ITEM 7 Prescribing Update May 25
North Lanarkshire Council · 21 May 2025
Back to IJB Performance, Finance and Audit Committee — 21 May 2025 and its agenda
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1 REPORT Item No: 7 SUBJECT: Prescribing: Sustainability and Value Programme 2024/ 2025 Progress Update TO: IJB Performance, Finance & Audit Committee Lead Officer for Report: Lucy Munro, Medical Director NL HSCP Author(s) of Report Fiona Sanderson Lead Pharmacist Primary Care North Health & Social Care Partnership DATE: 21 May 2025 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: Fiona Sanderson Lead Pharmacist Primary Care North Health & Social Care Partnership ☒ 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 2024/2025 2. The project workstream activities planned for 2025/2026 4. VARIATIONS TO DIRECTIONS 5. BACKGROUND/SUMMARY OF KEY ISSUES • 5.1 Analysis published by Public Health Scotland for financial year 2023/24 shows that the total (net) cost for dispensing items and providing services in 2023/24 was £1.62 billion, increasing by 6.5% from £1.52 billion in 2022/23. This follows a period of largely rising cost, increasing by 35.3% over the last 10 years (Figure1). • The total number of items reimbursed between 2022/23 and 2023/24 increased by 3.7%, from 110.3 million to 114.4 million items. Over the last 10 years the total number of items reimbursed has increased by 13% from 101.2 million items in 2014/15. NHS Lanarkshire are the 3rd highest Board in terms of prescription items per head of population (excluding Western Islands & Shetland) Figure 1 - Total (Net) cost (£) in NHS Scotland: 2014/15 - 2023/24 (Public Health Scotland) Yes ☐ No ☒ N/A ☐
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3 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. Figure 1 - Average total (net) cost (£) per head of population by NHS Board: 2023/24 (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 is higher than some of the other Health Board areas in Scotland. The prescribing data generally
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4 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 however the trend is unchanged. 5.1.3 In 2023/24 both South and North Lanarkshire IJBs ended the year with a prescribing overspend of £8.482m: North Lanarkshire £1.781m; and South Lanarkshire £6.701m. This related to a total spend of £157.493m. The budget had received a 2% allocation uplift but the numbers of items dispensed had increased by 3.00% and the price per item had increased from an average of £9.93 per item to £10.17. 5.1.4 The total primary care prescribing budget for NHS Lanarkshire in 2024/25 was £141.6M. The North Lanarkshire HSCP share of this was £64.5M. There hasn’t been any inflationary increase added to 2024-25 annual budgets as the Board wont received the 2% allocation uplift this year from Scottish Government Health & Social Care Department (SGHSCD). Based on the data received to date the cost per item remains high and currently stands at £10.31 and the number of items being dispensed has increased by 3.40% based on the same period in 2023-24. 5.1.5 In North Lanarkshire, the prescribing overspend forecast for 2024/25 at January 2025 was £3.962M with South Lanarkshire having an overspend of £6.19m bringing the total overspend to £10.152m 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 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 2024/5 included a Prescribing Services Efficiencies Plan with a view to bringing Lanarkshire’s prescribing levels closer to the level of a comparable health boards. This included reducing prescribing spending by £4.2m through 2024/25, noting that this would reduce the level of overspend but not eliminate it. The purpose of this plan 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 £4.2M (with at least £2.280M of this in the North HSCP) in the financial year 2024/25.
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5 • 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 • 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 • 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
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6 5.3.3 Prescribing culture • Implement Health Board guidance for prescribers to avoid prescribing specific drugs of low therapeutic value. Lanarkshire’s guidance was updated in Dec 24 in line with the publication of the national guidance. Bespoke reports around monitoring of the MOLCV are in development both locally and nationally. • Refresh and promote GP (General Practitioner) locum- specific prescribing guidance • 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). The Lead Pharmacist Primary Care NHSCP is now a member of the Lanarkshire Green Health Partenership Strategic Group and joint projects are being discussed. • Facilitate improved communication with Community Pharmacy. The new Lead Pharmacist for Community Pharmacy Services is now in post. Appendix 1 outlines the project plan workstreams and their current status of activity. 5.4 2025/6 Plan 5.4.1 Addressing polypharmacy Looking ahead, cost reduction work in 2025/26 will continue to 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 however referrals from the wider MDTs are now being triaged and accepted by the team where resource allows this to happen. 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. A significant number pharmacists have been trained in simulation facilitation and additional training for a smaller group in creating relevant scenarios. New polypharmacy dashboards have been developed and there will be a spotlight report regarding each locality progress to target on a monthly basis. This update will also be tabled at PMMB. The Lead Pharmacists for each Partnership will also have regular monthly updates from their locality leads around progress and any barriers or difficulties being faced.
