July 2018

Clare Howard FFRPS FRPharmS Clinical Lead

Medicines Optimisation PINCER in Wessex

Innovation Adoption in the NHS

Back at the beginning………… • In 2014, we started the Wessex Medicines Optimisation

Programme.

• We based the programme on areas of the NHS England Medicines Optimisation Dashboard where we felt we could improve or where we had a strong evidence base to implement an innovation.

• PINCER met that criteria. It had been shown in a Multicentre Cluster Randomised Trial to lead to demonstrable change in patient safety.

• It was recommended in NICE Guideline NG5

PINCER IN WESSEX Recently we have had a SoS commissioned review of medication error. They found 66 million potentially clinically significant errors per year, 71% of which in primary care. Prescribing in primary care accounts for 33.9% of all potentially significant errors.

Progress • By Dec 2016 over 150 practice staff has been trained ( GPs ,

Nurses , Pharmacists, Practice managers) • 235 practices using PINCER in 7 CCGs ( and the remaining 2

CCGs have just gone live ) • Then we got a grant for a facilitator to support remaining

practices. Chris visits CCGs and Practices.

Key themes • A CQUIN is very helpful in encouraging practices to download. • Practices and CCGs don’t always use the PRIMIS helpline to

resolve issues. There is a tendency to sit on queries. • ICE data in practice systems is an issue. • The CCG is instrumental to change. • Practices now need support to use the data and do their

action plans. • Still some concerns about uploading to CHART.

Number of Practice downloads of PINCER tool by quarter 2016/17

• Still have issues with Practices’ fears about uploading to CHART.

• CCG Medicines Management Teams are instrumental in either supporting this or not.

• You need to keep up the momentum.

• Phase 1 has been about using the tools and downloading the data.

• Phase 2 will be about using the data properly, action plans to address the findings and roll out of PINCER 3.

• We have just carried out enhanced PINCER training covering - Root cause analysis, high risk meds, QI methodology, Fishbone, five WHYs, actions from data.

We aren’t perfect…

• Our aim is to deploy full implementation of PINCER or PINCER 3 and to be confident that the findings in East Midlands can be used to show benefit in Wessex.

• Ultimately its about reducing the level harm from medicines that we expose our patients to. Need to remember that!

• AHSNs have put this as part of our bid for license renewal. Wessex and EM will continue. Yorkshire and Humber, GM and Oxford have stated their interest in being early wave adopters of PINCER.

• We (AHSNs and PRIMIS team) are sitting on a huge wealth of

data but also experience and expertise about how to help practices deliver real improvement.

Final destination

OUTCOME: GI BLEED

Query 1: In a patient aged ≥65 years prescription of an oral NSAID without co-

prescription of an ulcer-healing drug

Query 2: Prescription of an oral NSAID, without co-prescription of an ulcer-healing drug,

to a patient with a history of peptic ulceration

Query 3: Prescription of an antiplatelet drug to a patient with previous peptic ulcer or GI

bleed without co-prescription of an ulcer-healing drug

Query 4: Prescription of warfarin or a New oral anti-coagulant (NOAC) and an antiplatelet

in combination without co-prescription of an ulcer-healing drug

Query 5: Prescription of warfarin or NOAC in combination with an oral NSAID

Query 6: Prescription of aspirin in combination with another antiplatelet drug without

co-prescription of an ulcer-healing drug

OUTCOME: EXACERBATION OF ASTHMA

Query 1: Prescription of a non-selective beta-blocker to a patient with asthma

Query 2: Prescription of a long-acting beta-2 agonist inhaler (excluding combination

products containing inhaled corticosteroid) to a patient with asthma who is not also

prescribed an inhaled corticosteroid

OUTCOME: HEART FAILURE

Query 1: Prescription of an oral NSAID to a patient with heart failure

OUTCOME: STROKE

Query 1: Prescription of antipsychotics for >6weeks in a patient aged ≥65 years with

dementia but not psychosis

OUTCOME: KIDNEY INJURY

Query 1: Prescription of an oral NSAID to a patient with chronic renal failure with an

eGFR <45

Questions?