicines use is as safe as possible
make medicines optimisation routine part of practice
NICE
GuidelineMedicines
Optimisation
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systems for identifying, reporting and learning from
medicines incidents
communication when in settings of care
medicines Reconciliation
medicines Review
self-management plans
patient decision aids
clinical decision support
cross organisation working
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Lord Carter’s interim In 2012/13, expenditure on hospital medicines was over £6.5
report on productivity billion, accounting for 36.5% of total NHS medicines expenditure, a
in the NHS
rise of 11% over the previous year. Two of the key obstacles
identified: lack of quality data & absence of metrics to measure
relative performance
Medicines Optimisation Strategy 2016 -2020
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Clinical pharmacists
pilot & the workforce
10 point plan

£31m pilot will test out this new patient-facing role in which
clinical pharmacists have extended responsibility in General
practice
Antimicrobial
Resistance
(AMR)
Strategy 2013/18 and
annual
progress
report
and
implementation plan

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AMR is a serious global public health concern
without effective antibiotics; minor surgery and routine
operations become high risk procedures
25,000 people die each year in Europe as a result of
infections caused by resistant bacteria
without effective antimicrobials, the rate of post-operative
infection will be greater


Table 1: National Policy Drivers impact on Medicines Strategy
2.2 Local Policy Drivers
Seizing Opportunities - A Five Year Strategy for Bath and North East Somerset
2014/15 to 2018/19
This document sets out the Five Year CCG’s vision of ‘Healthier, Stronger, Together’.
The CCG have prioritised six key transformational projects which are summarised in table
2 with the identified medicines focus for each project.
In addition to these six transformational priorities Seizing Opportunities anticipates that the
financial challenge faced by the whole BaNES health economy over the five years will be
in the region of £50m. Reviewing medicines use from a cost effectiveness perspective is a
key area to support meeting the financial challenge. BaNES however already benchmarks
very well on its cost effective use of medicines compared to other CCGs. (see section 2.3)
Other key local policy drivers are summarised in table 3 with an indication of how they
impact on the Medicines Strategy.
Medicines Optimisation Strategy 2016-20
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Transformational Project
Prevention/ self-care
Increase the focus on prevention, selfcare and personal responsibility
-
-
Medicines Focus
reviewing the treatments for minor ailments
and encourage transitioning to self-care
linkage to diabetes self-management and
appropriate use of medication and disease
monitoring
encouraging development of Healthy Living
Pharmacies
Long Term Conditions
(Initially Diabetes)
Improve the coordination of holistic,
multidisciplinary long term condition
management
-
optimisation of diabetes type 2 medicines
improve use of blood glucose testing
support new models of delivery
maximise benefits of the community
pharmacy contract to support people with
long term medication
Stable and responsive urgent care
system
Create a stable, sustainable system
-
reduce demand for medicines in the urgent
care system through commissioning services
in community pharmacy
support the urgent care providers to be able
to sign post medicines requests to the
community pharmacy network
-
Frail older people pathways
Commission integrated, safe and
compassionate pathways
-
commission medicine review in care home
patients
commission medicines review for patients at
risk of emergency admission
maximise benefits of the community
pharmacy contract to support medicines use
Musculoskeletal Pathways
Redesign pathways to achieve clinically
effective services
-
support redesign of analgesic pathway
support redesign of rheumatology pathway
Interoperability of IT systems
Achieve interoperability across the
health and social care system
-
support IT clinical decision systems for
prescribing
support good transfer of information and
visibility of information on medicines across
the system
encourage
utilisation
of
electronic
prescribing and ordering systems
support integration of new technologies
-
-
Table 2: BaNES CCG Transformation projects and their Medicines Focus
Medicines Optimisation Strategy 2016 -2020
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Local Policy Driver
Joint Health and Wellbeing
Strategy
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Emerging
Strategy
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Primary
Care
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B&NES Community Service
Review: your care your way
Outline Business Case
Pharmaceutical
Assessment (PNA)
Needs

Impact for medicines strategy
contains key demographic data
describes BaNES as a generally healthy and
relatively wealthy population that has some of
the happiest people in the country, but with
pockets of deprivation
vision: delivery at scale
enablers: sustainable model of primary care,
enhanced services delivered 7 days a week
approach: cluster working / MDT model, Out of
hospital care
the proposed model is innovative and bold and
potentially an expanded range of medicines
optimisation services could be provided through
the community services model that emerges
The PNA identified some key findings which include:

