PRESCRIPTION CLERK TRAINING EVENT SAFE, EFFECTIVE AND COST-EFFECTIVE PRESCRIBING PRESCRIBING INCENTIVE SCHEME

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Colleen Lindsey
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1 PRESCRIPTION CLERK TRAINING EVENT SAFE, EFFECTIVE AND COST-EFFECTIVE PRESCRIBING PRESCRIBING INCENTIVE SCHEME

2 ACCESSING THE MEDICINES MANAGEMENT WEBSITE This we take you to a range of documents, policies and guidance which we will be referring to in this pack.

3 SAFE, EFFECTIVE AND COST-EFFECTIVE PRESCRIBING Formulary drugs Formularies are lists of medicines which have been locally approved for use which prescribers are encouraged to adhere It is locally agreed between primary and secondary care via the South West Essex Medicines Management Committee It is a joint formulary between both Basildon and Brentwood CCG and Basildon Hospital A formulary also allows the CCG to promote the most cost effective choice of medicines in each area All prescribers should be assigned to the local formulary on their clinical system (SystmOne) All our local formularies are available on our website. It is split up into different chapters like those in the British National Formulary (BNF) (see below). If you click on a chapter it will tell you what our first and second line products are

4 Unlicensed medicines, off-label and specials Unlicensed medicines do not have a marketing authorisation (license) and are not covered by any UK standard of quality, safety or effectiveness Off label means using a licensed medicine outside of the terms of the licence. This includes prescribing for a different indication or by a different route of administration from the licence e.g. crushing or dispersing tablets or opening up capsules Specials are unlicensed medicines that are manufactured specifically to meet the special clinical needs of an individual patient. They are often liquids and are not usually listed in the BNF Specials, like all unlicensed medicines, should only be prescribed when there is no licensed medicine available that meets the clinical needs of the patient Patients and carers must be informed that they are being prescribed a specials or unlicensed medicines Clear accurate records of the medicines prescribed and the reason for prescribing must be included in the patients notes Unlicensed specials are often very expensive If the clinical system lists the price as 0 this usually means the medicine is unlicensed, it has no set price and will be expensive Some specials are listed in the Drug Tariff and have a set reimbursement price (some are listed twice as either a suspension or solution and the price can vary considerably) Some specials creams are very expensive if ordered by the local pharmacy. Basildon and Brentwood CCG and Thurrock CCG have an agreement with Orsett Hospital that some creams can be ordered through them to help save costs (see list below) Name of preparation Coal tar solution 7%, betnovate ointment 25% in Unguentum Merck x 100g Coal tar solution 7%, betnovate ointment 50% in Unguentum Merck x 100g Dermovate ointment 10% in Unguentum Merck x 200g Dermovate ointment 60% and propylene glycol 40% x 200g Salicylic acid ( 2%, 3%, 5%, 10%)* in white soft paraffin x 100g (*delete as applicable) The GP has to fill in a Specials Form to order the cream from Orsett instead of through the local pharmacy. The form is available on our website under the specials tab:

6 Grey List drugs These are drugs which are not recommended for prescribing due to little evidence of effectiveness, cost-effectiveness or safety Sometimes there are not recommended as there are more suitable alternatives available The list includes drugs that have been rejected by the South West Essex Medicines Management Committee and/or those that are not approved nationally (e.g. by NICE) Furthermore the list may contain drugs that are either unlicensed or being used for unlicensed conditions The list is available on our website under the traffic light list for prescribing :

Traffic light list This tells prescribers who can prescribe and in what setting GREEN regarded as suitable for GP initiation and primary care prescribing.

7 Traffic light list This tells prescribers who can prescribe and in what setting GREEN regarded as suitable for GP initiation and primary care prescribing. Examples include bendroflumethiazide and atorvastatin. YELLOW specialist initiated and suitable for GP to continue. Examples include antiepileptics or drugs for parkinsons. AMBER initiated within a hospital or by a specialist but suitable for GP to continue under a shared care agreement. Examples include methotrexate and other drugs for treating rheumatoid arthritis. RED prescribing responsibility lies with a hospital consultant or a specialist. Examples include chemotherapy and fertility treatment. The list is agreed by the South West Essex Medicines Management Committee For amber drugs Shared Care Protocols (SCP) detail the responsibility of the consultant, the GP and the patient, these are available on our website:

8 Policy statements These are documents that state the CCGs position on the prescribing of a particular drug, appliance or device These are often products that are on the Grey List so have limited evidence for effectiveness Some policy statements are guidelines to help GPs when making decisions about prescribing for example Policy for the transfer of prescriptions from private to NHS These policies can be found on our website: Some policy statements you may find helpful: - Policy for the prescribing of sunscreen - Policy for the prescribing of vitamin D low doses - Policy for glucosamine - Policy for multivitamins - Policy for Omega 3 fatty acids - Policy for the provision of 7 day prescriptions

