Medicines Optimisation Strategy 2016-20

Medicines Optimisation Strategy 2016-20 Page 2 of 29

“Given that medicines remain the most common therapeutic intervention

in healthcare, and colleagues in research and the broad pharmaceutical

industry have worked hard to discover and develop safe and effective

medicines, we must all work even harder together to ensure that

individual patients and society gets as much value out of that effort as

possible, and resources are used wisely and effectively.”

Medicines Optimisation: Helping patients to make the most of medicines

Good practice guidance for healthcare professionals in England

Sir Bruce Keogh National Medical Director NHS England

Jane Cummings Chief Nursing Officer England

Dr Keith Ridge Chief Pharmaceutical Officer

May 2013

Medicines Optimisation Strategy 2016 -2020 3

Contents

1 Executive Summary 4

2 Background 6

2.1 National Drivers 7

2.2 Local Drivers 8

2.3 B&NES Medicines Use 11

3 Our Approach to Medicines Optimisation 13

4 Our Priorities 15

4.1 Operating Plan 26

5 Workforce 27

6 Conclusion 28

Appendix 1: Plan on a Page 29

Medicines Optimisation Strategy 2016-20 Page 4 of 29

1. Executive Summary

Bath and North East Somerset broadly has a healthy population but it does have areas of

deprivation and areas of clinical challenge where the CCG could improve outcomes for its

residents.

There has been a long culture of good medicines management over the years in BaNES.

Current use of medicines benchmarks well. In more recent years our GP practices have

engaged well with a range of activities with embedded practice pharmacists helping to

deliver good medicines optimisation.

The current financial climate is challenging for the NHS with significant pressures on the

health and social care system through a combination of:

Demographics – increase in over 85s

New technologies and medicines

Diseases of modern lifestyles

Consumer expectations Optimising medicines use to support a sustainable system and give the best value has never been more important. This strategy set out five key approaches to medicine optimisation for BaNES:

1. We will support local decision making to commission safe, effective and evidence-based medicines use within pathways

2. We will promote a safety culture around medicines use including effective use of

national and local reporting systems to report and learn from medication safety incidents

3. We will maximise care gains across health and social care by innovative

management of medicines at the best obtainable value

4. We will support workforce development activity to create a sustainable healthcare system with particular emphasis on the pharmacy workforce and medication review

5. We will use clinical audit , education and quality improvement to improve safe

and effective care and reduce variation in health outcomes

Medicines Optimisation Strategy 2016 -2020 5

Through consultation with the CCG Board, our patient public involvement group “Your Health Your Voice” and with the Medicines Team we have identified ten top priorities which are aligned to both the CCG and National priorities. This strategy set out ten key priorities for the next four years. The priorities are: 1. Diabetes Care – optimise the medicines we use 2. Frail Elderly - commission clinical pharmacy medicines reviews for all frail elderly 3. Antimicrobial Stewardship – lead a collaborative and work programme to support

this national priority

4. Improving Value from our Medicines - ensuring maximum benefit from investment

through a focus on outcomes

5. Musculoskeletal - support the review of rheumatology and pain medicines pathways 6. Workforce development - maximise the use of pharmacy staff in the health

community 7. Acute Kidney Injury – implement the national programme for primary care Acute

Kidney Injury and optimise management of patients with Chronic Kidney Disease 8. Stroke Prevention and VTE – optimise the medicines we use 9. Safer Care Culture – establish a local reporting and learning culture in primary care

including use of the National Reporting and Learning System (NRLS) GP eForm 10. Mental Health – optimise the medicines we use for this vulnerable group

Medicines Optimisation Strategy 2016-20 Page 6 of 29

2. Background

Medicines are the most common intervention and biggest cost after staff in healthcare.

Getting the most from medicines for both patients and the NHS is becoming increasingly

important as more people are taking more medicines. Medicines prevent, treat or manage

many illnesses or conditions.

This section of the report sets out some key national and local policy drivers and data

about BaNES medicines use that provides the context for the CCG’s medicines

optimisation strategy.

There are a number of concerns about England’s use of medicines:

30-50%* of medicines are not taken as intended and patients have insufficient

information to support taking medicines

5-8%* of hospital admissions are due to preventable adverse reactions to

medicines

Medication errors have risen as a proportion of all errors reported from 8.19% to

11.02% from 2005 to 2010

Medication wastage in England per year is approximately £300 million of which 50%

is estimated to be preventable

There is a real threat to healthcare from antibiotic resistance

*Range comes from different studies in the literature

Medicines Optimisation Strategy 2016 -2020 7

2.1 National Policy Drivers

There are many National Policy drivers that should impact on a CCG medicines strategy.

Table 1 highlights some of the key drivers and outline the potential impact for the CCG

Medicines strategy.

