The Pharmaceutical Price Regulation Scheme and medicines optimisation: ensuring the right patients, get the right choice of medicine at the right time

Transcription

1 The Pharmaceutical Price Regulation Scheme and medicines optimisation: ensuring the right patients, get the right choice of medicine at the right time Kent, Surrey and Sussex roadshow event Gatwick 19 May 2015 Organised by ABPI, NHS England, and Kent Surrey Sussex Academic Health Science Network

2 Contents 1. The national context The regional context Executive summary What s working well? Areas for development or change Development and actions for the future Roadshow key topics and discussion A national perspective on medicines optimisation Partnership with industry David Watson Barriers to utilising the PPRS for medicines optimisation Implementing medicines optimisation - the Medicines Optimisation Dashboard Review of local medicines optimisation data Medicines optimisation the patient s perspective and what it means in practice Local medicines optimisation programmes Polypharmacy - the pharmacist s perspective Polypharmacy NICE s perspective Polypharmacy and the use of audit tools Polypharmacy local medicines optimisation programmes Polypharmacy - patient s perspective Polypharmacy how to address it Treating COPD using inhalers local medicines optimisation programmes Treating atrial fibrillation local medicines optimisation programmes Future planning, actions and next steps Identifying Barriers Overcoming barriers Enablers Priority actions including a regional plan Annex Report details, disclaimer and references Disclaimer References

3 1. The national context Medicines have a vital role to play they prevent life threatening disease, manage long-term conditions, improve quality of life and reduce mortality. But there are many issues that prevent or reduce their effectiveness. These include patients reporting insufficient or complex supporting information, poor adherence, medicines wastage, the complications of using many medicines concurrently (polypharmacy) and patchy uptake of newer innovative medicines. We also need to tackle the challenges of budget constraints facing the NHS and growing demand which comes from an ageing population. We need to find new, innovative ways to deliver services, extract more value for money and to improve patient outcomes, quality and value from all medicines use. As part of their commitment to tackling this challenge, the pharmaceutical industry has agreed to underwrite the growth in branded medicines through direct payments to the Department of Health. Under the five year voluntary Pharmaceutical Price Regulation Scheme (PPRS) the industry is expecting to pay approximately 800 million to the NHS in 2015/16. This has been centrally factored into NHS England s overall Mandate budget from the Department of Health and is part of the funding growth provided. The PPRS agreement presents the NHS with a unique opportunity to ensure patients are getting the right medicines at the right time, less constrained by cost. It gives the NHS the flexibility to act based on the full long-term value of medicines rather than using short-term cost containment measures. When the PPRS was agreed in 2014, the Secretary of State for Health asked that the ABPI (Association of the British Pharmaceutical Industry) and NHS England build on the opportunity of the PPRS agreement and work together, to agree and carry through a solution for accelerating uptake of clinically and cost effective medicines. As a result, NHS England and ABPI are developing a joint programme of work, guided by the principles of medicines optimisation - as set out by the Royal Pharmaceutical Society in 2013 in their report Medicines Optimisation: Helping patients to make the most of medicines. This approach looks beyond the cost of medicines to the value they deliver and recognises medicines as an investment in patient outcomes. The PPRS/Medicines Optimisation programme goals are to: help patients to improve their outcomes, including better monitoring and metrics ensure patients have access to an evidence-based choice of medicine, particularly the newer innovative medicines improve adherence and help patients to take their medicines correctly avoid patients taking unnecessary medicines reduce wastage of medicines, and improve medicines safety. 2

