ITEM 8 Prescribing Efficiencies Programme
North Lanarkshire Council · 27 September 2023
Back to Health and Social Care Integration Joint Board — 27 September 2023 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 8 SUBJECT: Prescribing Efficiencies Programme TO: Integration Joint Board Lead Officer for Report: Dr Lucy Munro Medical Director for Health & Social Care North Lanarkshire Author(s) of Report Julie Russell Deputy Lead Prescribing Management (North HSCP) Dr Lucy Munro Medical Director for Health & Social Care North Lanarkshire DATE: 27 September 2023 1. PURPOSE OF REPORT This paper is coming to the IJB for: For approval ☐ For endorsement ☐ To note ☒ 2. ROUTE TO THE BOARD This paper has been: Prepared By: Julie Russell ☒ Reviewed By: Dr Lucy Munro ☒ Endorsed By: Dr Lucy Munro ☒
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2 3. RECOMMENDATIONS The IB is asked to note progress to date and background. 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Costs and Quality 5.1.1 Medication is the single most common healthcare intervention and is one of the highest health expenditure costs. NHS Lanarkshire annual prescribing costs are approximately £140 million/year. The Prescribing Team is set an annual target for efficiencies and in 22/23 achieved a total of £2.24 million across Lanarkshire in cost mitigation, £1.2 million of which was in North Lanarkshire. To note, the prescribing efficiencies work is undertaken on a pan Lanarkshire basis with local adaptation at partnership, locality and practice level. This provides consistency of communication with prescribers and the clinical governance required across the interface with secondary care colleagues with regard to medicines changes. The aim is to change prescribing while either improving the quality and appropriateness of medicines or leaving the quality of care unaffected. 5.2 Data and Finance 5.2.1 Data which describe prescribing efficiencies can be difficult to understand and can seem anomalous with current financial data. In 23/24 the savings target from the combined community prescribing budget is £5.4 million for NHS Lanarkshire, this is ambitious but we believe achievable. 5.2.3 PRISMS, the prescribing information system for Scotland, is the most reliable data for actual costs of medications in Scotland. These data sets run three months behind and are used to describe our current and predicted financial position. 5.2.4 Prescribing efficiency savings, on the other hand, are an estimated calculation of the annual saving which will be made over the coming financial year as the result of a particular action/set of actions. Example is thus; if medication A is changed to medication B in April of 2023 with a cost saving of £10/month, the resultant saving of £120 in financial year 2023/24 will not be seen in the PRIMS data until July 2024. Yes ☐ No ☐ N/A ☒
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3 5.2.5 This explains why the actions taken in the first quarter of 2023 in relation to prescribing will not be evident in the financial predictions at all until July 2023 at the earliest and not in full until July 2024. 5.2.6 The actions already taken in this financial year 2023/24 are projected to save circa £2 million in NHS Lanarkshire which is more in a single quarter than has been saved in a whole year for most of our recent years but the effect of the data streams is those savings will not be visible at present. Additionally, the unpredictably increasing cost of medicines could outstrip even these ambitious savings. 5.2.7 NHS Lanarkshire has higher costs/patient than other board areas (Graph 1) with items number being a specific issue in North Lanarkshire (Graph 2). 5.2.8 These patterns are typical of those we expect in deprived areas and when Graph 1 is adjusted for deprivation the unfavourable comparison with other boards disappears. This is important information as it helps us understand that our prescribers are not behaving in a way which is out of keeping with other similar areas and also helps us know what and how to target interventions most effectively. It is important to avoid any sense of ‘blame’ towards either prescribers or patients while still challenging prescribing habits and explaining the reasons why some medications are not being prescribed. Graph 1 – Annualised Gross Ingredient Cost per 1000 patients Graph 2 – Annualised items per 1000 patients