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current provision appears to be sufficient for the
Bath and Norton Radstock GP clusters
there is a gap in the provision for the
Chew/Keynsham GP cluster in the evenings
after 18:30 and on Sundays
current provision will cope with the demand
from new populations for the coming few years
Table 3: Local Policy Drivers impact on Medicines Strategy
Medicines Optimisation Strategy 2016-20
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2.3 Bath and North East Somerset Medicine Use
When the CCG’s prescribing costs are compared with the other CCGs (Graph 1) adjusted
for population factors using cost per weighted prescribing units it can be seen that BaNES
is in the lowest 10% of costs across England with the 8th lowest costs in the South of
England and the lowest costs in the South West (Graph 2).
Graph 1: NHS Information Portal Financial Comparisons (June- August 2015) all CCGs
Graph 2: NHS Information Portal Financial Comparisons (June- August 2015) CCGs South of England
Medicines Optimisation Strategy 2016 -2020
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There are a number of comparator graphs from the NHS Information Portal produced by
the NHS Business Services Authority which can be used to compare prescribing against a
therapeutic range of comparators against other CCGs in England. Indicators that relate to
some of the themes mentioned above have been summarised in Table 4.
Comparator
Comments on indicator
3 day antibiotics
BaNES Performance
in England
in top performing 15%
Volume of antibiotics
in top performing 13%
conserving our antibiotic usage to protect
against antibiotic resistance
Choice of antibiotics
in the worse
performing 5%
reducing the risk of CDiff Infections -there
have been significant improvements on this
Choice of Insulin’s
in top performing 25%
using the most cost effective insulins
appropriate lengths of treatment for urinary
tract infections
Choice of Type 2 oral in top performing 15%
antidiabetic agents
using the most cost effective diabetes
agents for Type 2
Volume of NSAIDS
(analgesic)
in top performing 45%
appropriate use of NSAIDs the assumption
is that lower usage is more appropriate
Choice of NSAIDs
(analgesic)
in top performing 45%
using the medicines in the class of drugs
with the better safety profile
Table 4: commentary on performance on various prescribing indicators from NHS Information Portal
June –August 2015
NHS England launched the Medicines Optimisation Dashboard a dashboard in June 2014
which has been revised to help CCGs to understand how well their local populations are
being supported, to optimise medicines use and inform local planning. The dashboard was
updated in 2015 and contains over 40 indicators. An analysis of BaNES CCG shows:
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good uptake of electronic prescribing
poor uptake of Medicines Use Reviews (MURs) by community pharmacy
average uptake of New Medicines Service (NMS) by community pharmacy
average performance for optimisation of medicines for Atrial Fibrillation
poor optimisation of medicines for heart failure
good optimisation of medicines for diabetes, asthma and osteoarthritis
 variable performance on optimising medicines for chronic obstructive pulmonary
disease (COPD)
Medicines Optimisation Strategy 2016-20
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3. Our approach to Medicines Optimisation in BaNES
The themes and information in the previous sections of the strategy were presented to our
CCG Board, our patient public involvement group “Your Health, Your Voice” and the CCG
Medicines Team. These consultation sessions led to reflections on the approach and
priorities for the CCG Medicines Strategy.
CCG Board

The session was supportive of the approach and priorities.

The Board recognised the need to support clinical pharmacists within primary care
to create a more sustainable model for the future

The Board recognised the importance of engagement with prescribers and
recognised the need to build on the current structure of practice pharmacists
Your Health, Your Voice

There was a broad range of participants at the session

There was a real interest in how GPs work and strong support of the themes
identified

The group were interested in supporting more feedback on patient experience
CCG Medicines Team

Several sessions with the team developed the priorities in more detail

There was a recognition of the limited national work and tools on understanding and
measuring patient experience of medicines usage

There was a real passion in the team to engage with the many potential agendas
and a recognition that there is a limited capacity to deliver an ambitious programme