4 As part of this programme, the ABPI and NHS England, in collaboration with the 15 regional AHSNs (Academic Health and Science Networks) held a series of 14 Roadshows around England from March to May The regional context On 19th May 2015, the ABPI and NHS England in collaboration with Kent, Surrey, Sussex (KSS) Academic Health Science Network organised a stakeholder event in Gatwick to discuss delivering improved patient outcomes across Kent, Surrey and Sussex through harnessing the opportunity of the Pharmaceutical Price Regulation Scheme (PPRS) and medicines optimisation. This was the twelfth of a series of 14 national roadshows organised in partnership with local AHSNs where over 90 attendees heard presentations on the PPRS and initiatives concerning medicines optimisation nationally. Additionally, AHSN, clinical network and pharmacist representatives from across the region discussed local medicines optimisation initiatives. These presentations and discussions allowed interested parties the opportunity to understand and discuss the issues surrounding the PPRS, medicine optimisation and patient engagement. The event was organised to ensure NHS medical, pharmacy, operations and finance staff, as well as patient representatives could gain a greater understanding of the PPRS, share knowledge of best practice in medicines optimisation and identify a local medicines optimisation action plan for Kent, Surrey and Sussex. 3. Executive summary 3.1 What s working well? Medicines optimisation is recognised by all parties as playing a key role in helping patients improve the outcome of their medicine use, providing cost-efficiencies in the NHS and helping to increase the use of newer medicines. The NHS will continue to raise awareness amongst healthcare professionals (HCPs) and patients that medicines optimisation is crucial to move to a more patient centric approach to prescribing and to safeguard patients. The pharmaceutical industry wants to ensure that the 2014 PPRS agreement, running from 2014 to 2018, where industry has agreed to underwrite the growth in the branded medicines bill, is recognised as a major enabler of medicines optimisation. It will help clinicians look beyond the cost of medicines and remove the barriers to prescribing branded innovative new medicines if there is clear evidence that it will benefit the patient. The national framework for PPRS/medicines optimisation will continue to be developed and the ABPI and NHS England set out the guiding principles and strategy for implementation of their joint programme. Part of this strategy is the development of NHS England s medicines optimisation dashboard. The dashboard, which will be reviewed and refreshed regularly, is helping to guide Clinical Commissioning Groups (CCGs) to specific areas where local medicines optimisation initiatives could have the greatest impact. 3

5 At the local level, on-going programmes for improving medicines optimisation were presented by AHSN, pharmacists, clinical network and National Institute for Health and Care Excellence (NICE) representatives. These included initiatives to address common medicines optimisation issues such as, reducing inappropriate polypharmacy, identifying and treating high-risk atrial fibrillation patients and empowering chronic obstructive pulmonary disease (COPD) patients to use their inhalers correctly. KSS AHSN has initiated projects in collaboration with the NHS and industry and will continue to identify and support these types of initiatives locally. 3.2 Areas for development or change The main barriers identified to being able to implement good local medicines optimisation initiatives more widely were communication problems and too much silo working of primary/secondary care and community pharmacists. This means that patients prescribed high-risk medicines, new medicines or are at risk of inappropriate polypharmacy are not identified and appropriately supported. It was suggested that for patients with long-term conditions, multidisciplinary teams are required to provide a full care package and IT communications need improvement locally to enable community pharmacists to have access to patients Summary Care Records. A lack of education on the benefits of taking high-risk medicines and how to use them correctly were also cited as issues with medicines optimisation. 3.3 Development and actions for the future To help identify medicines optimisation programmes, delegates at the roadshow were presented with a list of themes for development on the Medicines Optimisation Dashboard. These included acute kidney injury, antibiotic resistance, cardiovascular disease, stroke prevention, and heart failure. Locally, participants at the roadshow were invited to send feedback on the dashboard via England.MODashboard@nhs.net. From data in the Medicines Optimisation Dashboard it was noted that CCGs in Kent, Surrey and Sussex are not performing as many Medicines Use Reviews (MURs) or New Medicine Service (NMS) consultations and uptake of the GRASP-AF audit tool is lower compared to other CCGs nationally. These were areas identified by attendees for development. Attendees raised the issue that a better understanding of how the PPRS benefits GP prescribers and NHS financial staff was required with case studies that address finance issues and these need to be developed in future. Stakeholders at the roadshow identified the key enablers for medicines optimisation as: Good support to enable patients to understand the benefits of their medicines and how to take high-risk medicine correctly 4