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4 5.3 Operations and Governance 5.3.1 In 23/24 the savings target from the combined community prescribing budget is £5.4 million. This is to be achieved by the Prescribing Team and the newly established Prescribing Operational Group which aims to achieve recurrent and sustainable efficiencies using a collaborative approach involving process and system changes. £2.5 million of this overall target applies to the North Lanarkshire Health and Social Care Partnership. 5.3.2 The Prescribing Operational Group is chaired by Dr Veronica Rainey - Associate Medical Director South Lanarkshire, as part of the Sustainability and Value programme of NHS Lanarkshire. All of the North Lanarkshire Locality Lead GPs and Prescribing Advisors sit on the Prescribing Operational Group. The Prescribing Operational Group reports into the Partnerships’ Medicine Management Board chaired by the North Lanarkshire Medical Director, Dr Lucy Munro, as well as the Sustainability and Value programme. 5.3.3 There are 3 strands to cost mitigation; individual practice plans (these are specific to each practice), central prescribing actions (these apply to all practices) and Scriptswitch savings (software installed on GP systems as a decision making aid to prompt prescribers to choose cost effective options). 5.3.4 Current central work streams include switches of specific inhalers, mucolytic and analgesic medications. The aim of central switches is to gain ‘quick wins’ for cost efficiencies without affecting quality of care. For all central switches there is a clinical governance process through various groups including the 0 6000 12000 18000 24000 Apr 2021 May 2021 Jun 2021 Jul 2021 Aug 2021 Sep 2021 Oct 2021 Nov 2021 Dec 2021 Jan 2022 Feb 2022 Mar 2022 Apr 2022 May 2022 Jun 2022 Jul 2022 Aug 2022 Sep 2022 Oct 2022 Nov 2022 Dec 2022 Jan 2023 Feb 2023 Mar 2023 Apr 2023 Annualised Items per 1,000 patients NHS LANARKSHIRE Scotland NORTH LANARKSHIRE SOUTH LANARKSHIRE SOUTH LANARKSHIRE Central Services NHS Lanarkshire (Minus Central Services)
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5 Partnerships’ Medicines Management Board and Area Drug and Therapeutics Committee as well as authorisation from specialists within the therapeutic areas. Both this board and this committee have stakeholder involvement from the GP Sub-Committees. 5.3.5 The practice plans are identified by analysing prescribing data for each individual practice allowing for differences in prescribing amongst localities and practices to be addressed with the aim of reducing unwarranted variation, spreading good practice and reducing costs. 5.4 The Drug Tariff 5.4.1 The Scottish Drug Tariff is published for and on behalf of the Primary and Community Care Directorate, Scottish Government by Public Health Scotland (PHS). The Tariff contains information regarding the prescribing, dispensing and reimbursement of medicines and appliances on primary care NHS prescriptions 5.4.2 Historically the Prescribing Team’s efficiencies have been from switching medicine to equivalent but more cost effective options. This includes switching brands, formulations (e.g. liquids to tablets) and to other drugs within the same therapeutic class. This is in line with work streams in other Health Boards. 5.4.3 PHS has recently announced that that there is an unprecedented pressure in the Drug Tariff expected to last for at least the next 2 years. This is the result of drug shortages and increasing costs of medicines and means that prices may fluctuate in a much more inconsistent way than previously, this, in turn, has an impact on our ability to save through ‘switches’. 5.4.4 This fragility in the drug tariff accompanied by an increasing number of prescription items means that the traditional way of achieving efficiencies is no longer viable long term. This includes a move to tackling polypharmacy using realistic medicine principles and creating a health board list of low therapeutic value medications which could be stopped. 5.4.5 In addition, North Lanarkshire is an outlier in its prescribing of respiratory medicines and pain medicines. The latter is an indicator that we could be managing chronic pain differently locally. The North Lanarkshire Medical Director has facilitated a programme of activities aimed at managing chronic pain in North Lanarkshire differently beginning in North East sector involving localities as a whole. 6. CONCLUSIONS 6.1 The fragility of drug costs and supply has presented an opportunity to move from traditional cost efficiency switches to a more holistic polypharmacy review model and avoidance of drugs of low therapeutic value.
