Download New ABPI Code of Practice – what difference will the new

STEPS
Dr MIKE SCOTT
Chief Pharmacist
United Hospitals Trust
Antrim Hospital
Northern
Procurement Ireland
Distribution Interest Group (PDIG)
8 June 2006
STEPS
(Modified SOJA)
selection
pharmaceutical
economic
therapeutic
safe
Medicines Management
“Encompassing the entire way that
medicines are selected, procured,
delivered, prescribed, administered and
reviewed, to optimise the contributions
that medicines make to producing
informed and desired outcomes of
patient care.”
Audit Commission 2001
Integrated Medicines Management
Decreased length of stay
Decreased readmission rate
Reduced wastage of patients’ own
drugs
More accurate drug history
Improved appropriateness of medicine
use
Improved patient safety
Improved use of medical and nursing staff
time
Faster discharge process
Improved discharge prescription accuracy
Improved medicine use – counselling
Improved communication across the interface
Tasks Undertaken
Communication with primary care on
admission
Accurate medical history
Management of patients’ own drugs
Inpatient management including counselling
Pharmacist discharge and counselling
Communication with primary care on
discharge
More Accurate Drug History
Mean number of queries on the initial inpatient
kardex was reduced by 4.2 per patient,
reflecting improved medicines management
and impacting on length of stay.
Improved Medicine Use
There was a significant improvement in the
medication appropriateness index.
Control
Intervention
Admission Discharge
13.16
9.97
17.48
5.69
Health Service Journal Award 2003
Lack of Integrated Product Use
This was identified as a significant deficient
element in the current medicines
management system.
- different choice of agents in a therapeutic
class
- different generics and parallel imports being
used in primary care
- confusion for patients, particularly the elderly
Cost
SECONDARY CARE PROCUREMENT
Contract based - 3 years
All trusts contribute
Tender by generic name
Bids assessed by a pharmacist advisory panel
Recommendations made to the Executive Panel
for approval
Executive Committee of Trust Chief Executives
Success
This contract process has worked well and
achieved significant savings for the secondary
sector.
In the 2004-2007 contract savings in excess
of £2 million per annum were achieved
representing a 7.6% reduction.
87.2% being subject to good procurement
practice as defined by the Audit Commission.
Problems
Lack of primary care element
Loss leading to gain primary care business
(80% of spend is in the community)
Product name constraint therefore there is no
mechanism to consider therapeutically
equivalent usage
Procurement Primary Care
Independent contractors both GP and
pharmacist
GP prescribes ideally generically
Pharmacist supplies cheapest product by
procurement
Prices set by CSA on tariff
Hello!
Hello!
Northern Health and Social
Services Board (NHSSB)
Population of 440,000
Three stage process Stage one – branded generics
Stage two – therapeutic classes
Stage three – generic generics
NORTHERN AREA PRESCRIBING FORUM
Professional Secretary - Dr M
Scott
Consultants
General Practitioners
Community Pharmacists
Hospital Pharmacists
Board Director of Pharmacy
(Chairman)
Area Medical Advisor
Local Medical Committee
Locality Groups for Community
Pharmacists
Drug and Therapeutics Committee
IMPLEMENTATION
Phase
One
Primary Care
Prescribing advisors and prescribing support assistants actually
promoted and implemented the changes with GPs
Secondary Care
Consultants agreed to the product switches automatically carried
out by pharmacists
United gave notice to companies tendering for Regional Contract
that NHS price would be a determination in their adjudication –
hence different products used
THREE YEAR PERIOD
Calcichew
Adcal
Imdur
Elantan
Adalat LA
Isotard XL
Gaviscon
Peptac
Nitrate Patches
Nitrodur
Proctosedyl Preps
Uniroid Preps
Diltiazem brands
Slozem (once
daily)
Coracten
PRIMARY CARE PERCENTAGES
FOR NITRATES
Elantan LA 25
-10.4%
Elantan LA 50
-17.6%
Imdur SR
-27.2%
Modisal MR
-23.5%
Monomax SR
-31.9%
Ismo Retard
-58.3
Isotard XL
+223.9%
STAGE II
Therapeutic Tendering
Competitive tendering for
pharmacologically similar products
Current processes use generic name for
bidding purposes
By default excludes similar chemical
entities with the same pharmacological
actions and range of potential
Eeeny Meeny
Miny Mo
STEPS
selection
pharmaceutical
economic
therapeutic
safe
STEPS
Quality first, then safety, then costeffectiveness
Full product integration between primary
and secondary care
Full ownership by both general
practitioners and hospital consultants
Standardisation of generics (plus branded)
Therapeutic tendering
STEPS
Selection - agreed criteria (weighted)
1st Step - Clinical Evaluation
2nd Step – Safety Evaluation
3rd Step – Budgetary Impact Assessment
Selected medicines for 70% prescribing
No restrictions
Transparent and Defensible
STEPS
Improve quality of prescribing information
across primary / secondary care
Framework updated regularly with emerging
evidence
Three year formulary (for 70% prescribing
will be class specific)
No discount into the secondary care sector
International Links
STEPS
____________________
MATRIX CONSTRUCTION
AND
CLINICAL EVALUATION
STEPS
Matrix construction and Clinical Evaluation
Extensive literature review
Selection criteria identification
Expert panel – Consultants, GPs, Pharmacists
Relative weight assignments
Draft indicative scoring system
STEPS
Matrix construction and Clinical Evaluation
Validation questionnaire (Consultants)
Final scoring system for Matrix
Matrix sent to all relevant pharmaceutical companies
Data analysis
Drug entities relative scores
ACE INHIBITORS MATRIX
Number of licensed indications
Number of formulations
Trough / peak ratio BP lowering effect
Variability in biovailability
Interactions
Clinical efficacy
Side-effects
Dosage frequency
TOTAL 1000 pts
DRUG ENTITIES SELECTION
RISK ASSESSMENT
A - CRITICAL INFORMATION
STEP
1.