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7 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. There has been a move away from traditional switch projects due to shortages and changes to prices in the Scottish Drug Tariff however it was highlighted that other Boards have successfully completed a switch from DPP4 inhibitors to generic Sitagliptin. The switch within Lanarkshire would release approx. £1million in savings. 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 was the first Health Board in Scotland to implement such a list and with the publication of the national list, the Lanarkshire list has been updated to reflect any changes required. Reviews have taking place of patients already on these medications and they will be stopped where possible. Current data and graphs on use of MOLCV in Lanarkshire is suumarised below. Monitoring and changes to prescribing is noted at PMMB through the following graphs.
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8 5.4.4 Non medicines In 2024/25 the Non Medicines Effective Prescribing Group (NMEPG) was formed. This is representation from each of the specialties around non-medicines spend & the aim of the group is to review spend on each of the different areas with the wider teams, identify any outlier prescribing or quality & cost effective projects and feedback using a standard reporting template at the NMEPG. NHS Lanarkshire is working collaboratively with the national non medicines group to identify potential savings around non-medicines prescribing and there is also representation at the Effective Prescribing and Therapeutics group around the production of national indicators. Current spend for NHS Lanarkshire on non medicines is approx. £21.1m per annum. 5.4.5 Prescribing change schemes The concept of using change schemes to release efficiencies has been used in other Health Boards and palatability is being considered.
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9 It is becoming increasingly difficult to estimate future savings as work moves towards changing the overall trajectory of prescribing, rather than easily countable switches. This has been compounded by a delay in obtaining data due to a national issue with the Prescribing Information System for Scotland however this issue, has been, for the most part, resolved. For planning purposes, however, a savings target of £8.5M for Lanarkshire has been agreed and the main components of this final target are summarised below. 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. Total savings at the end of January 25 are £2.9M (Pan Lanarkshire) with £1.5M in the North. Predicted savings achieved are £0.556m below the planned level & this is due to a combination of polypharmacy reviews and medicines of low therapeutic value being slower than previously anticipated. However, savings achieved from practice and other switches are ahead of plan. 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 2025/26, including - • Continue to move forward with polypharmacy reviews across localities
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10 • Complete Benefits mapping profiles and dashboard reporting system • As NMEPG becomes more established, it is hoped that quality and cost efficient projects will be highlighted within this group. • Continue with ongoing project workstreams • Continue to 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 Annual savings set at £4.2M pan Lanarkshire. The target for North was £2.3M and the South £1.9M. 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 2024/25 workstreams are moving to polypharmacy reviews and drugs of low therapeutic value. Yes ☒ No ☐ N/A ☐
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11 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 ☐ 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:
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12 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; 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 Yes ☒ No ☐ N/A ☐ Yes / Date added ☒ No ☐ N/A ☐
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13 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 2025 = £2.3Million (as of January 25 £1.6m has been released) Completed project workstreams: Ongoing project workstreams: • Increase number of polypharmacy reviews in practices (estimated savings £120 per review) • Care Homes Medicines Waste Policy – Scope to see if this can be rolled out further. • Care Homes Stock order test of change almost complete • Collaborate with Care@Home Service to develop and test an alert system to identify patients with high volumes of unused medications • Identify workstreams and quality and cost effective projects around non medicines • Review Formulary adherence and processes around prescribing on Vision/eMIS • Analyse pharmacist input to the test of change pilot within HMP Shotts. Main focus and plans for 2025/26 • Move forward intently with all polypharmacy reviews across localities & ensure that target number of reviews are being met. • Implement and evaluate the Benefits mapping profiles and dashboard reporting system • Continue with ongoing project workstreams
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