The team were keen to have a worked up operational plan to support the strategy at
the earliest opportunity
Medicines Optimisation Strategy 2016 -2020
13
The five key elements to BaNES approach to Medicines Optimisation for the next four
years are:
We will support local decision making to commission safe, effective and evidence
based medicines use within pathways
We will promote a safety culture around medicines use: including effective use of
national and local reporting systems to report, and learn from medication safety
incidents
We will maximise care gains across health and social care by innovative
management of medicines at the best obtainable value
We will support workforce development activity to create a sustainable healthcare
system, with particular emphasis on the pharmacy workforce within GP practices and
medication review
We will use clinical audit , education and quality improvement to improve safe and
effective care and reduce variation in health outcomes
Medicines Optimisation Strategy 2016-20
Page 14 of 29
4. Our Priorities
Through consultation with the CCG Board, our patient public involvement group “Your
Health Your Voice” and with the Medicines Team we have identified ten top priorities:
1.
Diabetes Care
Optimise the medicines we use
2.
3.
Frail elderly
Commission clinical pharmacy medicine reviews for all
frail elderly
4.
Improving Value from Medicines
Ensure maximum benefit from the investment with a
focus on Primary Care and High Cost Secondary Care
5.
Antimicrobial Stewardship
Establish a BaNES Antimicrobial Resistance Strategic
Collaborative to implement the UK AMR Strategy
Musculoskeletal
Support the review of rheumatology and pain medicines
6.
Workforce development
Maximise the use of clinical, community and other
pharmacists to support a sustainable future model
7.
Acute Kidney Injury (AKI)
Implement programme for primary care AKI and optimise
management of patients with Chronic Kidney Disease
8.
Stroke prevention & venous thromboembolism
Continue to support optimising medicines in therapeutics
9.
Support the development of a safer care culture
Establish a local reporting and learning culture in primary
care including use of the NRLS GP eForm.
10.
Mental Health
Support the optimisation of medicines in this vulnerable
group
Medicines Optimisation Strategy 2016 -2020
15
Priority 1: Diabetes Care
WHY?
National
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Local
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Medicine Issues
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WHAT?
Key focus for next four
years
Diabetes is the long term condition with the fastest growing
prevalence
UK prevalence of 6.2% of adults
1 in 20 people in the UK have diabetes
3.9 million living with diabetes in the UK
Estimated to be 5 million by 2025
90% of these cases are Type 2 diabetes
£10 billion a year spent by NHS on diabetes which is 10% of
the NHS budget
Diabetes is CCG priority area
BaNES prevalence 6.5% of adults - rising to 7.1% by 2025
Total prescribing costs for medicines and devices associated
with blood glucose lowering and monitoring 6 months April –
September 2015/2016 was £1.2 million an increase of 7.9%
(£88,440) versus the same period 2014/15
Cost of consumables (test strips, lancets, needles) equates
to £550k 26% of diabetes medicine spend
Newly published NICE NG28
10% of NHS prescribing costs, £800 million per year on
medicines and devices associated with blood glucose
lowering and monitoring
Escalating prescribing costs, 8.2% increase from 2013/14 to
2014/15, 69% from 2005/2006 to 2014/15
There is additional unqualified spend on medicines and
treatments associated with preventing and treating the
complications of diabetes
Wide variance in prescribing practice and cost between
areas
Multiple NICE Guidance relevant to Diabetes
http://pathways.nice.org.uk/pathways/diabetes
Optimisation of the medicines we use. Aim is excellent outcomes
and safe use of our medicines.


Medicines Optimisation Strategy 2016-20
Work with service redesign programme to have a welldefined medicines pathway through audit and review
Optimise:
- New oral agents
- Insulin
- Cardiovascular medications for Diabetics
- Test strips and other consumables
Page 16 of 29
Priority 2: Frail elderly
WHY?
National
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Local
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Medicine Issues
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WHAT?
Key focus for next four
years
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In 2014, 17.6% of the population were 65 or older. By 2035
this is estimated to rise to 23%. Older people are at higher
risk of developing chronic health conditions; depression
affects 1 in 5 adults > 65y living in the community
Older people: independence & well being NICE NG32
Care homes – NICE SC1 managing medicines in care
homes
Pharmacy & care homes GPhC report Dec 15
From reports and a range of studies over the past 6 years,
there are clear concerns about current practice of medicines
use in care home environments
Dementia affects 1.3% of the entire UK population, and 7.1%
of the population aged 65 or older. The number of people
with dementia in the UK is forecast to increase to over 1
million by 2025 and over 2 million by 2051
National Dementia Strategy,
NICE dementia guideline QS30
Falls prevention - NICE CG161. Falls and fractures in people
aged 65 and over account for over 4 million hospital bed
days each year in England. The healthcare cost associated
with fragility fractures is estimated at £2 billion a year.
Malnutrition - NICE CG32: 5% of the elderly are underweight
(BMI <20kg/m2) rising to 9% for those with chronic diseases.
30% of admissions to acute hospitals and care homes are at
risk on the Malnutrition Universal Screening Tool
Care of dying NICE NG31
Population growth: expected changes across the BaNES
CCG age profile by 2021 with a 30% increase in the
population over 70
Care home LES currently in place – pharmacist involvement
in medication reviews
Reducing antipsychotics in dementia – audited 2012
Focus on admission avoidance, care for frail elderly at home
Polypharmacy / deprescribing guidance e.g. STOPP START
criteria, AWMSG
CHUMS Care homes’ use of medicines study
Medication review and falls risk
Appropriate use and education of care staff on sip feeds
Develop models of delivering care to their patient group
e.g. integrated clinical pharmacists
Medicines management shared learning
NICE managing medicines for people receiving social care
due Mar 2017 implications for services
Improving patient involvement in decisions
Improve support to help people improve adherence
Medicines Optimisation Strategy 2016 -2020
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Priority 3: Antimicrobial Stewardship
WHY?
National
“If we fail to act, we are
looking at an almost
unthinkable scenario where
antibiotics no longer work
and we are cast back into
the dark ages of medicine"
David Cameron,
UK Prime Minister
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Local
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Medicine Issues
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WHAT?
Key focus for next four
years

