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NHS Kingston and Richmond CCGs’ MEDICINES OPTIMISATION PRIORITIES 2018-21
NHS Kingston and Richmond CCGs’
MEDICINES OPTIMISATION PRIORITIES
2018-21
Kingston and Richmond CCG Medicines Optimisation Priorities 2018-21 Page 2 of 19
NHS Kingston and Richmond CCGs’ MEDICINES OPTIMISATION PRIORITIES
2018-21
Contents
1. Foreword............................................................................................................................................... 3
2. Executive Summary .............................................................................................................................. 4
3. Background ........................................................................................................................................... 5
4. Kingston and Richmond CCGs’ Mission and Medicines Optimisation Vision ....................................... 8
5. Priorities ................................................................................................................................................ 8
a. Medicines Optimisation Team ...................................................................................................... 8
The Medicines Optimisation Team ................................................................................................... 9 Interface and Secondary Care Support (ISPS) service ....................................................................... 9 Pharmacy / MO networks ................................................................................................................. 9 - London pharmacy leads ............................................................................................................ 9 - SWL MO collaborative work-streams ....................................................................................... 9 - SWL medicines optimisation group .......................................................................................... 9 - SWL medicines cabinet ............................................................................................................. 9 - Cardiovascular pharmacy working group ................................................................................. 9 - London Procurement Partnership ............................................................................................ 9
b. Primary care prescribing ............................................................................................................. 10
GP prescribing element of primary care prescribing ...................................................................... 10 Other aspects of the primary care prescribing ............................................................................... 11
- GPs with Extended Roles (formerly GPs with Special Interests) ......................................... 11 - Out of hours services .......................................................................................................... 11 - Primary care extended hours services ................................................................................ 11 - Home oxygen ...................................................................................................................... 11 - Community pharmacy initiatives ........................................................................................ 11 - Community services prescribing ......................................................................................... 11 - Central drugs ....................................................................................................................... 11
- SWL MO Collaborative Work-streams for primary care drugs ............................................... 11 c. Secondary care medicines commissioning ................................................................................. 11
Payment by results included drugs ................................................................................................. 12 Payment by results excluded drugs (aka High Cost Drugs/HCD) .................................................... 12 Individual Funding Request drugs (IFR drugs) ................................................................................. 12 ‘Miscellaneous High Cost Drugs’ ..................................................................................................... 12 STP-wide interface issues ................................................................................................................ 12 SWL Medicines Optimisation Group ............................................................................................... 12 SWL MO Collaborative Work-streams for secondary care drugs ................................................... 13
d. Commissioning support to CCG .................................................................................................. 13
Commissioner support partnerships ............................................................................................... 13 Primary care directorate and commissioning directorate .......................................................... 13 Quality directorate ...................................................................................................................... 14 Finance directorate ..................................................................................................................... 14 Corporate Affairs and Governance Directorate .......................................................................... 14 Kingston and Richmond Councils (Health & Wellbeing Board and Public Health) ..................... 15 NEL CSU London Commissioning Support Unit (CSU) ................................................................. 15 SWL Alliance support teams ....................................................................................................... 15 SWL Primary Care Team .............................................................................................................. 15 NW London and commissioning colleagues from other geographies ........................................ 15 NHS England – primary care contracts, medical director, MO dashboard ................................. 15
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NICE, MHRA, Guy’s Medicines Information, Specialist Pharmacy Services, Regional MO Committees (RMOCs), NHSE MO Clinical Reference Group and other clinical support services .................................................................................................................................................... 15 NHS Digital, Rightcare, NHS Business Services Authority and other support services ............... 15
Provider partnerships ...................................................................................................................... 15 Acute trusts ................................................................................................................................. 15 Other SWL and Surrey acute trusts ............................................................................................. 16 North West London Medicines Management Pharmacy Network ............................................. 16 Mental health trust ..................................................................................................................... 16 General Practice .......................................................................................................................... 16 Community Pharmacy ................................................................................................................. 16 Community services .................................................................................................................... 17 Care homes ................................................................................................................................. 17
Interfaces between services ............................................................................................................... 17
Out of scope ........................................................................................................................................ 17
Other key stakeholders relationships to develop further .................................................................. 17
6. Annual Medicines Optimisation Team Work-plan: 2018/19 .............................................................. 18
7. References ...................................................................................................................................... 18
1. Foreword
Kingston and Richmond CCGs have both experienced nearly 20 years of strong collaborative working between primary care prescribers and a centralised team of professional clinical pharmacists. This has supported the close management of the primary care prescribing budget whilst maintaining very high quality and cost-effectiveness standards against local, London and national standards. We work ever more collaboratively across South West London to bring governance and oversight to the prescribing and reimbursement for secondary care drugs, with consideration to the managed entry of new drugs, interface prescribing issues, shared care support and hospital only drugs. This process has greatly strengthened Kingston and Richmond’s influence as commissioners of NHS services with medicines optimisation requirements. Recently we have recommenced our input to North West London prescribing forums, which we hope will achieve considerable benefits particularly for Richmond, but also across South and North West London medicines optimisation networks. The era of clinical commissioning, health and social care integration and medicines optimisation gives us the opportunity to further consider the roles of medicines in all our commissioned pathways, beyond the core clinical commissioning support to member practices, to ensure that Kingston and Richmond patients have the best experience possible with their medicines. August 2018 Emma Richmond; Chief Pharmacist, NHS Kingston and Richmond CCGs Sylwia Ferguson; GP Lead for Medicines Optimisation, Kingston and Richmond CCGs
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2. Executive Summary
This document sets out the Medicines Optimisation (MO) Priorities for 2018-21 which have been developed to complement the Kingston and Richmond CCGs’ corporate objectives: 1. Enable local people, patients, carers and stakeholders to have greater influence on the services
we commission and keep the patient voice at the centre of what we do
2. Improve the quality, safety and effectiveness of healthcare services and ensure that national performance targets are met and that people experience high quality care
3. Work in partnership with local health and care providers, commissioners and the voluntary
sector to improve and transform services that achieve better health outcomes, are accessible and reduce inequalities
4. Ensure the continued development of the CCG as a clinically-led and well governed organisation
with strong leadership, and effective membership & staff engagement 5. Achieve a financially sustainable health economy balancing the need for effective use of
resources and better value for money with the need for innovation Pathway planning - medicines are the most common treatment intervention and most care pathways
commissioned involve medicines. Please refer to the introduction of some key medicines-related
facts and for a checklist of considerations when commissioning a pathway with medicines involved,
please refer to the useful resources accessed via https://www.sps.nhs.uk/articles/medicines-in-
commissioning-resources/ (may require registration – please request copy if cannot be obtained)
At all stages of the commissioning cycle (patient and public engagement, strategic planning, procuring
services, monitoring and evaluation) the following medicines-related aspects should be considered:
Assessing Needs and Provision Review
Deciding priorities and investments
Patient Safety and Governance
Legal aspects
Funding aspects
Service delivery
Staff training and competency
Patient experience Key points to consider in all pathways:
Who will decide whether a medicine is needed?
