ITEM 6 Prescribing Update
North Lanarkshire Council · 22 May 2024
Back to IJB Performance, Finance and Audit Committee — 22 May 2024 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: 6 SUBJECT: Prescribing: Sustainability and Value Programme 2023/ 2024 Progress Update TO: IJB Performance, Finance & Audit Committee Lead Officer for Report: Lucy Munro, Medical Director NL HSCP Author(s) of Report Karen Grant, Project Manager, Julie Russell, Lead Pharmacist for Prescribing Management Primary Care North DATE: 22 May 2024 1. PURPOSE OF REPORT This paper is coming to the IJB PFA for: For approval ☒ For endorsement ☐ To note ☐ 2. ROUTE TO THE BOARD This paper has been: Prepared By: Karen Grant, Project Manager, Julie Russell, Lead Pharmacist for Prescribing Management Primary Care North ☒ Reviewed By: ☒ Endorsed By: ☐
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2 3. RECOMMENDATIONS The IJB PFA is asked to note the following: - [rec 1. The savings for the financial year 2023/2024 2. The project workstream activities planned for 2024/2025 4. VARIATIONS TO DIRECTIONS 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Analysis published by Public Health Scotland in September 2023 shows that prescribing volumes have increased over the last 10 years in Scotland, with an overall increase of 11.6% from 98.8 million items in 2013/14 to 110.3 million items in 2022/23. The cost of items reimbursed (the Net Ingredient Cost) increased by 5.8% between 2021/22 and 2022/23 and increased by 33% over the last 10 years (Figure 1). Figure 1 - Total (Net) cost (£) in NHS Scotland: 2013/14 - 2022/23 (Public Health Scotland) 5.1.1 Prescribing costs vary between different health board areas and are influenced by a variety of factors including population demographics, prescribing culture and the prevalence of chronic disease. Yes ☐ No ☒ N/A ☐
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3 Figure 1 - Average total (net) cost (£)per head of population by NHS Board: 2022/23 (Public Health Scotland) 5.1.2 Lanarkshire has consistently significantly higher costs per patient in most main therapeutic areas of prescribing compared to the Scottish average and generally lies above most other Health Board areas in Scotland. The prescribing data generally follows the national trend but at a higher level. Previous work carried out by the Locality Quality Medicines Actions Groups and the Prescribing Quality and Efficiency Strategy achieved their targets the trend is unchanged. 5.1.3 In 2022/23 both South and North Lanarkshire IJBs ended the year with a prescribing overspend: North Lanarkshire £1.750m; and South Lanarkshire £3.750m. 5.1.4 The total primary care prescribing budget for NHS Lanarkshire in 2023/34 was £148.5M. The North Lanarkshire HSCP share of this was £76.4M. The budget had received the 2% allocation uplift in 2023/24 but the numbers of items dispensed has increased by 3.43% and the price per item had increased in the first 6 months from an average of £9.65 per item to £10.32. 5.1.5 In North Lanarkshire, the prescribing overspend forecast for 2023/24 at March 2023 was £3.835M. 5.1.6 Audit Scotland’s Integration Joint Boards Financial Analysis 2021/2022 report stated that IJBs have reached the point where ‘significant transformation will be needed to ensure the (1) long-term capacity, (2) financial sustainability and (3) quality of services individuals receive’. Audit Scotland have highlighted that there
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4 remains a significant overall and recurrent budget gap across all IJBs; and that failure to make the necessary changes to how public services are delivered will likely mean further budget pressures in the future. 5.1.7 The Sustainability and Value Programme 2023/4 included a Prescribing Services Efficiencies Project with a view to bringing Lanarkshire’s prescribing levels closer to the level of a comparable health board i.e. NHS Lothian. This included reducing prescribing spending by £2.7m through 2023/24 (as part of a £5.4m primary care prescribing target pan-Lanarkshire), noting that this would reduce the level of overspend but not eliminate it. The purpose of this project was to further assess the causes for Lanarkshire’s high prescribing costs and to develop and implement change ideas with associated action plans. 5.1.8 The main areas of change which were required in order to achieve cost savings of this magnitude are themed below, with examples of some to the change ideas discussed below. 5.2 Objectives Aim for a Pan Lanarkshire reduction in spending of £5.4M (with at least £2.7M of this in the North HSCP) in the financial year 2023/24. Evaluate potential cost saving of individual proposed change measures identified in Prescribing Efficiencies Workshop and prioritise those with greatest recurring financial impact. Effect cultural change by adopting a visible Pan Lanarkshire approach to efficiencies highlighting the responsibility of all stakeholders (including patients) to use resources responsibly. Support and enable collaboration at the interface between primary and secondary care to achieve our shared aim of reducing waste and improving levels of formulary adherence. Guidance and visible support for prescribers to implement and embed these changes i.e. clear and open communication with patients and their representatives that this is Lanarkshire wide guidance. 5.3 The following primary drivers were agreed: 5.3.1 Reduce waste inefficiencies and variation Identify high spend medications where we are able to safely switch to an alternative on a pan Lanarkshire basis Increase Formulary compliance by making the Preferred Formulary option the default setting on Vision