Medicines Optimisation Strategy 2016-20
Antimicrobial resistance (AMR) is an increasing global and
national problem, predicted 10 million extra global deaths a
year by 2050. Very few new antibiotics have been developed
in the past 30 years and very few are in development.
Stewardship of existing antibiotics is essential to allow us to
continue to successfully treat infections. 25,000 deaths pa
occur in Europe due to resistant infections.
UK 5 Year Antimicrobial Resistance Strategy 2013 to 2018
Progress report on the UK 5 year AMR strategy: 2014
Antimicrobial stewardship: systems and processes for
effective antimicrobial medicine use NG15 August 2015
AMR is a high priority in delivering the Forward View: NHS
Planning guidance 2016/17 – 2020/21
BaNES CCG has worked over the past 18 months to improve
the use of antibiotics. A whole economy wide collaborative
approach is required to implement the key objectives within
the UK 5 Year AMR Strategy: to improve the prevention of
infection, increase peoples understanding of the risks that
resistant infections bring, and encourage behaviour change
to reduce the inappropriate use of antibiotics.
80% of antibiotic use is in primary care and the community,
and half of this is for respiratory infections, many of which are
self-limiting and can be managed with supported self-care.
Maps onto health economy approach to infection including
Vaccination, Sepsis, AKI, Continence, Self-care, Nursing
Home Care, Diabetic care, Healthcare Acquired Infections
The 2015-16 BaNES Quality Premium dashboard shows
reducing antibacterial prescribing in primary care, but
prescribing of broad spectrum antibiotics remains
inappropriately high at both a CCG and GP practice level
The national Sepsis CQUIN is driving increased use of
antimicrobials in acute providers
New health economy wide Infection Management pathway
guidance is a priority
The establishment of a BaNES Antimicrobial Resistance
Strategic Collaborative, chaired by the CCG Clinical Chair,
reporting to the Health and Wellbeing Board. Membership
would include wide representation from NHS and private
health care providers, public health, PHE, academic and
clinical networks, patient and public representation, and local
healthcare professional representation. The purpose of the
Collaborative is local implementation of the UK 5 Year AMR
Strategy key objectives:
- Improving infection prevention and control practices
- Optimising prescribing practice
- Professional education, training and public engagement
- Developing new drugs, treatments and diagnostics
- Better access to and use of surveillance data
Page 18 of 29
Priority 4: Improving Best Value from Medicines
WHY?
National
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Local
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WHAT?
Key focus for next four
years
£15.5 billion total estimated NHS expenditure on medicines
for 2014-15
£6.7 billion overall hospital expenditure on medicines which
was 42.9 % of the total
7.8% overall increase for 2014-15 over the previous year
15.4% rise in cost of hospital medicines from 2013-14 to
2014-15
3.2% rise in cost of in Primary Care from 2013-14 to 2014-15
£29.65 million medicines spend for BaNES CCG
(13% of total CCG spend)
£24.75 million primary care prescribing
£4.9 million on secondary care prescribing
6.2% Primary care growth (14/15 to 15/16)
17.5% Secondary Care growth (14/15 to 15/16)
Ensure maximum benefit from investment in medicines focussing on
outcomes and projects in:
a. Primary Care
i. Focus on 2 or 3 therapeutic areas driving growth each year
: e.g. Diabetes, NOACs and Pregabalin
ii. Focus on practices with above CCG average growth:
practice visits and support
iii. Grow capacity to deliver clinical medicine reviews in our
vulnerable elderly
iv. Continue to engage with local prescribing incentive
schemes, national rebate schemes which meet CCG
criteria and Improving Value schemes e.g. Dressings and
Stoma
v. Work with Community Pharmacy to improve uptake in
Medicine Use Reviews and New Medicine Service
b. Secondary Care High Cost Drugs
i. Improve the horizon scan process, data quality coming
through providers & data challenge
ii. Focus on 2/3 therapeutic areas driving growth each year :
e.g. Gastro and Rheumatology
iii. Maximise uptake of bio-similars and other procurement
opportunities
iv. Be assured that home care medicines provision is being
utilised to best affect
v. Improve the quality of assurance of utilisation of High Cost
Drugs e.g. Introduction of BluTech
c. Specialist Commissioning High Cost Drugs
i. Anticipate some repatriation to CCG commissioning and
need to ensure appropriate assurance processes are in
place
Medicines Optimisation Strategy 2016 -2020
19
Priority 5: Musculoskeletal
WHY?
National
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Local
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Medicine Issues
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WHAT?
Key focus for next four
years
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Each year over 5 million people in the UK develop chronic pain
but only two thirds will recover. Patients with chronic pain are
more likely to utilise NHS resources 5 times more frequently than
individuals without chronic pain.
Medicines for non-cancer pain relief (including opioids, nonsteroidal anti-inflammatories (NSAIDS) & medicines to treat
neuropathic pain) have the potential for abuse, addiction and
carry significant safety concerns due to side effects (especially in
the frail elderly population).
NSAIDs use contributes to increasing risk of GI & Cardiovascular
side effects and Acute Kidney Injury
NHS BaNES benchmarks high for elective and non-elective MSK
& Trauma (falls & fractures)
Pain Management & MSK service redesign offers scope for
improving quality & reducing spend. It is a priority for the CCG
LTC survey: 47% of respondents not very or not at all confident
about managing their condition.
With ageing population, demand for MSK related services is set
to increase significantly
Cost and Safety: NHS BaNES CCG benchmarks very high for
the use of buprenorphine (£140kpa) v opioids when compared to
other CCGs locally and nationally (spend and quantity).
Cost and Safety: The use of drugs for the treatment of
neuropathic pain (nortriptyline £80kpa, pregabalin £260kpa)
High Cost Rheumatology Drugs (biologics £1.5 million) account
for 36% of the BaNES spend on High Cost Drugs
All redesigned pain management & MSK pathways/services
include medicines used appropriately within the wider scope of
integrated model of care (including self-care).
Develop plans for a community pain management model
including a specialist pain pharmacist as part of a MDT approach
to optimising medicines.
Ensure best value for money from the biologic drugs used in the
NICE pathways for rheumatology indications by using biosimilars
Education of prescribers & patients around analgesics (including
used of patient decision aids and self-care)
Medicines Optimisation Strategy 2016-20
Page 20 of 29
Priority 6: Workforce development
WHY?
National
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
Local