Who will supply the medicine?
How will the medicine be taken or administered?
How will the effects of the medicine be monitored and reviewed?
Primary care prescribing budget impact
Training/specialist use considerations
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The key MO focus areas to deliver these objectives in Kingston and Richmond are: a. Medicines Optimisation Team (workforce and management; strategy and governance) – to
ensure team is able to deliver the following services b. Primary care prescribing
o Support for GP practice prescribing and medicines optimisation initiatives to achieve quality and cost effective prescribing
o To ensure quality and cost-effectiveness of the medicines optimisation elements of non-GP primary care prescribing
o SWL MO Collaborative work-streams for primary care prescribing and pathway review c. Secondary care medicines
o Payment by results (PbR) included drugs – formulary, hospital only, shared / transfer
of care
o Payment by results excluded drugs (aka High Cost Drugs/HCD) - NICE criteria for
funding, medicines-related CQUINs, gain share agreements, secondary care drug
pathway reviews
o Individual Funding Request drugs (IFR drugs)
o ‘Miscellaneous High Cost Drugs’
o SWL MO Collaborative work-streams for secondary care drug pathway review d. Commissioning support to CCG
o To ensure quality, cost-effectiveness and efficiency of the medicines optimisation elements of commissioned services through application of general and/or provider specific principles. Working with key commissioner and provider partners the MO Team aims to promote these principles
These work-streams are outlined in this document and will be supported by an annual work-plan for the recently combined Kingston and Richmond CCGs’ Medicines Optimisation Team. This is overseen by Medicines Optimisation Group (MOG) and ensure it will be reviewed regularly and refreshed annually. 3. Background
Historically the Kingston and Richmond Prescribing / Medicines Management Teams led on Medicines Management for the Primary Care Group and Trust with the benefit of active GP Prescribing Leads. It focused on the prescribing of medicines, the impact on the prescribing and drugs budget, the access to high-risk and high-cost medicines and safety elements. In recent years, the concept of Medicines Optimisation was introduced nationally and adopted by the renamed Medicines Optimisation Teams. It is a broader term that still encompasses medicines management but indicates a change in attitude towards medicines. The National Medical Director (Sir Bruce Keogh), Chief Nurse (Jane Cummings) and Chief Pharmaceutical Officer (Keith Ridge) support four principles of “medicines optimisation” that could revolutionise medicines use and outcomes whether prescribing, dispensing, administering or taking medicines:
aim to understand the patient’s experience, evidence based choice of medicines, ensure medicines use is as safe as possible, make medicines optimisation part of routine practice.