Driver Impact for medicines strategy

NHS Five Year

Forward View

prevention of disease and public health

optimisation of medicines use to improved efficiency, reduced demand and reduced demand

2016/17 NHS

Planning Guidance

help deliver the must dos: financial balance, sustainable

quality general practice, improved access to A&E

NHS Outcomes

Framework

(Domains)

safe use of medicines (4 and 5)

evidence based use of medicines (1, 2 and 3)

equality and access to medicines (1, 2, 3 and 4)

patients experience with their medicines ( 1, 2, 3, 4 and 5)

NHS Constitution the right to receive treatment that is appropriate

the right to drugs that have been recommended by NICE

the right to expect local decisions on funding of drugs

the right to an explanation when NHS decides not to fund

Royal

Pharmaceutical

Society: Medicines

Optimisation

aim to understand the patient experience

evidence based choice of medicines

ensure medicines use is as safe as possible

make medicines optimisation routine part of practice

NICE Guideline-

Medicines

Optimisation

systems for identifying, reporting and learning from

medicines incidents

communication when in settings of care

medicines Reconciliation

medicines Review

self-management plans

patient decision aids

clinical decision support

cross organisation working

Lord Carter’s interim

report on productivity

in the NHS

In 2012/13, expenditure on hospital medicines was over £6.5

billion, accounting for 36.5% of total NHS medicines expenditure, a

rise of 11% over the previous year. Two of the key obstacles

identified: lack of quality data & absence of metrics to measure

relative performance

Medicines Optimisation Strategy 2016-20 Page 8 of 29

Clinical pharmacists

pilot & the workforce

10 point plan

£31m pilot will test out this new patient-facing role in which

clinical pharmacists have extended responsibility in General

practice

Antimicrobial

Resistance (AMR)

Strategy 2013/18 and

annual progress

report and

implementation plan

AMR is a serious global public health concern

without effective antibiotics; minor surgery and routine

operations become high risk procedures

25,000 people die each year in Europe as a result of

infections caused by resistant bacteria

without effective antimicrobials, the rate of post-operative

infection will be greater

Table 1: National Policy Drivers impact on Medicines Strategy

2.2 Local Policy Drivers Seizing Opportunities - A Five Year Strategy for Bath and North East Somerset

2014/15 to 2018/19

This document sets out the Five Year CCG’s vision of ‘Healthier, Stronger, Together’.

The CCG have prioritised six key transformational projects which are summarised in table

2 with the identified medicines focus for each project.

In addition to these six transformational priorities Seizing Opportunities anticipates that the

financial challenge faced by the whole BaNES health economy over the five years will be

in the region of £50m. Reviewing medicines use from a cost effectiveness perspective is a

key area to support meeting the financial challenge. BaNES however already benchmarks

very well on its cost effective use of medicines compared to other CCGs. (see section 2.3)

Other key local policy drivers are summarised in table 3 with an indication of how they impact on the Medicines Strategy.

Medicines Optimisation Strategy 2016 -2020 9

Transformational Project Medicines Focus

Prevention/ self-care

Increase the focus on prevention, self-

care and personal responsibility

- reviewing the treatments for minor ailments

and encourage transitioning to self-care

- linkage to diabetes self-management and

appropriate use of medication and disease

monitoring

- encouraging development of Healthy Living

Pharmacies

Long Term Conditions

(Initially Diabetes)

Improve the coordination of holistic,

multidisciplinary long term condition

management

- optimisation of diabetes type 2 medicines

- improve use of blood glucose testing

- support new models of delivery

- maximise benefits of the community

pharmacy contract to support people with

long term medication

Stable and responsive urgent care

system

Create a stable, sustainable system

- reduce demand for medicines in the urgent

care system through commissioning services

in community pharmacy

- support the urgent care providers to be able

to sign post medicines requests to the

community pharmacy network

Frail older people pathways

Commission integrated, safe and

compassionate pathways

- commission medicine review in care home

patients

- commission medicines review for patients at

risk of emergency admission

- maximise benefits of the community

pharmacy contract to support medicines use

Musculoskeletal Pathways

Redesign pathways to achieve clinically

effective services

- support redesign of analgesic pathway

- support redesign of rheumatology pathway

Interoperability of IT systems

Achieve interoperability across the

health and social care system

- support IT clinical decision systems for

prescribing

- support good transfer of information and

visibility of information on medicines across

the system

- encourage utilisation of electronic

prescribing and ordering systems

- support integration of new technologies

Table 2: BaNES CCG Transformation projects and their Medicines Focus

Medicines Optimisation Strategy 2016-20 Page 10 of 29

Local Policy Driver Impact for medicines strategy

Joint Health and Wellbeing

Strategy

contains key demographic data

describes BaNES as a generally healthy and relatively wealthy population that has some of the happiest people in the country, but with pockets of deprivation

Emerging Primary Care

Strategy

vision: delivery at scale

enablers: sustainable model of primary care, enhanced services delivered 7 days a week

approach: cluster working / MDT model, Out of hospital care

B&NES Community Service

Review: your care your way

Outline Business Case

the proposed model is innovative and bold and

potentially an expanded range of medicines

optimisation services could be provided through

the community services model that emerges

Pharmaceutical Needs

Assessment (PNA)

The PNA identified some key findings which include:

current provision appears to be sufficient for the

Bath and Norton Radstock GP clusters

there is a gap in the provision for the

Chew/Keynsham GP cluster in the evenings

after 18:30 and on Sundays

current provision will cope with the demand

from new populations for the coming few years

Table 3: Local Policy Drivers impact on Medicines Strategy

Medicines Optimisation Strategy 2016 -2020 11

2.3 Bath and North East Somerset Medicine Use

When the CCG’s prescribing costs are compared with the other CCGs (Graph 1) adjusted

for population factors using cost per weighted prescribing units it can be seen that BaNES

is in the lowest 10% of costs across England with the 8th lowest costs in the South of

England and the lowest costs in the South West (Graph 2).

