Prescribing Incentive Scheme Proposal 2020/21

Historically there has been an incentive scheme in place for member practices since the PCT formed in 2002. The 2020/21 Prescribing Incentive Scheme (PIS) builds on previous years schemes and aligns with the Bedfordshire CCG, Quality, Innovation, Productivity and Prevention (QIPP) agenda.

The purpose of the scheme is:

To encourage and reward medicines optimisation, cost-effective and high quality prescribing.

Principles

Incentives should reward improvements in patient care and efficient use of resources. It is therefore important that the PIS does not simply reward low cost prescribing, but should include criteria relating to the quality of prescribing.

The scheme is designed to support financial stability without compromising patient care. The scheme should encourage practices to consider how patients can be supported to get the best from

their medicines, and how they can benefit from cost-effective quality prescribing. The CCG recognises that practices that are already achieving the targets specified in the scheme should

be rewarded in the same way as those practices meeting the targets for the first time. Practices may want help or support to facilitate change. The Medicines Management Team (MMT) is

able to provide advice and support to practices to implement the scheme. The scheme will run from 1st April 2020 to 31st March 2021.

Payment

The scheme payment is adjusted to list size, at £125/point/10,000 patients. If practices achieved every point the total value of the scheme would be £500,000., however to achieve this every practice would have to achieve a 5% underspend on budget, and this would represent a £3M underspend on the drugs budget. Typically the annual payment to practices is in the region of £300K - £350K.

The total points available in 2020/21 per practice will be 82 points, this equates to a payment of £10,250 per 10,000 patients if all points are achieved.

Eligibility to participate in the scheme

The scheme will be open to all practices

Indicator Points Target Points per month for achieving target

Rationale Comments

Anticholinergics – (In urinary incontinence) 9.0

Audit female patients over 75 years on an anticholinergic with a view to offer a drug holiday (about 4 weeks) or switch to a more cost effective treatment.

9 pts at end of year QIPP Indicator Audit to be submitted by March 2021

Spend on anticholinergics for urinary incontinence 3.0 £60 per 1000 pts (over 18’s)

0.5pts / month from September 2020

QIPP indicator Spend per 1000pts on anticholinergic items for urinary incontinence

Total Annual Antimicrobial Use 3.0 0.965 items / STAR-PU (unless targets change)

3 points if achieved at the end of the year

Part of the Quality Premium

Numerator: Annual oral antibacterial items Denominator: STAR-PU value for oral antibacterial items

Antimicrobial Prescribing Audits 6.0 Submission of a UTI Prophylaxis audit and Acne and rosacea prescribing audit

3 pts for submission of each audit

To support Quality Premium

1 Audit to be submitted by end of September 2020, 1 to be submitted by end of March 2021

Dry Eye Self-care spend/1000 patients 6.0 £7.50 per 1,000 pts 0.5 From April

20 QIPP IndicatorSpend per 1,000 patients on hypromellose, carmellose, carbomer, sodium hyaluronate 0.1% items.

Triple Therapy Combination inhaler 3.0 Greater than 60% on a triple therapy

combination inhaler

3pts if achieved by March 2021

QIPP indicator

Numerators: Triple therapy combination inhalers on repeatDenominator: all COPD pts on repeat triple therapy Patient numbers identified through published SystmONE searches submitted in April 20, June 20, Sept 20, Dec 20 and Mar 21

ICS step-down in COPD 3.0 65% or less of COPD patients on preventer inhaler on an ICS inhaler

3pts if achieved by March 2021

QIPP indicator

Numerator: COPD ICS patientsDenominator: all patients on a preventer inhaler for COPDPatient numbers identified through published SystmONE searches submitted in April 20, June 20, Sept 20, Dec 20 and Mar 21

Management of high dose opioids

3.0 Practices to develop a plan on the management of patients on high dose opioids and Gabapentinoids.

Patient Safety

Submit plan by September 2020

9.0 Reduce dose of patients taking MED of >120mg by 20% Using baseline data from S1 in April 2020, due March

20213pts for 40% of patients with 20% dose reduction6pts for 60% of patients with 20% dose reduction9pts for 80% of patients with 20% dose reduction

3.0 Audit patients who are on a high dose Gabapentinoid plus an opioid (that is 1.8g Gabapentin per day or more; 300mg

Pregabalin per day or more)

Due September 2020

NOAC – Quality Indicator 6.0 Baseline assessment of dosing & monitoring using SystmONE NOAC searches, quality improvement review, follow up review.

Patient Safety Baseline assessment submitted by September 2020, quality improvement & follow up review March 2021

Lowest acquisition cost NOAC as a proportion of all NOACs

3.0 65% by December 2020 3.0 pts at end of year

QIPP indicator Numerator: Total items of edoxaban Denominator: Total items of NOACs

The practice has achieved spend in line with budget

15.0 0% N/A

The percentage that the prescribing budget is underspent by

10.0 Up to 5% N/A

Prescribing Incentive Scheme Proposal 2020/21

Anticholinergics for Urinary Incontinence

In line with NICE NG123 and Quality Standard QS77 BCCG is asking practices to review all female patients aged 75 and over, taking a medication for the treatment of urinary incontinence. The reason for targeting this area of prescribing was to ensure that patients taking medication for this condition were gaining benefit from the treatment, not experiencing side effects and were not unknowingly being put at risk of cognitive decline as a result of the cumulative anticholinergic burden of these and other concomitant medications. Currently there are at least 1,000 patients 75 years or over taking an anticholinergic who would be appropriate for a review.

