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Greater Manchester Medicines Management Group

2020 Vision

Appendix of Greater Manchester

Medicines Optimisation Strategy

2015-2020

A shared vision of Medicines Optimisation for Greater Manchester

This Appendix provides additional background and context to GM Medicines Optimisation Strategy

February 2015

Status (v0.4) Date: Feb 2015

Greater Manchester Medicines Optimisation Strategy 2015-2020

Appendices:

Appendix 1 – NHS Prescribing patterns 3

Appendix 2 - Key Safety Publications summary – Francis, Berwick, Keogh 8

Appendix 3 - Berwick Review 9

Appendix 4 - Keogh Review 12

Appendix 5 – Winterbourne View Review 12

Appendix 6 – Better Quality Care for all - The NHS outcomes framework 13

Appendix 7 - CCG Strategic plan themes 15

Appendix 8 - Medicines Optimisation Strategies and policy 16



Appendix 1 NHS Prescribing patterns

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

1

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

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

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



GM Primary Care Prescribing

Secondary care data is not available in this granularity, so HSCIC data is being used to estimate projected spends at current growth rates.

Greater Manchester - Unmitigated Prescribing Growth Projections

GM Area Team

Hospital Issued (13.9%) Primary Care (2.1%) Hosp Rx

FP10HP (-4.9%) Total

Spend

Cost (£M)

% of total spend

Cost (£M)

% of total spend

Cost (£M)

% of total spend

Total

13/14 334.6 40.3% 492.9 59.3% 3.8 0.5% 831.2

14/15 381.1 42.9% 503.3 56.7% 3.6 0.4% 888.0

15/16 434.1 45.6% 513.8 54.0% 3.4 0.4% 951.3

16/17 494.4 48.4% 524.6 51.3% 3.3 0.3% 1022.3

17/18 563.1 51.1% 535.6 48.6% 3.1 0.3% 1101.9

18/19 641.4 53.8% 546.9 45.9% 3.0 0.2% 1191.3

19/20 730.6 56.6% 558.4 43.2% 2.8 0.2% 1291.8

Projected Growth over 6 years 396.0 65.5 -1.0 460.6

Compound Growth over 6 years 118% 13% -26% 55%

Compound growth at 1.7% 370.2 545.4 4.2 919.7

Compound QIPP Challenge 360.4 13.0 -1.4 372.0

Source: HSCIC Hospital Prescribing England 2013-14 Assumptions: Growth at current rates, modified by active interventions in many CCGs and Trusts NOT factored in: PPRS , Biosimilars, Generics, Service reconfiguration, Medicines Optimisation activity High impact areas

Highest Cost Highest Items Highest Cost per item

1. Central Nervous System CVS Stoma 2. Respiratory System CNS Malignancy 3. Cardiovascular System GI Dressings 4. Gastro-Intestinal System Endo Incontinence 5. Endocrine System Resp Respiratory 6. Nutrition and Blood Nutrition Appliances 7. Infections Infections Endocrine



2 year trends of Growth patterns in primary care



Fig X GM Top 50 expenditure - Cost Difference,



Fig X GM Top 50 expenditure - Item Difference



Appendix 2 - Key safety publications – Francis, Berwick Keogh, Winterbourne In the last 2 years, there have been several landmark reports, which have had a significant impact on the NHS; The Francis report, into care at Mid Staffordshire hospital, which generated the government’s response in the form of the Berwick review. The Keogh review was focussed on 14 trusts with apparently higher rates of mortality.

Professor Berwick’s report is an inspirational, but practical summary and action plan for the NHS to implement; whereas The Keogh review presented a new way to inspect hospitals in a more holistic manner.

The two reports, while having different remits, produced very similar conclusions or recommendations (see appendices for direct relevance to GMMMG).

Berwick Review Keogh Review Winterbourne View

Recommendations Key Findings Recommendations

Leadership

Patient and Public

Involvement

Staff

Training and Capacity-

Building

Measurement and

Transparency

Structures

Enforcement

Patient experience

Safety

Workforce

Clinical and operational

effectiveness

Leadership and

governance

Personalised services Supported in the community, close to home and family. Hospital treat and assessment o Only if necessary o Quality care near to home o Moved quickly to home or

community support.

While different language is used, it is clear that a focus on listening to patients, our staff and providing the leadership and development for them is crucial for the NHS to develop as it needs to do.

The most powerful statements in all the reports are contained in the overarching goal of the Berwick Report:

‘Place the quality of patient care, especially patient safety, above all other aims.

Engage, empower, and hear patients and carers at all times.

Foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work.

Embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.’

and

‘The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and

improvement of patient care, top to bottom and end to end.’

GMMMG must define and communicate where it’s roles and functions contribute directly and indirectly to these aims.



Appendix 3 - Berwick review. A promise to Learn, a commitment to act. Makes ten recommendations in categories: Highlighted where GMMMG can make a contribution to delivering the aims, recognising that other parts of the NHS .

The overarching goal

The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.

Leadership

All leaders with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support

Patient and public involvement

Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.

Staff

Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported.

Training and Building Capacity

Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives.

The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at scale, within the NHS.