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We have welcomed this more holistic approach and aspire to fully integrate this concept into all services commissioned for our local population to optimise patient outcomes. Key medicines-related facts:
“Getting the most from medicines for both patients and the NHS is becoming increasingly important because more people are taking more medicines. Medicines prevent, treat or manage many illnesses or conditions and are the most common intervention in healthcare. However, it has been estimated that between 30% and 50% of medicines prescribed for long-term conditions are not taken as intended (World Health Organization 2003). This issue is affected by the increasing number of people with long-term conditions. In 2012, the Department of Health published ‘Long-term conditions compendium of information: third edition’, which defines a long-term condition as 'a condition that cannot, at present, be cured but is controlled by medication and/or other treatment/therapies'. The report suggested that about 15 million people in England have a long-term condition and the number of long-term conditions a person has increases with age: 14% of people under 40 and 58% of people over 60 have at least 1 long-term condition. The presence of 2 or more long-term conditions in a person is called 'multimorbidity'. In 2008, the number of people with multimorbidity was 1.9 million, but this is expected to rise to 2.9 million by 2018. Twenty-five per cent of people aged over 60 report having 2 or more long-term conditions. Data from the Health and Social Care Information Centre (HSCIC) shows that between 2003 and 2013 the average number of prescription items per year for any one person in England increased from 13 (in 2003) to 19 (in 2013). When a person is taking multiple medicines this is called polypharmacy, a term that has been used in health care for many years. With an increasing ageing population, polypharmacy has become more important to consider when making clinical decisions for individual people1,2”. Also cross-referenced in these documents are the appropriate and problematic aspects of polypharmacy3, the need for shared decision making using best clinical evidence4,5,6,7,8, medicines adherence9, GMC good practice guide for prescribing10, safety aspects11 (5% to 8% of unplanned hospital admissions are due to medication issues), avoiding patient harm and improving safety 12,13, unintentional change in medicines when transferring between different care providers (between 30% and 70% of patients have an error or unintentional change to their medicines)14, safety issues reporting methods15,16,17,18
An interesting paper from the King’s Fund19 outlines the complexity and magnitude of NHS spend on medicines, growing from £13 billion in 2010/11 to £17.4 billion in 2016/17; i.e. at a growth substantially faster that for the total NHS budget over the same period, albeit the growth being higher in the hospital sector. The spend in 2016/17 totalled £9bn in primary care, plus £8.3bn in secondary care. This illustrates some of the reasons for NICE and the National Prescribing Centre producing a toolkit20 to support the (then) emerging CCGs in July 2011 “An organisation competency framework to ensure the effective delivery of medicines management functions and responsibilities” which outlined MO indicators underpinning the six overarching competencies allocated to the six CCG domains central to the authorisation process. To operate to maximum potential, these competencies must be fully integrated into the CCG working with all internal and external stakeholders. This is illustrated throughout this priorities document for MO in Kingston and Richmond.
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The specific challenge in Richmond and Kingston when faced with overall financial challenge is that the prescribing expenditure, when normalised for population by gender, age and temporary residents, is currently the most, and 2nd most, cost-effective nationally (see Table 1). Although this leaves limited capacity to make further savings, we continue to explore where further improvements in quality and cost-effectiveness may be possible.
Table 1: South London CCG
(2017/18 data) NIC
ASTRO-PU* (standardised)
Indicator (NIC/ASTRO-PU*
(standardised)
National Ranking (n=195)
Richmond CCG 21,608,905.87 714,673 30.236 1
Kingston CCG 20,775,896.53 652,272 31.852 2
Lambeth CCG 37,257,263.92 1,102,073 33.807 7
Croydon CCG 44,428,462.13 1,293,971 34.335 9
Merton CCG 24,246,009.46 693,501 34.962 13
Southwark CCG 32,062,787.76 889,875 36.031 22
Wandsworth CCG 40,134,484.38 1,089,818 36.827 28
Bromley CCG 46,028,624.08 1,239,046 37.148 29
Sutton CCG 24,780,790.48 646,413 38.336 38
Bexley CCG 32,585,124.67 833,834 39.079 47
Greenwich CCG 33,354,130.46 851,032 39.193 50
Lewisham CCG 38,251,248.52 932,327 41.028 74
South London average 36.070
England average 42.545 *Net Ingredient Cost / Age-sex-temporary resident originated prescriber units; i.e. standardised population with key
demographics taken into account
Some of the potential risks posed by focusing further on the cost of prescribing relate to ensuring sufficient prescribing for the prevention and management of patient’s conditions. There may still be some cost-efficiencies achievable through SWL-wide collaborative work-streams, mainly around the large-scale processes that are complex to influence as involve so many stakeholders across the geographical and care setting boundaries. Corporate support at a SWL Alliance level should help support these projects under the leadership of the SWLA Senior Responsible Officer for medicines optimisation, in addition to the local medicines optimisation lead GPs to support implementation in Kingston and Richmond through locally commissioned services, prescribing incentive schemes or other initiatives.
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4. Kingston and Richmond CCGs’ Mission and Medicines Optimisation Vision
Within this, our Vision for Medicines Optimisation is to improve the health of the local population by promoting safe, effective and efficient use of medicines across Kingston and Richmond boroughs through CCG commissioning of patient-focused services. The Kingston and Richmond CCGs’ Medicines Optimisation Group will support assurance that this vision is delivered. 5. Priorities
We aim to make this vision a reality through focus on Kingston and Richmond CCGs’ shared corporate priorities with a focus on the following:
a. Medicines Optimisation Team
Workforce and management: The Kingston and Richmond CCGs’ MO team has been created to maximise the effectiveness within the Local Delivery Unit and sits under the Quality Directorate alongside safeguarding and continuing healthcare. The senior pharmacists lead / support on each of the key areas outlined in the key focus areas to deliver the medicines optimisation priorities for Kingston and Richmond CCGs; i.e.
