Medicines optimisation can cut waste, emergency admissions and the cost of long term conditions. But a review of rheumatoid arthritis care reveals how far it has to go, writes Matthew Shelley
The drive for medicines optimisation appears to be gaining momentum across the NHS as a potentially effective means of improving both outcomes and efficiency.
Championed by the Royal Pharmaceutical Society and NHS England, its central concern is to ensure that healthcare professionals and patients make the most effective use of medicines.
This seemingly common sense objective has implications in every sphere from healthcare practice to procurement. Perhaps most of all it has ramifications for managers who need to provide the mechanisms and corporate will to make it work.
Many argue that this demands better, more robust and up to date data on which to base decisions.
A progressive outlook
Inderjit Singh, chief pharmacist at University Hospital Birmingham Foundation Trust, is among those who see medicines optimisation as a force for progress. “It’s an extremely important idea, though in some ways a rebadging of what hospital pharmacy has been doing for some time,” he says.
“What we need is multiprofessional collaboration to get the best value from medicines utilisation without compromising outcomes.”
Headway is being made, according to Mr Singh, who believes it can reduce waste, unnecessary treatments, avoidable emergency admissions and, sometimes,
‘We need multiprofessional collaboration to get the best value from medicines utilisation’
A major area of interest is rheumatoid arthritis (RA), where there is growing evidence that changes in combinations of drugs, and when they are given, can significantly affect the overall cost of care and help more patients maintain quality of life and remain in work.
The emergence of biosimilars – less costly potential alternatives to existing “biologic” drugs (manufactured from living organisms) for the treatment of RA – is also potentially important.
Tim Sheppard on disparities in care
I can only agree with the sentiment delivered recently by Simon Stevens for his first address under the new Conservative administration: “There’s no nobler ambition… than advancing the health and supporting the wellbeing of all families, and all communities, across the length and breadth of this country.”
Yet I am also aware in my role of the significant disparities of wellbeing across our country and the variations in the way care is provided. Delivering advancements in healthcare against a backdrop of a £22bn funding gap will require the NHS to look at its system of delivery, the variation in models of care, and accurately understand local patient populations in order to deliver the ambitions Mr Stevens has set out in his NHS Five Year Forward View.
Healthcare providers need to look to the wealth of data within the UK health system. Utilising data, combined with the right analytical skills and modelling, can provide a holistic view of the delivery of care – nationally, regionally, even to the individual patient - and provide actionable insights for change and improvements in efficiency and patient outcomes.
The management of chronic conditions within the NHS is a foundational element of the forward view in recognition of the long term impact these conditions have for both the patient and the system. The manifesto calls for “new care models that can be deployed in different combinations locally”.
To achieve this will require a true understanding of current service pathways, the treatment delivered today and the ability to apply best practice using integrated local trust data.
Our study exploring the patient pathway for rheumatoid arthritis, examining in-depth diagnosis and treatment across England. The study highlighted that the investment in treatment to manage this chronic condition is widely inconsistent.
When examining the patient pathways we uncovered significant variation – with 28 per cent of pathways exceeding the average number. This level of disparity represents a significant cost to the NHS, with the average cost of patient pathways increasing over 50-fold in some cases.
This type of insight is a real world example that data, information technology and analytical expertise are the key enablers for system change within the NHS. To deliver real improvements will require a deeper understanding of patient pathways and the treatments administered at a local level.
Trusts need timely access to high quality data and expertise to truly create a step-change in patient outcomes, efficiency, effectiveness and reduce healthcare inequality.
Tim Sheppard is general manager, UK and Ireland, IMS Health
The principles behind medicines optimisation – evidence based choice of drugs, understanding the patient experience, and an emphasis on safety – should theoretically ensure that biosimilars are adopted on efficacy rather than price.
Mr Singh sees NHS managers as being the lynchpin: “For management, the message is to ensure that there is appropriate resource and strategic direction in pharmacy and buy-in from clinicians. They have to facilitate the process.”
The development of a prototype medicines optimisation dashboard bringing together a range of data – designed to help clinical commissioning groups and trusts focus more sharply on how well patients are supported to use their medicines – is a promising development.
‘We are often poor at sharing best practice in the NHS’
So too is work being done by specialist information companies such as IMS Health in pulling together NHS data in ways that make it possible for the health service to gain a better understanding of how well medicines are, and can be, used.
“We are extremely data rich but in terms of analysis, very poor,” says Mr Singh. “And in the NHS we are often poor at sharing best practice.
“The data is there to be able to identify anomalies and best practice. That’s where work like what has been done by IMS can fill a void.”
Today IMS Health was due to publish a report reviewing the effective use of the biologic anti-TNF (tumour necrosis factor) drugs for RA in England.
The findings show that 15 years after the arrival of the first biologics, they are not always in optimal use.
While some trusts – mainly those with large caseloads and a substantial team of specialists – are highly effective, there is a cohort with major inefficiencies in drug spending. While the average patient pathway is 3.4 events, there were instances of up to 87, with 28 per cent exceeding the average, often with a substantial impact on cost.
According to Laura-Jane Bedding, manager of supplier services at offering development for IMS Health, the report is the first of a series that knit together NHS datasets so trusts can benchmark themselves and understand how to improve.
She says: “What people will see in this report is the power of joined up data as a means to guiding cost effective decision making.
“It’s not pointing to goodies and baddies. It’s about saying that there are inconsistencies across the country and allowing people to ask why this is the case and look at whether that can change if they learn from what others are doing.
“Better management of pathways can reduce emergency admissions and time spent in hospital settings, and that’s good for everyone.”
The report also has implications for the medicines optimisation agenda as a whole.
‘It can reduce emergency admissions and time spent in hospitals’
While the data is extensive and robust, the company says there are gaps. It wants to provoke debate in the NHS and among policymakers about how to generate the data needed for service improvement.
IMS is working with 42 trusts on making use of real world evidence to conduct healthcare research.
It already has information available to identify which patients respond in what ways to specific drugs given at particular stages. The company now hopes to work with more trusts to make available the outputs of these studies.
This could enable improved treatment of a range of illnesses, as well as informing national guidelines and allowing closer working with the pharmaceutical industry on how to get the best from drugs.
What’s best for patients
The company also wants CCGs to be able to identify which services are best for their patients. “We are aiming to provide real world evidence on patient outcomes to fuel the advance of healthcare,” says Ms Bedding.
‘There are a variety of different possible approaches depending on the patient and stage of illness’
The advances that medicines optimisation can bring are welcomed by Ailsa Bosworth, chief executive of patient support group the National Rheumatoid Arthritis Society. “Medicines optimisation is vitally important because there are a variety of different possible approaches depending on the patient and the stage of the illness,” she says.
With RA the goal is systems that get patients into hospital treatment within 12 weeks of the onset of symptoms, rather than the current nine months.
And once in treatment, Ms Bosworth argues that the NHS is not always good enough at monitoring, recording and reviewing each case.
She says: “Good care is cheaper in the long run. You are more likely to have remission or lower the disease activity with effective treatments.
“It also reduces the likelihood of co-morbidities, including depression, and again this reduces the burden on the NHS.
“Overall it’s less of a drain on the NHS and the hospital system – less clinician time, less likelihood of unnecessary admissions.”
This demands detailed and high quality comparative information. “Measurement is essential – you have to be able to measure what you are doing and what the results are, otherwise you will just end up in a black hole,” says Ms Bosworth.