Wirral CCG Prescribing Incentive Scheme 13-14 Summary Wirral wide scheme to run from July 2013 February 2014. Incentive monies available up to 1.50 per head of practice population (based on April 2013 population figures of 331,126). The scheme consists of three sections; 1. Practice growth performance (1/3 of total payment) 2. Clinical areas related to QIPP and locally identified prescribing targets (1/3 rd of total payment) 3. Education and practice engagement (1/3 rd of total payment). All the parts of the scheme are independent of each other and each section must be signed up to. CM CSU Medicines Management Team (MMT) will be able to offer advice on best practice and how to achieve targets. Incentive monies received must be spent in line with current local and national guidelines. Section 1. Overall Prescribing Cost Growth This will focus on rewarding each practice on managing their prescribing growth. The measure will be total prescribing spend for the period April to December 2013, compared to the same period the previous year. The payment will be achieved if percentage growth is either; 1. At or below national data for the same period of previous year 2. Significant improvement of 1.5% or more compared to same period of previous year 3. Maintain or achieve negative cost growth for the same period of previous year. This data will be included in the monthly Prescribing Summary Reports. Page: 1/10
Section 2. Clinical Areas Please see Appendix 1 for an explanation of the rationale for areas included in Section 2. Practices must choose two of the following sections to fulfil Section 2. 2.1 Antibiotics. a) Practice to submit evidence of completion the following e-learning packages by all prescribers (GPs, Registrars and NMPs) within 3 months of launch of scheme. Urinary Tract Infections: A Primary Care Puzzle. Available at: http://www.elearning.rcgp.org.uk/course/info.php?id=117&nopopup=1 AND Managing Acute Respiratory Tract Infections. Available at: http://elearning.rcgp.org.uk/course/view.php?id=17 Practice to submit evidence of practice discussions relating to e-learning and how this has changed prescriber practice. This evidence must be submitted within 3 months of launch of the scheme. Plus EITHER b) Practice to submit evidence of completion of an antibiotic audit within 3 months of launch of scheme. OR Practice to either demonstrate a reduction or maintenance of cephalosporin and quinolone prescribing rates, compared to either Wirral CCG average or improvement from own baseline, using October to December 2013 epact data compared to October to December 2012. The e-learning modules can be accessed via the Royal College of GPs website (http://www.rcgp.org.uk/) and are free of charge. Registration is required; however prescribers do not need to be a member of the Royal College to register. Access can be gained via NHS computers. Outcome Measure: Practices should complete the provided audit proforma for any audit work and submit evidence of completion of CPD/meetings held to discuss the learning, 3 months after launch of the scheme. epact data will be collated and provided by the MM team by the end of the scheme. 2.2 Completion of Hospital Interface Reporting Forms. THREE or more interface forms to be completed by the practice during the incentive scheme period. For the purpose of the scheme, it must be the practice staff that complete the forms, not the MM team. Interface forms may focus on specific areas eg COX2s, pregabalin or oxycodone or may cover a variety of interface issues. Outcome Measure: Practices to submit the interface forms to the Medicines Information email (wir-pct.medicinesinformation@nhs.net). The forms can be found on the MM team website on the following link: http://mm.wirral.nhs.uk/hospitalconcerns/. The MM Team will collate the data at the end of the scheme. Page: 2/10
