NHS Tayside Assurance and Advisory Group: third progress report

Annex B: AAG Recommendation 5: Prescribing

Report from the Scottish Government Effective Prescribing and Therapeutics Team

Report Author: Alpana Mair, Head of Effective Prescribing and Therapeutics

Situation and Background

Due to its financial position NHS Tayside has been provided with support to improve its management of key areas of expenditure with prescribing in primary and secondary care seen as a priority area for review and intervention. Effective Prescribing & Therapeutics Branch (EP&TB) have been working with colleagues in NHS Tayside to review their prescribing action plans for 2017/18. In October 2018 EP & TB were also asked to review plans for 2018/19, and review of efficiency achievements for 2017/18. This paper summarises the EP&TB view of a number of submissions from the NHS Tayside Prescribing Management Group (PMG) in November 2018.

The drugs budget for 2018/19 and the efficiency target have been set by NHS Tayside with collaboration across primary and secondary care with finance and clinical teams and include horizon scanning and projected growth.

Assessment

1. Prescribing (costs) position 2017/18.

• The efficiency target for primary care prescribing was £3.5m of which £2.7m (76%) has been achieved. Two key areas contributed to the short fall: off-patent benefits for four drugs were not realised and there were delays in establishing the oral nutritional supplements (ONS) work. NHS Tayside understands that reliance on benefits deriving from medicines coming off-patent remains a high risk strategy, but they are included to provide a comprehensive assessment. These should be realised in 2018/19.
• The ONS work is a medium term intervention which should deliver in the medium to long term. Continued focus should be on the review of patients' needs for ONS which should build on the progress made for nursing home patients led by dietetics.
• Polypharmacy work included completion of 5,641 reviews. This is likely to correlate with the overall volume reduction in primary care medicines dispensed by 0.26%, which is a fall above the Scottish average. Momentum and pace should be built on this success.
• Refreshed formulary compliance reporting commenced with quarter one data for 2017/18. This has resulted in an improving position, which is further confirmed by the 2018/19 quarter one data.
• Quality Prescribing for Respiratory - led by the Respiratory Managed Clinical Network (MCN), the focus here is on decreasing the volume of corticosteroid inhalers, which has translated into significant efficiency savings for NHS Tayside. This more restricted choice of inhalers is an important intervention to improve patient safety, by reducing steroid burden. It also generates efficiencies and is an area that the Board should continue to address.
• Quality Prescribing for Diabetes was included for 2017/18 as gliptin reviews, which delivered limited efficiencies as it was still in the planning stage during 2017/18. The Diabetes MCN were engaged throughout to support the development of other effective medicines interventions for implementation in 2018/19 for managing patients with diabetes.
• Quality Prescribing for Chronic Pain was included for 2017/18 as lidocaine use review and off-patent benefits from pregabalin. There was over achievement against the lidocaine use target last year. More recent data shows that only 5% of patients prescribed lidocaine are using it long term, which suggests significant opportunity for further efficiencies.
• No finance update has been provided on secondary care prescribing.

2. Prescribing (costs) plan 2018/19

• The PMG presented a Prescribing Efficiency Plan for 2-18/19 which set a target of £5.3m. The year-to-date target of £1.6m has already been exceeded at £1.7m. There are some areas, however, that have not delivered savings to date or where the trajectories have not been achieved. The range of interventions has built on those from 2017/18 and consideration will now need to be given to other actions that may be needed to ensure there is not a shortfall.
• Certain key 2017/18 interventions remain relevant as the work needs more time to progress and deliver. To help coordinate the interventions, arrangements have been established to ensure both primary care and secondary care prescribing reports are submitted to the Performance and Resources Committee for scrutiny on a quarterly basis, starting in November 2018. This may support improved communication and engagement with clinicians and reporting to the Board.
• Polypharmacy reviews are being progressed at pace in 2018/19 and it is anticipated that this will generate a further correlated fall in total medicine volumes by the end of the year.
• Formulary compliance has been shown to improve already in 2018/19 from 90.73% to 91.93%. Improved practice formulary compliance reporting and introduction of the electronic formulary will help this position.
• Quality Prescribing for Respiratory is included in 2018/19 and, through the leadership of the Respiratory MCN, the financial target is likely to be exceeded. The group may want to review this target.
• Quality Prescribing for Diabetes is included with further gliptin reviews. We are aware that the Diabetes MCN has already engaged with the diabetes prescribing strategy but further planning is required, due to the complex nature of the interventions required to deliver improvements. We would recommend that the Diabetes MCN develop a clear action plan to address the opportunities and widen the scope
• Quality Prescribing for Chronic Pain seems to have made more progress in some IJB areas than in others. The lessons from those performing well should be shared with the other areas.
• Secondary care work continues with a challenge to engage with clinicians. The new governance structure and operational structure aims to improve this. PMG is now co-chaired by an Associate Medical Director from secondary care, and this should strengthen the dialogue between teams. In addition, the Board has stated that they are awaiting implementation of HEPMA. In the absence of this, secondary care indicators have been developed for use which uses the HMUD data and the board should consider using this to drive improvements locally.

Recommendations

In summary, good progress has been made against the established targets so far this year. The PMG should continue to focus its efficiency targets and plans on long term gains such as the review of medication which is starting to have an effect on the volume growth, and which also has the benefit of clinical engagement. They should continue to ensure robust modelling and reporting of all factors affecting the final year outturn position.

The new reporting structure that has been put in place in secondary care should make use of the available data and ensure that the work is supported by written reports at review meetings. All reports should feed into the newly established Performance and Resources Committee for scrutiny, on a quarterly basis.

Below is a summary of key recommendations:

• Continue the work that has commenced in 2018/19 such as the review of appropriate prescribing both in the polypharmacy reviews and the reviews being undertaken by therapeutics areas.
• Continue to focus the ONS work on review of patients needing treatment.
• Build on the framework that has now been set up for secondary care to address prescribing and support this with data-driven reports on progress in line with those produced by the primary care group.
• Build on the work that has been carried out with the Respiratory MCN.
• Consider widening the scope of the diabetes reviews to include areas other than gliptins; such as a review of people over 75 who are on sulphonlyureas. This is a patient safety issue. It is important to recognise the clinical skills required to perform these reviews may be in limited supply.
• There are some areas identified where the efficiencies projected may not be realised in the current year and the Board should consider plans to address these areas.
• Ensure that reporting frameworks and information that has been helpful in promoting clinical engagement and driving change in primary care are shared with other IJB areas.