Medicines Optimisation Team - workforce and management; strategy and governance
Primary care prescribing
Commissioning support to CCG
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The Medicines Optimisation Team The Kingston and Richmond CCGs’ Medicines Optimisation Team will deliver these, working collaboratively with the following partners: Interface and Secondary Care Support (ISPS) service: The two South West London (SWL) Commissioning Pharmacists at NEL CSU London Commissioning Support Unit (CSU) are commissioned to provide a service on behalf of all six SWL CCGs. Synergy is achieved through their integration within CSU acute contracts, finance, claims management and Individual Funding Request (IFR) teams and will need to be retained during the process of ‘in-housing’ elements of these services into the SWL Alliance office during 2018-19. Pharmacy / MO networks The capacity and capability of the K&R CCGs’ MO team is also supplemented by collaboration with the following: - London pharmacy leads: primary and secondary care chief pharmacists– includes networking
with specialist pharmacy services, Royal Pharmaceutical Society, NHS England, Medicines and Healthcare products Regulatory Agency (MHRA), National Institute for Heatlh and Care Excellence (NICE), Department of Health when required
- SWL MO collaborative work-streams to support the SWL Sustainability and Transformation Partnership through a five-year (2016-21) plan including broad projects on deprescribing, review of primary and secondary care prescribing pathways, reducing pharmaceutical waste with specific focus on care homes, wound dressings, oral nutritional supplements, stoma and incontinence products. Input to these work-streams and their local implementation form a key part of the local MO Team’s delivery and productivity
- SWL medicines optimisation group: developing the interface prescribing policy and associated appendices to the service level agreement with SWL acute trusts (shared care guidelines, hospital only drugs, PBR excluded drugs NICE criteria for funding, medicines-related CQUINs, gain share agreements, commissioning issues that affect SW London)
- SWL medicines cabinet: SWL chief pharmacists with CSU pharmacists - Cardiovascular pharmacy working group – South London network pharmacists collaborate with
specialists to create guidelines and position statements for effective management of new drug entry and/or interpretation of national policy
- London Procurement Partnership – various start and finish London-wide groups to provide QIPP support to different therapy areas; e.g. oral nutrition, stoma, respiratory, in addition to reduced procurement prices for contracts negotiated on the behalf of London Trusts and rebate schemes which comply with the consensus agreed principles
A focus on professional excellence through peer support and continuing professional development is actively encouraged through line management and matrix working in this niche expertise of pharmacy to ensure high clinical, legal and ethical standards are upheld, including those in the NHS Constitution around decision making. Strategy and governance: A recent SWL-wide internal audit recommended that a review of the decision-making governance across the whole area, and specifically within Kingston and Richmond, be undertaken which is welcomed and will be addressed during 2018/19. This priorities document aims to fulfil the first phase of this process for Kingston and Richmond CCGs. Identified potential risks to this delivery will be logged and reviewed monthly in the corporate risk register.
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b. Primary care prescribing
GP prescribing element of primary care prescribing There are 21 GP practices in Kingston CCG and 28 in Richmond CCG. In 2018/19 the primary care prescribing budget for the two CCGs totals £43.3m, of this 93.8% on average is for the GP practice prescribing budgets. The CCGs’ primary care pharmacist service supports the GP practices in both boroughs under the leadership of the two Heads of Primary Care Prescribing giving GP Provider Support at organisation, locality and/or practice level by providing medicines-related clinical and professional advice and individual work-plans. Tools to support this function include use of software and databases to optimise resources for prescribing analysis and the opportunity for positive intervention; e.g. ePACT2, ScriptSwitch. The team will also consider alternative / additional tools such as Optimise RX, Eclipse Live and Pincer. GP practice and membership engagement is achieved through the team structure permitting a
named, allocated primary care pharmacists as first point of contact for practices.
Engagement with the localities, federations and clinical networks is a key element of delivering this
support service. As part of the alignment of the service to both boroughs, practice and locality needs
will be considered; e.g. comparative prescribing data to complement other data sources such as data
packs provided by Public Health where applicable. This will enable practices to see if there could be a
geographic element to any trends observed. The MO team is structured to support both clinical
networks and practice-specific support as follows:
Guidelines and recommendations on MO issues
Support management of practice prescribing budgets (prescribing plans, comparative data, meetings, undertake drug searches for patient list and recommendations where appropriate), MO ideas for STP/QIPP and analysis of practice non-medical prescribers, out of hours and GPs with Extended Roles prescribing
ScriptSwitch database updates and practice feedback (/ alternative systems)
Prescribing Incentive Scheme / equivalent practice submissions collation, analysis and proposals for follow-up work-streams
Review and advice on medicines systems at practice (not individual patient) level: o use of clinical systems for repeat prescribing, repeat dispensing, recalls for monitoring,
formulary choices o medicines reconciliation and community pharmacist liaison following patient discharge o reducing inappropriate polypharmacy with patient engagement to minimise
pharmaceutical waste, optimise medicines use and reduce medicines related hospital admissions
o appropriate use of monitored dosage systems and finding other solutions
Local managed entry of new drugs: input to Drug and Therapeutics Group meetings at KHT, WMUH, mental health trust, overview of other SWL/NWL trusts where applicable, South London cardiac and stroke network
Clinical audit methods; e.g. to support MHRA drug withdrawals and alerts, Yellow card reporting
Medicines information to healthcare professionals, primarily regarding local issues
Liaison with other local providers to enhance collaborative working regarding use of medicines
Identify and share good practice between each borough practice team and align where appropriate