6 Integrated multi-disciplinary care teams to treat patients with long-term conditions and provide lifestyle advice such as smoking cessation clinics HCPs trained in for example, correct spirometry and inhaler technique and identifying inappropriate polypharmacy Well-trained and incentivised community pharmacists to provide high quality NMS counselling on, for example, using inhalers or anticoagulants Integrated communication between primary/secondary care and community pharmacists Access for community pharmacists to the Summary Care Record The learning from the roadshow will be used by KSS AHSN to inform their local medicines optimisation action plan. 4. Roadshow key topics and discussion 4.1 A national perspective on medicines optimisation NHS England views medicines optimisation as an essential method of ensuring patients can take their medicines safely and effectively. Commenting on this Sir Bruce Keogh, National Medical Director of the NHS said: [We have] the opportunity to turn our health care system into unequivocally the best one in the world the aim of today is think about how we can more effectively use our medicines to make a massive contribution to the safety, effectiveness and economy of the care we offer to patients. Sir Bruce went on to set out the NHS context of challenges and opportunities and made clear how the UK must build on its R&D excellence and become the go to place for new drugs, treatments and devices. He stressed the value of AHSNs as bodies that are based on natural geographies and bring together all the right players and emphasised their key role in making sure that new medicines and treatments reach patients much faster. Dr Keith Ridge, Chief Pharmaceutical Officer, NHS England, introduced the issues and opportunities around medicine optimisation and the principles of the PPRS agreement. He made clear the value of medicines in preventing life-threatening diseases and improving the quality of life for people with long-term conditions. Reflecting this, medicines are the most commonly used therapeutic intervention in the NHS; it spends 14.4 billion each year on them 1-15 percent of its annual budget. However, percent of medicines are not taken as intended 2, 3 and in the primary care setting, this has contributed to an estimated 300 million per year spent on medicine wastage, with around a half of this being avoidable. Currently, there is inadequate review and monitoring of medicines outcomes and wide variation in medicine use across England. Additionally, and partly because Medicines Use Reviews 4 are often not performed regularly enough, polypharmacy (patients on five or more medicines 5 ) has become common, especially in older patients. In England, these issues 5

7 contribute to 5-8 percent of hospital admissions being due to preventable adverse drug reactions. 6, 7 To help improve patient outcomes, quality and value from medicine use, innovative new ways to deliver services to patients are needed. Developed in collaboration with patients, the NHS and the pharmaceutical industry, the Royal Pharmaceutical Society published guidance on medicines optimisation in , focused on seven principles and a patient centred approach as set out in figure 1. Figure 1: A Patient Centred Approach to Medicines Optimisation Keith Ridge summarised, by saying: We need to move on from the low hanging fruit of medicines management to medicines optimisation, where we think about medicines as an investment. With the Five Year Forward View 9, medicines will need to be put in context of the seven principles of medicines optimisation, which will look beyond the cost to the value they deliver to patients. Using the medicines optimisation principles requires a significant change in practice for prescribers but ultimately it will lead to a reduction in medicines wastage, as well as improved outcomes and safety for patients. NHS England and the ABPI are developing a joint programme of work for medicines optimisation, which takes forward this approach and looks beyond the cost of medicines to the value they deliver. National Institute for Health and Care Excellence (NICE) Medicines Optimisation guidelines published in March 2015, 10 also set out what needs to be done by all health and social care practitioners and organisations to put in place the person-centred systems and processes that are needed. Dr Ridge concluded by introducing the PPRS agreement 11, which he explained, presents a unique opportunity to ensure that patients are getting the right medicines at the right time, less constrained by cost. 6

8 4.2 Partnership with industry David Watson David Watson, Director Pricing and Reimbursement for the ABPI explained the PPRS for and how it aligns with and enables medicines optimisation. Recognising the financial challenges facing the NHS and that the UK is a low and slow user of newer, more innovative medicines, the ABPI negotiated a five year agreement with the Government, on behalf of the NHS. Under the PPRS agreement industry has committed to underwrite growth in the branded medicines bill and refunds to the NHS spend in excess of the agreement. Repayments for 2015/16 are expected to be approximately 800m and estimated to be a total of around 4 billion over the duration of the five-year scheme. The scheme is a one off opportunity, reflecting the climate of austerity, with benefits for all the key stakeholders. It enables: Patients and clinicians to use branded medicines, based on clinical factors not cost; NHS commissioners to remove barriers to clinicians choosing which medicines to use; Industry to have stability, whilst also supporting innovative companies and accepting a level of risk driven by austerity issues; and The Government and the taxpayer to have a predictable branded medicines bill. David Watson said: In the past, the PPRS has featured price cuts on the cost of branded medicines but this didn t benefit the NHS because it had little control on spending limits. With the new PPRS, there is a cap on the bill of 93 percent of branded medicines. The intention of the PPRS is to remove some of the affordability challenges of prescribing innovative medicines and allow the use of the right medicines, with less cost constraints, which will lead to better outcomes for patients. At the request of the Secretary of State, the ABPI and NHS England are working together to accelerate the uptake of clinically and cost effective medicines and hence maximise the benefits of the PPRS. The joint PPRS/Medicines Optimisation programme is a core component of the work and involves working in partnership with national and local stakeholders to raise awareness and understanding of the PPRS; communicate the importance of medicines optimisation to healthcare professionals; share best practice examples; and to understand and overcome any barriers that exist. The pharmaceutical industry sees medicines optimisation as looking beyond the cost of medicines in isolation to the value they deliver as an investment in patient outcomes. The joint PPRS/Medicines Optimisation work programme is led by a joint steering group and includes raising awareness and understanding of the PPRS, strategic communication plans, a medicines optimisation patient panel, and further developing the Medicines Optimisation dashboard. The key outcome of the roadshow is to have a local Medicines Optimisation action plan in place for each AHSN. 5. Barriers to utilising the PPRS for medicines optimisation 7

