2020 Vision - GMMMGgmmmg.nhs.uk/docs/150204 GM Medicines Optimisation... · Greater Manchester...

Greater Manchester Medicines Management Group

1

2020 Vision

Greater Manchester

Medicines Optimisation Strategy

2015-2020

A shared vision of Medicines Optimisation for Greater Manchester

February 2015

Status – Draft v0.4 Feb 2015

Greater Manchester Medicines Optimisation Strategy 2015-2020

Document Control

Title of document Greater Manchester Medicine Optimisation Strategy

Author‟s name Andrew White / GMMMG

Author‟s job title Head of Clinical Decision Making, GMCSU

Doc. Status (V0.4)

Based on N/A

Signed off by GMMMG

Next review date (2 yrs from publication)

Distribution CCGs, GP surgeries, Community Pharmacies, Provider Trusts, Internet, Patient groups, XXXXX

Consultation History

Version Date Consultation

v0.1 14.04.14 Andrew White

V0.2 14.07.14 Steering group views 07.05.14 GMMMG 19.06.2014 Substantial redraft

V0.3 05.01.15 Strategy Workshop – 16.10.14 GMMMG feedback – 20.11.14

V0.4 04.02.15 Full re-write



Contents Page

1. Executive Summary 5

2. Vision 6

3. Mission 6

4. Areas of Work 7

5. Context - Defining the need for a GM Medicines Optimisation Strategy

5.1. National Drivers

5.2. Greater Manchester Drivers

7

9

6. Leadership, interdependencies and partners 15

7. Key areas of work

7.1. Patient Experience;

7.2. Promoting Excellence

7.3. Co-ordinated Care

16

16

18

22

8. Governance 24

9. Communications 26

10. Ongoing Monitoring 27

Appendix - See separate document

Provides additional background and context to GM Medicines Optimisation Strategy



1 Executive Summary

This strategy applies to all clinicians treating patients within NHS commissioned care in Greater Manchester. It outlines what the people of Greater Manchester should expect of care by 2020 (at the latest).

Vision: Enabling Medicines Optimisation

Mission Statement: High Quality, patient-centred access to medicines across health and social care.

It proposes a strategic joined up, person centred approach to manage and optimise resources effectively across the Health economy. Medicines Optimisation is integral to Clinical Quality and a key part of the work of all Health and Social Care Commissioners and Providers within Greater Manchester.

Medicines Optimisation is about enabling prescribers and patients to make the most appropriate, agreed treatment choices together.

The Strategy sets out a 5 year vision, with three broad aims,

Improving Patient Experience

Promoting Excellence

Co-ordinating care

This strategy can only be delivered by gaining wide clinical engagement, with high quality managerial support. This will be owned and implementation enabled and tracked by highly skilled senior Doctors, Pharmacists and other clinical leaders who will facilitate change with front line clinicians.

It is backed up by detailed 2 year objectives, which will deliver milestones using the available resources to deliver the strategy.

Insert Signatures and/or Pictures

Kath Sutton

Dr Kath Sutton Chair, Greater Manchester Medicines Management Group Chair, Trafford Clinical Commissioning Group Other joint signatories?



2 Vision

Enabling Medicines Optimisation

3 Mission statement

High quality, patient centred access to medicines across health and social care

4 Areas of Work

In the development of the strategy, stakeholders were engaged and the following three themes (and their components) developed. They will inform the areas of work for this strategy. These were:

1. Improving Patient Experience This will cover areas such as: Seamless patient journey, Outcomes, Safety, Patient representation, Communication, Choice and involvement, Respect and dignity, Improved use of technology

2. Promoting Excellence Ensuring the best care is available to all through: Early adoption of evidence based care, NICE approved treatments available equitably, Dis-investment in less effective care, Working together with other providers. Includes Trusts, Public Health, Social Care, Involvement in commissioning process. Reducing variation through: Benchmarking, Minimisation of duplication of guidance and improved sharing of best practice, Improved working with other organisations

3. Coordinating Care

Improving integration and coordination though: Strengthening of shared care arrangements and protocols, Improving discharge information, Engagement with patient groups, Patient held records, Optimal patient pathways, Self-care, Signposting

Through the implementation of these themes we will enable improvements in clinical quality in all settings by identifying unexplained variation and achieve improved patient and population outcomes, safety and experience.



5 Context – Defining the need for a GM Medicines Optimisation Strategy

5.1 National Drivers

It is likely that integration with social care will become the norm. High quality support to commissioners and providers of health and social care is fundamental to ensure any problems are not shifted from one sector to another and are focussed around the person.

The combination of these factors will require transformational changes to the way we deliver healthcare for the population.

To achieve this change, investment in „up-stream‟ interventions, such as medicines, will be required to prevent disease, complications or exacerbations of long term conditions.

5.1.1 National policies

The NHS England strategy is intended to complement the other supportive agencies and bodies assisting the NHS to deliver its mission of „1High Quality Care for All - now and for future generations’.