Consideration of primary care prescribing rebates in line with local policy
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If there is capacity, they will aim to:
Undertake ScriptSwitch annual practice evaluation
Attend network / membership meetings when relevant item on agenda
MO-related newsletters, surveys, workshops, data packs, amber warning card reporting, cost effective prescribing tips, media story responses, care home support etc
Liaise with practice-employed practice pharmacists, community education provider networks (CEPN), pharmaceutical company representatives where appropriate
Identify and share good practice between practices
Support patient and carer communities
Clinical audit support
Non-medical prescribing by the Primary Care Pharmacists
Out of scope:
Patient level support other than exceptional cases; e.g. real time interface between secondary care and community pharmacies and the practice, direct patients’ medicines information queries (need to be signposted to PALS to coordinate response and keep database), contribution to multidisciplinary reviews for complex patients with multi morbidities
Other aspects of the primary care prescribing include: - GPs with Extended Roles (formerly GPs with Special Interests) - Out of hours services - Primary care extended hours services - Home oxygen - Community pharmacy initiatives - Community services prescribing
Whilst indicative budgets for these cost centres are set and monitored by the CCGs’ MO team, the providers should provide regular assurance that they are being used appropriately - Central drugs are monitored and interventions made if required - SWL MO Collaborative Work-streams for primary care drugs: undertaking a 5-year programme to
achieve a net £10m savings across the six CCGs in SW London (2016-2021). These work-streams currently include the following for primary care prescribing budget:
o Primary Care Drug pathways (NEL CSU ISPS lead) o DROP-list / deprescribing / self-care (Merton CCG lead) o Reducing pharmaceutical waste in care homes (Sutton CCG lead) o Reducing pharmaceutical waste overall (Croydon CCG lead) o Oral nutritional supplement review (Wandsworth CCG lead) o Wound care review (Kingston CCG lead)
c. Secondary care medicines commissioning
This involves secondary care MO service provision (included / excluded from PBR tariff), interface issues from a balanced primary and secondary care perspective and STP-wide interface issues (SWL/NWL/pan-London)
Secondary care medicines commissioning: There are 4 areas of secondary care prescribing budgets
discussed here:
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Payment by results included drugs – costs are included in the PBR tariff but the MO Team have input
to the entry of new drugs (formulary), categorisation (NWL RAG / SWL hospital only) and associated
management guidelines for shared / transfer of care as this has significant effect on patient care and
all the primary care prescribing budget lines. As such annual discussions across the STP-wide
geography form part of the annual interface prescribing policy review
Payment by results excluded drugs (aka High Cost Drugs/HCD)
o Estimated budget for 2018/19 from SLAM-PLD prediction model for K&R CCGs = £9.1m
o This budget sits within acute commissioning directorate as, depending on how the hospitals
report via SLAMs, it is divided or not from the other hospital activity.
o The MO Teams actively support management of this spend with SWL and pan-London
collaboration relating to procurement and pathway improvements
o Charged by the provider to the CCG, via the Commissioning Support Unit who host several teams
to process the claims
Claims Management Team verify that the patients are attributed to the correct CCG
and that the use of the drug complies with the standard ‘tick box form’ to
demonstrate NICE guidance has been followed
ISPS (Interface and Secondary care Prescribing Support) team produce the ‘tick box
forms’ in collaboration with the MO teams in the 6 SWL CCGs.
Tick box forms are then taken through the SWL Medicines Optimisation Group for
comment before being uploaded to the Blueteq system for 2-way secure electronic
access
Blueteq enables the claims to be monitored for renewals and/or expiry and allow
reports to be pulled to show trends where there is a need and capacity
o Other functions include gain share agreements, MO-related CQUINs etc
o The resource in the ISPS team is extremely challenged (currently 2 pharmacists and a pharmacy
technician covering 6 CCGs) and has been raised as a risk to costs and possibly quality if not
resolved.
Individual Funding Request drugs (IFR drugs)
o Budget for 2018/19 for K&R CCGs’ IFR drugs = approximately £100k
o From September 2018 the support function for the IFR triage and panel will transfer to a SWL
hosted model and the local MO team will only provide advice by exception so these costs will
be excluded from this prioritisation document.
‘Miscellaneous High Cost Drugs’
o Budget for 2018/19 for K&R CCGs = £119.8k
o This budget has recently been passed to the Medicines Optimisation Team from the acute
commissioning directorate for management. When there is adequate capacity, a diagnostic
‘deep-dive’ into these charges will be undertaken with the CSU as would seem to fall outside the
routine pathway for charges (described under i.)
STP-wide interface issues
These are largely managed through: SWL Medicines Optimisation Group: developing the interface prescribing policy and associated appendices to the service level agreement with SWL acute trusts (shared care guidelines, hospital only drugs, PBR excluded drugs NICE criteria for funding, medicines-related CQUINs, gain share agreements, commissioning issues that affect SW London). Representation from the MO Team has
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input to the NW London equivalent to raise awareness of boundary issues and try to achieve consistency where possible SWL MO Collaborative Work-streams for secondary care drugs: undertaking a 5-year programme to achieve a net £10m savings across the six CCGs in SW London (2016-2021). These work-streams include the review of Secondary Care Drug pathways (NEL CSU ISPS lead) for gastro-intestinal, dermatology and musculoskeletal conditions
d. Commissioning support to CCG
The MO Team ensure quality and cost-effectiveness of the medicines optimisation elements of commissioned services is achieved through application of general and/or provider specific principles in contracts when involved in the process early enough Commissioner support partnerships:
Primary care directorate and commissioning directorate
