NHS Tayside Transformation Support Team: report

5. AAG Recommendation 5 – Medicines Management

"In relation to service development, the clear focus on optimal drug prescribing and wastage minimisation should continue unabated"

5.1 NHS Tayside's Assessment – Rating = Red

"The organisation has developed a revised NHS Tayside Drugs Formulary with measures to establish high levels of compliance, incorporating alignment with the NHS Lothian Joint Formulary and NHS Fife Formulary. Working with the Scottish Government Prescribing Support Unit, the Pharmacy Team has developed a range of dashboards and measures to ensure effective tracking of improvements, together with a software support kit to GP practices to facilitate the switch to cost effective prescribing choices and to achieve cost reductions. Through the Prescribing Management Group and weekly huddles, the focus has been on understanding and tackling variation in medicines use, building a robust infrastructure and analysis and review of the comparative prescribing practice and clinical engagement, to address variation and best practice.

In addition to the work on formulary compliance and variation in prescribing practice, there has also been a range of work on primary and secondary care improvement interventions, including pain pathway, anti-coagulation and biosimilars. There is evidence to demonstrate that this work is delivering ahead of trajectory for both primary and secondary care but is yet to provide a visible reduction in overall costs of prescribing. Additional work is required to explore further opportunities within respiratory prescribing, diabetes and polypharmacy, while implementing key changes in the chronic pain pathway and associated prescribing.

At this stage, given the need to evidence substantial change in overall prescribing costs and variation from the extensive range of actions and interventions, the status of this recommendation is assessed as 'Red'."

5.2 TST Comment – Rating = Red

The TST agrees that there should be a RAG rating of Red against recommendation 5 in recognition of the potential challenges of clinical engagement regarding the revised formulary processes, and the desire to understand better the variation in medicines use in comparison to the other Boards.

Activity since the publication of the AAG Staging report (27 ^th June 2017) has focussed on ensuring that there is a robust infrastructure to deliver the change required through: consolidation of the Prescribing Management Group ( PMG) and delivery teams; review of current comparative prescribing situation; agreement of interventions that align with existing strategies and that will deliver realistic efficiencies. Currently the focus has shifted towards: engagement of clinical groups; development of effective data presentation and further analysis of where variation is appropriate.

Of particular note is the focus on formulary review and compliance which fits with the national focus on more effective use of formularies, ultimately working towards the Single National Formulary. Formulary compliance interventions are focussing on direct oral anticoagulants (edoxaban); combination inhalers; long acting muscarinic agonists (tiotropium); sulfasalazines and melatonin. Though these are logical choices for focus there may be areas for further opportunity identified as work progresses.

Though no formulary compliance reports have been submitted with the AAG Action Plan Progress Report, examples have been shared at meetings with the SG Therapeutics Branch.

In addition to the formulary work, there are a range of primary and secondary care prescribing improvement interventions outlined within the 2017/18 Realistic Medicine projects. By 31 ^st June 2017 the primary care projects achieved 35.8% greater than the YTD target and the secondary care targets achieved 35.5% greater than the YTD target. The comparative assessment carried out by the Therapeutics branch shows that the work on respiratory prescribing demonstrates what NHS Tayside can achieve in terms of prescribing improvement.

In terms of future work, whilst recognising the challenges, the TST is keen to see the Board explore potential opportunities to include polypharmacy and diabetes improvement activities within the plan. Chronic pain prescribing is also a clear and challenging area requiring continued focus. Work now needs to focus on developing robust interventions to address any inappropriate variation. In particular, there is the need to address inappropriate use of lidocaine patches, for which NHS Tayside is a high prescriber compared with the rest of the UK. Work in this area has started to derive efficiencies.