NHS Tayside Transformation Support Team: second progress report

AAG Recommendation 5 – Medicines Management

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

NHS Tayside's Assessment

"The Prescribing Management Group functions as a collaborative between the three Tayside IJBs and NHS Tayside Board, to allocate, monitor and agree actions to make optimal use of the prescribing budget. The IJB and NHS Tayside prescribing forums have a responsibility to ensure actions are delivered to make certain their local prescribing performance is safe, clinically effective and cost effective and the identified opportunities set by PMG [Prescribing Management Group] are delivered. This is supported by the weekly prescribing huddles the purpose of which is to maintain momentum and pace surrounding the individual projects. Real-time weekly data reports are actively monitored at the weekly huddle to track progress.

An updated whole system Tayside Area Formulary ( TAF) was launched in April 2017 with the latest compliance figures showing a rate of over 90%, which is exceptional given the short timescale that the formulary has been implemented. This has been aided by the development and publication of formulary compliance dashboards. The dashboards were built in collaboration with NSS ISD [ NHS National Services Scotland's Information Services Division] and visualise performance at both a corporate level and individual General Practice level. The GP reports are shared monthly. In addition to showing compliance they highlight the top 10 non-formulary medicines prescribed with associated costs.

Using benchmarking intelligence, analysis and engagement, the Board recognised that it was an outlier in Scotland within the CNS BNF ^[12] chapter, specifically relating to Chronic Pain. The end-to-end pain pathway has been revised with engagement from both Secondary and Primary care clinicians and reviewing the potential for social prescribing as an alternative to medicines. Additional formulary work and actions were implemented with lidocaine plasters moved to being "restricted" and protocols introduced.

Engagement with the Scottish Government's Effective Prescribing and Therapeutics Branch during August 2017 identified the potential benefit of Poylpharmacy Medicine reviews, with a target of 3,500 set for the Board to achieve by March 2018. This is currently on trajectory with 1,787 reviews completed by the end of November 2017.

Polyphamacy Programme - To achieve the ambitions stated in Realistic Medicine, we have engaged with multiple stakeholders to identify five key strands of a polypharmacy transformation programme. These are:

• Introduction of standards for prescribing and feedback to prescribers on polypharmacy
• Further development of formulary implementation
• Phased introduction of social prescribing of health weight and physical activity interventions
• Introduction of a polypharmacy Locally Enhanced Service ^[13] ( LES) for community pharmacy
• Implementation of public engagement and communication programme

The Scottish Therapeutics Utility tool training has been delivered to all GP practices in NHS Tayside. This has enabled "prescribing champions" within each practice to improve the repeat prescribing processes, with a clear focus on waste and variation.

Since April 2017, Prescribing Support Technicians have been working with 11 GP practices which were identified as having the greatest variation on Cost Per Treated Patient within NHS Tayside. This additional dedicated support has focused on cost saving improvement plan with each of the practices. Of the cohort of 2,970 patients identified, 2,321 patients have had medicines switched, 121 stopped medicines and 512 patients excluded with the estimated benefit of £215,000pa achieved.

A public and staff communications plan has been developed and deployed during the last four months. This has been a multi-media approach and has included videos, social media and newsletters. Significantly over the period September/October 2017 every primary care prescription dispensed has had a patient leaflet with a focus on "Why your medicine has changed" and "Medicines Waste".

For the period to September 2017, compared to the same period in the previous year there has been a 0.5% decrease in the volume of items prescribed; this is five times better than the NHS Scotland average of 0.1% decrease over the same period. There is still variation between the three Health and Social Care Partnerships with all but one exceeding the Scottish average, Dundee and Perth & Kinross are showing the largest reduction of 0.8% on a like for like basis.

A PMG development session with attendance from Scottish Government Therapeutics Branch on 20 December 2017 reviewed the proposed plans for 2018/2019. The plans are being developed in conjunction with the North of Scotland Health Boards. Forward planning and horizon scanning is undertaken as part of the development of the associated financial plans.

Next Steps

The 3,500 polypharmacy reviews will be completed by March 2018 and continue into 2019. A number of new additional initiatives have been identified for progress within the period January - March; these include appropriate cost effective treatment for thyroid disorders and review of diabetes prescribing in line with the Diabetes strategy 2018 through continued; engagement with the Diabetes Managed Care Network. Further development of the diabetes work will look at the medication reviews for patients on multiple antidiabetic medication, and nutritional supplements for Care Homes. Work will continue to be progressed on respiratory, pain care pathways, formulary compliance and will also focus on secondary care."

TST comment

NHS Tayside has continued to receive support and challenge from the Scottish Government's Effective Prescribing and Therapeutics Branch and although it has taken some time to reach agreement on key priorities, work is now well underway across a range of fronts.

As highlighted above, NHS Tayside is on target in relation to the delivery of polypharmacy reviews and good progress has been made with the development and implementation of the Tayside Formulary. Both the progress made and the anticipated impact on the Board's year-end financial position is welcomed.

In terms of the impact of this work, because the savings trajectory represents the cumulative delivery of interventions across the financial year, it is weighted towards the year end when the bulk of the savings are expected to be seen. This aligns with other NHS Boards' prescribing plans. However, there is an inevitable risk associated with this situation, since if the expected impact is not coming through, there will be very limited opportunity to undertake corrective action. This will require the Board to closely monitor progress and reflect on whether this can be addressed in future years.

Prescribing data shows that there is a variation across the three HSCPs areas of Dundee, Perth and Kinross and Angus, and, in order to address any unwarranted variation, strong leadership and joint working is required. To this end it is noted that NHS Tayside has implemented an organisation wide (including IJBs) Prescribing Management Group ( PMG) to ensure a whole system approach is taken to this issue. It will be essential for NHS Tayside and the Integrated Joint Boards' ( IJB) prescribing teams to continue to build on their relationship and set shared objectives to address long term prescribing issues. This should include developing the role of multidisciplinary team members in addressing prescribing issues.

Medical engagement was highlighted early on as an issue to be addressed and we have seen indications that this has improved. The majority of the changes to date have been driven by pharmacy colleagues. Continuing wider team (medical, nursing management) work and engagement will be necessary for sustainability and forward planning.

Looking to future years, as a key cost driver, this will continue to be a priority area for improvement and there is still a lot of work to be done. A key focus going forward should be on establishing collaborative agreement of actions between the Health and Social Care Partnerships ( HSCPs) and the Board in tackling prescribing issues. The majority of work to date has been targeted in primary care and there has been evidence of good engagement. Going forward there needs to be a greater focus on addressing secondary care prescribing including improved reporting of the impact.

NHS Tayside's prescribing team must continue to identify prescribing improvement practices and support this with quantitative data reports. It is important that the Board puts plans in place now to address potential prescribing pressures going forward. Recognising that these plans will encompass a number of interventions, the Board should ensure it achieves a suitable balance between low risk areas such as improvement in prescribing to reduce variation alongside monitoring the impact of price changes. Areas that have been highlighted for attention by the Effective Prescribing and Therapeutics Branch include polypharmacy, pain prescribing (including lidocaine patches and pregabalin), respiratory, diabetes and secondary care prescribing all of which are included in NHS Tayside's plans for 2018/2019.

TST rating in September 2017 = Red
TST rating in January 2018 = Amber