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Copyright © 2016 Mark Stone, unlicensed use of presentation prohibitedCopyright © 2016 Mark Stone, unlicensed use of presentation prohibited

Dispensing Doctors & Primary Care Networks

MARK STONE, Pharmacist Partner, Tamar Valley Health Practice,

DDA Board member, East Cornwall Locality Vice Chair, RMOC

South Member, SW Clinical Senate

[email protected]

Where are we now for prescribing?

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Copyright © 2016 Mark Stone, unlicensed use of presentation prohibitedCopyright © 2016 Mark Stone, unlicensed use of presentation prohibitedCopyright © 2016 Mark Stone, unlicensed use of presentation prohibitedCopyright © 2016 Mark Stone, unlicensed use of presentation prohibited

The Growth in Prescription Cost: Generics and Price Reductions

Copyright © 2016 Mark Stone, unlicensed use of presentation prohibited

Prescription Dispensed in the Community Cost Analysis England HSCIC 2019

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Cost (£million) 7,510.1 8,079.6 7,936.6 8,196.8 8,372.7 8,325.5 8,539.4 8,834.4 8,805.1 8,523.1 8,625.1 8,852.6 9,266.6 9,204.9 9,170.0 8,830.6

7,200

7,700

8,200

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9,200

9,700

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illio

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Cost Of Prescriptions

Cost (£million)


Prescribing Costs England

• Total NHS expenditure on medicines in 2017-18 was £18.2 billion (2016-17 £17.4 billion) note before discounts!

Growth 4.6% (2016-17 to 2017-18)

• Cost of medicines issued by hospital £9.2 billion

Growth 10.8% (2016-17 to 2017-18)

• Cost of medicines dispensed in the community for 2018 was £8.3billion

Growth -3.7% (from 2017) . In 2003 £7.5 billion

Prescribing Costs in Hospitals and the Community England 2018 & 2018 NHS DigitalCopyright © 2016 Mark Stone, unlicensed use of presentation prohibited

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Prescribing Items: Year on Year Growth Stalls

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Items (millions) 649.7 686.1 720.3 752.0 796.3 842.5 886.0 926.7 961.5 1000. 1030. 1064. 1083. 1,104 1,105 1,108

600

700

800

900

1000

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ms

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Prescription Items

Items (millions)


Prescribing Costs England

Medicines dispensed in the community, average items value in 2018

£7.96 (3.9% decr. from 2017)

£11.56 in 2003

Item volume growth in 2018

1,109 million items (0.3% increase )

649.7 million items in 2003

Prescription Cost Analysis England 2017 & 2018 NHS Digital


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Key Demand Growth Drivers: Old Age

National Population Projections: 2014-based Statistical Bulletin, Office For National Statistics, 29 October 2015

Petty et al. BMC Health Services Research 2014, 14:76

Mean number of medicines per patient on repeats

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Obesity Statistics House Commons Briefing Paper 2019

Adult obesity in England has risen from 15% in 1993 to 29% in 2017

The Decreasing Health Workforce: Where is the 5,000?!

Palmer W (2019) 'Is the number of GPs falling across the UK?' Nuffield Trust blog, 08 May.

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Public Perception Of Medicines

Has The Opioid Epidemic Come To The UK?

The Global Use of Medicine in 2019 and Outlook to 2023 IQVIA and its affiliates

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NHS Low Value Medicines Programme

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What's the likely effect of PCNson the prescribing of medicines?



Service Start Date

Personalised Care April 2020, full

delivery 2023/24

CVD Prevention and DiagnosisApril 2021(or later)

TacklingNeighbourhood

Inequalities

April 2020

PCN DES Service Start Date

Structured Medication ReviewApril 2020

Enhanced Health in Care Homes April 2020

Anticipatory careApril 2020

Supporting Early Cancer DiagnosisApril 2020

PCN DES Networks Services

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PCN Effect On Prescribing

1. Structured Medications Reviews and Optimisation (Pharmacists 6/228hrs)

i. Reducing poly-pharmacy (↓)

Review by DH into ‘over-prescribing’, target people ‘stuck on meds’

ii. Antibiotic stewardship (↓)

2014-19 reduction antibiotic primary care prescribing by 15%, target 25% by 2024

iii. Optimising medicines for asthma and COPD (↑)