It is grounded in the impact of several landmark reports; 2The Francis report, into care at Mid Staffordshire hospital, which generated the government‟s response in the form of the 3Berwick review. 4The Keogh review was focussed on 14 trusts with apparently higher rates of mortality.The latter reviews, while having different remits, produced very similar conclusions or recommendations (see appendices for direct relevance to GM Medicines Optimisation).

The Five Year Forward View2 is a strategy that articulated why change is needed, what success looks like and how we get there.

It focused on 4 areas: Improving the Health of our nation, financial efficiency, matching demand and supply, introduced new care models – with integration being common to all and making clear that small changes were not enough, Transformation is essential!

I laid out areas for focus, all with implications for Medicines use: • Improving the health of workforces • Patients taking an active and engagement in their own health, and improved

NHS responsiveness when ill. • Support for carers and volunteers • New care models - delivering integrated and responsive care • Understanding the true cost and value of the NHS to UK plc – including how we

can „future proof‟ the NHS, using technology, innovation and genomics to benefit patients and taxpayers

1 High Quality Care for All - now and for future generations. NHS England 2013 http://www.england.nhs.uk/about/imp-

our-mission/ 2 The Francis report: The Mid Staffordshire NHS Foundation Trust Public Inquiry - Chaired by Robert Francis QC

2013 http://www.midstaffspublicinquiry.com/report 3 The Berwick review: A promise to learn – a commitment to act. Improving the Safety of Patients in England.

Berwick 2013 https://www.gov.uk/government/publications/berwick-review-into-patient-safety 4 The Keogh review: Review into the quality of care and treatment provided by 14 hospital trusts in England: overview

report Keogh 2013 http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/Overview.aspx

http://www.england.nhs.uk/about/imp-our-mission/

http://www.england.nhs.uk/about/imp-our-mission/

http://www.midstaffspublicinquiry.com/report

https://www.gov.uk/government/publications/berwick-review-into-patient-safety

http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/Overview.aspx



‘You have the right to drugs and treatments that have been recommended by NICE1

for use in the NHS, if your doctor says they are clinically appropriate for you.

You have the right to expect local decisions on funding of other drugs and treatments to be made rationally following a proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you and your doctor feel would be right for you,

they will explain that decision to you.’

These publications and others, past and future, focus on listening to patients, our staff and providing the leadership is crucial for the NHS to develop as it needs to do.

The NHS outcomes framework5 has 5 outcome domains which will be used to inform the work of the GM Medicines Optimisation Strategy (further detail in appendices).

1. Preventing people from dying prematurely

2. Enhancing quality of Life for people with long term conditions

3. Helping People to recover from episodes of ill health or following injury

4. Ensuring people have a possible experience of care

5. Treating and caring for people in a safe environment and protecting them from

avoidable harm

The NHS Constitution6 establishes the principles and values of the NHS in England. It

sets out rights to which patients, public and staff are entitled, and pledges which the

NHS is committed to achieve, together with responsibilities, which the public, patients

and staff owe to one another to ensure that the NHS operates fairly and effectively.

5 The NHS Outcomes Framework. NHS England 2014 www.gov.uk

6 NHS Constitution for England. DH. 2010 www.gov.uk

https://www.gov.uk/government/publications/nhs-outcomes-framework-2014-to-2015

https://www.gov.uk/government/publications/the-nhs-constitution-for-england



5.2 Greater Manchester Drivers There are several drivers of the Medicines Optimisation strategy from Greater Manchester and the wider Health economy. We list below the most significant issues, but is not intended to be comprehensive:

5.2.1 Greater Manchester Agreement: Devolution to the Greater Manchester Combined Authority7

This wider agreement devolves responsibility for o A consolidated transport budget, including franchised bus services, o Strategic planning o A £300 million Housing Investment Fund. o The role currently covered by the Police and Crime Commissioner.

o usiness support budgets, o Initiatives to encourage a GM work programme o Integrated health and social care (subject to business plan)

The integration of health and social care across Greater Manchester, making best use of existing budgets and including specific targets for reducing pressure on A&E and avoidable hospital admissions will be developed, with incentives to develop this plan. This will be supported by multi-year allocations for health and care funding settlements.

5.2.2 Healthier together8

This Major Service Transformation and reconfiguration programme across GM has the overall vision of:

For Greater Manchester to have the best health and care in the country “Right care, Right place, Right time. Excellence for all.”

An ambitious plan to create a few specialist hospital centres and vibrant district hospitals; supported by excellent community and primary care.

Will be implemented from 2015 onwards. (Subject to consultation at time of writing.)