Medicine Issues






WHAT?
Key focus for next four
years






NHS England 10 point plan a commitment to new ways of
working including clinical pharmacists in general practice
In 2015 NHS England announced a £31m to pilot the role of
clinical pharmacists working in general practice
Open letter from DH Dec 15 stated “We need a clinically
focussed community pharmacy service that is better
integrated with primary care.”
New technologies are going to being developed at a fast
pace including Genomic medicines and digital technologies
On-going shift to federated GP practice model
Big community service review
3 groups of practices have secured 12 months funding for a
clinical pharmacist working within General Practice for 16/17
CCG commissions sessional pharmacists and care home
pharmacists to work across all practices
Currently the CCG has one pharmacy technician in the team
Currently no healthy living pharmacies in BaNES
Poor uptake of Medicines Use Reviews (MURs) and average
uptake of New Medicines Service (NMS) by pharmacists
Very limited cross health community posts or training
30-50% of medicines are not taken as intended
Patients have insufficient information to support taking
medicines (ten days after starting a new medicine 30% of
patients are already non-adherent)
5-8% of hospital admissions are due to preventable adverse
reactions to medicines
Medication wastage in England per year is approximately
£300million of which 50% is estimated to be preventable
Non-medical prescribing needs to be developed further
Maximise the use of clinical pharmacists in General Practice,
Community Pharmacists and others in workforce to support
the delivery of a sustainable healthcare
Focus with community pharmacy to support self-care work
programme & develop a programme of medicines
optimisation with medicines use in people with: type 2
diabetes, asthma and MSK pain and antibiotics in line with
other work streams through a Pharmacy Forum
Support Public Health to commissioning Healthy Living
Pharmacy services in BaNES
Support other providers to develop pathway models of
working e.g. outreach services to support development of the
pharmacy workforce
Through CPD prepare the work force for the new
technologies e.g. genomic medicines and digital technologies
Develop
innovative
cross
organisational
training
opportunities and new roles for pharmacists, pre-regs and
technicians within our local health community
Medicines Optimisation Strategy 2016 -2020
21
Priority 7: Acute Kidney Injury (AKI)
WHY?
National
Local
Medicine Issues
In the UK up to 100,000 deaths each year in hospital are
associated with acute kidney injury.
Up to 30% could be prevented with the right care and
treatment NCEPOD. Adding insult to injury, 2009
It is estimated that one in five people admitted to hospital
each year as an emergency has acute kidney injury: Wang,
et al. 2012
About 65% of acute kidney injury starts in the community:
Selby, et al. 2012
AKI is a national patient safety work programme delivered by
Think Kidneys and acute providers are delivering an AKI
CQUIN in 2016-17
The Primary Care AKI work programme commences in 201617
Prevention of AKI will reduce avoidable admissions, deaths,
and Chronic Kidney disease
NICE CG169: Acute kidney injury: prevention, detection and
management
NHS England: Commissioning excellent nutrition and
hydration
Think Kidneys
Reducing avoidable death is a high priority in delivering the
Forward View: NHS Planning guidance 2016/17 – 2020/21


The RUH are currently working to the 2015-16 AKI CQUIN
No activity has commenced to support the AKI work
programme in Primary Care this will be a priority

Maps onto Urgent care, Diabetes, Infection Management,
Sepsis, Care Homes, Hydration and Self-care, workforce
development