2.3 Omega 3 fatty acid supplements. Using audit, review and if appropriate, revise prescribing of omega 3 in line with NICE guidance. Outcome Measure: Practices should complete the provided audit proforma. 2.4 Pregabalin. Review pregabalin with a view to a specified reduction (ie 7%) in prescribing in line with updated local guidance. This will account for patients who have either been stopped or stepped down. Outcome Measure: The number of pregabalin via epact. MM Team will provide the data based on October to December epact data 2013. 2.5 Oxycodone. Undertake an audit to review all oxycodone prescribing and if appropriate, switch to morphine. A Wirral wide oxycodone audit is an identified work project for the MM Team. If practices wish to undertake the audit themselves for the purpose of the scheme, the MM Team can provide list of patients but the practice will be required to undertake the audit and complete the proforma themselves. Outcome Measure: Using the proforma supplied, practices are asked to submit the number of patients reviewed, rather than measuring a reduction on prescribing (acknowledging there will many circumstances where it is clinically appropriate to prescribe and is beyond the control of the practice.) Section 3. Education and Practice Engagement. Practices are required to show evidence of at least three of the following targets; 1. Production of practice annual prescribing plan incorporating agreed work from MMT and demonstrating agreed action against plan, within 3 months of launch of the scheme. 2. Prescribing audit of choice (but not one of the audits in section 2, if already chosen for the previous section). 3. Attendance of at least 2 divisional GP prescribing meetings planned from July 13 to March 14. 4. At least twice yearly in house prescribing reviews with clinicians (practices are asked to submit records of meetings held with the practice to discuss prescribing issues). 5. Practice to nominate an appropriate person as a named Medicines Co-ordinator, who will be actively involved in the repeat prescribing process (this person may already be carrying out this role). The Medicines Co-ordinator will also be responsible for disseminating information provided by the MM team to all relevant practice staff. The Medicines Co-ordinator will attend the training sessions provided by the MM Team and where appropriate, to submit evidence to illustrate implementation of at least ONE suggested MM project. Page: 3/10
Monitoring Arrangements The Medicines Management Team will provide monitoring reports and facilitate discussion of progress at the quarterly prescribing cluster meetings. Payment Timescale The Medicines Management team will assess performance against incentive scheme targets and summarise a final list for review by the Consortia Prescribing Lead GP and Chief Officer. The payments will be arranged by the CCG finance team. Payments will be made to practices mid April 2014. Final payment will be based on prescribing data available in February 14 (ie December 13 data) unless otherwise specified. General Points Practices will be required to inform the MM team of their section 2 choices within 1 month of signing up to the incentive scheme. Once they have made their decision this cannot be changed. All 3 sections of the scheme must be completed for full payment. If only 1 area in section 2 is achieved, the practice will receive half of the total payment for that section. The MM team will assist practices in making decisions on which areas to choose. If areas are chosen where current prescribing is zero, then the practice will be asked to reconsider their choice. Consortia Chief Officers and Chairs