5.2.3 Staying Well, Living Well – Our Strategy for improving Primary Care within Greater Manchester - GM LAT9

The Primary care strategy complements Healthier Together and articulates areas where care will be different:

Quality and safety

Involvement in care

Multidisciplinary care

Access and responsiveness

Increased out of hospital services

7Greater Manchester Agreement: Devolution to the Greater Manchester Combined Authority GOV.UK 8 Healthier Together www.healthiertogethergm.nhs.uk

9 Staying Well, Living Well – Our Strategy for improving Primary Care within Greater Manchester NHS England GM

LAT. Link

https://www.gov.uk/government/publications/devolution-to-the-greater-manchester-combined-authority-and-transition-to-a-directly-elected-mayor

http://www.healthiertogethergm.nhs.uk/

http://democracy.rochdale.gov.uk/documents/s19414/Primary%20Care%20Commissioning%20Strategy%20v12%20FINAL.pdf



GM Population facts

Population

2.7 million people live in Greater Manchester

Life expectancy:

76.4 yrs for males and 80.8 yrs for females.

This is lower than the regional and national averages, with only Stockport similar to and Trafford better than average.

Disability

22.4% of people aged 16-64 in GM are disabled, higher than the national average of 20.8%.

Growing population

The population of Greater Manchester grew by 7.0% (179,000) between 2002 and 2012. o Due to a higher birth rate in and people are living longer, not always in good health.

As this population ages

Current projections suggest that by 2025, o 35% more people will have long term limiting conditions, o 40% will have mobility problems, o 6% more cases of dementia o 35% to 45% rise in visual and/or hearing impairment.

Almost 1 in 3 people have a long term condition and many are living with 3 or more LTCs and will increase over the next 5 yrs.

70% of the health and social care budget is spent on patients with LTCs.

Demand for community-based services is projected to rise by a third in the next 15 years.

Deprivation and employment

The unemployment rate in Greater Manchester is 9.4%. (UK ave of 7.7%)

Over a quarter of all children living in GM are living in significant deprivation.

Ref: New Economy: http://neweconomymanchester.com

Disease affecting quality and length of life: 1. Respiratory disease, 2. Cardiovascular disease (CVD) 3. Cancer, 4. Liver disease 5. Mental Health

Lifestyle risk factors 1. Smoking, 2. Obesity 3. Excess alcohol consumption 4. Sedentary lifestyle

Ref: ONS, Labour Force Survey

5.2.4 The GM Population - Larger, ageing population, with greater care needs

The baseline data for GM is generally poorer than much of the rest of the UK, but with significant effort to improve outcomes.

5.2.5 GM Health improvement areas

These diseases and conditions have a significant impact on the economy, which could be treated and lead to a productive population. Most are able to be resolved by or will have medicines as a vital part of management.

http://neweconomymanchester.com/



GM Medicines Facts

Medicines expenditure

£831.2M expenditure - 14% of NHS spend

7% growth in medicines (14% in Acute care)

Average NHS allocation uplift of 1.7%

£15M avoidable medicines wastage

Biggest NHS cost after staff Medicines

50% of Women, 43% of men regularly take a prescribed medicine – the most common health intervention

30-50% are not taken by patients as intended

Patients get poor supporting information

5 to 8% of hospital admissions due to preventable ADRs of medicines

Increased numbers of patients living with a greater number of conditions and risk associated with polypharmacy.

Errors at avoidable levels

The threat of antimicrobial resistance Variation The NHS in the GM represents:

5.1% of England's population,

Spends 5.8% of the national expenditure on medicines.

There is a wide variation of care offered to patients. o Could be due in part to higher health needs, o 14% higher cost is unlikely to be attributable to differences in need alone. o Some differences are a result of specific commissioning decisions, o Others due to differences in custom and practice, patient choice.

While some of this variation is clinically justifiable, evidence based and patient centred, much is unfortunately not. Prescribing data is very robust and can demonstrate variations which are independent of population and demographic differences.

5.2.6 Medicines impact

5.2.7 Overall GM impact

The NHS can expect flat growth at best, with the Five Year Forward View suggesting that 3% Year on Year efficiencies will be required (unprecedented vs historic NHS levels) to continue the meet the increasing health needs of a population with ever increasing expectations.

We must transform care by changing what is currently seen as existing healthcare delivery through the use of different locations, technologies, pathways, professionals, self-care and better integration of services, with appropriate access to information to prevent duplication and minimise risk.

Not all variations in delivery will involve every one of these changes, but it is likely that a combination will be required and that the optimised and changed use of medicines and technologies will be a key enabler to ensure the safe transition to a different health and care system.



5.2.8 NHS Financial situation

a) GM Prescribing Expenditure

The figure x below shows the national trend in prescribing expenditure from 2011 to 2014. This shows consistent growth in secondary care (40% of total cost), with trends for total usage influenced to the greatest extent by Primary care fluctuations.