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5 Examine Script Switch use and improve the acceptance rate Resume project in Care Homes to test stock order of formulary wound dressings. Test use of Script Switch in Pharmacotherapy hubs Develop agreed process of medication ordering within Care Homes and standardize this pan-Lanarkshire Liaise with LIST to map areas over ordering and help guide targeted change measures Collaborate with Care @ Home Service and DNs to develop and test and alert system to identify patients with high volumes of unused medications or who are not compliant with medications for review by practice pharmacist 5.3.2 Quality prescribing Nursing are leading a review of ANP/DN/GPN prescribing Address high volume continence and stoma prescribing; Targeted delivery of PQES by Locality Prescribing Management Teams prioritizing practices with highest prescribing spend. Develop and test MDT (Multidisciplinary team) models to increase polypharmacy reviews and de-prescribing 5.3.3 Prescribing culture Develop and test Health Board guidance for prescribers to avoid prescribing specific drugs of low therapeutic value Refresh and promote GP (General Practitioner) locum- specific prescribing guidance Deliver a pharmacy-led training workshop at GPST training days, commencing August 2023 Develop and test a process for working across the Primary /Secondary Care interface to increase alignment to the NHS Lanarkshire Formulary Improve signposting to alternative management options (Social Prescribing) Facilitate improved communication with Community Pharmacy Appendix 1outlines the project plan workstreams and their current status of activity. 5.4 2024/5 Plan 5.4.1 Addressing polypharmacy
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6 Looking ahead, cost reduction work in 2024/25 will focus on polypharmacy reviews – i.e. consultations with people who are on multiple medications to determine whether they still need to be on all of them. A data-driven approach will be taken, to ensure that the resource is targeted in areas where the greatest yield will result. Past evidence shows that an average of £120 per reviewed patient per annum can be saved from annual prescribing costs. Polypharmacy reviews address the culture of prescribing and result in sustained change rather than relying on medication equivalent switches. Simulation training is an important tool in upskilling pharmacists to have complex risk/benefit-orientated conversations with patients 20 pharmacists trained in simulation facilitation and additional training for a smaller group in creating relevant scenarios. 5.4.2 Targeted work In addition, targeted local work will take place, with bespoke reports created for each GP practice, highlighting where their prescribing varies from comparators and enabling conversations to take place between practice teams and locality prescribing advisors on how prescribing practice might change to reduce future prescribing costs. 5.4.3 Medications of low therapeutic value A list of medications of low therapeutic value has been launched. This is a range of medicines from which evidence suggests patients are unlikely to benefit and NHS Lanarkshire has been the first Health Board in Scotland to implement such a list. Reviews will take place of patients already on these medications and they will be stopped where possible. The implementation approach taken to this work is summarised in Appendix 6. 5.4.4 Non medicines The year 2024/25 will also be characterised with a stronger focus on non-medicines spend, with NHS Lanarkshire working collaboratively with a national group to identify potential savings from non-medicines prescribing e.g. dressings, catheters and stomas. It is becoming more difficult to estimate future savings as work moves towards changing the overall trajectory of prescribing, rather than easily countable switches. This is compounded by a delay in obtaining data due to a national issue with the Prescribing Information System for Scotland. For planning purposes, however, a savings target of £2.2M for North Lanarkshire has been set composed of: Polypharmacy Reviews £1.08m Review of medicines of low therapeutic value £0.81m Script Switch savings £0.3m