Measurement and transparency

Transparency should be complete, timely and unequivocal. All data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.

All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.

Structures and regulation

Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.

Enforcement

We support responsive regulation of organisations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to wilful or reckless neglect or mistreatment.



Moving forward However, our most important recommendations for the way forward envision the NHS as a learning organisation, fully committed to the following:

Placing the quality of patient care, especially patient safety, above all other aims.

Engaging, empowering, and hearing patients and carers throughout the entire system and at all times.

Fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work.

Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.

Sections with particular resonance for GM Medicines Strategy

‘The other, better, way is through improvement – introducing new models of care and new partnerships among clinicians, patients and carers that can produce better care at lower cost. Only a culture of learning and improvement can follow that better way.’

‘Suggested improvement skills required for each group in a provider organisation’

‘While “Zero Harm” is a bold and worthy aspiration, the scientifically correct goal is “continual reduction”. All in the NHS should understand that safety is a continually emerging property, and that the battle for safety is never “won”; rather, it is always in progress.’

How GM can help this learning culture



‘NHS to embrace wholeheartedly a culture of learning’



Appendix 4 – Keogh Review - Review into the quality of care and treatment provided by 14 hospital trusts in England.

Patient experience

Safety

Understanding issues around the trust’s safety record and ability to manage these (such as compliance with safety procedures or trust policies that enhance trust, training to improve safety performance, the effectiveness of reporting issues of safety compliance or use of equipment that enhances safety);

Workforce

Clinical and operational effectiveness

Understanding issues around the trust’s clinical and operational performance (such as the management of capacity and the quality – or presence - of trust wide policies, how the trust addresses clinical and operational performance) and in particular how trusts use mortality data to analyse and improve quality of care;

Governance and leadership

Understanding the trust’s leadership and governance of quality (such as how the board is assured of the performance of the trust to ensure that it is safe and how it uses information to drive quality improvements).

Other key learnings from individual hospital reports where GMMMG could make a difference

Infection control - regional learnings and spread of good practice

Major service change - Evidence base of successful pathway changes - including the use of medicines

Re-admission rates - Ensuring medicines related harm is reduced through evidence based interventions

Clinical leadership - Leadership to the system provided directly by GMMMG and brief evidence to inform leaders

Appendix 5 Care Homes – Winterbourne View2

The report sets out the type of care that people with learning disabilities/autism and behaviour that challenges should get, but is equally applicable to care homes in general.

People should receive local personalised services that meet their needs. People should be supported in the community, in their home or close to their home

and family. People should only go to hospital for assessment and treatment if it is necessary

and they cannot get the support they need at home or in a community service. People that do have to go into hospital for assessment and treatment should

receive good quality care as near to their home as possible. People should be moved on from hospitals as quickly as possible – either back

home or on to other community support.

2 Winterbourne View Hospital: Department of Health review and response 2013 DH www.GOV.UK

https://www.gov.uk/government/publications/winterbourne-view-hospital-department-of-health-review-and-response



The 5 domains of the NHS Outcomes framework can all be supported by GMMMG 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

Appendix 6 - Better Quality Care for all - The NHS outcomes framework

The 5 outcome domains will be used to inform the work of the GM Medicines Optimisation Strategy.

This Outcomes Framework specifically references the role of Medicines Optimisation.

‘Medicines play a crucial role in maintaining health, managing chronic conditions, and curing disease. In the NHS we invest approximately £13 billion on medicines each year. To date medicines have been managed in relative isolation in the various sectors in the NHS. This has resulted in fragmented services and relatively poor outcomes for patients, in relation to their medicines.’

‘Medicines optimisation (making sure people get the right medicines and use them as prescribed) offers a step change in the way that we support patients to take their medicines and will focus on engaging with patients and the public around what services and support are needed to ensure they get optimal benefits form the medicines they take.’

Areas where GMMMG can

have a significant impact



Outcome indicator

Description

5.4 Incidence of medication errors causing serious harm

1.1 Under-75 mortality rate from cardiovascular disease

1.2 Under-75 mortality rate from respiratory disease

1.5 Excess under-75 mortality rate in adults with serious mental illness

2.1 Proportion of people feeling supported to manage their condition

2.2 Employment of people with long-term conditions

2.6ii A measure of the effectiveness of post-diagnosis care in sustaining

independence and improving quality of life

3a Emergency admissions for acute conditions that should not usually

require hospital admissions

3b Emergency readmissions within 30 days of discharge from hospital

3.6ii Proportion offered rehabilitation following discharge from acute or

community hospital

The most obvious outcome indicator, which references medicines specifically is 5.4, but

Medicines contribute to many other areas, examples are below:



Appendix 7 - CCG Strategic plan themes

The 12 GM CCGs have produced 5 year strategic plans to cover the same timescale as this Strategy, with 2 year details action plans.

The plans highlight areas of priority:

Medicines Optimisation will contribute toward these wider health economy priorities and have already identified the following areas as areas of focus which this strategy will aim to support their effective delivery.