Fig. X Annual Estimated Cost Growth 2011-12 to 2013-14 - England

10

Area Team

Hospital Issued Primary Care Hosp Rx in community

Total Cost (£) % Growth since

12/13 Cost (£) % Growth since

12/13 Cost (£) % Growth since

12/13

GM AREA TEAM 334.6 13.9 492.9 2.1 3.8 -4.9 831.2

Fig Y Annual Estimated Cost Growth 2011-12 to 2013-14 – Greater Manchester

The net 7% GM growth in all prescribing is a rate likely to continue for the lifetime of this strategy. This investment in prescribing, higher than expected overall NHS uplifts, will be required to deliver improved outcomes and enhances experiences for patients.

Fig z Net ingredient cost England 2011-12 to 2013-14

10

Hospital Prescribing England 2013-14. HSCIC 2014 http://www.hscic.gov.uk/catalogue/PUB15883

http://www.hscic.gov.uk/catalogue/PUB15883



b) Primary Care Prescribing

The headline expenditure has been in decline for recent years, largely due to blockbuster patent expires; as the volume and frequency have diminished, the cost growth has risen from broadly negative, to moderate growth in most economies.

There is wide variation in these trends across GM, largely due to local patterns of prescribing. There are also marked changes due to commissioning decisions and service transfers.

The areas of cost pressure are different to those areas of item growth, mainly due to the proportion of generic: branded usage. Despite the generic changes in the last 5 years, the top categories for both items and cost in Primary Care remain the same, but the order is changing.

Below is a breakdown of Overall costs and items, trends and then by BNF section, More information in the Appendix..

Highest Cost BNF Chapters

Highest Items BNFchapters

Highest Cost BNF sections

1. Central Nervous Cardiovascular Stoma 2. Respiratory Central Nervous Malignancy 3. Cardiovascular Gastro-intestinal Dressings 4. Gastro-Intestinal Endocrine Incontinence 5. Endocrine Respiratory Respiratory 6. Nutrition and Blood Nutrition & Blood Appliances 7. Infections Infections Endocrine

c) Secondary and Specialist Care prescribing

Many Acute Trusts have seen a decrease in drug costs per patient episode in recent years through efficiency and procurement. However Payment by Results excluded PbRe drugs (high cost, low volume) are driving cost growth at around 14 % per year (higher in many specialties). These pass through directly for commissioners, this particularly affects: Cancer, Rheumatology, Sexual Health, Haematology and Gastroenterology.

The most prolific area of drug development is within biologics, which are most likely to have the biggest impact on secondary/ specialist care, partly counterbalanced by a wider number of biosimilars being available.

The introduction of biosimilars in recent years does present a new opportunity for commissioners and providers to work together to yield savings to the health system. 20% reductions in branded price are most likely on current evidence.

The relative impact on NHS England and CCG budgets is unclear, mostly due to the changes in specialist commissioning thresholds and the likely transfer to CCGs of some specialisms. As generic prices have a relatively minimal impact on total secondary care drug costs, it is likely that current growth rates are unlikely to slow.

Safer prescribing and dispensing is a priority for all trusts and the RPS11 standards for Hospital Pharmacy will be the minimum standard that patients should expect in the lifetime of this strategy.

11

Professional Standards for Hospital Pharmacy Services - Optimising Patient Outcomes from Medicines Royal Pharmaceutical Society 2012 www.rpharms.com

http://www.rpharms.com/support-pdfs/rps---professional-standards-for-hospital-pharmacy.pdf



d) Future growth estimates

While the PPRS will allow some surety with branded drugs GM currently uses 19% branded drug and 81% generics.. Cost growth will probably be slightly lower than item growth, due to the influence of PPRS and volatility of generics prices. These growth rates take into account planned investment in medicines optimisation. It is also however an estimate which will be able to be influenced by focussed attention on local priorities, especially the managed exit and entry of older and new drugs. A planning assumption for the life of this strategy is that items and costs will grow by:

Primary care prescribing: 3-4% item growth

2.1% cost growth

Secondary care prescribing: 7% item growth

14% cost growth

Potential Spend in 2019/20 at current growth rates vs 2013/14: Primary Care: £559M + 13%

Secondary Care: £731M + 118%

Total spend: £1290M + 55%



6 Leadership, interdependencies and partners

How the service interacts with the NHS and social care bodies will be crucial to ensure it complements, supports other bodies to ensure no contradictions or gaps or duplication.

The diagram below illustrates where this strategy will provide leadership and advice , with partners through it‟s implementation body – the Greater Manchester Medicines Management Group.

Strategy & Assurance Advisory Implementers Operators

Mix Lower volume/higher value High volume/Lower value

Output type Strategy report Advisory report Change made Service delivered

National NHS England NICE

Regulators

CRGs Professional bodies

NHSTDA CPPE

Regional

NHS England, GM Combined Authority

Senates, Networks. LPNs, CSUs Procurement

CSU, AHSN LAT, AGMA, AGMCCGs

Providers

Local CCGs, Providers CSUs, GPs, Pharmacies, Prescribers

GMMMG will have a predominantly advisory role to health and social care across Greater Manchester, but will have a wider impact as the City region develops

GMMMG needs to ensure it has a defined role, complementing, and leading, other bodies, through relationships with the health and social care economy of: GM CCGs, AGMA, Healthier Together, CCGs , Providers, Local Authorities, clinical senates, AHSNs and the NHS England Regional and National leadership.