9 Delegates questioned why the reimbursement of PPRS payments was not ring-fenced to a specific medicines budget at CCG level. NHS England has announced that 796m of industry payments is included in NHS England s baseline budget for 2015/16. If the PPRS had not been agreed, allocations would be lower. The opportunity is there through the PPRS agreement to accelerate the uptake of clinically and cost effective medicines. Further discussions are needed to ensure full understanding of how to reap the benefits of the PPRS agreement locally. Many felt this meant that, while NHS England was receiving the payments, CCGs were not benefiting from the PPRS agreement. A better understanding of how the PPRS benefits prescribers and NHS financial staff with case studies that address finance issues need to be developed in future. Ridge concluded: The PPRS creates a unique opportunity to refocus medicine use on value rather than cost containment. PPRS payments have been factored into the additional 2 billion for NHS England and are going to make a significant contribution to NHS basic funding over the next five years. 6. Implementing medicines optimisation - the Medicines Optimisation Dashboard Jonathon Fox, Medicines Optimisation Programme Lead at NHS England, gave an update presentation on the Medicines Optimisation Dashboard project. The prototype Medicines Optimisation Dashboard 12 was launched in June 2014 and brought together data from NHS England and wider stakeholders for the first time, including for all 211 CCGs in England. It is primarily aimed at CCGs and Trusts, but AHSNs are part of its wider audience. It enables access to 30 different metrics such as medicine safety, prescribing comparators, Medicine Use Reviews, and uptake of NICE approved new medicines. Dashboard data will be refreshed every six months and the addition of new metrics will be reviewed annually. By showing variation across England, the Dashboard allows CCGs to benchmark where they are in relation to others. This can help to inform and improve the use of medicines and guide AHSNs as to where resources are required for specific local medicines optimisation programmes. Jonathan Fox said: The medicines optimisation dashboard shines a light on variation across CCGs and is an indication of how well patients are supported. It can be used by CCGs or AHSNs as a tool for evidence based decisions, guiding and measuring the success of medicines optimisation initiatives. Initial evaluation results (by Keele University) show that the majority of CCGs feel that the Dashboard is useful. The final evaluation will inform future work, and themes already identified for development include polypharmacy, mental health, diabetes, stroke prevention, chronic obstructive pulmonary disease, cancer, heart failure and hypertension. 8

10 7. Review of local medicines optimisation data Using the Medicines Optimisation Dashboard data for Kent, Surrey and Sussex CCGs, delegates identified that there were fewer Electronic Prescriptions Services (EPS) and repeat dispensing prescriptions, as well as fewer MURs and referrals to the New Medicines Service (NMS) 13, 14 being performed by Kent, Surrey and Sussex CCGs than other CCGs nationally. Access to audit tools such as GRASP AF was also below the national average and there were concerns that emergency diabetic admissions were higher from Kent, Surrey and Sussex CCGs than other CCGS nationally. Some delegates commented that the data in the database used Quality and Outcomes Framework (QOF) 15 indicators and may not reflect an accurate overview of the region. The majority of delegates stated that based on this data, Kent Surrey and Sussex CCGS should look at methods of improving uptake of NMS and MUR referrals. In addition, a lot of attendees thought that the NMS should be promoted more heavily as it is a useful service that many thought had been more rigorously evaluated than the MUR. One delegate at the roadshow stated: We must work with community pharmacists to promote their use of the NMS and perhaps targets should be put in place locally to improve the uptake of this service. Another added: community pharmacists have to be better trained in performing MURs and they also have to have access to the Summary Care Record when patients are prescribed new medicines because they are often best placed to explain the medicine and how to use it and this will help patients remain adherent to their medicine. 8. Medicines optimisation the patient s perspective and what it means in practice Delegates were shown a compelling video featuring a patient who suffered kidney failure due to drug interactions. She explained how medicines optimisation in practice could have helped her and stated: Taking medicines correctly is ultimately the patient s responsibility but without expert guidance we can t do that. Often in your care there are so many people involved and they all tell you different things about your medication that it is easy to become confused by it all. I was often brushed off and I had to battle with the people giving me my medication. This led to her taking three different drugs which interacted to cause kidney failure and hospital admission. She said: If there had been more interaction between my doctors, community pharmacists and hospital there might have been a better outcome. The best way to impact care is to communicate, no medicine should be given that interacts and causes damage like it has to me. 9. Local medicines optimisation programmes 9