Liaison with, and input to K&R committees, such as Primary Care Commissioning Committee, should ensure that service specifications support providers to engage with patients to help them obtain the most benefit from their medicines and minimise the risk of harm medicines wastage by awareness of medicines optimisation in all aspects of commissioned services; e.g. recommending MO CQUINs, quality premium and/or self-development improvement plan where appropriate
Support development and management of locally commissioned services for primary and community care contractors, particularly those delivered by community pharmacists (care home advice and palliative care out of hours), GPs with medicines optimisation aspects (shared care drugs, anticoagulation, cardiology, diabetes), community services (learning disabilities service or adult attention deficit disorder service provided by Your Healthcare) – aim to ensure suitable access to these services across the population
Support Locally Commissioned Services Subgroup (LCSSG) when required
Urgent care: o Input in most efficient way to support urgent care support development of primary care
to deliver appropriate urgent care for the population of Kingston and Richmond o Raise awareness of current services available / scope for future development through
the 76 community pharmacy contractors in Kingston and Richmond CCGs to support urgent care
o Ensure community pharmacy access is optimised through various channels; e.g. 111, medicines use reviews, new medicines service
o Support out of hours services; e.g. formulary use, adherence to local guidelines prescribing and budget monitoring, access to supply of medicines
o Create / share innovations in urgent care models
Planned care:
o Input in most efficient way to support planned care and development of suitable providers to deliver appropriate planned care for the population of Kingston and Richmond; for example for ADHD and melatonin, IV antibiotics, palliative care, tissue viability, multiple sclerosis, diabetes, cardiac, rheumatology, ophthalmology via local CCG, providers or other commissioners in SW London, South London HIN, pan-London groups, etc
o Raise awareness of current services available / scope for future development through the 76 community pharmacy contractors in Kingston and Richmond CCGs to support planned care
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o Integrated care o Support advice to care homes; e.g. locally commissioned service, Your Healthcare
nonmedical prescriber issues), frail elderly prescribing (falls clinic) o End of life care – access to palliative care medicines out of hours service (locally
commissioned service) o Input to MO element of specific therapeutic group pathway review
Quality directorate Close working with others in the directorate is important to assure medicines safety, incident reporting and supporting role of medicines and devices safety officer, in addition to GP clinical leads representing Kingston and Richmond CCGs on the various provider Clinical and Quality Review Groups (CQRGs) and support for use of amber warning cards (or equivalent). Support Quality lead and clinical leads attending CQRGs with providers by encouraging and supporting reporting of, and shared learning from, serious incidents and near misses from medication errors/incidents
Finance directorate
Performance assurance through regular Programme Delivery Group meetings through highlight reports and local Project Workbooks which feed into the SWL MO collaborative workstream project overview documents and SWL chief pharmacist collaborative networks. SWL governance review due for oversight of these processes.
Primary care prescribing budget o Horizon scanning for cost pressures o Budget negotiation with Director of Finance including QIPP contribution o NHS England and Practice consultation on methods for setting o Report to NHS Business Services Authority o Monthly adjustments and forecast outturns from July data o Development and monitoring of prescribing incentive scheme (see under GP provider
section) o Year-end reporting
Secondary care prescribing: o Budget setting as part of the acute contract management with CSU – although scope for
improvement in method used if data becomes more reliable o Oversight of claims management and challenges made by CSU on CCG behalf for PBR
excluded and IFR drugs, standards included in contracts with acute providers to enable these transparent processes and enable smooth operation with multiple providers
Corporate Affairs and Governance Directorate
Support regarding medicines related issues; e.g. Freedom of Information requests, complaints, fraud allegations, Patient Advice and Liaison Service (PALS) queries, Amber Warning Cards
Registering and managing the risks associated with medicines (clinical, safety, financial and reputational) by ensuring:
o NHS constitution requirements regarding patients’ access to medicines are fulfilled with clear, accessible processes for prioritising investment in healthcare interventions
o Services that involve medicines comply with statutory regulations and can stand up to legal challenge
o Governance processes need review with corporate office to outline codes of conduct that set out how CCGs commission or interact with commercial bodies (relating to medicines), and monitors them
o Support national policy development and implementation regarding medicines and unplanned emerging issues; e.g. input and support provided to pandemic flu/national
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vaccination shortage issues, antibiotic prescribing guideline developments, “stop press” updates
o Equality and diversity are given due consideration wherever relevant to decisions made
The Kingston and Richmond CCGs’ Medicines Optimisation Group (MOG) is accountable to the CCGs’ governing bodies via the Integrated Governance Committee (IGC) and Quality, Safety and Performance Committee (QSP) respectively
Kingston and Richmond Councils (Health & Wellbeing Board and Public Health) – There is a reciprocal agreement for mutual support around medicines with the two local authorities Public Health departments for data provision and support; e.g. Joint Strategic Needs Assessment (JSNA), Pharmaceutical Needs Assessment (PNA), control of entry pharmacy contract applications to Health and Wellbeing Board from NHS England, Patient Group Directions, Locally Commissioned Services (prescribing data analysis, budget management, prescribing recharge etc; e.g. for drug misuse services, intrauterine contraceptive device (IUCD) service, smoking cessation, immunisations and vaccinations, sexual health, health checks), clinical data packs for networks, annual reports. NEL CSU London Commissioning Support Unit (CSU) - oversight of, and input to CSU contract and services for Interface and Secondary Care Prescribing Support (ISPS), High Cost Drugs Claims Management, IFR support service (drug element) – synergy of these services will need to be retained during the process of ‘in-housing’ this service into the SWL Alliance office during 2018-19.