Graph 1: NHS Information Portal Financial Comparisons (June- August 2015) all CCGs

Graph 2: NHS Information Portal Financial Comparisons (June- August 2015) CCGs South of England

Medicines Optimisation Strategy 2016-20 Page 12 of 29

There are a number of comparator graphs from the NHS Information Portal produced by

the NHS Business Services Authority which can be used to compare prescribing against a

therapeutic range of comparators against other CCGs in England. Indicators that relate to

some of the themes mentioned above have been summarised in Table 4.

Comparator BaNES Performance

in England

Comments on indicator

3 day antibiotics in top performing 15% appropriate lengths of treatment for urinary

tract infections

Volume of antibiotics in top performing 13% conserving our antibiotic usage to protect

against antibiotic resistance

Choice of antibiotics in the worse

performing 5%

reducing the risk of CDiff Infections -there

have been significant improvements on this

Choice of Insulin’s in top performing 25% using the most cost effective insulins

Choice of Type 2 oral

antidiabetic agents

in top performing 15% using the most cost effective diabetes

agents for Type 2

Volume of NSAIDS

(analgesic)

in top performing 45% appropriate use of NSAIDs the assumption

is that lower usage is more appropriate

Choice of NSAIDs

(analgesic)

in top performing 45% using the medicines in the class of drugs

with the better safety profile

Table 4: commentary on performance on various prescribing indicators from NHS Information Portal

June –August 2015

NHS England launched the Medicines Optimisation Dashboard a dashboard in June 2014

which has been revised to help CCGs to understand how well their local populations are

being supported, to optimise medicines use and inform local planning. The dashboard was

updated in 2015 and contains over 40 indicators. An analysis of BaNES CCG shows:

good uptake of electronic prescribing

poor uptake of Medicines Use Reviews (MURs) by community pharmacy

average uptake of New Medicines Service (NMS) by community pharmacy

average performance for optimisation of medicines for Atrial Fibrillation

poor optimisation of medicines for heart failure

good optimisation of medicines for diabetes, asthma and osteoarthritis

variable performance on optimising medicines for chronic obstructive pulmonary disease (COPD)

Medicines Optimisation Strategy 2016 -2020 13

3. Our approach to Medicines Optimisation in BaNES

The themes and information in the previous sections of the strategy were presented to our

CCG Board, our patient public involvement group “Your Health, Your Voice” and the CCG

Medicines Team. These consultation sessions led to reflections on the approach and

priorities for the CCG Medicines Strategy.

CCG Board

The session was supportive of the approach and priorities.

The Board recognised the need to support clinical pharmacists within primary care

to create a more sustainable model for the future

The Board recognised the importance of engagement with prescribers and

recognised the need to build on the current structure of practice pharmacists

Your Health, Your Voice

There was a broad range of participants at the session

There was a real interest in how GPs work and strong support of the themes

identified

The group were interested in supporting more feedback on patient experience

CCG Medicines Team

Several sessions with the team developed the priorities in more detail

There was a recognition of the limited national work and tools on understanding and

measuring patient experience of medicines usage

There was a real passion in the team to engage with the many potential agendas

and a recognition that there is a limited capacity to deliver an ambitious programme

The team were keen to have a worked up operational plan to support the strategy at

the earliest opportunity

Medicines Optimisation Strategy 2016-20 Page 14 of 29

The five key elements to BaNES approach to Medicines Optimisation for the next four

years are:

We will support local decision making to commission safe, effective and evidence based medicines use within pathways

We will promote a safety culture around medicines use: including effective use of national and local reporting systems to report, and learn from medication safety incidents

We will maximise care gains across health and social care by innovative management of medicines at the best obtainable value

We will support workforce development activity to create a sustainable healthcare system, with particular emphasis on the pharmacy workforce within GP practices and medication review

We will use clinical audit , education and quality improvement to improve safe and effective care and reduce variation in health outcomes

Medicines Optimisation Strategy 2016 -2020 15

4. Our Priorities

Through consultation with the CCG Board, our patient public involvement group “Your

Health Your Voice” and with the Medicines Team we have identified ten top priorities:

1. Diabetes Care

Optimise the medicines we use

2. Frail elderly

Commission clinical pharmacy medicine reviews for all

frail elderly

3. Antimicrobial Stewardship

Establish a BaNES Antimicrobial Resistance Strategic

Collaborative to implement the UK AMR Strategy

4. Improving Value from Medicines

Ensure maximum benefit from the investment with a

focus on Primary Care and High Cost Secondary Care

5. Musculoskeletal

Support the review of rheumatology and pain medicines

6. Workforce development

Maximise the use of clinical, community and other

pharmacists to support a sustainable future model

7. Acute Kidney Injury (AKI)

Implement programme for primary care AKI and optimise

management of patients with Chronic Kidney Disease

8. Stroke prevention & venous thromboembolism

Continue to support optimising medicines in therapeutics

9. Support the development of a safer care culture

Establish a local reporting and learning culture in primary

care including use of the NRLS GP eForm.

10. Mental Health

Support the optimisation of medicines in this vulnerable

group

Medicines Optimisation Strategy 2016-20 Page 16 of 29

Priority 1: Diabetes Care WHY?