2.
3.
4.
5.
Labelling
Packaging
Storage conditions
Blisters
Patient information leaflets
Accept
B - ADDED VALUES STEP
(EXTRA POINTS)
1.
2.
3.
4.
Calendar packs
EAN barcode
Pack size
Tab/cap colouring and
marking
5. Label instructions space
BUDGET IMPACT ANALYSIS
DDD profiling
DDD fractions refining
Cost calculation both primary and
secondary care prices
Affordability (selection / budget)
FINAL SELECTION OF
PRODUCT LINES
Therapeutic Classes Completed
Statins
Proton Pump Inhibitors
ACE Is
(now being regionalised)
July 06
July 06
Oct 06
In progress –
ARBs
SSRIs
Oct 06
Oct 06
Key Requirements
COMMUNICATION
80 meetings with key stakeholders
Interactive sessions
OWNERSHIP – LOCAL
Consultants
GPs
Key Messages
1) Patient care is enhanced
2) Efficiency
a)
b)
Reduced cost to achieve the same quality
of patient care
Reimbursement of the efficiency to –
i. Pay for new expensive treatment modalities
ii. Pay for primary care infrastructure, eg CPN
DEVELOPMENT
Development
1) Regional Steering Group
Regional Steering Group
Chair -
Consultant Clinical
Pharmacologist
Consultants
GPs
Hospital Pharmacists
Community Pharmacists
Prescribing Advisors
ABPI representation
Decide and oversee the work programme
Development
1) Regional Steering Group
2) Regional Pharmaceutical Procurement
Unit
Regional Pharmaceutical
Procurement Unit
Regional Procurement Pharmacist
2.5 wte Pharmacists
1 wte Clerical Officer
Requiring a Pharmacoeconomic
Pharmacist
Linked to SGCE and PCEG
Development
1) Regional Steering Group
2) Regional Pharmaceutical Procurement Unit
3) Reorganisation of hospital contracts
Reorganisation of the Hospital
Contracts
Coverage of all main therapeutic classes
Rolling 3-year contacts rather than one
massive contract
Regional generic generics contract
Development
1)
2)
3)
4)
Regional Steering Group
Regional Pharmaceutical Procurement Unit
Reorganisation of hospital contracts
Primary Care aspects
Primary Care Aspects
Linkage to quality and outcomes framework
for new GMS contract
Linkage to regional prescribing incentive
scheme
Linkage to new community pharmacy
contract based on quality
Linkage to community pharmacy “Managing
Your Medicines scheme” (IMM)
Development
1)
2)
3)
4)
5)
Regional Steering Group
Regional Pharmaceutical Procurement Unit
Reorganisation of hospital contracts
Primary Care aspects
Guidance
Guidance
Assessment relative to indication, eg
ACEIs in hypertension
in heart failure
in diabetic patients
Regional guidance
NICE
? SMC
OTHER
APPLICATIONS
DRESSINGS
Surgical dressings
Wound management products
Aug 06
FOR BOTH PRIMARY AND SECONDARY CARE
BENEFITS
Optimised patient care
Fully integrated product use in both sectors
Selection of product on safety and therapeutic
efficiency as the prime determinant
Quality at best value for the service
Robust, transparent, defensible system of
selection
Web-based formulary – evidence based
Dynamic with regular updates
Compliance with EU legislation
Matrices created for the
different categories
Hydrocolloids
Silver dressings
Logistics assessment
Pharmaceutical Clinical
Technology
1) Medical and surgical disposables
•
•
Significant involvement of pharmacy in
their management
Improved management and cost control
2) Point of Care Testing
•
Managed and controlled by pharmacy via
the regional contracting process
Pharmaceutical Clinical
Technology
a) Medical and surgical disposables
eg
sutures
Oct 06
endosurgery
Jan 07
endoscopy
Jan 07
b) Point of Care Testing
- urine testing
- blood glucose
- misc, eg troponin, BNP,
drugs of abuse screen
Oct 06
Dec 06
Mar 07
Pharmaceutical Services
Improvement Programme (PSIP)
Repeat dispensing
Minor ailments
28-day dispensing
Generic substitution
Medicines governance
Integrated medicines
management
Therapeutic tendering
Pharmaceutical
Clinical Technology