GMMMG role



7 Key areas of work

The GMMMG work will be delivered along the following themes:

1. Improving Patient Experience

2. Promoting Excellence

3. Coordinating Care

This section makes recommendations to the Greater Manchester Health and Care system to consider and implement with suggested timescales, whilst ensuring best value for taxpayer resources.

These key areas of work will be backed up by a detailed 2 year workplan (once strategy approved by GMMMG)

7.1 Improving Patient Experience

Promote the person focussed use of medicines to achieve improvements in health and wellbeing AGREED with patients and the public

1. Outcomes

a) All outputs will be focussed on improving Patient outcomes, using high quality evidence and PROMs (where available)

Action: all outputs to be in plain English and indicate patient benefits and risks.

b) Focus on improvement in treatment and understanding of Mental Illness in specialist and generalist environments

Action: Promote and lobby for training and development, Provide materials which are accessible to all clinicians and patients.

2. Safety

a) Support patients to use their medicines in the most effective, efficient and safest way possible; to prevent (and treat) ill health, in a way that is understood and agreed by them.

Action: All treatments to be agreed with patients before prescribing, explaining the holistic benefits and avoidable risks

b) Ensure that effective systems are in place for dealing with National Patient Safety alerts and notices pertaining to medicines and that there is a robust local system in place for reporting and learning from medication errors.

Action: Continue to incorporate into all GMMMG outputs. Set up system to receive, analyse and learn from errors. Encourage increased reporting.

c) Reducing in-patient and emergency admissions caused by drug problems – Adverse drug reactions (ADRs), interactions and contraindications. Invest in the development of systems and processes to improve patient safety through a reduction in medication adverse events.

Action: Use BI tools to interrogate drug problems using GP and SUS data. Analyse and learn from errors, communicate to develop a learning culture.



3. Patient representation and feedback

a) Ensure useful and representative involvement of patients in decision making.

Action: Through GMMMG reports and participation with HealthWatch and other patient groups.

b) Develop and champion innovative methods to ask patients what they want from medicines and feedback to effect change in care provision.

Action: Consider adoption of NICE patient involvement process for GMMMG and ensure all output is in Plain English and actively responsive to patient feedback.

4. Communication

a) Ensure all communication is prompt and understandable to all. Focussing on priority areas:

Prevention of ill health

Equity

Agreeing, publishing and managing patients and clinicians treatment expectations

Education to allow patients to take ownership for their own health (signposting to partners)

Action: All outputs to ensure priority areas are addressed where relevant

b) Ensure real-time information is shared with health professionals, the public and technology companies on progress of decisions / appraisals are published (including supporting information)..

Action: Develop and enhance publication and communication scheme

5. Choice, involvement, respect and dignity

a) Promote patient decision aids more widely to allow prescribers and patients to understand the absolute benefits and risk of treatments and so make better decisions about prescribing.

Action: Produce or signpost to best practice decision aids from GMMMG website

6. Improved use of technology

a) Ensure all outputs leverage the benefits of improved IT systems which match public and health professionals‟ needs, improving accessibility to best quality care standards

Action: Work with partners to develop outputs including web-based, web links, apps.

b) Integrated IT systems to enhance safe care. Encourage and lobby for patient information to be shared with all front line clinicians who patients give permission to be shared with,.

Action: Ensure Summary Care Record in available as a minimum and lobby for a full read/write access patient record for all authorised health and social care professionals across GM.

c) Support effective discharge of patients into the community through the provision of structured self-medication and rehabilitation pharmaceutical care programmes. e.g. „Refer to Pharmacy‟

Action: Promote and monitor discharge standards and communication



7.2 Promoting Excellence

Promote the clinical and cost-effective use of medicines to achieve improvements in health and wellbeing for the population and reduce health inequalities

1 Early adoption of evidence based care

a) Ensure equitable early adoption of innovative treatments which improves health and wellbeing outcomes, while providing added value to existing pathways of care

Action: New Therapies processes to consider commissioning and potential de-commissioning implications of therapies assessed to ensure equity and affordability of availability.

b) Manage introduction of new treatments into system, with safety the prime consideration. Implementing research and evaluation findings can lead to efficiencies of clinical outcomes, cost benefits and patient convenience. Report on areas of innovative drug development.

Action: Recommend monitoring/ audit of new treatments to ensure „real world‟ data informs wider implementation or adoption with partner agencies i.e. AHSN, networks

c) Access to clinical research is encouraged regionally through the MAHSC and primary and specialist care providers should be „research active and ready‟ and GM is an active participant in the development and adoption of new technologies..