National Diabetes is the long term condition with the fastest growing

prevalence

UK prevalence of 6.2% of adults

1 in 20 people in the UK have diabetes

3.9 million living with diabetes in the UK

Estimated to be 5 million by 2025

90% of these cases are Type 2 diabetes

£10 billion a year spent by NHS on diabetes which is 10% of

the NHS budget

Local

Diabetes is CCG priority area

BaNES prevalence 6.5% of adults - rising to 7.1% by 2025

Total prescribing costs for medicines and devices associated

with blood glucose lowering and monitoring 6 months April –

September 2015/2016 was £1.2 million an increase of 7.9%

(£88,440) versus the same period 2014/15

Cost of consumables (test strips, lancets, needles) equates

to £550k 26% of diabetes medicine spend

Medicine Issues

Newly published NICE NG28

10% of NHS prescribing costs, £800 million per year on

medicines and devices associated with blood glucose

lowering and monitoring

Escalating prescribing costs, 8.2% increase from 2013/14 to

2014/15, 69% from 2005/2006 to 2014/15

There is additional unqualified spend on medicines and

treatments associated with preventing and treating the

complications of diabetes

Wide variance in prescribing practice and cost between

areas

Multiple NICE Guidance relevant to Diabetes

http://pathways.nice.org.uk/pathways/diabetes

WHAT?

Key focus for next four

years

Optimisation of the medicines we use. Aim is excellent outcomes

and safe use of our medicines.

Work with service redesign programme to have a well-

defined medicines pathway through audit and review

Optimise:

- New oral agents

- Insulin

- Cardiovascular medications for Diabetics

- Test strips and other consumables

Medicines Optimisation Strategy 2016 -2020 17

Priority 2: Frail elderly WHY?

National In 2014, 17.6% of the population were 65 or older. By 2035 this is estimated to rise to 23%. Older people are at higher risk of developing chronic health conditions; depression affects 1 in 5 adults > 65y living in the community

Older people: independence & well being NICE NG32

Care homes – NICE SC1 managing medicines in care homes

Pharmacy & care homes GPhC report Dec 15

From reports and a range of studies over the past 6 years, there are clear concerns about current practice of medicines use in care home environments

Dementia affects 1.3% of the entire UK population, and 7.1% of the population aged 65 or older. The number of people with dementia in the UK is forecast to increase to over 1 million by 2025 and over 2 million by 2051

National Dementia Strategy,

NICE dementia guideline QS30

Falls prevention - NICE CG161. Falls and fractures in people aged 65 and over account for over 4 million hospital bed days each year in England. The healthcare cost associated with fragility fractures is estimated at £2 billion a year.

Malnutrition - NICE CG32: 5% of the elderly are underweight (BMI <20kg/m2) rising to 9% for those with chronic diseases. 30% of admissions to acute hospitals and care homes are at risk on the Malnutrition Universal Screening Tool

Care of dying NICE NG31

Local

Population growth: expected changes across the BaNES CCG age profile by 2021 with a 30% increase in the population over 70

Care home LES currently in place – pharmacist involvement in medication reviews

Reducing antipsychotics in dementia – audited 2012

Focus on admission avoidance, care for frail elderly at home

Medicine Issues

Polypharmacy / deprescribing guidance e.g. STOPP START criteria, AWMSG

CHUMS Care homes’ use of medicines study

Medication review and falls risk

Appropriate use and education of care staff on sip feeds

WHAT?

Key focus for next four years

Develop models of delivering care to their patient group e.g. integrated clinical pharmacists

Medicines management shared learning

NICE managing medicines for people receiving social care due Mar 2017 implications for services

Improving patient involvement in decisions

Improve support to help people improve adherence

Medicines Optimisation Strategy 2016-20 Page 18 of 29

Priority 3: Antimicrobial Stewardship WHY?

National

“If we fail to act, we are looking at an almost

unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine"

David Cameron,

UK Prime Minister

Antimicrobial resistance (AMR) is an increasing global and national problem, predicted 10 million extra global deaths a year by 2050. Very few new antibiotics have been developed in the past 30 years and very few are in development. Stewardship of existing antibiotics is essential to allow us to continue to successfully treat infections. 25,000 deaths pa occur in Europe due to resistant infections.

UK 5 Year Antimicrobial Resistance Strategy 2013 to 2018

Progress report on the UK 5 year AMR strategy: 2014

Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use NG15 August 2015

AMR is a high priority in delivering the Forward View: NHS Planning guidance 2016/17 – 2020/21

Local

BaNES CCG has worked over the past 18 months to improve the use of antibiotics. A whole economy wide collaborative approach is required to implement the key objectives within the UK 5 Year AMR Strategy: to improve the prevention of infection, increase peoples understanding of the risks that resistant infections bring, and encourage behaviour change to reduce the inappropriate use of antibiotics.

80% of antibiotic use is in primary care and the community, and half of this is for respiratory infections, many of which are self-limiting and can be managed with supported self-care.

Maps onto health economy approach to infection including Vaccination, Sepsis, AKI, Continence, Self-care, Nursing Home Care, Diabetic care, Healthcare Acquired Infections

Medicine Issues

The 2015-16 BaNES Quality Premium dashboard shows reducing antibacterial prescribing in primary care, but prescribing of broad spectrum antibiotics remains inappropriately high at both a CCG and GP practice level

The national Sepsis CQUIN is driving increased use of antimicrobials in acute providers

New health economy wide Infection Management pathway guidance is a priority

WHAT?

Key focus for next four years

The establishment of a BaNES Antimicrobial Resistance Strategic Collaborative, chaired by the CCG Clinical Chair, reporting to the Health and Wellbeing Board. Membership would include wide representation from NHS and private health care providers, public health, PHE, academic and clinical networks, patient and public representation, and local healthcare professional representation. The purpose of the Collaborative is local implementation of the UK 5 Year AMR Strategy key objectives: - Improving infection prevention and control practices - Optimising prescribing practice - Professional education, training and public engagement - Developing new drugs, treatments and diagnostics - Better access to and use of surveillance data

Medicines Optimisation Strategy 2016 -2020 19

Priority 4: Improving Best Value from Medicines WHY?