11 Rob Berry, Head of Innovation at KSS AHSN explained that the KSS AHSN works with other stakeholder groups locally to identify medicines optimisation programmes and these include the Local Professional Networks (Pharmacists), Local Pharmaceutical Committees and Strategic Clinical Networks. To date, KSS AHSN is concentrating its medicines optimisation programmes around the themes of the Patient Safety Collaborative, the Older People s Programme and Enhancing Quality & Recovery 16. Berry stated: At the KSS AHSN we act as an honest broker taking into account the views of patients, the NHS and the pharmaceutical industry before we initiate projects. Additionally, we face challenges as to which medicines optimisation programmes to prioritise and so for each proposal we receive, we perform a cost benefit model to ensure that projects should be funded. Three workshops on local medicines optimisation programmes for reducing polypharmacy, improving the use of high-risk medicines with the use of inhalers to treat COPD and identifying and treating patients suffering from atrial fibrillation were discussed. 9.1 Polypharmacy - the pharmacist s perspective Professor Nina Barnett, Consultant Pharmacist, Care of Older People, Medicines Use and Safety Division, NHS Specialist Pharmacy Service in London North West Healthcare NHS Trust detailed the scale of the problem of polypharmacy and how it could be addressed. According to Barnett, more than one third of over 75 s take four or more medicines regularly 17 and this goes up to eight if that person is in a care home 18. The number of different medicines people are taking also ranges from two-28, whereas in the 1980s the over 75s were taking just three medicines. Barnett explained: The problem with inappropriate polypharmacy is that it increases adverse drug reactions and can lead to costly hospital admissions, as well as patients stopping taking their medicines. Barnett listed the evidence-based tools HCPs can refer to for deprescribing to reduce polypharmacy, which include: the Beers criteria 19 ; Medication Appropriateness Index 20 and STOPP/START criteria and toolkit 21, 22. Barnett concluded: Reducing inappropriate polypharmacy requires a patient centered approach where HCPs and patients work together in partnership to ensure patients get the best outcomes from taking their medicines. 9.2 Polypharmacy NICE s perspective Zoe Girdis, Medicines Education Regional Technical Advisor, NICE described the NICE guidelines on medicines optimisation 10 in the context of helping to reduce inappropriate 10