will be kept fully informed of any discrepancies. The scheme will close at the end of February 2014 to ensure there is sufficient time to collate data to send to CCG Finance Team before the end of the financial year. References 1. Key therapeutics - Medicines management options for local implementation. NICE Medicines and Prescribing Centre. Available at http://www.nice.org.uk/mpc/keytherapeutictopics/home.jsp 2. NHS Commissioning Board. Quality Premium: 13-14 Guidance for CCGs. Draft guidance. December 2012. Available at http://www.england.nhs.uk/wpcontent/uploads/2013/02/qual-premium.pdf Page: 4/10
Agreement and Signatories for Wirral Prescribing Incentive Scheme This agreement is based on current information and is subject to review in light of guidance subsequently received. The scheme is effective from July 2013 and will run until February 2014. We the undersigned wish to participate in the Incentive Scheme in accordance with the terms and conditions laid out in this document. Please tick to select your preferred 2 options for section 2: clinical areas; Antibiotics (Evidence of CPD and audit to be submitted by 31.10.13) Hospital Interface Reporting Forms Omega 3 fatty acid supplements Pregabalin Oxycodone Please tick to select your preferred 3 options for section 3: education and practice; engagement Annual prescribing plan (to be submitted by 31.10.13) Prescribing audit of choice (please state title) Attendance at 2 prescribing cluster meetings Twice yearly in house reviews Nomination of medicines co-ordinator Senior Partner Date Practice Name Date Please send completed agreement form via email to the Medicines Management Team, for the attention of Nina Rogerson nina.rogerson@cmcsu.nhs.uk Deadline for submission of agreement: 16.8.2013 Page: 5/10
Appendix 1 Rationale for Choice of QIPP Areas to Include in Wirral CCG Incentive Scheme 2013/14 The areas chosen reflect Wirral performance against the national prescribing comparators, published in the Key Therapeutic Topics document produced by the Medicines and Prescribing Centre at NICE 1, or areas of local significance identified by the MM team. Please see Appendix 2 for CCG performance against the national comparators. 1. Antibiotics. Overview Wirral position: Table 1 below illustrates Wirral position for antibiotic prescribing in Quarter 3 2012/13. Table 1: Wirral Antibiotic prescribing Quarter 3 12-13. Wirral National Wirral position within North West Cephalosporin & quinolone prescribing as a proportion of all antibiotic prescribing (%) 8.07% 5.5% Quinolones prescribing ( per STAR PU) 9.55 per 1,000 STAR PU 6.83 per 1,000 STAR PU 1 st highest Cephalosporins ( per STAR PU) 22.06 per 1,000 STAR PU 15.17 per 1,000 STAR PU 3 rd highest It is widely acknowledged that broad spectrum antibiotics have the highest propensity to cause Clostridium difficile infection. Fluoroquinolones, second and third generation cephalosporins and clindamycin carry the highest risk. One of the objectives for Domain 5 of the CCG Outcomes Indicator Set 2013/14 requires NHS Wirral CCG to achieve a reduction in the number of cases of Clostridium difficile infection of 20% from baseline. Providing qualifying criteria are met, the CCG will be eligible for 12.5% of the quality premium 2 if this objective is achieved, demonstrating no reported cases of MRSA bacteraemia for the CCG population during 2013/14. The inclusion of an antibiotic element in the 2013/14 incentive scheme, to maintain downward pressure upon overall antibiotic prescribing rates and upon broad spectrum antibiotic prescribing, will support the CCG in achieving these objectives. Rationale for choice of e-learning packages: Urinary tract infections are the fourth highest indication for antibiotic prescribing in primary care. There an increasing number of patients diagnosed in the community with UTIs caused by Extended-Spectrum Beta- Page: 6/10