National £15.5 billion total estimated NHS expenditure on medicines for 2014-15

£6.7 billion overall hospital expenditure on medicines which was 42.9 % of the total

7.8% overall increase for 2014-15 over the previous year

15.4% rise in cost of hospital medicines from 2013-14 to 2014-15

3.2% rise in cost of in Primary Care from 2013-14 to 2014-15

Local

£29.65 million medicines spend for BaNES CCG (13% of total CCG spend)

£24.75 million primary care prescribing

£4.9 million on secondary care prescribing

6.2% Primary care growth (14/15 to 15/16)

17.5% Secondary Care growth (14/15 to 15/16)

WHAT?

Key focus for next four years

Ensure maximum benefit from investment in medicines focussing on outcomes and projects in:

a. Primary Care i. Focus on 2 or 3 therapeutic areas driving growth each year

: e.g. Diabetes, NOACs and Pregabalin ii. Focus on practices with above CCG average growth:

practice visits and support iii. Grow capacity to deliver clinical medicine reviews in our

vulnerable elderly iv. Continue to engage with local prescribing incentive

schemes, national rebate schemes which meet CCG criteria and Improving Value schemes e.g. Dressings and Stoma

v. Work with Community Pharmacy to improve uptake in Medicine Use Reviews and New Medicine Service

b. Secondary Care High Cost Drugs i. Improve the horizon scan process, data quality coming

through providers & data challenge ii. Focus on 2/3 therapeutic areas driving growth each year :

e.g. Gastro and Rheumatology iii. Maximise uptake of bio-similars and other procurement

opportunities iv. Be assured that home care medicines provision is being

utilised to best affect v. Improve the quality of assurance of utilisation of High Cost

Drugs e.g. Introduction of BluTech

c. Specialist Commissioning High Cost Drugs i. Anticipate some repatriation to CCG commissioning and

need to ensure appropriate assurance processes are in place

Medicines Optimisation Strategy 2016-20 Page 20 of 29

Priority 5: Musculoskeletal

WHY?

National Each year over 5 million people in the UK develop chronic pain

but only two thirds will recover. Patients with chronic pain are

more likely to utilise NHS resources 5 times more frequently than

individuals without chronic pain.

Medicines for non-cancer pain relief (including opioids, non-

steroidal anti-inflammatories (NSAIDS) & medicines to treat

neuropathic pain) have the potential for abuse, addiction and

carry significant safety concerns due to side effects (especially in

the frail elderly population).

NSAIDs use contributes to increasing risk of GI & Cardiovascular

side effects and Acute Kidney Injury

Local

NHS BaNES benchmarks high for elective and non-elective MSK

& Trauma (falls & fractures)

Pain Management & MSK service redesign offers scope for

improving quality & reducing spend. It is a priority for the CCG

LTC survey: 47% of respondents not very or not at all confident

about managing their condition.

With ageing population, demand for MSK related services is set

to increase significantly

Medicine Issues

Cost and Safety: NHS BaNES CCG benchmarks very high for

the use of buprenorphine (£140kpa) v opioids when compared to

other CCGs locally and nationally (spend and quantity).

Cost and Safety: The use of drugs for the treatment of

neuropathic pain (nortriptyline £80kpa, pregabalin £260kpa)

High Cost Rheumatology Drugs (biologics £1.5 million) account

for 36% of the BaNES spend on High Cost Drugs

WHAT?

Key focus for next four

years

All redesigned pain management & MSK pathways/services include medicines used appropriately within the wider scope of integrated model of care (including self-care).

Develop plans for a community pain management model including a specialist pain pharmacist as part of a MDT approach to optimising medicines.

Ensure best value for money from the biologic drugs used in the NICE pathways for rheumatology indications by using biosimilars

Education of prescribers & patients around analgesics (including used of patient decision aids and self-care)

Medicines Optimisation Strategy 2016 -2020 21

Priority 6: Workforce development WHY?

National NHS England 10 point plan a commitment to new ways of working including clinical pharmacists in general practice

In 2015 NHS England announced a £31m to pilot the role of clinical pharmacists working in general practice

Open letter from DH Dec 15 stated “We need a clinically focussed community pharmacy service that is better integrated with primary care.”

New technologies are going to being developed at a fast pace including Genomic medicines and digital technologies

Local

On-going shift to federated GP practice model

Big community service review

3 groups of practices have secured 12 months funding for a clinical pharmacist working within General Practice for 16/17

CCG commissions sessional pharmacists and care home pharmacists to work across all practices

Currently the CCG has one pharmacy technician in the team

Currently no healthy living pharmacies in BaNES

Poor uptake of Medicines Use Reviews (MURs) and average uptake of New Medicines Service (NMS) by pharmacists

Very limited cross health community posts or training

Medicine Issues

30-50% of medicines are not taken as intended

Patients have insufficient information to support taking medicines (ten days after starting a new medicine 30% of patients are already non-adherent)

5-8% of hospital admissions are due to preventable adverse reactions to medicines

Medication wastage in England per year is approximately £300million of which 50% is estimated to be preventable

Non-medical prescribing needs to be developed further

WHAT?