Action: Early input to research planning to ensure ethical and managerial approval is granted through all studies having agreed start to finish planning including exit strategies.

2 NICE approved treatments available equitably

a) Ensure NICE TAs are implemented equitably across GM, making recommendations in GM Formulary and integrated into pathways, ideally across GM as default. Ensure funding is released through adoption of innovations within NHS Constitution requirements, recommend where adoption may allow less effective care to be de-prioritised. Action: Integrate NICE TAs in to GM Formulary and pathways. Audit usage to ensure equitable uptake. Share best practice.

b) Develop or promote implementation resources that help implement TAs / guidelines, with health and care involvement. Developed through events and whole system thinking Action: Facilitate events to identify, develop and promote best practice.

c) Monitor and support implementation of all NICE guidance across providers and independent contractors via the GMMMG.

Action: Bi annual report to GMMMG regarding compliance and implementation support.

3 Dis-investment in less effective care - to allow investment elsewhere

a) Identify appropriate opportunities to disinvest in less suitable treatment and (if available) suggest alternative treatment to improve, social care savings

Action: All Guidance to indicate investment and disinvestment implications.

b) Develop and review further the Do Not Prescribe and „Grey‟ lists of less suitable treatments and enhance to include all NICE „Do not do‟ recommendations.

Action: Enhance BI monitoring tools, develop and disseminate implementation tools to accelerate reduction in inappropriate prescribing.

c) Identify areas for prescribing efficiency and develop policy and audits to define their place in therapy. Work with prescribers to rationalise potentially wasteful usage. Areas already identified include: Over-ordering of medicines, Nutrition, Specials, Red Drugs



Action: Revise GM QIPP/ Meds Optimisation plan annually and utilise enhanced BI monitoring tools, develop and disseminate implementation tools to accelerate reduction in inappropriate prescribing.

4 Working together across all commissioners and providers in health and social care

a) Encourage (and commission) audits and real world evidence „Portfolio studies‟.- not RCT‟s - investigating how drugs are being used and their value to the Health and Care system.

Action: To build and commission and share a portfolio of audit tools and results, used to enhance care provision and commissioning.

New Models of Care – additional work required

5 Leadership in the commissioning process

a) The GMMMG will continue to provide strong professional pharmaceutical and medicines optimisation leadership and expertise for the health and social care economy, to improve the quality and safety & provide standards or advice, to support clinical leaders and front line staff to do their job better.

Ensure that the GMMMG and subgroups are fit for purpose in the context of the NHS Outcomes framework, Healthier Together, Clinical Senate, AHSN, Professional Networks. Maintain processes of internal scrutiny, performance management and review to monitor the effectiveness and productivity of the GMMMG and members.

Action: GMMMG governance to be aligned with Heads of Commissioning and Finance and AGMCCGs and AGMA to ensure approval of outputs

b) Collaborate with the Non-Medical Prescribing Leads to ensure robust governance and monitoring arrangements for non-medical prescribing.

Action: GMMMG governance to be aligned with Heads of Commissioning and Finance to ensure approval of outputs

c) GMMMG becomes the „go to‟ group for facilitating and approving medicines use and pathways included in commissioning decisions and processes

Action: GMMMG governance to be aligned with Heads of Commissioning and Finance to ensure approval of outputs

6 Reducing variation

a) Benchmarking shared widely to identify unwarranted and avoidable variation in care. This will be prioritised to measures which enhance the health and wellbeing of the population.

Action: Continue to monitor and support improvement in National care indicators Develop, expand and maintain GM indicators, which relate prescribing to incidence, interventions and outcomes to improve health and care outcomes.

Distribute to health professions initially as improvement tools, then when validated publish widely (publicly?)

b) Collaborative development and QA of KPIs, CQUINs and Quality premiums, using high quality evidence to incorporate in contracts with providers in primary, secondary and social care settings

Action: Distribute to health professions initially as improvement tools, then when validated publish widely

c) Recommend a GM Prescribing and Medicines optimisation specification within service agreements / contracts with NHS, Private and Independent health and care providers, including clear lines of accountability for the governance of medicines through the update of robust terms and schedules.



Action: Review the standards of provision of pharmaceutical services in provider organisation contracts, update to GM or national standards, whichever is highest.

7 Minimise duplication of guidance and improved sharing of best practice

a) Share best practice and advice systems and processes embedded to:

Scan best practice nationally and internationally e.g. NICE, SIGN, SMC, AWNMG, Royal College, CKS, and consider adoption, promotion, signposting or adaption for use in GM.

Decrease duplication and potential confusion in production and dissemination of guidance, by integrating into GMMMG outputs to inform best care.

Wider, prompt adoption of GMMMG guidance by all CCGs, NHS and care providers

All providers and commissioners and networks to coordinate at GM level by default.