BCCG MMT are proposing that searches are run on SystmONE to identify all patients aged 75 and over who are currently taking a treatment for Urinary frequency, enuresis and incontinence. Each patient’s notes to then be reviewed to establish the ongoing need for an anticholinergic, the potential to switch to a more cost effective product and the need for the patient to be reviewed in clinic.

To encourage the use of the most cost-effective anticholinergics in patients who require ongoing treatment the total spend on total anticholinergics for urinary incontinence will be monitored. It is anticipated that by reviewing, stopping and switching to more cost effective alternatives during the patient audit this will directly impact the spend. The variation in practice spend is shown below:

0.00

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

180.00

target; 60

Anticholinergic prescribing for urinary incontinence - December 2019 (ad-justed for solifenacin price difference)

Adj

uste

d sp

end

/ 10

00 p

atie

nts

Prescribing Leads feedback:Given high patient numbers and the need in many cases for a face to face review it was felt that the available points should be increased to 9.

Link to GP Contract PCN Service Specification: SMRs and Medicines Optimisation. From 1st April 2020, each PCN will use appropriate tools to identify and prioritise patients who would benefit from a SMR, which will include those on medicines commonly associated with medication errors.

Antimicrobial Prescribing

To improve the quality of antimicrobial prescribing and minimise inappropriate antimicrobial prescribing in line with the NHS England Quality Premium or the national incentive scheme depending on which is published.

Antimicrobial prescribing rates have reduced across Bedfordshire CCG in 2018-19 to below the NHS England stretch target of 0.965 items / STAR-PU however there are still some high prescribing practices.

To ensure attention remains on antibiotic prescribing and to continue to encourage high prescribing practices to review their prescribing it is proposed that this indicator remains in the 20/21 incentive scheme. The target can be adjusted if new national targets are released.

Much work has been done on the prescribing of antibiotics in acute situations, and for the last 2 years practices have been asked to audit acute prescribing as part of the PIS, but there remain many patients who are taking antibiotics long term for prophylaxis or treatment e.g. acne. Practices are asked to audit two groups of patients prescribed antibiotics long term - for UTI prophylaxis and for acne / rosacea. The BCCG antimicrobial guidelines are clear that patients prescribed long term antibiotic prophylaxis should be reviewed every 6 months and prophylaxis stopped however in pilot practices 19/46 (41%) patients on UTI prophylaxis did not have evidence that a review had taken place in primary or secondary care.

Link to GP Contract PCN Service Specification: SMRs and Medicines Optimisation. From 1st April 2020, each PCN will actively work with their CCG to optimise quality of prescribing of antimicrobial medicines.

Dry eye Prescribing – Self care

NHS England’s advice on conditions which should be managed with over the counter medicines includes the management of dry, sore and tired eyes. NHS England advice that a prescription for treatment of dry or sore eyes should not routinely be offered in primary care as the condition is appropriate for self-care.

In order to support primary care prescribers in the management of dry eye syndrome a treatment guideline has been developed including treatment options for mild, moderate and severe dry eye. The products which fall into the mild and moderate treatment categories are hypromellose, carmellose, carbomer and sodium hyaluronate 0.1% - higher strengths are used in severe disease.

The graph shows the variation in spend between practices on these products, indicating an inequality in the level to which self-care is being promoted within GP surgeries across Bedfordshire. The lowest quartile is £7.50 / 1000 patients and is therefore recommended as the target for this indicator.

0

5

10

15

20

25

30

35

40

45

Self care ocular lubricant spend - December 2019

Spen

d /

1000

pat

ient

s

Practices are asked to review all patients on ocular lubricants for mild and moderate dry eye and recommend self-care. Patients newly presenting with dry eye should be encouraged to buy OTC products and try any variety of products to find the one that works for them following the recommendations made in the Dry Eye management guidelines.

Link to GP Contract PCN Service Specification: SMRs and Medicines Optimisation. From 1st April 2020, each PCN will actively work with their CCG to optimise the quality of prescribing of nationally identified medications of low priority. Which is likely to include items defined as appropriate for self-care by NHS England, alongside a metric monitoring prescribing rates.

COPD Indicator

Both NICE COPD guidelines and GOLD 2019 have emphasised restricting the use ICS/LABA combinations to those with asthmatic features suggesting steroid responsiveness. The latest GOLD guidance has in addition emphasised the need to review patients for de-escalation of pharmaceutical therapy and to consider switching from LABA/ICS to LABA/LAMA if the original indication was inappropriate (e.g. ICS in the absence of a history or exacerbations, raised eosinophils), there is lack of response to ICS or side effects warrant discontinuation.

The 2019/20 BCCG PIS scheme focused on identifying patients suitable for ICS step-down and in addition increasing the proportion of patients on ICS triple therapy combination inhalers to 40% of those on any form of triple therapy (ICS/LABA/LAMA).