Key focus for next four years

Maximise the use of clinical pharmacists in General Practice, Community Pharmacists and others in workforce to support the delivery of a sustainable healthcare

Focus with community pharmacy to support self-care work programme & develop a programme of medicines optimisation with medicines use in people with: type 2 diabetes, asthma and MSK pain and antibiotics in line with other work streams through a Pharmacy Forum

Support Public Health to commissioning Healthy Living Pharmacy services in BaNES

Support other providers to develop pathway models of working e.g. outreach services to support development of the pharmacy workforce

Through CPD prepare the work force for the new technologies e.g. genomic medicines and digital technologies

Develop innovative cross organisational training opportunities and new roles for pharmacists, pre-regs and technicians within our local health community

Medicines Optimisation Strategy 2016-20 Page 22 of 29

Priority 7: Acute Kidney Injury (AKI) WHY?

National In the UK up to 100,000 deaths each year in hospital are associated with acute kidney injury. Up to 30% could be prevented with the right care and treatment NCEPOD. Adding insult to injury, 2009 It is estimated that one in five people admitted to hospital each year as an emergency has acute kidney injury: Wang, et al. 2012 About 65% of acute kidney injury starts in the community: Selby, et al. 2012 AKI is a national patient safety work programme delivered by Think Kidneys and acute providers are delivering an AKI CQUIN in 2016-17 The Primary Care AKI work programme commences in 2016-17 Prevention of AKI will reduce avoidable admissions, deaths, and Chronic Kidney disease NICE CG169: Acute kidney injury: prevention, detection and management NHS England: Commissioning excellent nutrition and hydration Think Kidneys Reducing avoidable death is a high priority in delivering the Forward View: NHS Planning guidance 2016/17 – 2020/21

Local

The RUH are currently working to the 2015-16 AKI CQUIN

No activity has commenced to support the AKI work programme in Primary Care this will be a priority

Maps onto Urgent care, Diabetes, Infection Management, Sepsis, Care Homes, Hydration and Self-care, workforce development

Medicine Issues

The 2015-16 AKI CQUIN contains an element of medication review in all care organisations

Optimise medication to prevent AKI and manage CKD in at risk people, including medication review and Advice on Sick day Guidance

Links to Antimicrobial Stewardship as 50% of primary care AKI is related to UTIs

WHAT?

Key focus for next four years

Establish an implementation programme for primary care AKI working with all sectors, and linking to Sepsis and Antimicrobial Stewardship programmes

Optimise management of patients with CKD, including diabetics, to prevent AKI

Medicines Optimisation Strategy 2016 -2020 23

Priority 8: Stroke Prevention and Venous thromboembolism WHY?

National Atrial fibrillation (AF) is a major risk factor for stroke; it affects about 1.6% of the population

NICE estimates less than half of those with AF who need anticoagulation therapy are currently receiving it

NICE CG180- AF – anti-platelets no longer an option, anticoagulants recommended to reduce stroke risk

NICE QS 93: AF

DH Cardiovascular outcomes strategy (2013)

The incidence of Venous Thromboembolism (VTE) is 1-2 per 1,000 of the population and the risk increases with age.

One in 20 people will have a VTE at some time in their life. Approximately half of patients presenting with VTE have been hospitalised in the previous eight weeks.

NICE CG 144 (updated 2015) & NICE QS 29 VTE diagnosis & management

NHSE VTE prevention programme

Local

Sentinel Stroke National Audit Programme (SSNAP) –BaNES CCG score “D” – the second lowest on quality

Use of GRASP AF tool by all practices 2014-15 - to identify AF patient, those inadequately treated and reduce variation between practices

Review of anticoagulant prescribing undertaken 2014-15; links with BaNES CCG priorities in enhancing quality of life for people with long-term conditions and improving quality and patient safety.

Current warfarin monitoring LES needs to include evidence of safe and effective anticoagulation

Self-monitoring for warfarin patients – no current CCG policy, NICE DG 14 recommends as an option

Medicine Issues

High risk & complex prescribing (weight / age / renal status)

Shared decision making should be a key element of regular review of care

Increase in prescribing growth due to NOACs – cost increase of over £400,000 in 12 months to October 2015 contributing to approx. 30% of overall CCG prescribing cost growth. Whilst the cost is increasing for oral anticoagulants, it could lead to longer term savings from a reduction in stroke events and resulting complications

WHAT?

Key focus for next four years

Better identification of AF patients

Greater uptake of drug therapy leading to fewer strokes

Ensuring safe prescribing– process for initiation & regular review including shared decision making

Look to adopt innovation in anticoagulation

Develop proposal to pilot new models of a community coagulation service

Medicines Optimisation Strategy 2016-20 Page 24 of 29

Priority 9: Safer Care Culture WHY?

National It is anticipated that there are 1.8 million serious prescribing errors in primary care each year - evidence predicts 5% of general practice prescriptions are erroneous, of which 0.18% are serious Developing an open, learning and safer culture locally is a high priority in delivering the Forward View: NHS Planning guidance 2016/17 – 2020/21 NHS England published a Patient Safety Alert: Improving medication error incident reporting and learning in 2014 directing small healthcare providers including general practices, dental practices, community pharmacies and those in the independent sector to report medication error incidents to the National Reporting and Learning System (NRLS) using the e-form on the NRLS website, or other methods and take action to improve reporting and medication safety locally, supported by medication safety champions in local professional committees, networks, multi-professional groups and commissioners. Medication errors are the most commonly reported safety incidence from GP practices, which have a very low reporting rate. The NRLS GP eform has been designed to simplify GP reporting. Currently anticoagulants and aspirin are the medicines most frequently reported.