SWL Alliance support teams
The shift from local to SW London IFR panels during 2018/19 will, in theory, free up some local capacity within the MO team who will no longer be involved in the process of decision making for this cohort of patients requiring non-commissioned medicines on exceptional basis, however ad hoc advice may still be sought and would be supported. The SWLA Medicines Optimisation collaborative work-streams to support the SWL Sustainability and Transformation Partnership (STP) through a five year (2016-21) plan involve close working with the SWL Alliance finance, project management, communications, corporate and quality teams, the latter team’s director being the MO senior responsible officer (SRO) for SWL. SWL Primary Care Team – for professional and contractual issues; e.g. prescribing elements of contracts, patient group directions, controlled drugs, community pharmacy locally commissioned services, control of entry, contract changes, also prioritisation and feedback in relationship to NHS England’s Medicines Optimisation Dashboard found at: https://www.england.nhs.uk/medicines/medicines-optimisation/dashboard/ NW London and commissioning colleagues from other geographies – liaison as required NHS England – primary care contracts, medical director, MO dashboard – liaison as required NICE, MHRA, Guy’s Medicines Information, Specialist Pharmacy Services, Regional MO Committees (RMOCs), NHSE MO Clinical Reference Group and other clinical support services – mix of national and pan-London levy funded support services for specialist NHS Digital, Rightcare, NHS Business Services Authority and other support services: IT initiatives such as electronic prescribing system (EPS), summary care records (SCR), Rightcare data packs, epact2 Provider partnerships: Acute trusts: As lead commissioner for acute services from Kingston Hospital Drug and Therapeutic Group (DTG), the relationship, particularly with the pharmacy team, needs to be close and
Kingston and Richmond CCG Medicines Optimisation Priorities 2018-21 Page 16 of 19
collaborative. During 2018/19 a review of associated contracts and other services supported by the hospital team (e.g. Your Healthcare) will be reviewed and assessed for opportunity with the new chief pharmacist at KHT for further improvements. Entry of new drugs into the Joint Formulary for Kingston is currently via the KHT Drug and Therapeutics Group where a member of the CCGs’ MO team, and ideally a local GP, attends to represent primary care. However the arrangement for management of this formulary is under review as the aspiration to broaden the scope to the whole of SW London is explored. Other SWL and Surrey acute trusts’ Drug and Therapeutic Committee (DTC) decisions are shared through our pharmacy networks to optimise resources. North West London Medicines Management Pharmacy Network and their NWL Joint Formulary arrangements are of particular relevance to Richmond CCG, but have some impact on Kingston and the other CCGs in SWL. The CCGs’ MO team have pharmacist representative here to influence where possible the alignment of policy between SWL and NWL which could otherwise cause confusion and / or inconsistency for prescribers, community pharmacies and patients. Mental health trust: Also changing within 2018/19 is the lead commissioner for the SWL St Georges mental health trust contract. This will move from Merton CCG to Kingston and Richmond CCGs. As a result of this, the K&R CCGs’ MO team will pick up the lead role for primary care pharmaceutical input to the trusts’ Drug and Therapeutics Committee, in addition to running the Mental Health Interface Prescribing Forum to ensure safe and appropriate entry of new drugs using critical appraisal skills, awareness of budget and care pathway impact and application of appropriate decision making principles and communications of any decisions to prescribers and community pharmacies. Liaison pre-and post-meeting with the GP clinical leads enables us to have a consistent Kingston and Richmond voice and to mutually understand the wider implication of proposals. During 2018/19, and working collaboratively across the six SWL CCGs with Sutton CCG as the lead, Pharmacy Integration Fund monies are being applied to support the MO needs of patients with learning disabilities in care homes. This would enable us to employ a core team of pharmacist support that would be hosted and managed by SWL St Georges mental health trust. We also hope to continue working with other mental healthcare providers where appropriate to improve patient access to medicines; e.g. CAMHS for adult ADHD, plus community paediatric pathways, East London Foundation Trust and Richmond Wellbeing Service.
General Practice
GP representation at K&R CCGs’ Medicines Optimisation Group
Support development and management of locally commissioned services for those delivered by GPs with medicines optimisation aspects (shared care drugs, anticoagulation, cardiology, diabetes) – aim to ensure suitable access to these services across the population
Liaise with Surrey and Sussex Local Medical Committee (LMC) when appropriate regarding GP MO issues
Community Pharmacy
Support development and management of locally commissioned services by primary care directorate for those delivered by community pharmacists (care home advice and palliative care out of hours) – aim to ensure suitable access to these services across the population
Regular attendance at Kingston and Richmond Local Pharmaceutical Committee (LPC) and informal meetings to take forward community pharmacy medicines optimisation issues
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Raise awareness of current services available / scope for future development through the 76 community pharmacy contractors in Kingston and Richmond to support primary care development; i.e. national essential, advanced and enhanced services such as New Medicines Reviews (NMS), Medicines Use Reviews (MUR), Digital Minor Illness Referral Service (DMIR)
Community Pharmacy representation at K&R CCGs’ Medicines Optimisation Group
Input as appropriate to the development and renewal of the Pharmaceutical Needs Assessment (PNA) as part of the Local Authorities Joint Strategic Needs Assessment (JSNA)
Community services
Align expectations for MO oversight of community service providers across Kingston and Richmond with regular meetings with leads for MO and input to the relevant Clinical, Quality, Review Group (CQRG) and provider contract – to cover (where applicable):
o Formularies – agreement and adherence by urgent care and community non-medical prescribers