The 2015-16 AKI CQUIN contains an element of medication
review in all care organisations
Optimise medication to prevent AKI and manage CKD in at
risk people, including medication review and Advice on Sick
day Guidance
Links to Antimicrobial Stewardship as 50% of primary care
AKI is related to UTIs


WHAT?
Key focus for next four
years


Medicines Optimisation Strategy 2016-20
Establish an implementation programme for primary care AKI
working with all sectors, and linking to Sepsis and
Antimicrobial Stewardship programmes
Optimise management of patients with CKD, including
diabetics, to prevent AKI
Page 22 of 29
Priority 8: Stroke Prevention and Venous thromboembolism
WHY?
National








Local






Medicine Issues



WHAT?
Key focus for next four
years





Atrial fibrillation (AF) is a major risk factor for stroke; it affects
about 1.6% of the population
NICE estimates less than half of those with AF who need
anticoagulation therapy are currently receiving it
NICE CG180- AF – anti-platelets no longer an option,
anticoagulants recommended to reduce stroke risk
NICE QS 93: AF
DH Cardiovascular outcomes strategy (2013)
The incidence of Venous Thromboembolism (VTE) is 1-2 per
1,000 of the population and the risk increases with age.
One in 20 people will have a VTE at some time in their life.
Approximately half of patients presenting with VTE have
been hospitalised in the previous eight weeks.
NICE CG 144 (updated 2015) & NICE QS 29 VTE diagnosis
& management
NHSE VTE prevention programme
Sentinel Stroke National Audit Programme (SSNAP) –
BaNES CCG score “D” – the second lowest on quality
Use of GRASP AF tool by all practices 2014-15 - to identify
AF patient, those inadequately treated and reduce variation
between practices
Review of anticoagulant prescribing undertaken 2014-15;
links with BaNES CCG priorities in enhancing quality of life
for people with long-term conditions and improving quality
and patient safety.
Current warfarin monitoring LES needs to include evidence
of safe and effective anticoagulation
Self-monitoring for warfarin patients – no current CCG policy,
NICE DG 14 recommends as an option
High risk & complex prescribing (weight / age / renal status)
Shared decision making should be a key element of regular
review of care
Increase in prescribing growth due to NOACs – cost increase
of over £400,000 in 12 months to October 2015 contributing
to approx. 30% of overall CCG prescribing cost growth.
Whilst the cost is increasing for oral anticoagulants, it could
lead to longer term savings from a reduction in stroke events
and resulting complications
Better identification of AF patients
Greater uptake of drug therapy leading to fewer strokes
Ensuring safe prescribing– process for initiation & regular
review including shared decision making
Look to adopt innovation in anticoagulation
Develop proposal to pilot new models of a community
coagulation service
Medicines Optimisation Strategy 2016 -2020
23
Priority 9: Safer Care Culture
WHY?
National
It is anticipated that there are 1.8 million serious prescribing errors in
primary care each year - evidence predicts 5% of general practice
prescriptions are erroneous, of which 0.18% are serious
Developing an open, learning and safer culture locally is a high
priority in delivering the Forward View: NHS Planning guidance
2016/17 – 2020/21
NHS England published a Patient Safety Alert: Improving medication
error incident reporting and learning in 2014 directing small
healthcare providers including general practices, dental practices,
community pharmacies and those in the independent sector to
report medication error incidents to the National Reporting and
Learning System (NRLS) using the e-form on the NRLS website, or
other methods and take action to improve reporting and medication
safety locally, supported by medication safety champions in local
professional committees, networks, multi-professional groups and
commissioners.
Medication errors are the most commonly reported safety incidence
from GP practices, which have a very low reporting rate. The NRLS
GP eform has been designed to simplify GP reporting. Currently
anticoagulants and aspirin are the medicines most frequently
reported.
Local
In 2014-15 BaNES GPs prescribed 3,800,000 prescriptions, and
190,000 are anticipated to be erroneous with 340 causing serious
harm. Currently reporting to support local learning is not well
established, and development of a local reporting and learning
culture is required.
Medicine Issues
Medicines are the most frequently identified safety incidents in
primary care, with anticoagulants reported most frequently.
WHAT?
Key focus for next four
years


Establish a local reporting and learning culture in primary care
organisations to enable the health economy to improve patient
care.
Support implementation and national reporting using the NRLS
GP eForm.
Medicines Optimisation Strategy 2016-20
Page 24 of 29
Priority 10: Mental Health
WHY?
National