Local

In 2014-15 BaNES GPs prescribed 3,800,000 prescriptions, and 190,000 are anticipated to be erroneous with 340 causing serious harm. Currently reporting to support local learning is not well established, and development of a local reporting and learning culture is required.

Medicine Issues

Medicines are the most frequently identified safety incidents in primary care, with anticoagulants reported most frequently.

WHAT?

Key focus for next four years

Establish a local reporting and learning culture in primary care organisations to enable the health economy to improve patient care.

Support implementation and national reporting using the NRLS GP eForm.

Medicines Optimisation Strategy 2016 -2020 25

Priority 10: Mental Health WHY?

National Mental ill-health forms at least 23% of burden of disease in UK

1 in 4 adults experiences mental health problems or illness at some point during their lifetime.

2 in 100 people will have a severe mental illness such as schizophrenia or bipolar disorder at any one time.

Approximately 50% of people with enduring mental health problems will have symptoms by the time they are 14

1 in 16 people over 65 and 1 in 8 over the age of 80 will be affected by dementia

Life expectancy - severe mental illness is associated with a 10-year reduction in life expectancy

the prevalence of major depression in people seen in primary care is between 5% and 10%

Local

Estimates suggests that 16% of the working age population - 28,800 - had a common mental illness in 2010/2011

1595 people in the 2012/13 financial year registered with a serious mental illness in GP practices in B&NES

1,545 people in B&NES in 2008 have a diagnosed dementia estimated to rise to 1,955 by 2025

In the financial year 2012/13 there were 588 emergency hospital inpatient admissions for self-harm

Intentional self-poisoning was the most common form of self-harm (92%)

Work programme on self-harm developing priorities

Medicine Issues

Supporting Patients & Medicines Adherence (work with providers and community pharmacy)

Medicines Reconciliation (providers)

Supporting Prescribers (providers)

Cost effectiveness (about 13% of Prescribing spend)

Evidence Based Prescribing (robust AWP formulary)

WHAT?

Key focus for next four years

Support the optimisation of medicines for people with mental health with a particular focus on:

Work to support appropriate use of antipsychotics: - in people with dementia and learning difficulties

(to ensure appropriate use) - and with psychosis (to support medicines adherence)

Self-Poisoning – support emerging work programme with Public Health to reduce medicines self-poisoning

Explore use of innovation to support people to manage their medicines use

Medicines Optimisation Strategy 2016-20 Page 26 of 29

4.1 How do the Medicine Priorities map against CCG priorities?

Appendix 1 depicts how the priorities map against the CCG priorities and provides the

“Medicines Optimisation Strategy on a Page”.

4.2 Operating Plan

A detailed work plan linked to the annual operating plan will be developed to provide the

framework to deliver the priorities over the next four years. Diagram 1 shows the initial

draft scheduling of the four year operating plan.

1 6 12 18 24 30 36 42 48

Apr-16 Apr-20Complete 4 year

operating plan

Diabetes Care

Frail elderly

Antimicrobial

Stewardship

Improving Value

from Medicines

Musculoskeletal

Workforce

development

Acute Kidney

Injury (AKI)

Stroke prevention

& VTE

Safer care culture

Mental Health

Months

Medicines Optimisation Strategy 2016 -2020 27

5 Workforce to deliver the strategy

Current Comments for the future

CCG

Medicines

Team

3 FTE Pharmacists

1 FTE Pharmacy technician

(fixed term to Sept 2016)

Consideration needs to be given for

enhancing the team

Investment for mainstreaming the

pharmacy technician and introducing

a second were made in the round for

2016/17

A proposal for additional project

support is currently being considered

Practice

Pharmacists

and Care

Home

Pharmacists

Currently contract these

through a self-employed route

10 support the 27 practices

5 supporting the Care

Home Project

An option paper for the future model

of provider medicines function will be

brought forward to JCC in 2016

An invest to save proposal to support

medicines reviews for Community

MDTs will be brought forward in the

2017/18 contracting round

Community

Pharmacist

39 contractors in BaNES

commissioned by NHS E

under the national contract

No functional Local

Professional Network – this

is NHS E led

Plans are developed to hold quarterly

Community Pharmacy Forum in

BaNES in 16/17

RUH There is a department of

pharmacists, technicians and

the support staff

Outreach and other joint models for

some specialities needs to be

explored further

Sirona There are a team of two part

time pharmacists working for

community services

There is an opportunity for additional

joint working

Development

of Primary

Care

Pharmacists

Three transformation fund

pilots of clinical pharmacists in

Primary Care employed by the

GP practices to carry out Core

Contract work

There is an opportunity to work with

the pilots

Sharing of learning across practices

will be implemented

Any changes in workforce would have to lead to a revision in the strategy.

Medicines Optimisation Strategy 2016-20 Page 28 of 29

6. Conclusion

A medicines optimisation strategy is central to the work of the CCG due to the key role

medicines have in our health system. Medicines account for approximately 13% of the

CCG spend but impact on all aspects of the CCG’s strategy and work plan.

This strategy has set out five key approaches to medicines optimisation for the CCG.

The strategy also sets out ten key priorities for work over the next four years to support

delivering transformational change to our community, supporting our CCG to be high

performing, leading our health and care system collaboratively through the commissioning

of high quality, affordable, person-centred care which harnesses the strength of clinician-

led commissioning and will empower and encourage individuals to improve their health

and wellbeing status.