o Promote use of ScriptSwitch or equivalent prescribing support tools o Oversight of MO issues in falls clinics, tissue viability service, etc
Care homes
Assurance on appropriate ordering, receipt of medicines, safe custody, handling, administration, record keeping and disposal of medicines
Support outcomes based commissioning of integrated community services
Input to intelligence networks as appropriate
Participate in the SWL MO collaborative workstream on invest to save models of medicines reviews and other interventions
Links with CQC, local inspectors, new staff etc
Interfaces between services
Ensure medicines optimisation is considered when services are moved from secondary to primary care; e.g. budgets, clinical, practical and medico-legal aspects
Interface prescribing policy (SWL / NWL)
Out of scope
Specialist medicines, including cancer drugs and controlled drugs monitoring (currently managed by NHS England)
Medicines incidents, serious incidents with MO components – investigated by providers, reported via CQRGs and only discussed by exception with MO Team
IT and IG issues, emergency planning, Patient Group Directions, etc – provider or corporate issues unless by specific arrangement
Other key stakeholders relationships to develop further
Patients, carers and their communities – lay membership of MOG and IFR panel, questionnaires on medicines optimisation issues, to develop opportunities for involvement in patient participation groups and further engagement events
Kingston and Richmond Healthwatch – currently via Local Pharmaceutical Committee input in patient questionnaire but to develop further
Pharmaceutical industry – joint working policy to be updated with the CCG Governance Lead, explore opportunities beyond LPP contracts and approved rebates. Also to outline codes of conduct that set out how CCGs commission or interact with commercial bodies (relating to medicines), and monitors them
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Practice-employed pharmacists, non-medical prescribers in primary and community care – to formalise this relationship and provide enhanced support
Registrars and new Kingston and Richmond prescribers – investigating best way to achieve this through existing education and training structures
Consider role of dentists, optometrists and appliance contractors locally and where a closer relationship might benefit patient care – to date has comprised of inclusion in Prescribing Update newsletter distribution where applicable
6. Annual Medicines Optimisation Team Work-plan: 2018/19 These appendices (separate documents) will be kept updated for review and oversight by the (soon to be created) Medicines Optimisation Group: Appendix 1: Medicines Optimisation Team management workplan
Appendix 2: Primary care prescribing quality and budget management
o Support for GP practice prescribing and medicines optimisation
o Non-GP primary care prescribing
o Other aspects of the primary care prescribing budget; GPs with extended roles; out of hours
services; primary care extended hours services; home oxygen; central drugs
Appendix 3: Secondary care medicines commissioning and STP-wide interface issues
Appendix 4: Commissioning support to CCG
7. References 1 NICE Quality standard (QS120), “Medicines optimisation”; (24 March 2016), nice.org.uk/guidance/qs120 2 NICE guideline [NG5] “Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes” (March 2015) https://www.nice.org.uk/guidance/ng5/ 3 The King's Fund “Polypharmacy and medicines optimisation – making it safe and sound”, (2013), https://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation 4 Department of Health and Social Care “Equality and excellence: liberating the NHS”; (2010) https://www.gov.uk/government/publications/liberating-the-nhs-white-paper 5 The King's Fund “Making shared decision-making a reality: no decision about me, without me”; (July 2011), https://www.kingsfund.org.uk/publications/making-shared-decision-making-reality 6 Department of Health and Social Care “NHS Constitution – the NHS belongs to us all” (March 2012, updated October 2015) https://www.gov.uk/government/publications/the-nhs-constitution-for-england 7 Greenhalgh T et al. “Evidence based medicine: a movement in crisis?”; (2014) BMJ 348:3725 8 Sackett D et al. Evidence based medicine: what it is and what it isn't. (1996) BMJ 312:71–72 9 “Medicines adherence: involving patients in decisions about prescribed medicines and supporting
adherence” (January 2009) Clinical guideline [CG76] https://www.nice.org.uk/guidance/cg76 10 “Good practice in prescribing and managing medicines and devices” (2013) ; General Medical
Council https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-
managing-medicines-and-devices 11 Department of Health, “Exploring the costs of unsafe care in the NHS”, 12 The Francis Report “The Mid Staffordshire NHS Foundation Trust Public Inquiry” (February 2013) http://webarchive.nationalarchives.gov.uk/20150407084231/http://www.midstaffspublicinquiry.com/report 13 The Berwick report (2013) Department of Health and Social Care “Berwick review into patient safety: Recommendations to improve patient safety in the NHS in England”. (August 2013) https://www.gov.uk/government/organisations/department-of-health-and-social-care
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14 Royal Pharmaceutical Society “Keeping patients safe when they transfer between care providers – getting the medicines right: good practice guidance for healthcare professions” (July 2011) https://www.nhs.uk/news/2011/07July/Documents/Transfer%20of%20Care%20Professional%20Guidance%20-%20FINAL.pdf 15 Medicines and Healthcare products Regulatory Agency (MHRA) and Commission on Human Medicines “Yellow Card reporting”, (1964) https://yellowcard.mhra.gov.uk 16 National Patient Safety Agency (NPSA); now NHS England “The National Reporting and Learning System (NRLS)” (2010) https://improvement.nhs.uk/resources/learning-from-patient-safety-incidents/ 17 NHS England and the MHRA “ Patient safety alert improving medication error reporting and learning” (March 2014), https://www.england.nhs.uk/wp-content/uploads/2014/03/psa-med-error.pdf 18 NHS England “ National Patient Safety Alerting System (NPSAS)” (March 2014), via the Central Alerting System (CAS) https://www.cas.mhra.gov.uk/Home.aspx 19 “The rising cost of medicines to the NHS: What’s the story?” (April 2018) King’s Fund
https://www.kingsfund.org.uk/sites/default/files/2018-04/Rising-cost-of-medicines.pdf 20 “CCG authorisation: the role of medicines management” (May 2012)
https://www.pcc-cic.org.uk/sites/default/files/articles/attachments/ccg_authorisation_-
_the_role_of_medicines_management_may_2012v1_0.pdf