12 polypharmacy. According to Girdis, the way to approach polypharmacy is to work with patients to address their concerns and beliefs about their medicines and to ensure there are definite timelines to review, and if appropriate even stop taking certain high-risk medications. Girdis stated: Patients live with their conditions 24 hours a day so what they want to achieve from taking their medicine may be very different from what a clinician wants and this is where decision aids with proper conversations can make the difference. Girdis concluded: The guidelines recommend routinely involving people in decisions about their medicines, preventing medicines-related problems and targeting risky times, such as transferring from one care setting to another to make sure patients are getting the best outcome from their medicines. 9.3 Polypharmacy and the use of audit tools Lauren Fensome of PRIMIS, at The University of Nottingham detailed the polypharmacy initiative, which is just beginning with a stakeholder group that was set up in May This group is currently discussing issues such as the scope, feasibility and funding of audit tools to identify patients where polypharmacy is inappropriate. 9.4 Polypharmacy local medicines optimisation programmes Jayesh Shah, Prescribing Adviser, Surrey Downs CCG described how in Brighton and Hove CCG commissioned a pharmacist-led service to provide individual clinical MURs for each patient in care homes. He stated: In we performed 1,000 MURs in care homes and made 6,000 interventions to help optimise medicines. This produced an annual cost saving of 330,000 on medicines costs and 380,000 estimated cost saving on unnecessary hospital admissions caused by medication issues. Shah then presented a case study showing the benefits of reducing polypharmacy. He explained: One patient was taking 25 different medicines and this was reduced to five following an MUR with a clinical pharmacist. After we reduced the number of medicines she was taking, the patient reported feeling more alert and her memory loss improved. Additionally, she has had fewer falls and has reduced her GP visits from 12 a year to one. She is also now able to understand what to take and when and can prepare her own pill box so feels more in control of her health. Laraine Clark, Pharmacist at Canterbury and Coastal CCG, continued with the theme of reducing inappropriate polypharmacy with a presentation on the benefits of performing MURs with patients who are over 75 years old. Clark discussed how in GP practices in Whitstable clinicians searched patient databases and referred suitable patients. This resulted in identifying 132 patients over 75 years old who were taking more than 12 medicines. According to Clark, 30 patients have had an MUR and issues that were most commonly seen were with aspirin and clopidogrel, quinine sulphate and simvastatin usage. 11

13 Clark commented: In 16 of the 30 patients reviewed, eight remain on dual anti-platelet therapy or have had their therapy changed, one was given a clear stop date for taking clopidogrel and seven patients needed interventions. She concluded: With older patients, there has to be more communication between the care settings and regular MURs performed because information is not being transferred and it is this which is leading to inappropriate polypharmacy. 9.5 Polypharmacy - patient s perspective A local patient who suffers from asthma, diabetes, hypertension and carpel tunnel syndrome and had also been prescribed multiple medicines detailed the benefits of having her medicines reviewed by a clinical pharmacist. She stated: I wasn t using my inhaler properly and only found this out when I went to the pharmacist. Since there isn t a family doctor anymore, we almost need a nurse or another floating teacher at the GP surgery to show or explain to you how to take your medicines correctly. 9.6 Polypharmacy how to address it Delegates at the roadshow suggested that barriers to addressing polypharmacy are a lack of understanding by prescribers about the patients quality of life and desires of the outcomes they wish to achieve from taking medicines. There is also poor communication between primary care and community pharmacists, which means there can be issues with prescribing. Delegates also said that dosette boxes need to be reviewed, with patients and pharmacists looking at what goes in the dosette box. Additionally, the lack of a thorough medicines reconciliation on hospital admission and discharge can cause polypharmacy and HCPs need to be more aware of prescribing high-risk medicines, especially in those patients with declining renal function. To address the issue of inappropriate polypharmacy, attendees suggested that more patient education events were needed and for nurses, GPs and clinicians there should be specific training on polypharmacy and its consequences. Participants at the roadshow also stated that to reduce polypharmacy community pharmacists should have access to patients Summary Care Records and provide a standardised MUR and have accredited training to perform this. Additionally, to reduce potential harm it was mooted that community pharmacists should be incentivised to undertake NMS consultations, with targets put in place for performing the NMS. To ensure that there is funding for projects to reduce polypharmacy, attendees stated that economic modelling should be used to not only show the direct monetary value of reducing the medicines burden, but also the estimated health and social care cost savings. Delegates at the roadshow identified their key priorities in reducing polypharmacy as being patient focused on improving quality of life, ensuring all HCPs have access to data 12

