At a recent HSJ webinar an expert panel explored how medicines optimisation can work at an ICS level. Thelma Agnew reports
Edward Jones believes that integrated care systems have an unprecedented opportunity to improve the use of medicines. “This is about getting the right medicines to the right patients at the right times. It’s not just about reducing inappropriate prescribing. It’s getting medicines to where they are needed, often to disadvantaged groups.”
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According to NHS England, medicines optimisation “looks at the value which medicines deliver, making sure they are clinically-effective and cost-effective”. ICSs may support this by bringing together everyone involved in prescribing across the health and care economy.
“This is a systems’ issue,” said Mr Jones, a senior policy adviser in the NHS Confederation’s ICS network, where he leads on medicines policy commissioning, finance and governance. “Medicines optimisation isn’t just a pharmacy issue, it’s everyone’s business, from the consultants and acute care pharmacists to the GP, through to social care workers and district nurses who spend the most time with patients when they are at home.
“ICSs give us an opportunity to go further and faster on medicines optimisation.”
Mr Jones was speaking at an HSJ webinar. Held in December 2022, and run in association with Spirit Health Group, the event brought together a small panel to consider how medicines optimisation can work at an ICS level. It followed on from a discussion held at the HSJ Medicines Forum in October.
The success of ICSs depends, to a large degree, on getting medicines right, insisted Mr Jones. “We know that medicines are the most common healthcare intervention in the world, the highest cause of avoidable harm, and the second highest NHS spend after workforce.
“That makes medicines optimisation absolutely critical to ICSs’ four core purposes: improving health outcomes, tackling health inequalities, making the health and care system more financially sustainable, and of course the broader social and economic development of society. For ICSs to do the job they have been tasked to do, medicines optimisation is at the heart of that.”
It soon became clear that the panel, though candid about the challenges in adjusting to the new era, saw ICSs as a chance to focus attention on prescribing’s role in patient outcomes, build on progress in partnership working in this area and, importantly, break with some old, bad habits.
There seems little risk that prescribing will get lost among other priorities. “In our integrated care board we spend £1bn a year on medicines, and it’s volatile, so it doesn’t take an awful lot to push that up the agenda,” said Ewan Maule, director of medicines and pharmacy at North East & North Cumbria ICB.
For Mr Maule, the most exciting thing about ICSs is the new acceptance that collaboration, not competition, is the way to drive efficiency. “A lot of us realised that some time ago, but the rest of the system needed to catch up.”
Many ICSs are starting out with a deficit, he pointed out. He hopes that the newly-statutory organisations do not respond to financial pressures in the usual way, with cuts that prove counterproductive. “We can deal with [financial pressures] by slashing and burning or do it through using medicines as an investment, a resource, in order to improve patient outcomes so we don’t just see overprescribing as being the problem but also see underprescribing and underinvestment in prevention as a problem.”
Medicines optimisation “isn’t what it once was”, Mr Maule added. “It’s not about switching one brand of a product to save a few quid. It’s about supporting patients to have their own agency and their decision making about their medicine, what matters to them, what aligns with their values.”
Workforce is probably the “trickiest” challenge that will need to be addressed, to unlock the potential of medicines optimisation across pathways and sectors
Chris Barker, chief executive of Spirit Health Group, agreed that medicines optimisation “is not just about saving money, it’s how can we invest in medicines to get better outcomes for patients across the system.
“It’s also about making sure the entire multidisciplinary team is working together jointly so we don’t have the various different parts of the patient pathway perversely incentivised to do one thing rather than the other.”
A “one team” approach to medicines optimisation is essential, agreed the panel. Mr Edwards said this sort of approach, with pharmacists and other colleagues across all the different organisations within the ICS “working together, hand in glove”, is part of the “roadmap for the future”.
He explained that systemising medicines optimisation means getting the governance right, so all the different component parts come together. And he emphasised the importance of using digital data and technology to share records, embracing opportunities for multidisciplinary teams to redesign pathways, and giving local citizens the agency “to do what they need to do to drive improvement on the ground”.
Collaborative working on medicines optimisation did, of course, exist before ICSs were established. “It was those early partnership workings that made the covid vaccine roll out so successful,” said Mildred Johnson, clinical director of pharmacy and medicines optimisation at Maidstone and Tunbridge Wells Trust.
“For me, moving into a formal and statutory ICS is just an enabler for those initial partnerships to mature, to develop,” she added.
“My main message is we need to start thinking at scale,” said Ms Johnson. “What can we do to reduce duplication of work? Where can we do it across the wider system for the wider benefit of patients? Thinking at scale should be the norm. We want to ensure that medicines optimisation can improve patient care.”
The panel hoped ICSs will use medicines optimisation to tackle the health inequalities that have been exposed by the covid-19 pandemic. “We need to be really clever about how we use the data about health inequalities so we find those underserved populations, and we manage and support them and prescribe appropriately and ensure they can access all the services they need to,” said Mr Maule.
Workforce is probably the “trickiest” challenge that will need to be addressed, to unlock the potential of medicines optimisation across pathways and sectors, suggested Mr Jones. The panel agreed that staff need the freedom to build portfolio careers, where they gain experiences and build relationships in different organisational settings. “It’s part of fostering that culture of one team,” said Mr Jones.
In particular, pharmacists need to have freedom of movement, without it creating skills shortages in some parts of the system. “The only way we will stop robbing Peter to pay Paul is have an approach that builds on those portfolio careers that people want to have,” said Mr Maule. “We need to make it easy to move between sectors.”
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