Local






Medicine Issues





WHAT?
Key focus for next four
years
Mental ill-health forms at least 23% of burden of disease in
UK
1 in 4 adults experiences mental health problems or illness at
some point during their lifetime.
2 in 100 people will have a severe mental illness such as
schizophrenia or bipolar disorder at any one time.
Approximately 50% of people with enduring mental health
problems will have symptoms by the time they are 14
1 in 16 people over 65 and 1 in 8 over the age of 80 will be
affected by dementia
Life expectancy - severe mental illness is associated with a
10-year reduction in life expectancy
the prevalence of major depression in people seen in primary
care is between 5% and 10%
Estimates suggests that 16% of the working age population 28,800 - had a common mental illness in 2010/2011
1595 people in the 2012/13 financial year registered with a
serious mental illness in GP practices in B&NES
1,545 people in B&NES in 2008 have a diagnosed dementia
estimated to rise to 1,955 by 2025
In the financial year 2012/13 there were 588 emergency
hospital inpatient admissions for self-harm
Intentional self-poisoning was the most common form of selfharm (92%)
Work programme on self-harm developing priorities
Supporting Patients & Medicines Adherence (work with
providers and community pharmacy)
Medicines Reconciliation (providers)
Supporting Prescribers (providers)
Cost effectiveness (about 13% of Prescribing spend)
Evidence Based Prescribing (robust AWP formulary)
Support the optimisation of medicines for people with mental health
with a particular focus on:



Work to support appropriate use of antipsychotics:
- in people with dementia and learning difficulties
(to ensure appropriate use)
- and with psychosis (to support medicines adherence)
Self-Poisoning – support emerging work programme with
Public Health to reduce medicines self-poisoning
Explore use of innovation to support people to manage their
medicines use
Medicines Optimisation Strategy 2016 -2020
25
4.1 How do the Medicine Priorities map against CCG priorities?
Appendix 1 depicts how the priorities map against the CCG priorities and provides the
“Medicines Optimisation Strategy on a Page”.
4.2 Operating Plan
A detailed work plan linked to the annual operating plan will be developed to provide the
framework to deliver the priorities over the next four years. Diagram 1 shows the initial
draft scheduling of the four year operating plan.
1
Apr-16
6
12
18
Months
24
30
36
42
48
Apr-20
Complete 4 year
operating plan
Diabetes Care
Frail elderly
Antimicrobial
Stewardship
Improving
Value
from Medicines
Musculoskeletal
Workforce
development
Acute
Kidney
Injury (AKI)
Stroke prevention
& VTE
Safer care culture
Mental Health
Medicines Optimisation Strategy 2016-20
Page 26 of 29
5 Workforce to deliver the strategy
CCG
Medicines
Team
Current
 3 FTE Pharmacists

 1 FTE Pharmacy technician
(fixed term to Sept 2016)


Comments for the future
Consideration needs to be given for
enhancing the team
Investment for mainstreaming the
pharmacy technician and introducing
a second were made in the round for
2016/17
A proposal for additional project
support is currently being considered
Practice
Pharmacists
and
Care
Home
Pharmacists
Currently
contract
these 
through a self-employed route
 10 support the 27 practices
 5 supporting the Care 
Home Project
An option paper for the future model
of provider medicines function will be
brought forward to JCC in 2016
An invest to save proposal to support
medicines reviews for Community
MDTs will be brought forward in the
2017/18 contracting round
Community
Pharmacist

39 contractors in BaNES 
commissioned by NHS E
under the national contract
 No
functional
Local
Professional Network – this
is NHS E led
There is a department of 
pharmacists, technicians and
the support staff
Plans are developed to hold quarterly
Community Pharmacy Forum in
BaNES in 16/17
There are a team of two part 
time pharmacists working for
community services
Development Three transformation fund 
of
Primary pilots of clinical pharmacists in
Care
Primary Care employed by the 
Pharmacists GP practices to carry out Core
Contract work
There is an opportunity for additional
joint working
RUH
Sirona
Outreach and other joint models for
some specialities needs to be
explored further
There is an opportunity to work with
the pilots
Sharing of learning across practices
will be implemented
Any changes in workforce would have to lead to a revision in the strategy.
Medicines Optimisation Strategy 2016 -2020
27
6. Conclusion
A medicines optimisation strategy is central to the work of the CCG due to the key role
medicines have in our health system. Medicines account for approximately 13% of the
CCG spend but impact on all aspects of the CCG’s strategy and work plan.
This strategy has set out five key approaches to medicines optimisation for the CCG.
The strategy also sets out ten key priorities for work over the next four years to support
delivering transformational change to our community, supporting our CCG to be high
performing, leading our health and care system collaboratively through the commissioning
of high quality, affordable, person-centred care which harnesses the strength of clinicianled commissioning and will empower and encourage individuals to improve their health
and wellbeing status.
Medicines optimisation can be one of the key foundations for the CCG success and this
strategy is intended to maximise the potential medicines optimisation has to help deliver
the CCG ambition and vision.
Medicines Optimisation Strategy 2016-20
Page 28 of 29
CCG Mission
Appendix 1 – Plan on a Page
Healthier, Stronger, Together
CCG Focus –
high quality
health and
care system
“to lead our health and care system collaboratively through the commissioning of high quality, affordable, person centred care which
harnesses the strength of clinician led commissioning and empowers and encourages individuals to improve their health and well
being status”.
• Improving quality, safety and
individuals experience of care
• Improving consistency of care and
reducing variability of outcomes
CCG Approach:
• We want to lead a reconfigured
system that meets the current and
future needs of our population,
targeting deprived areas, is financially
sustainable with care offered in the
optimum setting
• Providing proactive care to
help people to age well and to
support people with complex
care needs
• Creating sustainable health
system within a wider health
and social care partnership
• Empowering and encouraging
people to take personal
responsibility for their health
and wellbeing
• Reducing inequalities and social
exclusion and supporting our
most vulnerable groups.
Improving the mental health and
wellbeing of our population
• Providing proactive care to
help people to age well and to
support people with complex
care needs
• We will encourage Providers
to collaborate, innovate and
work in effective partnerships to
deliver seamless and integrated
care
• We will invest resources in
areas and activities that
support better prevention and
early intervention
• We will focus on both the
mental health and physical health
needs of individuals.
Medicines Optimisation Approach