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7 6. CONCLUSIONS All project workstreams aligned to reducing waste inefficiencies and variation, quality prescribing, and prescribing culture to aid cost savings were identified by the Prescribing Management Team in collaboration with the Primary Care Prescribing Efficiencies Operational Group. This has resulted in a total saving of £3.9M (Pan Lanarkshire) and £2.1M in the North to 31st March 2024. The ongoing projects will be reviewed for 2024/25, along with new identified projects as noted below in Appendix 1. As has been highlighted in finance monitoring reports to the IJB and the Performance and Audit Sub-Committee, prescribing volatility and uncertainty continues to represent a high-risk area within the IJB’s budget. 7. IMPLICATIONS Further work will be carried out for 2024/25, including - Move forward with polypharmacy reviews across localities Complete Benefits mapping profiles and dashboard reporting system Continue with ongoing project workstreams Seek new workstreams 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 ☒ 7.2 ASSOCIATED MEASURE(S) 7.3 FINANCIAL
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8 Annual savings of 5.4million pan Lanarkshire. The target for South was £2.7M. This paper has been reviewed by Finance: 7.4 RISK ASSESSMENT/RISK MANAGEMENT There is an operational risk register with mitigations which will be updated now that the 2023/24 workstreams are moving to polypharmacy reviews and drugs of low therapeutic value. The relevant IJB risk is; IJB06.21 – Prescribing Activity and Costs, Current Risk Level High. 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 Patient and Staff group involvement in all workstream activities ☒ Provide stakeholders with information on how to get involved Engagement opportunities available for any of the workstream activities, in particular the work on Guidance on Items that should no longer be prescribed ☒ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs This is part of the Project Communications and Engagement Plan ☒ Measure how well we involve community stakeholders in the planning, design and delivery of our services This is part of the Communications and Engagement Plan ☒ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery Feedback from patient support groups fed into the Primary Care Prescribing Efficiencies Operational Group ☒ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings Opportunities available at governance group meetings as well as other meetings supporting the workstreams Yes ☒ No ☐ N/A ☐
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9 ☐ 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 and attached to report: EQIA added to website: 8. BACKGROUND PAPERS N/A 9. APPENDICES Appendix 1– North Lanarkshire Health and Social Care Partnership Primary Care Prescribing Efficiencies Project Summary of the Project Workstream Activities to date. CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Yes ☒ No ☐ N/A ☐ Yes / Date added ☒ No ☐ N/A ☐
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10 Dr Lucy Munro, Medical Director for Health and Social Care North Partnership, Lanarkshire Headquarters, Kirklands Hospital, Bothwell, 01698 752618 Lucy.Munro@lanarkshire.scot.nhs.uk
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11 Appendix 1 North Lanarkshire Health and Social Care Partnership Primary Care Prescribing Efficiencies Project Summary of the Project Workstream Activities to date: Overall projected savings for North Lanarkshire to 31st March 2024 = £2.13Million Completed project workstreams: Medication Switches: Oxycodone MR to Oxypro MR switch, Ethosuximide to Epesri switch Training on quality prescribing for trainee prescribers (including GP, nursing and AHP trainees) Increase ScriptSwitch compliance -savings made as of January 2024 £770,242 and at 154% of the target Quantity limits for scripts (noted a 4 month saving of over £10k) Scriptswitch use across all pharmacy hubs Publication of guidance on products of low therapeutic value which should not routinely be prescribed in Lanarkshire (estimated savings from this to be £1.5M) Care Home Pathway standardisation project rolled out Increase the use of social prescribing by developing an easily accessible and up to date directory of services (Vaslan Locator Tool and VanL tool “ALISS”) Ongoing project workstreams: Increase number of polypharmacy reviews in practices (estimated savings £120 per review) Review and reduce over-ordering from community pharmacies Care Homes Medicines Waste Policy development (1 care home returned over £2700 worth of products) Care Homes Stock order test of change Collaborate with Care@Home Service to develop and test an alert system to identify patients with high volumes of unused medications Develop Stoma Prescribing Guidelines- part of national workstream (also consideration for non-medicines prescribing guidelines) OOH stock supply project, reducing waste in inefficiencies Review Formulary adherence and processes around prescribing on Vision/eMIS
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12 Main focus and plans for 2024/25: Move forward intently with all polypharmacy reviews across localities Complete Benefits mapping profiles and dashboard reporting system Continue with ongoing project workstreams Begin new identified workstreams based on workshop held on 22nd February e.g Identifying work with prisons services, over ordering of inhalers PRIMARY CARE PRESCRIBING EFFICIENCIES PROJECT