Lactamases (ESBLs) or carbapenem-resistant coliforms. The inclusion of e-learning would aim to generate discussion regarding best practice. Acute respiratory tract infections are the largest group of diseases dealt with in primary care. This e-learning package encourages prescribers to reflect on their prescribing decisions and to identify barriers to change. 2. Completion of Hospital Interface Reporting Forms. The MM team are anecdotally aware of a significant number of non-formulary prescribing issues originating from secondary care. However without evidence there is little that can be done to address these issues. Completing the forms is a time consuming process for practices, so incentivising this process may assist in providing the necessary data to bring about change. 3. Omega 3 fatty acid supplements. New national QIPP topic but no national numerical comparator. GPs expressed interest in including this, as growing area of prescribing. Over the past twelve months omega 3 prescribing accounts for a spend of 258,000 with 12,000 prescriptions. This is an identified workstream for the CCG Cardiology QIPP Group. 4. Pregabalin. Identified as the number 1 MM QIPP priority by Prescribing Lead GPs for 13-14. Switching only 10% of all pregabalin prescribing could save Wirral CCG 127K. Work initiated in collaboration with MM team but successful implementation will require intensive GP input. 5. Oxycodone. Second MM QIPP priority identified by Prescribing Lead GPs for 13-14. Switching 50% of oxycodone prescribing to morphine could save 150K for the Wirral CCG. Page: 7/10
APPENDIX 2 QIPP Prescribing Q3 2012/13, North West PCT's Produced by: Primary Care Informatics Data source: NHSBSA Information Services Portal Prescriber Code Prescriber Name Score ACE inhibitor % Low cost lipid modifying drugs Hypoglycaemic agents NSAIDs ADQ/STAR PU NSAIDs: Ibuprofen & Naproxen % Items Antibacterial /STAR PU Cephalosporins & quinolones % Inhaled Corticosteroids NIC/ADQ Enteral Feeds Long/Intermediate (SIPS) Cost Per Insulin Analogues PU 5HG00 ASHTON,LEIGH & WIGAN 11 71.22 68.95 81.03 1.48 72.34 0.39 5.01 0.58 93.27 0.47 1.74 2.0110 3.85 1.86 7.12 30.791 62.398 28.33 5ZT00 BLACKBURN WITH DARWEN CTP 23 70.60 79.34 80.47 1.42 69.79 0.41 4.99 0.53 82.46 0.37 1.64 2.3870 2.87 1.77 6.37 10.384 63.344 18.25 5HP00 BLACKPOOL 29 75.71 77.31 85.25 1.28 71.06 0.38 4.00 0.68 74.51 0.42 0.88 2.0670 2.79 2.36 5.36 20.968 61.954 22.23 5HQ00 BOLTON 15 66.21 71.41 79.98 1.10 72.23 0.39 5.76 0.56 87.26 0.48 1.32 2.3870 2.88 1.83 5.58 38.055 59.698 37.41 5JX00 BURY 19 68.57 73.14 81.27 1.14 68.87 0.38 4.74 0.54 72.65 0.30 1.33 2.2990 2.12 1.86 6.36 21.923 64.495 28.70 5NP00 CENTRAL & EASTERN CHESHIRE 26 72.95 74.23 84.44 0.88 70.68 0.36 5.68 0.51 89.78 0.40 0.98 2.1060 2.46 1.72 6.25 29.084 62.808 17.90 5NG00 CENTRAL LANCASHIRE 24 74.02 69.10 83.23 0.92 66.99 0.36 7.18 0.51 83.71 0.43 0.95 1.8590 2.80 1.64 6.49 25.156 63.933 24.86 5NE00 CUMBRIA TEACHING 31 71.97 76.03 88.29 1.03 56.86 0.36 5.71 0.52 80.77 0.23 1.12 1.9040 2.29 1.82 5.76 19.882 57.514 19.97 5NH00 EAST LANCASHIRE TEACHING 22 70.39 77.29 83.45 1.11 64.13 0.38 4.96 0.55 76.50 0.43 1.62 2.0820 2.51 1.75 6.05 19.172 62.800 26.98 5NM00 HALTON & ST.HELENS 14 71.57 68.90 84.64 1.32 67.77 0.42 6.70 0.66 82.06 0.52 1.57 2.4350 3.29 2.16 6.27 15.619 62.034 47.15 Hypnotics ADQ/STAR PU Laxatives ADQ/STARPU Lipid Modifying drugs: Ezetimibe % Antidepressants ADQ/STARPU 3 Days Trimethoprim ADQ/Item Minocycline ADQ/1000 patients Antidepressants 1st choice % Wound care products NIC/ Item 5NQ00 HEYWOOD, MIDDLETON & ROCHDALE 12 67.54 70.41 78.69 1.85 64.14 0.44 4.89 0.56 81.66 