Consider accredited content development o To allow concentration of expertise, skills, succession planning and resilience o Promote cross organisational sharing of good practice – NHS, Pharma,

academia – e.g. collaboration on professional standards.

o Consider a shared horizon scanning process with similar economies and

potentially produce a regionally agreed, federated workplan

Action: Develop a process to include all issues above and implement from Dec 2015

b) Best practice audit standards and SOPs for use in local settings to inform benchmarking and shared improvement developed for all GM best practice outputs


c) Produce and share evidence summaries to support local decision makers in Area prescribing committees, Formulary groups, IFR panels. To form the basis of evidence based Policy for commissioners


d) Homecare development. Ensure all provider are fully compliant with the Hackett report.

Understand baseline financial arrangements and quality standards.

Identify top opportunity areas demonstrating a saving or quality improvement in service - defining measurable outcomes.

Support the implementation of the activity in accordance with agreed outcomes


e) All GMMMG output i.e. treatment guidelines, pathways and policy should be linked to the the Joint formulary and prescribing decision aids.

Action: Produce and maintain a joint, coordinated development pipeline for all groups and outputs and implement from Dec 2015

8 Improved networking across organisations and care economies

a) Make better use of Population Health resources

JNSA/JHWS – commissioning tools providing clear objectives to all

Identify common local health needs and working towards the same goals and aims.


b) Investigate opportunity for a formulary covering a wider geography to reduce variation




c) Identify education and development needs to support the delivery of education and training to a multidisciplinary audience on prescribing and therapeutics, to facilitate the implementation of evidence related to prescribing.



7.3 Coordinating Care

1 Strengthening of shared care arrangements and protocols

a) Continue to define and maintain the interface prescribing resources to promote patient safety and increased interaction across the interface for the benefit of patient care. All Interface Materials enhanced to common GM standards and maintained through biannual review.

Action: Annual reports to GMMMG on updated portfolio of materials and pipeline. Monthly approval of subgroup outputs

b) Shared care GM standards to include:

Communication with Social Care and voluntary sectors

Involvement of all HCPs and Social Care

Key people involved in an individual‟s care

Action: Update all SCPs to GM Standards

2 Improving discharge information

a) Ensure Medicines reconciliation and discharge transfer of care standards are promoted and implemented in providers and GP practices

Action: Reports on key areas to GMMMG

3 Engagement with patient groups

a) Shared patient decision aids to support front line patient/ clinician interactions


4 Patient held records

a) Using technology: patients accessing their own information/Single patient record. Include clear communication on patient dashboard including medications, blood test requirements, clinic appointments and pointers to information sources

Action: Work with key partners (AHSN) to enable patient viewable integrated health and care records.

5 Optimise patient pathways

a) Ensure involvement and leadership of joint GM clinical pathway reviews to ensure the medicines used are reviewed to be consistent with NICE pathways and the Joint Formulary. Priority areas: Diabetes, Respiratory, Cardiovascular, Antimicrobials, using the Rheumatology pathways as examples of best practice.


b) Develop pathways to create seamless patient journeys, which meet needs not fulfilled by national guidance. Considering the following elements:

Start from onset of symptoms/prevention/ public health messages

Involve patient Inclusion of self-management/self-care

Motivate patients to seek advice/information

Signposting to appropriate information/contact

Indicating how treatments are used, not just the medicines to be used

Incorporating shared decision making and shared care to include the patient

Allow patients to take ownership of test results, pathway etc.




c) Pathways should be across the widest area possible to reduce likelihood of inequity. This will be challenging across GM, so should fit with natural patient journeys/ geographies. Enhanced by Sharing learning across GM. CCG‟s may produce own pathways, GMMMG should consider for wider dissemination / appropriateness and QA.

Action: Develop GM standards for guidelines

6 Enhancing Primary and Community care

a) Develop and disseminate Repeat Prescribing standards to cover GM.

Action: Implementation in CCGs, practices, providers, pharmacies

b) Promote the expansion of clinical medication review services to minimise adverse effects resulting from the use of medicines and optimise treatment benefits. With particular focus on care establishments, due to their high use of medicines and limited medical review.


7 Self-care

c) Facilitate and promote support for self care and manage, particularly those with long term conditions, through locality providers, Medicines Management teams, co-commissioning of the community pharmacy contractual framework and the Expert Patient Programme.


d) Promoting the uptake of non-pharmacological interventions to improve health and use of over-the-counter medicines where appropriate, including the expansion of the Pharmacy minor/common ailment schemes.


e) Investigate options for Telecare to enhance understanding.

Video/Skype conference for information

Reference to help societies/groups

Action: Work with key partners (AHSN) to enable platforms and/ or content

8 Signposting more here?

9 Ensuring best value for taxpayer resources a) Ensure all PbR excluded drugs have prior approval for use or are individually approved to

ensure clinical effectiveness. b) Better links with 1o and 2o care providers to get Value for Money for NHS procurement

Necessary?