Data from April to October 2019 has shown that while there is a significant increase in the number of patient’s prescribed triple therapy combination inhaler, there has been an increase in the number of patients prescribed an ICS inhaler for COPD.

-600-400-200

0200400600800

1000 Change in Inhaler Prescribing Apr 19 to Oct 19

Part three of the COPD PIS 2019/20 project is for practices to audit and identify COPD patients suitable for step-down from ICS, these audits are due to be submitted by March 2020. BCCG is proposing that by the end of March 2021 all practices should reduce prescribing of ICS in COPD in line with the lowest third of practices at the end of January 2020. This is a target of 65% or below and be the equivalent of stepping 340 patients down from ICS.

40%

45%

50%

55%

60%

65%

70%

75%

80%

85%

90%

0

10

20

30

40

50

60

ICS Data by Practice January 2020

% of Pts on ICS for COPD Pts to Step-down to reach target

In addition four practices have already achieved 60% of patients receiving a combination triple therapy as a proportion of all triple therapy patients. BCCG is proposing this as a target for the 2020/21 and would equate to approximately patients being changed to a triple therapy inhaler.

0%

10%

20%

30%

40%

50%

60%

70%

80%

0

10

20

30

40

50

60

70

80

Triple Therapy Data by Practice January 2020

% on Triple Therapy Combination Inhaler Pts to reach 60% Target

NOAC Safety Quality Improvement Indicator

NOAC Safety Quality Improvement Indicator

BCCG Currently has over 7,000 patients prescribed a NOAC for atrial fibrillation or the treatment or prevention of venous thromboembolism. NOACs are clinically effective but high risk medications, which require monitoring and regular review to ensure they are prescribed correctly. In 2017 audits estimated that 20% of patients across BCCG were on the incorrect dose of and a NOAC and requested practices audit the prescribing of all patients on NOACs.

In 2019 BCCG have published a set of searches on SystmONE to identify patients potentially on the incorrect dose of a NOAC, who have not had a CrCl calculated in the last year and who have not received adequate monitoring.

A review across of 11 practices and 3989 patients identified that 30% (900) patients had not had a CrCl calculated in the last year (only 243 patients had no record of U&Es in the past year), 611 patients had never had a CrCl calculated, 12% (249 out of 2090) of patients were identified as requiring a dose review and 8% (228 patients) were not readcoded for AF or VTE.

BCCG is proposing a Quality Improvement Projects for NOACs to:

Evaluate the current quality of their prescribing and monitoring of NOACs to identify areas for improvement; baseline assessment using SystmONE NOAC searches (September 2019).

Identify quality improvement activities and set improvement goals to improve performance in the monitoring and prescribing of NOACs.

Re-assessment of NOAC prescribing and monitoring using the NOAC searches

Link to GP Contract PCN Service Specification: SMRs and Medicines Optimisation. From 1st April 2020, each PCN will use appropriate tools to identify and prioritise patients who would benefit from a SMR, which will include those on medicines commonly associated with medication errors.

Management of high dose Opioids and Gabapentinoids

The focus of the opioid audit this financial year is to identify all patients curently being prescribed an opioid with a morphine equivalent dose (MED) of >120mg/day and to have a patient specific action plan for their pain management.

The BCCG MMT propose to progress this workstream by encouraging a 20% dose reduction for this patient group (and any other new patients who may now be on MED >120mg). The dose reduction will be demonstrated on the audit spreadsheet supplied.

The graph below from Open Prescribing shows that BCCG is still above the national median line for prescribing high dose opioids compared to other opioid doses.

Gabapentin/pregabalin and opioids are both commonly prescribed for pain and the likelihood of co-prescribing of gabapentinoids and opioids is high. Gabapentin and pregabalin are widely used for neuropathic pain. However, there is no good quality and reliable evidence for use in neuropathic pain other than in post herpetic neuralgia and diabetic neuropathy. Concomitant treatment with gabapentin/pregabalin and opioids is associated with a substantial increase in the risk of opioid-related death.

This quality improvement activity is offered as there is an important linked safety issue: patients taking high dose gabapentinoids (1.8g or more of gabapentin or 300mg or more of pregabalin) with an opioid have a significantly increased mortality; this is dose dependent on the gabapentinoid. The number of deaths where the coroner has noted Gabapentinoids has increased exponentially https://binged.it/2N49Gte .

The following graphs from ePACT2 - Safer Management of Controlled Drugs show the number of patients being co-prescribed gabapentinoids and an opioid in the same month. Pregabalin may be lower than the national average, but the number of patients is steadily increasing and we have to review these patients and reduce their doses appropriately.

Prescribing leads feedbackThere was considerable discussion of this challenging target at all prescribing leads meetings. It was agreed to increase the points offered to a maximum of 9 and to offer lower points values for partial achievement (i.e. a 20% reduction in a defined number of the patients).

Link to GP Contract PCN Service Specification: SMRs and Medicines Optimisation. From 1st April 2020, each PCN will actively work with their CCG to optimise the quality of prescribing medicines that can cause dependency.