9 Quantities on prescriptions Ideally, quantities for all items for individual patients should be synchronised Medications should have clear directions and where possible avoid directions such as as directed It is important to ensure the quantities are correct for the prescription duration (e.g. 28 days) to ensure cost effective and safe prescribing Below are some guidelines for quantities of different medications Tablets and capsules Dose Abbreviation Number of Number of Quantity days supply months supply One daily 1 OD Two daily 2 OD One twice daily 1 BD One three times a day 1 TDS One four times a day 1 QDS Eye drops For eye drops on average there are 20 drops in 1mL A bottle(s) closet in volume but which contains the number of ml s required should be prescribed for example if 3mL is required a 5mL bottle should be prescribed where available or if 14mL is required either 2 x 10mL or 10mL + 5mL should be prescribed depending on availability Majority of eye drops expire 28 days after opening For single dose preparations, the same unit dose can be used for both eyes but it is good practice to use separate units if one eye is infected and the other is not Dosage ml s required for 1 month (one eye) ml s required for 1 month (both eyes) 1 drop once daily 2mL 4mL 1 drop twice daily 3mL 6mL 1 drop three times daily 5mL 10mL 1 drop four times daily 6mL 12mL 1 drop five times daily 7mL 14mL

10 Creams and ointments Body site Creams or ointments Lotions 7 days One month 7 days One month Face 15-30g g 100ml 400ml Both hands 25-50g g 200ml 800ml Scalp g 200g-400g 200ml 800ml Both arms or legs g g 200ml 800ml Trunk 400g 1600g 500ml 2000ml Groins and genitalia 15-25g g 100ml 400ml

11 Inhalers

12 Which drugs should not be ordered early You know that many patients ask for their medication to be prescribed earlier than they should have it Some of these requests may be valid for example a patient going on holiday However, some medication should not be given early without a valid reason or without GP involvement These could be drugs that can be abused or it could indicate that their condition is not being controlled and so the patient may need a review The table above (quantities on prescriptions) is a useful way to determine if the patient is actually ordering early or whether the repeat template has been set up wrong Drugs Examples Reasons Opioids - Morphine (Zomorph / MST / Morphgesic) - Oxycodone (OxyContin / OxyNorm/ Longtec/Shortec) - Fentanyl - Buprenorphine - Codeine products These are Controlled Drugs and can be abused. If the patient is ordering too early, refer to a GP Sleeping tablets Drugs for anxiety Triptans Inhalers Insulin - Temazepam - Zopiclone - Nitrazepam - Diazepam - Lorazepam - Sumatriptan - Rizatriptan - Naratriptan - Frovatriptan - Salbutamol (Ventolin) - Terbutaline (Bricanyl) - Lantus - Levemir - Humalog - NovoMix - Insuman Some of these are Controlled Drugs and can be abused. If the patient is ordering too early, refer to a GP Some of these are Controlled Drugs and can be abused. If the patient is ordering too early, refer to a GP This could indicate uncontrolled migraines or underlying problems that need to be investigated refer to a GP. NB patients should not routinely have more than 12 triptans in 4 weeks although many patients will use more than this. It is worth discussing this with the GPs These are relievers which means that patients use them generally when they are out of breath. If patients are using too much, it could indicate worsening condition. As these may be required, it would be better to issue but to flag to a GP Sometimes it is not easy to spot early ordering, request help from GP or Diabetes Nurse if too frequent ordering becomes apparent. A specific chart is available on website. Too frequent ordering may indicate difficulties using, confusion... Insulin has a short expiry date which can lead to waste if patient stockpiles

13 Urgent requests for medicines It is common place for practices to receive requests for prescriptions as urgent, however the practice may want to review their protocol for processing such requests to ensure safe and appropriate procedures and avoid unnecessary interruptions to routine clinics This is particularly relevant when it is a request from a third party (relative, pharmacy, care-home). If there is any concern regarding a specific request, the patient/carer should be contacted directly to establish the reason for an urgent request Below is a suggested list of medicines that could be considered as appropriate to process as an urgent request Each practice may agree their own protocol that allows requests for other medicines to be processed as routine prescriptions to be available within a suitable timeframe Category Epilepsy drugs Inhalers Beta-blockers Anticoagulants Insulin Examples Phenytoin, carbamazepine, valproate, lamotrigine, levetiracetam, midazolam, epistatus Salbutamol, terbutaline, sirdupla, DuoResp, tiotropium Propranolol, bisoprolol, atenolol Warfarin, rivaroxaban, apixaban, dabigatran, dalteparin, enoxaparin Humulin, NovoRapid, Humalog, Lantus, Abasaglar Lithium *** BLOOD TESTS SHOULD BE UP TO DATE *** Immunosuppressants *** BLOOD TESTS SHOULD BE UP TO DATE *** Azathioprine, ciclosporin, mercaptopurine, methotrexate, mycophenolate