14 concerning patients that are taking multiple medicines, potential safety issues automatically flagged, and thorough accredited, standardised MURs. 9.7 Treating COPD using inhalers local medicines optimisation programmes Jo Wookey, Clinical Co-lead Respiratory Programme, and Sue Wales, Senior Improvement Manager at the KSS AHSN led a workshop to discuss the medicines optimisation issues surrounding the treatment of COPD using inhalers. According to delegates at the roadshow, the barriers to medicines optimisation for COPD patients locally include: insufficient integration of services with GPs, community pharmacists and clinicians, for example all working in silos where community pharmacists don t have access to the patient s Summary Care Record. Additionally, there is a lack of skilled HCPs such as independent nurse prescribers and pharmacists, who are trained in the correct use of inhalers and spirometers. Another barrier identified is the lack of trust from patients that feel they know their condition better than their prescriber. One delegate commented Patients don t see their condition as a problem and therefore they don t buy into taking their medicine as and when they should. Roadshow attendees stated enablers of medicines optimisation for treating COPD are empowered patients, integrated support for a holistic approach to COPD treatment and HCPs trained to perform standardised NMS reviews and MURs, as well as the correct use of inhalers and spirometers. To empower patients, delegates suggested that GPs and community pharmacists should be better funded to enable them to spend more time with patients to help them to understand their condition, provide consolidated follow-up and patient education. The holistic approach to COPD treatment would include personalised COPD plans for each patient, suggesting flu and other vaccine uptake, training on improving inhaler technique and helping patients to stop smoking, if appropriate. They also suggested that patients should be referred to community groups such as the BreatheEasy Groups 23, volunteers and expert patients for peer-to-peer support. To improve integration of services, attendees stated that community pharmacists should have both read and write access to the patient Summary Care Record and more GP practice based pharmacists should be employed to review any exacerbations of patient s conditions, perform MURs and train patients how to use inhalers or refer them to smoking cessation clinics. 9.8 Treating atrial fibrillation local medicines optimisation programmes Jen Bayly, Enhancing Quality Heart Failure Programme Lead, KSS AHSN and Nicky Jonas, AF project Support, South East Coast Strategic Clinical Network KSS Academic Health led a workshop to discuss medicines optimisation in the context of treating atrial fibrillation. 13

15 Participants agreed that treating patients with atrial fibrillation would reduce mortality and stroke risk. They identified the barriers to increasing the numbers of patients being treated as: a lack of cross organisation working between acute, community and primary care; insufficient funding for implementing NICE guidance on atrial fibrillation programmes 24 and not enough trained HCPs to use tools such as GRASP-AF to identify at risk patients or initiate and monitor the use of oral anticoagulant medicines. Roadshow attendees stated enablers of medicines optimisation for atrial fibrillation are empowered patients; well trained HCPs; and health economics data to provide cost models for implementing NICE guidance. Delegates suggested that to empower patients there should be more pharmacists, nurse specialists or GPs that specialise in atrial fibrillation with whom patients can discuss options for anticoagulation to explain the benefits and also the potential risks of the treatment in guided conversations. There also need to be more multi-disciplinary teams with whom patients can access lifestyle advice to work alongside their treatment. Attendees stated that HCPs in CCGs require training on the use of GRASP-AF audit tool to enable better uptake across Kent, Surry and Sussex. Community pharmacists should be offered training and incentives to enable them to perform standardised NMS reviews with patients that have recently begun anticoagulation therapy or MURs with patients already using anticoagulants. It was also suggested that industry could help provide health economics data to demonstrate the cost savings that can be made in acute care to provide a case for investment in atrial fibrillation programmes in primary and community care. 10. Future planning, actions and next steps 10.1 Identifying Barriers The roadshow identified several barriers to implementing medicines optimisation programmes locally, these included: beliefs of patients about the risks of taking medicines with a lack of support for patients using high-risk medicines; insufficient resources such as funding and time; poor integration of services; insufficient education amongst HCPs on the safety issues surrounding polypharmacy, the use of anticoagulants and inhalers; and too much variation across the region for training in the way community pharmacists perform MURs and NMS consultations Overcoming barriers To overcome the lack of support for patients on high-risk medicines it was proposed that there should be programmes put in place which enable patients to take their medicines correctly and to become experts in their own healthcare, with inappropriate polypharmacy, the use of inhalers and anticoagulants being priorities. To address the variation in care across the KSS AHSN, projects that help all HCPs standardise the use of spirometers and inhalers; initiate and monitor anticoagulant therapy, as well as allow better training of community pharmacists to perform MUR and NMS counselling to the same standard were 14