We will support local decision making to commission safe, effective and evidence based medicines use within pathways

We will promote a safety culture around medicines use: including effective use of national and local reporting systems to report, and learn from medication safety
Incidents

We will maximise care gains across health and social care by innovative management of medicines at the best obtainable value

We will support workforce development activity to create a sustainable healthcare system, with particular emphasis on the pharmacy workforce and medication
review

We will use clinical audit , education and quality improvement to improve safe and effective care and reduce variation in health outcomes
• Increasing the focus on prevention,
self-care and personal responsibility
• Improving the co-ordination of
holistic, multidisciplinary long term
conditions management (focusing
initially on Diabetes)
• Creating a sustainable
urgent care system that can
respond to changes in
demand
• Redesigning musculoskeletal
services to improve their
efficiency (productive elective
care)
• Commissioning safe,
compassionate care for frail
older people
• Ensuring the interoperability of
IT systems across the health
and care system
• Delivering the plans for the Better Care Fund to support our model
of integrated care with a focus on;
• 7 day working
• Protection of Adult Social Care Services
• Integrated reablement and hospital discharge
• Admission avoidance
• Early intervention and prevention
Medicines Optimisation top ten priorities
1.
Diabetes Care – Optimisation the
Medicines we use
CCG Priorities:
Aim is excellent outcomes and
safe use of our medicines use.
Work with Service
redesign programme to
have a well-defined
medicines Pathway
Through audit and review,
optimise:
New oral agents
Insulin
Cardiovascular
medications
Test strips and other
disposables
6.
Pharmacy Workforce
Maximise the use of clinical,
community and other pharmacists
to support a sustainable future
model.
With a focus on:



Community Pharmacy
workforce colleagues
to support Self-care work
programme
Support Public Health to
commissioning Healthy
Living Pharmacy services
in BaNES
Develop a programme of
Medicines optimisation
with medicines use in
people with: type 2
diabetes, asthma and MSK
pain and antibiotics in line
with other work streams
2.
Frail Elderly
3.
Commission clinical pharmacy
medicines reviews for all frail
elderly.
Ensure the safe, appropriate
and effective use of medicines
in frail and older people
wherever they are cared for
with focus on:
admissions avoidance,
urgent care settings, the Fall
Pathway and continuity of
care





7.
Acute Kidney Injury
Establish an implementation
programme for primary care
AKI working with all sectors,
and linking to Sepsis and
Antimicrobial Stewardship
programmes
Optimise management of
patients with CKD, including
diabetics, to prevent AKI
8.
Antimicrobial
Stewardship
4.
Establish a BaNES
Strategic Collaborative to
implement the UK AMR
Strategy including:
Improved infection
prevention
Optimise prescribing
practice
Professional education,
training and public
engagement
Develop new drugs,
treatments and diagnositcs
Better access to and use of
survelillance data
Stroke prevention &
reducing the risk,
improving the treatment
and prevention of venous
thromboembolism (VTE)
Continue to support for
optimising medicines in this
therapeutic area
Improving Value from
Medicines
5.
Support the review of
rheumatology and pain
medicines pathways
Ensure maximum benefit
from investment with a focus
on outcomes and projects in
a.
b.
Musculoskeletal
as part of the strategic
programme and develop a
medicines work
programme linked to this
service redesign
Primary Care
Secondary Care
High Cost Drugs
Ensure best value for
money from the biologic
drugs used in the NICE
pathways for
rheumatology indications
9.
Safer care culture
10. Mental health
Establish a local reporting
and learning culture in
primary care organisations to
enable the health economy
to improve patient care.
Support the optimisation of
medicines in this vulnerable
group with a particular focus
on

Self-Poisoning – support
emerging work
programme with Public
Health to reduce
accidental medicines selfpoisoning

Continue developing work
to support appropriate use
of Antipsychotics: in
people with LD, dementia
and with psychosis
Support implementation and
national reporting using the
NRLS GP eForm