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6 6.2 Of note, 11% of all unplanned hospital admissions are attributable to medicines related harm and the World Health Organisation (WHO) has made polypharmacy one of its top 3 health priorities. 6.3 This will improve quality and safety of prescribing in line with the principles of Realistic Medicine. Decreasing the number of items prescribed will result in a more sustainable way to manage prescribing costs and culture change. Many other Health Boards have already made the move to this way of working. This correlates well with prescribing stewardship and the aim of the work on chronic pain. 7. IMPLICATIONS 7.1 As the cost of living, transport and raw materials rise so does the cost of medications. Despite being ambitious and successful against target, it may be difficult for the prescribing efficiencies programme to keep pace with those increasing costs. The most effective and sustainable way to mitigate costs long term will be to prescribe less in an ever demanding environment thus a collaborative culture or prescribing stewardship will have to be created. A new focus on polypharmacy reviews, the work on chronic pain and the list ‘low therapeutic value’ drugs are the start of that change. 7.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☒ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☒ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☐ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☐ Health and Social Care Services contribute to reducing health inequalities ☐ People who use Health and Social Care Services are safe from harm ☒ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☐ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒
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7 7.2 ASSOCIATED MEASURE(S) N/A 7.3 FINANCIAL This paper has been reviewed by Finance: 7.4 RISK ASSESSMENT/RISK MANAGEMENT Risk will be updated and reviewed in coming quarter. Relevant Risk Register Details Current Risk Level Risk Owner Choose an item. 7.5 ENGAGEMENT & PARTICPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details regarding the engagement and participation that was undertaken. Objectives Further Details ☒ Involve stakeholders in the development work aimed at achieving the national outcomes ☒ Provide stakeholders with information on how to get involved ☒ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs ☐ Measure how well we involve community stakeholders in the planning, design and delivery of our services Yes ☐ No ☒ N/A ☐
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8 ☐ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery ☒ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings ☐ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff ☐ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: Currently being completed for Prescribing Operation Group EQIA added to website: Currently being completed for Prescribing Operation Group 8. BACKGROUND PAPERS None. 9. APPENDICES Appendix 1 - NHS Lanarkshire primary care prescribing efficiencies project presentation Yes ☐ No ☒ N/A ☐ Yes / Date added ☐ No ☒ N/A ☐
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9 CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Dr Lucy Munro Medical Director
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10 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed
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11 Appendix 1 - NHS Lanarkshire primary care prescribing efficiencies project presentation Slide 1 NHS LANARKSHIRE PRIMARY CARE PRESCRIBING EFFICIENCIES PROJECT SOUTH HEALTH AND SOCIAL CARE FORUM Dr Veronica Rainey Associate Medical Director South Lanarkshire HSCP
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12 Slide 2 GROSS ANNUAL BUDGET - £141.3M OVERSPEND AT MARCH 23 - £5.5M COST PER ITEM – UPWARD TREND ITEMS DISPENSED – UPWARD TREND
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13 Slide 3 NHS Lanarkshire prescribing spend is significantly higher than the national average. This has been compounded by recent high inflation and an increase in waiting lists for procedures resulting in a significant overspend which is unsustainable. It is essential that we act now to improve quality and efficiency and drive down costs in line with the Prescribing Quality & Efficiency Strategy (PQES). This is also a great opportunity to review our prescribing practice and culture across Lanarkshire in order to make good quality, sustainable changes
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14 Slide 4 Prescribing Efficiencies workshop March 22nd 2023 Attended by 11Prescribing Advisors Attended by 8 Locality Lead GPs Prescribing leads Head of Finance Primary Care Improvement Advisor
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15 Slide 5 Many areas across Lanarkshire have been identified where improvements can be made and where projects which were paused during the pandemic can be restarted. We are adopting a whole systems approach in order to ensure that the improvements being made across NHSL are shared, scaled and consistently embedded as normal practice. Areas for change which have been identified are mapped to the key improvement themes. This project involves all prescribers and many services across Primary Care.
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16 Slide 6 REDUCE WASTE, INEFFICIENCIES AND VARIATION QUALITY PRESCRIBING PRESCRIBING CULTURE
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17 Slide 7
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18 Slide 8 PRIMARY CARE PRESCRIBING EFFICIENCIES PROJECT
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19 Slide 9 Develop and test Health Board guidance to prescribers to avoid prescribing specific drugs of low therapeutic value.
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20 Slide 10
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21 Slide 11
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22 Slide 12 Comments and Suggestions please