0.50 1.62 2.2940 2.50 2.10 6.22 29.100 60.516 22.73 5J400 KNOWSLEY 12 72.82 64.34 84.46 1.25 65.56 0.40 7.52 0.66 90.99 0.69 1.35 2.7470 4.38 2.18 5.79 18.512 60.824 43.42 5NL00 LIVERPOOL 11 74.62 62.66 81.59 1.16 68.31 0.37 8.32 0.62 93.45 0.85 1.28 2.7450 3.32 2.17 5.84 27.665 60.403 26.98 5NT00 MANCHESTER 15 71.49 69.62 80.68 1.23 68.75 0.36 3.78 0.56 90.27 0.44 1.62 3.2950 2.41 2.03 6.07 22.108 55.393 31.86 5NF00 NORTH LANCASHIRE TEACHING 25 69.47 72.38 82.09 1.08 69.32 0.33 5.80 0.61 82.97 0.35 1.04 1.8940 3.09 1.85 5.78 18.843 59.653 19.64 5J500 OLDHAM 12 65.94 64.28 79.90 1.54 60.01 0.41 3.70 0.54 94.58 0.44 1.63 2.2110 2.74 1.74 6.25 26.664 59.782 22.63 5F500 SALFORD 23 74.89 69.76 77.47 0.98 65.68 0.36 5.51 0.54 53.75 0.36 1.09 3.1210 1.39 2.05 6.48 22.376 61.951 23.37 5NJ00 SEFTON 14 72.95 62.68 83.43 1.02 70.86 0.37 7.75 0.61 92.16 0.55 1.27 2.8380 4.64 1.75 5.58 23.651 61.298 26.41 5F700 STOCKPORT 26 71.91 71.18 82.28 0.92 67.72 0.35 3.19 0.57 82.09 0.20 1.32 2.3170 3.27 1.82 7.18 19.628 64.262 23.24 5LH00 TAMESIDE & GLOSSOP 17 68.76 66.08 82.74 1.40 61.69 0.34 5.61 0.57 96.50 0.32 1.36 2.3150 2.25 1.96 5.62 19.733 62.745 19.08 5NR00 TRAFFORD 13 71.90 63.37 80.27 1.13 49.84 0.35 6.29 0.50 96.18 0.25 1.11 2.4150 3.25 1.63 6.97 36.093 58.271 27.41 5J200 WARRINGTON 16 69.28 71.12 83.64 1.27 65.06 0.40 7.08 0.61 81.63 0.29 1.60 2.0320 4.14 1.85 5.78 26.196 63.768 27.00 5NN00 WESTERN CHESHIRE 26 70.78 73.94 83.64 0.94 72.18 0.35 6.68 0.52 90.27 0.39 1.02 2.0730 3.29 1.61 5.71 10.767 60.967 23.07 5NK00 WIRRAL 15 69.53 72.53 79.79 1.21 66.21 0.39 8.07 0.58 96.90 0.39 1.45 2.6330 2.35 2.03 6.30 16.938 66.437 25.60 National Average National Top Quartile National Bottom Quartile 71.08 70.69 84.38 1.01 65.36 0.34 5.50 0.51 83.17 0.30 1.07 1.9870 3.07 1.56 6.04 21.439 63.321 24.28 73.31 73.22 86.76 0.86 71.06 0.32 4.18 0.46 79.44 0.23 0.87 1.7340 2.43 1.31 5.64 15.262 65.617 22.16 69.32 68.13 81.98 1.16 62.73 0.37 6.41 0.56 91.94 0.37 1.28 2.2580 3.76 1.85 6.35 26.664 60.824 29.64 Points Rag Status NOTE: The following indicators have been retired: 0 Red National bottom quartile Alendronate as % of all bisohosphonates 1 Amber National 3rd quartile Low cost PPI's % 2 Light Green National 2nd quartile 3 Dark Green National top quartile RAG Status may differ due to mathematical roundings On behalf of the Wirral CCG, July 2013 Page: 8/10
APPENDIX 2 Summary of QIPP Prescribing Comparators: NPC Key Therapeutic Topic QIPP comparator description Comments 1. Renin-angiotensin system drugs Number of prescription for angiotensin converting enzyme (ACE) inhibitors as a percentage of the total number of prescription for all drugs affecting the renin-angiotensin system excluding aliskiren. Number of prescription for simvastatin and pravastatin as a percentage of the total number of prescription for all statins, 2. Lipid modifying drugs plus the total number of prescription for combination of simvastatin/ezetimibe, plus total number of prescription for ezetimibe alone 3. Proton Pump Inhibitors (PPIs) Number of prescription for low cost PPI preparations (omeprazole, lansoprazole and pantoprazole) as a percentage of the total number of prescription for all PPIs. 4. Hypoglycaemic agents Number of prescription for metformin and sulphonylureas as a percentage of the total number of prescription for all antidiabetic drugs. 5. Non-steroidal anti-inflammatory drugs (NSAIDs) Number of average daily quantities (ADQs) per Star-PU for all NSAIDs (BNF section 10.1.1) 6. NSAIDs: Ibuprofen & naproxen % Number of prescription for ibuprofen and naproxen as a percentage of the total number of prescription for all NSAIDs. 