Medicines optimisation can be one of the key foundations for the CCG success and this

strategy is intended to maximise the potential medicines optimisation has to help deliver

the CCG ambition and vision.

Appendix 1 – Plan on a Page

CC

G M

issio

n

Healthier, Stronger, Together “to lead our health and care system collaboratively through the commissioning of high quality, affordable, person centred care which

harnesses the strength of clinician led commissioning and empowers and encourages individuals to improve their health and well

being status”.

CC

G F

ocu

s –

hig

h q

ualit

y

hea

lth a

nd

care

syste

m

• Improving quality, safety and

individuals experience of care

• Improving consistency of care and

reducing variability of outcomes

• Providing proactive care to

help people to age well and to

support people with complex

care needs

• Creating sustainable health

system within a wider health

and social care partnership

• Empowering and encouraging

people to take personal

responsibility for their health

and wellbeing

• Reducing inequalities and social

exclusion and supporting our

most vulnerable groups.

Improving the mental health and

wellbeing of our population

CC

G A

pp

roach

:

• We want to lead a reconfigured

system that meets the current and

future needs of our population,

targeting deprived areas, is financially

sustainable with care offered in the

optimum setting

• Providing proactive care to

help people to age well and to

support people with complex

care needs

• We will encourage Providers

to collaborate, innovate and

work in effective partnerships to

deliver seamless and integrated

care

• We will invest resources in

areas and activities that

support better prevention and

early intervention

• We will focus on both the

mental health and physical health

needs of individuals.

Medicines Optimisation Approach

We will support local decision making to commission safe, effective and evidence based medicines use within pathways

We will promote a safety culture around medicines use: including effective use of national and local reporting systems to report, and learn from medication safety Incidents

We will maximise care gains across health and social care by innovative management of medicines at the best obtainable value

We will support workforce development activity to create a sustainable healthcare system, with particular emphasis on the pharmacy workforce and medication review

We will use clinical audit , education and quality improvement to improve safe and effective care and reduce variation in health outcomes

CC

G P

rio

riti

es

:

• Increasing the focus on prevention,

self-care and personal responsibility

• Improving the co-ordination of

holistic, multidisciplinary long term

conditions management (focusing

initially on Diabetes)

• Creating a sustainable

urgent care system that can

respond to changes in

demand

• Commissioning safe,

compassionate care for frail

older people

• Redesigning musculoskeletal

services to improve their

efficiency (productive elective

care)

• Ensuring the interoperability of

IT systems across the health

and care system

• Delivering the plans for the Better Care Fund to support our model

of integrated care with a focus on;

• 7 day working

• Protection of Adult Social Care Services

• Integrated reablement and hospital discharge

• Admission avoidance

• Early intervention and prevention

Medicines Optimisation top ten priorities

1. Diabetes Care – Optimisation the

Medicines we use

Aim is excellent outcomes and

safe use of our medicines use.

- Work with Service redesign programme to have a well-defined medicines Pathway

Through audit and review,

optimise:

- New oral agents - Insulin - Cardiovascular

medications - Test strips and other

disposables

2. Frail Elderly

Commission clinical pharmacy

medicines reviews for all frail

elderly.

Ensure the safe, appropriate

and effective use of medicines

in frail and older people

wherever they are cared for

with focus on:

admissions avoidance,

urgent care settings, the Fall

Pathway and continuity of

care

3. Antimicrobial Stewardship

Establish a BaNES

Strategic Collaborative to

implement the UK AMR

Strategy including:

Improved infection prevention

Optimise prescribing practice

Professional education, training and public engagement

Develop new drugs, treatments and diagnositcs

Better access to and use of survelillance data

4. Improving Value from Medicines

Ensure maximum benefit

from investment with a focus

on outcomes and projects in

a. Primary Care b. Secondary Care

High Cost Drugs

5. Musculoskeletal

Support the review of

rheumatology and pain

medicines pathways

as part of the strategic

programme and develop a

medicines work

programme linked to this

service redesign

Ensure best value for

money from the biologic

drugs used in the NICE

pathways for

rheumatology indications

6. Pharmacy Workforce

Maximise the use of clinical,

community and other pharmacists

to support a sustainable future

model.

With a focus on:

Community Pharmacy workforce colleagues to support Self-care work

programme

Support Public Health to commissioning Healthy Living Pharmacy services in BaNES

Develop a programme of Medicines optimisation with medicines use in people with: type 2 diabetes, asthma and MSK pain and antibiotics in line with other work streams

7. Acute Kidney Injury

Establish an implementation

programme for primary care

AKI working with all sectors,

and linking to Sepsis and

Antimicrobial Stewardship

programmes

Optimise management of

patients with CKD, including

diabetics, to prevent AKI

8. Stroke prevention & reducing the risk, improving the treatment and prevention of venous thromboembolism (VTE)

Continue to support for

optimising medicines in this

therapeutic area

9. Safer care culture

Establish a local reporting

and learning culture in

primary care organisations to

enable the health economy

to improve patient care.

Support implementation and

national reporting using the

NRLS GP eForm

10. Mental health

Support the optimisation of

medicines in this vulnerable

group with a particular focus

on

Self-Poisoning – support

emerging work programme with Public Health to reduce accidental medicines self-poisoning

Continue developing work to support appropriate use of Antipsychotics: in

people with LD, dementia and with psychosis