14 High Risk Medicines While all medicines have a need to be monitored, some are notorious for causing more problems than others and need to be treated with special care Usually there are because they are highly toxic, easy to abuse or their use needs to be restricted for some other reason The practice should have a procedure in place to ensure that blood results for high risk medications are checked prior to the next prescription being issued Prescription clerks may have a role in ensureing effective recall of patients for the monitoring of their medicines for example patients with long term conditions, medication reviews or patients requiring routine blood tests for certain conditions Below is a list of medicines for which there may be need for regular monitoring: Drugs ACE inhibitors and angiotensin II Mesalazine receptor antagonists Acetylcholinesterase inhibitors Methotrexate (donepezil, galantamine, rivastigmine) Amiodarone Minocycline Antipsychotic agents Mycophenolate Apixaban NSAIDs Azathioprine Phenytoin Carbimazole Penicillamine Ciclosporin Pioglitazone Corticosteroids (long term oral therapy) Propylthiouracil Dabigatran Rivaroxaban Digoxin Sirolimus Dronedarone Statins Eplenerone Tacrolimus Hydroxycarbamide Theophylline and aminophlline Hydroxychloroquine Thyroxine Leflunomide Valproate and sodium valproate Lithium Warfarin Mercaptapurine

15 PRESCRIBING INCENTIVE SCHEME Prescribing incentive schemes are designed to focus practices on cost effective, quality and safe prescribing and are a key enabler for improving prescribing The aim of the scheme is to raise prescribing performance to that of best practice as defined by NICE and local guidance An evidence-based and cost-effective approach to prescribing should be adopted (savings should not be made at the expense of patient care) Practices receive a financial reward for achieving various targets Funding obtained through good performance can be used by the practice to improve facilities and care for their patients such as new diagnostic equipment, furnishings etc Each practice has compulsory targets it has to meet and also practice specific targets (see below)

16 Area of prescribing Target/requirement Comments Points Compulsory Targets Financial Target Bimonthly prescribing actions ScriptSwitch Prescription clerk training event See Basildon and Brentwood CCG Gain Share Scheme. Prescribing Lead (or deputy) to implement bimonthly prescribing actions within their practice. Practice to have ScriptSwitch in place and achieve 45% combined acceptance rate. Practice to be represented at Medicines Management training event for prescription clerks. Antibiotics Volume of antibiotics to be less than 1,000 items per 1,000 STARPUs or practice to demonstrate a 5% reduction in volume of antibiotics. Vitamin D Practice to demonstrate 25% reduction in vitamin D (colecalciferol and ergocalciferol) prescribing costs compared to previous year. DROP-List/Grey- List prescribing Gliptins Emollients DROP List cost per ASTROPU should be less than 150 per 1,000 ASTROPUs (or demonstrate an agreed percentage reduction in costs). Alogliptin should account for at least 70% of all gliptins (including gliptin combinations). Alternatively, practice must demonstrate 40% increase in proportion of gliptins prescribed as alogliptin, compared to baseline. Practice to review volume and product choice for emollients in order to reduce spend compared to previous years spend. Cost-effective/quality prescribing. Six actions to be implemented during the year Medicines Management Team to advise actions. Cost-effective/quality prescribing. Medicines Management Team to provide afternoon training event (September 2017). CCG priority to reduce volume of antibiotic prescribing. Low strength vitamin D products for maintenance or insufficiency are not recommended for GP prescribing. Reduce prescribing of low priority drugs which have poor evidence/cost effectiveness. Alogliptin is first-line formulary choice gliptin. Audit template available for gliptin switch. See primary care guidance and ScriptSwitch for further details Prescribing Policy Safe Prescribing Practice must have a prescribing policy in place and should demonstrate adherence to this policy. Practice to review 6 areas of prescribing using Medicines Management template. Medicines Management Team to produce template for practice adaption/adoption. Medicines Management to set up SystmOne template. 2 4

17 Area of prescribing Target/requirement Comments Points Practice specific targets Practice specific targets. Agree 3 targets from the list at the practice visit: 1) Implementation of generic/branded/specials/ recommendations. 2) Review blood glucose testing strips/pen needles/lancets. 3) Implementation of good housekeeping in stoma/incontinence appliances. 4) Review quantities of controlled drugs prescribed, in line with local and national guidelines. 5) Reduction in volume of cephalosporins/quinolones/ co-amoxiclav/minocycline (audit required). 6) Practice to review patients on 10 or more medications (Medicines Management Team support available). 7) Review of oral nutritional supplements (ONS) and/or infant formula feeds (Dietitian support available). 8) Audit of COPD patients on triple therapy. 9) Audit of medications for type II diabetes. 10) Audit of anticoagulants /NOACs to ensure choice is appropriate. 11) Other target as agreed between Medicines Management Team and practice. Total points available total (4 points for each target)

GENERIC MEDICINES (Non-Innovator Brand) PRESCRIBING POLICY

GENERIC MEDICINES (Non-Innovator Brand) PRESCRIBING POLICY First issued by/date Issue Version Purpose of Issue/Description of Change Planned Review Date August 2018 1.0 Promoting generic prescribing whenever