Trusts spend millions dealing with unnecessary hospital admissions and adverse drug reactions, but one has implemented a medicine optimisation programme that looks to be capable of reversing that trend. By Andy Cooke
Effervescent pill in water
Between 30 and 50 per cent of medicines are not taken as recommended. Adverse drug reactions account for around one in 15 hospital admissions, yet 70 per cent of those reactions are avoidable and 30 per cent of patients are already non-adherent within 10 days of starting a new medicine.
The associated loss of health benefit for the NHS from poor use of medicines is estimated to be at least £500m a year. Tackling this has become a priority for clinical commissioning groups and is termed “medicines optimisation”.
Turning a problem and a catchphrase into a meaningful impact on patient experience and patient outcomes is the challenge for Bedfordshire Clinical Commissioning Group’s prescribing team. The recent changes in NHS structure − and the creation of CCGs in particular − provide an opportunity to meet this challenge in a new way.
Focus for care
Bedfordshire CCG has three strategic areas of focus:
- care right now;
- care for the patient’s condition into the future; and
- care when it’s not that simple.
This represents a move away from the traditional concepts of secondary care, community care and mental health commissioned in siloes to a more integrated approach for 21st century healthcare.
Safety and patient experience underpin everything we do. To achieve this, our operating culture is to work in partnership, with service redesign being led by clinicians with a clear focus on improving patient outcomes and patient experience.
By adopting this approach for medicines management, we are starting to transform and optimise the use of medicines through a patient pathway focused service redesign model.
In recognition that almost all service redesign initiatives impact on − and are themselves impacted by − medicines use, it is sensible to integrate medicines optimisation projects within patient pathways and service redesign.
We use a programme budget approach to service redesign that includes prescribing to get best value for improving patient outcomes. This is achieved by ensuring we use the most cost effective treatment − whether through prescribing medicines or other treatment − and the chosen treatment is used to best effect to improve patient outcomes.
‘There is an assumption that if we get the correct diagnosis and give the right treatment then the patient will get better’
A service redesign for diabetes has achieved substantial savings through improved use of blood glucose testing and insulin. This has been reinvested in services elsewhere in the patient pathway. Before CCGs were established, primary care medicines management was predominantly focused on improving cost effective prescribing by applying evidence based medicine choices for populations and individuals.
Over the past decade, primary care trusts were highly successful in improving both the quality and cost effectiveness of prescribing; some of the successes in Bedfordshire PCT are set out in the box below.
Bedfordshire PCT: successful outcomes of medicines management
- Reduction in antibiotic prescribing from highest to lowest in the East of England, contributing to a reduction in C. difficile infections to less than half within three years.
- A 50 per cent reduction in the prescribing of NSAIDs associated with higher rates of cardiovascular disease (diclofenac and cox-2 selective inhibitors) since 2009. Equivalent to 25 fewer cardiovascular events in Bedfordshire each year.
- Savings of over £1m a year from greater use of generically available statins, and a move from a ranking of 126th to 17th in the national “better care, better value” indicators in two years.
- Commissioning a dietetic service promoting “food first”, which has reduced the use of sip feed cartons to 40 per cent below the national average.
- Primary care prescribing spend is 8 per cent below the average for England, even though Bedfordshire has average population demographics. This means it has over £4m in additional healthcare funding available than if its prescribing costs were average.
There is an assumption that if we get the correct diagnosis and give the right treatment then the patient will get better. In the NHS we are very good at getting the right diagnosis and we have been very good at choosing the right treatments − but patients’ health does not improve as much as it should. Here lies the problem.
There is additional complexity, which the NHS has not been so good at tackling. In order to turn a vision of medicines optimisation into strategy, and strategy into improved patient outcomes, Bedfordshire CCG has created a portfolio of individual but interrelated projects, using the NHS Leadership Framework to support an effective change in practice. Individual projects join together within patient pathways.
The right medicine
A large proportion of our population take medicines on a regular basis and we know that poor medicines adherence has a major impact on health outcomes. We are introducing medicines optimisation as a Making Every Contact Count initiative in Bedfordshire. This will reflect its importance to overall public health and help to integrate medicines optimisation within both health and social care. The initiative uses two simple questions to provide an opportunity for either a brief intervention or signposting to a community pharmacist:
- Can you take your medicines? This opens a dialogue in which patients can highlight any practical problems such as inhaler technique, inability to remove small tablets from foil strips or any misunderstanding about the role of their medicines.
- Do you take your medicines? This encourages patients to be honest about adherence problems − be they deliberate or unintentional − so they can be fully supported by their community pharmacist or GP practice.
There are a growing number of people with dementia who receive ongoing medical care while still living in their homes. The national strategy for patient care supports keeping patients at home rather than caring for them in residential homes. This presents a number of challenges around the management of medication.
‘Making in-year savings through cost effective medicine choices is more important than ever’
This is a vulnerable patient group, members of which frequently receive complex medicine regimes with an increased risk of adverse drug reactions, drug interactions and risk of non-adherence. It is also important that the patient’s carer is well informed about the medicines and is able to follow instructions for administration. Often these patients are housebound and do not have full access to the support that is available from community pharmacists
We are commissioning a project that will ensure patients with dementia who live in their own homes receive appropriate support from community pharmacists to ensure their medicines are used safely. The project involves integrated working between health and social care to support the holistic needs of patients. We expect to:
- reduce the rate of hospital admissions;
- ensure appropriate use of anti-psychotic medication; and
- improve the quality of care.
Poor inhaler technique is a significant factor in poor outcomes for patients with chronic obstructive pulmonary disease and asthma, and associated unplanned hospital admissions. This is particularly true for older patients who require assistance to use their inhaler devices. We have a highly successful pharmacy technician led project supporting patients and care home staff to maximise the benefits and minimise the harm from their inhalers. Our other projects are listed in box 2.
Medicines optimisation projects for delivery in Bedfordshire 2013-16
- Further rollout of multidisciplinary care homes support
- Optimisation of inhaler devices for patients with carers
- Support and training on medicines administration for carers
- Service to improve medicines support from community pharmacists for patients with dementia who are living at home
- Rollout of healthy living pharmacies
- Improved quality and timeliness of medicines and prescribing information transferred across interfaces
- Promotion and support of self-care
- Inclusion of medicines adherence in the Making Every Contact Count scheme
Potential stumbling blocks
CCGs will continue to be required to balance annual budgets. Making in-year savings through cost effective medicine choices is more important than ever.
Commissioning organisations have become reliant on prescribing savings and a CCG’s prescribing budget forms a larger proportion of overall budget than for PCTs; a balance is therefore required in committing resources to both the shorter term financial savings of medicines management and the longer term benefits of medicines optimisation.
‘There are a number of innovative ways of measuring outcomes from medicines optimisation projects that are more patient focused
Measuring outcomes is a real challenge for sustainability and the embedding of practice, as well as a possible psychological barrier. The success of evidence based medicine and use of robust prescribing data have created a comfortable reliance on high quality data.
There are a number of innovative ways of measuring outcomes from medicines optimisation projects, which are more patient focused than traditional ePACT prescription data. We are keen to work in partnership with academic organisations to add to the growing pool of evidence demonstrating how patients benefit from medicines optimisation.
To be successful in our aims and move beyond a purely health focused model will require ownership and leadership throughout health and social care. Building networks with local authorities will be a significant challenge but, with public health now embedded within local authority structures, we have a familiar and enthusiastic partner.
Successful implementation of early projects will both directly benefit patients and support new trusted relationships, setting the foundations for further improvements in patient care.
Andy Cooke is head of medicines management at Bedfordshire Clinical Commissioning Group