7. Antibacterial prescribing Number of prescription for antibacterial drugs (BNF 5.1) per Star-PU 8. Quinolones and Cephalosporin Number of prescription for cephalosporins and quinolones as a percentage of the total number of prescription for selected antibacterial drugs (BNF 5.1) 9. Inhaled Corticosteriods Total Cost (NIC) per ADQs for all Corticosteroids (Respiratory) (BNF section 3.2) 10. Alendronate 11. Intermediate and long acting insulin analogues Number of prescription for alendronic acid (sodium alendronate) as a percentage of the total number of prescription for all bisphosphonates and other drugs affecting bone metabolism (BNF 6.6.2) Number of prescription for long acting human analogue insulins detemir and glargine as a percentage of the total number of prescription for all long acting and intermediate acting insulins excluding biphasic insulins. 12. Enteral Feeds (Sip) Total Cost (NIC) per PU for all Enteral Feeds (Sip) (Toolkit Indicator) 13. Hypnotics Total number of average daily quantities (ADQs) for benzodiazepines (indicated for use as hypnotics) and Z drugs per Star-PU*. 14. Laxatives ADQ/ STARPU Total number of average daily quantities (ADQs) for laxatives per Star-PU New comparator (Feb 2012) 15. Lipid Modifying drugs: Ezetimibe % Number of for ezetimibe and ezetimibe/simvastatin combinations as a percentage of the total number of prescription for all statins, plus the total number of prescription for combination of simvastatin/ezetimibe, plus total number of prescription for ezetimibe alone. New comparator (Feb 2012) 16. Antidepressants ADQ/STARPU Total number of average daily quantities (ADQs) for all antidepressant prescribing (BNF 4.3) per Star-PU New comparator (Feb 2012) 17. 3 Days Trimethoprim Total number of average daily quantities (ADQs) per item for trimethoprim 200mg tablets New comparator (Feb 2012) 18. Minocycline Total number of average daily quantities (ADQs) for minocycline per 1000 patients New comparator (Feb 2012) 19. Antidepressants: First choice % Number of for "1st choice" generic SSRIs as a percentage of selected "other antidepressants" New comparator August 2012 20. Wound Care products: Nic/ Item Cost (NIC) per item for w ound care products (epact section 20.03) New comparator August 2012 On behalf of the Wirral CCG, July 2013 Page: 9/10
APPENDIX 2 QIPP Prescribing Q3 2012/13, NHS Wirral Divisions Produced by: Commissioning Support Unit - Business Intelligence Team Data source: PPA Prescribing toolkit Wirral GP Divisions QiPP Prescribing Profile Quarter 3 2012/13 GP Consortia Group ACE inhibitor % Low cost lipid modifying drugs Oral Hypoglycaemic agents NSAIDs ADQ/STAR PU NSAIDs: Ibuprofen & Naproxen % Items Antibacterial /STAR PU Cephalosporins & Quinolones % Inhaled Corticosteroids NIC/ADQ Long/ Intermediate Insulin Analogues Enteral Feeds (SIPS) Cost Per PU Hypnotics ADQ/STAR PU Laxative ADQ/STAR PU Lipid Modifying drugs: Ezetimibe % Antidepressants ADQ/STAR PU 3 Days Trimethoprim ADQ/Item Minocycline ADQ/1000 Patients Wirral GP Commissioning Consortium 70.91 74.53 79.02 1.31 66.37 0.36 8.38 0.56 96.81 0.38 1.55 2.89 2.30 2.17 6.28 17.81 Wirral Health Commissioning Consortium 68.31 70.65 79.52 1.10 64.88 0.35 8.27 0.58 96.80 0.37 1.21 2.43 2.45 1.93 6.67 12.11 Wirral NHS Alliance 70.73 74.50 83.94 1.26 62.23 0.34 7.92 0.60 97.79 0.50 1.77 2.66 2.04 1.97 6.51 34.34 National Average 71.08 70.69 84.38 1.01 65.36 0.34 5.50 0.51 83.17 0.30 1.07 1.99 3.07 1.56 6.04 21.44 National Top Quartile 73.31 73.22 86.76 0.86 71.06 0.32 4.18 0.44 79.44 0.23 0.87 1.73 2.43 1.31 5.64 15.26 National Bottom Quartile 69.32 68.13 81.98 1.16 62.73 0.37 6.41 0.51 91.94 0.37 1.28 2.26 3.76 1.85 6.35 26.66 National bottom quartile National 3rd quartile National 2nd quartile National top quartile RAG Status Red Amber Light Green Dark Green * RAG Status may differ due to mathematical roundings Page: 10/10