16 suggested. Additionally, delegates commented that access to the Summary Care Record needs improvement for community pharmacists and a process should be put in place to inform community pharmacies post-hospital discharge, to flag up patients at risk of inappropriate polypharmacy or those taking high-risk or new medicines that may need additional support Enablers Stakeholders at the roadshow identified key enablers of medicines optimisation locally as empowering patients to support them to take high-risk medicines such as anticoagulants and inhaler based medicines correctly; better integrated networks of care; and accredited training for HCPs to enable them to perform standardised MURs and NMS counselling and train patients on for example, correct inhaler technique Priority actions including a regional plan A number of actions were discussed at the roadshow for medicines optimisation locally and attendees at the roadshow formulated a list of priorities, which included: Supporting patients taking high-risk medicines with patient education events Increasing the uptake of NMS referrals in community pharmacies Reducing inappropriate polypharmacy of older patients with standardised MURs Developing training of community pharmacists to enable patient counselling and guided conversations on inhaler and anticoagulant use Producing health economics data to support programmes for reducing inappropriate polypharmacy and atrial fibrillation Improving communication channels between primary and secondary care An action plan for the KSS AHSN was not put in place at the roadshow but is being developed for a future date. Dr Des Holden, Medical Director, KSS AHSN and Medical Director, Surrey and Sussex Healthcare NHS Trust summarised: The challenge of the Five Year Forward View is to keep people healthy so they don t become patients. With the medicines optimisation programme, this means that every HCP contact counts and we must have regular reviews of older people and those with long-term conditions to ensure those with for example, polypharmacy issues are safely getting the best outcome from their medicines. 15

17 11. Annex Report details, disclaimer and references Report compiled by Dr Sue Pearson, Director, International Science Writer. Web: For further information and discussion about the report, please contact: Aileen Thompson, Director of Communications, ABPI. Helen Haggart, Public Affairs Consultant, ABPI Disclaimer The series of Pharmaceutical Price Regulation Scheme (PPRS) / Medicines Optimisation Roadshows was organised and jointly funded by NHS England, the Association of the British Pharmaceutical Industry (ABPI) and the 15 Academic Health Sciences Networks (AHSNs) as part of the joint ABPI and NHS England PPRS / Medicines Optimisation programme. This report records the key themes that were discussed at the roadshow and any positions or views expressed are those of attendees and East Midlands AHSN, and may not represent the positions or views of NHS England or the ABPI. The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. The ABPI represents innovative research-based biopharmaceutical companies, large, medium and small, leading an exciting new era of biosciences in the UK. The ABPI is recognised by government as the industry body negotiating on behalf of the branded pharmaceutical industry for statutory consultation requirements including the PPRS: the pricing scheme for branded medicines in the UK. About the Pharmaceutical Price Regulation Scheme (PPRS) / Medicines Optimisation Programme The PPRS/ Medicines Optimisation Programme was developed in response to the Secretary of State s challenge to NHS England and the ABPI to accelerate uptake of clinically and cost effective branded medicines which maximises the benefits of the 2014 PPRS Agreement, including creating real clinical pull for patient access to these medicines. The programme was set out in a paper to the Ministerial Industry Strategy Group (MISG) and endorsed at the MISG meeting on 9th July The primary aim of the Programme is to improve patient outcomes, quality of care and value through improving the delivery of high quality patient care and taking full advantage of the 2014 PPRS agreement. The Medicines Optimisation Programme is overseen by a steering group, jointly chaired by NHS England and ABPI. Membership of the group comprises representatives from the Royal Pharmaceutical Society, AHSNs, CCGs, Academy of Medical Royal Colleges, Royal College of Nursing, British Generic Manufacturers Association and National Voices. 16

18 11.2 References 1 Health Survey for England Medication Adherence: WHO Cares? 3 Patient adherence to medicines 4 Medicines Use Review 5 Polypharmacy and medicines optimisation 6 Adverse drug reactions as cause of admission to hospital: prospective analysis of patients 7 Adverse Drug Reactions in Hospital In-Patients: A Prospective Analysis of 3695 Patient- Episodes 8 Medicines Optimisation: Helping patients to make the most of medicines 9 FIVE YEAR FORWARD VIEW 10 Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes 11 Pharmaceutical Price Regulation Scheme Medicines Optimisation Supporting information for the prototype dashboard 13 The New Medicines Service 14 Support for New Medicine Service 17

19 15 The NHS Outcomes Framework 2014/15 outcomes.pdf. 16 Kent, Surrey, Sussex Academic Health Science Network 17 Polypharmacy Guidance October pdf 18 Care homes use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people 19 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults 2012 List of drugs to avoid in older people 20 The medication appropriateness index at 20: where it started, where it has been, and where it may be going STOPP/START criteria for potentially inappropriate prescribing in older people: version STOPP START Toolkit Supporting Medication Review olkit2011.pdf 23 Breathe Easy British Heart Foundation Support Groups 24 Atrial fibrillation: the management of atrial fibrillation 18