8 Governance

Greater Manchester Medicines Management Group (GMMMG) has been in existence since 2004. It has evolved over this time to support changing agendas. It should be reviewed at least every 3 yea9rs to ensure fitness for purpose.

It is current configured as such:

Main Functions of the Groups

1. Greater Manchester Medicines Management Group (Patient Experience?)

The GMMMG is the leadership group, optimising patient experiences of medicines, promoting excellence and coordinating care in GM.

The group consists of GPs, pharmacists and other key healthcare professionals. It identifies and champions the appropriate use of medicines across Greater Manchester taking into account cost effectiveness, quality, equity and patient safety. It also has a role in setting standards and monitoring health economies prescribing.

Accountable to the GM CCG Association Governing Group

Clinically Chaired

Oversees strategy and workplan,

Approves subgroup recommendations

Is facilitated and supported by RDTC Newcastle and NWCSU.

2. Formulary sub-group (Promoting Excellence?)

The GM joint formulary ensures that patients receive excellent, evidence based choices, seamless, coordinated care across all health and social care interfaces.

Adherence to the formulary is strongly recommended by providers and commissioners superseding all local formularies.

The formulary is applicable to new initiations and treatments around 80% of patients should expect to receive.

The formulary is a good indicator of quality, patient focussed prescribing if compliance is high.

Maintains the „Do Not Prescribe‟ and Grey lists of less suitable treatments.

Greater Manchester Medicines Management

Group

Formulary Sub Group

Interface Sub Group

New Therapies Sub Group



3. Interface subgroup (Coordinating Care?)

The Interface Prescribing Subgroup make recommendations on the appropriate coordination of safe medical treatment.

Maintains the Red/ Amber/ Green list for prescribing responsibility.

Makes decisions on the most appropriate place for prescribing of named drugs (the RAG list) based solely on safety and monitoring of the drug and or disease.

Oversees the production and availability of Shared Care Protocols, for all drugs designated „amber‟ across Greater Manchester.

It recommendations are primarily to promote patient safety and enhancement of services for patients prescribed specialist medicines.

Indicates the commissioning implications of its decisions and advises GMMMG accordingly, particularly for newly considered drugs and existing drugs whose RAG status is changed.

4. New Therapies subgroup (Promoting Excellence/ Patient Experience?)

The New Therapies Subgroup considers new drug applications and to make recommendations on new drugs and business cases to GMMMG.

Recommendations are based on clinical evidence in order to manage the introduction of new medicines (< 18 months since launch) which have health economy-wide implications for primary, secondary, specialist and/or social care.

Identifies therapies considered less suitable for prescribing within Greater Manchester.

It liaises with Greater Manchester CCG medicines management groups, secondary care trust Drug & Therapeutics Committees and other relevant bodies to ensure that any new drug with wider health economy implications

Recommendations include clear guidance on audit requirements, periods of evaluation where necessary

To provide guidance on newly licensed therapies and indicates the products‟ place in treatment.

Ensuring that prescribers and patients have balanced information with which to inform their treatment decisions.



9 Communication

9.1 The GMMMG website:

The shop window of the GMMMG must be:

THE point of first contact to allow self service support for the system

Easily accessible

Simple, understandable layout

High quality, authoritative content which is regularly updated (or reviewed)

Open access to uphold the need for transparency

Signposting for resources NOT covered by GMMMG

Website url: www.GMMMG.nhs.uk

9.2 Learning and development resources

To support implementation

o Web based & face to face

In collaboration with partners

o e.g. Clinical Networks, Senates, AHSN

9.3 To front line clinicians

Useful advice – Relevant, valid and Easy to find

Push communications – via locality leads

Pull advice – via sign up to RSS feeds

New technology – e.g. Apps on smart devices

http://www.gmmmg.nhs.uk/



10 Ongoing Monitoring

There will be regular reporting of progress. This will take two forms: Corporate reporting and Clinical reporting.

10.1 Clinical reporting / measurement

Report Frequency To whom

Regular reports on overall progress of 2 year action plan

Quarterly GMMMG Local Area Prescribing/ Medicines Management Committees disseminated to local clinicians

Regular reporting through BI Portal(s) to allow granular analysis: GM, CCG, Cluster, GP practice

levels

Monthly Quarterly Bi Annual Annual

CCGs, Locality clusters, GP practices NHS Trusts

Patient reporting Annual Patient & Public Involvement forums, Healthwatch, Quality surveillance?

10.2 Corporate reporting / measurement

Report Frequency To whom

Medicines Optimisation report Annual GMMMG AGG of GM CCGs

Report of GMMMG outcomes Bi-annual

GM Heads of Commissioning GM Heads of Finance

Policy and guidance outputs Quarterly GM Heads of Commissioning GM Heads of Finance

Andrew White Head of Clinical Decision Making North West Commissioning Support Unit February 2014

2020 Vision - GMMMGgmmmg.nhs.uk/docs/150204 GM Medicines Optimisation... · Greater Manchester...

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