Themes Area of Focus

Long Term conditions Multiple LTCs

Cancer LTCs

Cardiovascular LTCs

Respiratory LTCs

Mental Health/Dementia

Diabetes

Self Care Patient empowerment

Self care plans

Quality and Safety Repeat prescribing improvements

waste reduction

Care homes

medicines safety thermometer/ medication

errors

QP5

IT support to Medicines Optimisation Compliance

Safe transfer of care/discharge

Finance/QIPP QIPP/monitoring/standards

Nutrition

Specials

Red drugs

Care homes

Where to re-invest savings - plans

Specialised Commissioning Transfer PBR drug management

Out of Hospital support and development Quality Improvement

Different settings

Care homes,

Urgent care,

Integrated care

7 day working

Co- Commissioning of primary care

Community Pharmacy development Defining role and integration with wider

primary care services

CCG commissioned services to support

wider plans



1. Aim to understand the patient’s experience,

2. Ensure evidence based choice of medicines,

3. Make medicines optimisation part of routine practice

4. Ensure medicines use is as safe as possible.

PATIENT EXPERIENCE STANDARD 1: Putting patients first STANDARD 2: Episode of care STANDARD 3: Integrated transfer of care

SAFE & EFFECTIVE USE OF MEDICINES STANDARD 4: Effective use of medicines STANDARD 5: Medicines expertise STANDARD 6: Safe use of medicines STANDARD 7: Supply of medicines

DELIVERING THE SERVICE STANDARD 8: Leadership STANDARD 9: Governance and financial management STANDARD 10: Workforce

Appendix 8 - Medicines Optimisation Strategies and policy

a) Medicines Optimisation

There are significant moves to socialise the principles of Medicine Optimisation across the NHS, beyond the pharmacy world. Work is emerging from many respected sources:

1. NICE - Medicines Optimisation Clinical Guideline3

To be updated at launch – Feb 2015

.

2. Royal Pharmaceutical Society

a. Medicines Optimisation Good Practice Guidance 4-

Which defined four principles, which are supported by resources and case studies

to assist implementation.

These are intended to have a ‘patient centred approach’, focussing on ‘Improved

patient outcomes’ and ‘Aligned measurement and monitoring of medicines

optimisation.’

b. Professional standards for hospital pharmacy5

These standards represent quality pharmacy services, and are broad and

applicable across the full range of service providers. The standards underpin

patient experience and the safe, effective management of medicines within and

across organisations. Grouped into three domains, the 10 standards describe what

a quality pharmacy service should deliver.

3 Medicines Optimisation Clinical Guideline. NICE. Due for publication Feb 2015 www.nice.org.uk

4 Medicines Optimisation Good Practice Guidance. Royal Pharmaceutical Society. 2013

www.rpharms.com/ 5 Professional standards for hospital pharmacy. Royal Pharmaceutical Society. 2013 www.rpharms.com/

http://www.nice.org.uk/

http://www.rpharms.com/

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



It’s main areas of focus are:

Optimising medicines use in the specialised comm ‘high cost drugs list’;

Development and delivery of a work plan for high cost medicines;

To work in collaboration with national medicines procurement groups To

reach consensus on issues such as the repatriation of patients to

secondary care, rebate and gain share arrangements; To support the on-going implementation of home care reforms.

3. NHS England - Medicines Optimisation Clinical Reference Group6

Which will work:

‘to ensure that the systems and levers currently in place for the procurement,

selection and use of medicines in secondary care, are as effective as possible in

supporting patients to take their medicines; in reducing harm from medicines,

whilst ensuring best value.’

This group is expected to provide guidance for local implementation. The GM

Medicines Optimisation Strategy will involve consistent implementation across

the health economy.

4. Specialist Pharmacy Services (SPS) Review7

The proposed structure has been confirmed by NHS England in May 2014

The service will be nationally commissioned, provided in 10 footprints across 4 regions. The service will have three functional groupings

Medicines Information Medicines Assurance

Medicines Safety

These will operate at scale to support local delivery of services by providers and commissioners, reducing duplication of effort and ensuring local concentration on delivery of the highest quality, safe care. The GMMMG will need to ensure it complements, not duplicates the outputs of SPS.

5. Medication Safety Thermometer8

Being piloted in Greater Manchester, with the likelihood of being rolled out nationally.

A measurement tool for improvement, which focuses on Medication Reconciliation, Allergy Status, Medication Omission, and Identifying harm from high risk medicines in line with Domain 5 of the NHS Outcomes Framework.

Proportion of patients with reconciliation started within 24 hour

Proportion of patients who have had an omitted dose in the last 24 hours

Proportion of patients with medicine allergy status documented

Proportion of patients with an omission of a critical medicine

Proportion of patients receiving a high risk medication in the last 24 hours

Proportion of patients on a high risk medicine that trigger an MDT referral

6 NHS England - Medicines Optimisation Clinical Reference Group www.england.nhs.uk

7 The Review of Specialist Pharmacy Services in England. NHS England 2014 www.england.nhs.uk

8 Medication Safety Thermometer

https://www.england.nhs.uk/ourwork/commissioning/spec-services/npc-crg/medicines-optimisation/

http://www.england.nhs.uk/2014/05/28/sps/

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