2018 1,400 people died from an asthma (33% 10yr)

COPD accounts for 10% of hospital admissions (incr 50%, 10yrs)

iv. Frail elderly, patients with complex needs (↓)

Evidence from Vanguard work




2. Enhanced Health In Care Homes (Pharmacists 6/228hrs)

i. Medication review in care homes (↓)

Targeting frail elderly on >10 meds

Medicines reduction of items 6%

ii. Review at the transition of care (↓)

Target prescribing error rate 20-70%, 37% of >65yrs people medicines-related harm

Reduced reported emergency hospital admissions by 21 per cent

Reduced oral nutritional support usage by 7 per cent

Made drug cost savings of £125-305 per resident

NHSE Vanguard East and North Hertfordshire https://www.england.nhs.uk/2018/03/care-home-pharmacists-to-help-cut-over-medication-and-unnecessary-hospital-stays-for-frail-older-patients/Prevalence and Economic Burden of Medication Errors in The NHS in England : Elliott, et al; Policy Research Unit in Economic Evaluation of Health and Care Interventions (EEPRU), 2018. 174 p.


https://www.england.nhs.uk/2018/03/care-home-pharmacists-to-help-cut-over-medication-and-unnecessary-hospital-stays-for-frail-older-patients/

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3. Cardio-vascular disease prevention and diagnosis (↑)(Pharmacists 6/228hrs, Social prescribers 3-4/133hrs)

Target - High blood pressure 2nd largest cause of premature mortality

Increase diagnosis of high blood pressure by 15%

by reducing the blood pressure of the nation as a whole (5mmHg), over 10 years could avoid

£850m of NHS and social care spend

45,000 lost quality adjusted life years

New QoF Target non-diabetic <140/90

NG136 (Aug 19) anti-hypertensive in =<10% CVD risk

Tackling high blood pressure, PHE 2015Copyright © 2016 Mark Stone, unlicensed use of presentation prohibited



4. Other contractual drivers for PCNs (↑)

IAGP with extended access to provide 50hrs of consultation

time per week

Savings and impact fund (↓)

£75 million in 2020/21, min £300 million in 2023/24

Avoidable A&E attendances and admissions, timely

discharge, prescribing costs

Quality Improvement (↑/↓)

Medicines safety and End of life care


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Avoiding the harm from medicines• Potentially hazardous prescribing 0.28%-10.2%, inadequate

monitoring 10.4%-41.9% (S J Stocks, 2016)

• 66 million (est) potentially clinically significant errors occur per year,

71.0% in primary care (Elliot et al, 2018)

• 7.1% percentage of hospital admissions are related to medicines (Winterstein et al (SR 15 studies) 2002)

• 69.5% care home residents were exposed to at least one

medication error (mean 1.9) (CHUMS Aldred et al, 2011)

• Almost half of all patients may experience an error with their

medication after they have been discharged from hospital (Kripalani S et al,

2007)

• WHO challenge to reduce medication-related harm by 50% by Global Patient Safety Challenge, WHO, 2017)

East Cornwall PCN Medicines Strategy


QOF Quality Improvement: Prescribing Safety

Identify areas to improve (baseline assessment):

1. Patients at significant risk of gastrointestinal adverse effects who have

without co-prescription of a proton-pump inhibitor (PPI) in the

months

2. Patients receiving lithium and being monitored in primary care

not had a recorded check of their lithium concentrations, eGFR, U+Es ,

the previous 6 months

3. Girls and women of childbearing potential currently being

valproate have had an annual specialist medication review and are

this in compliance with the pregnancy prevention programme.


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Avoiding the harm from medicines

Reducing the incidence of common medicines harm

Where we are: Composite metric combining results from individual gastro intestinal bleed indicators.

VALUE: No. of patients at increased risk per 10,000 patients at risk

East Kernow Locality Medicines Strategy

Medicines Safety Dashboard, NHSBSA, https://apps.nhsbsa.nhs.uk/MOD/MedicationSafety/atlas.html



QOF Quality Improvement: Prescribing Safety

1. Patients:

Improving information, through ad-hoc advice to on the

NSAIDs/valproate/lithium and risk identification at point of dispensing

2. Improving shared care across the neighbourhood health system:

Community pharmacy (2019 CPCF, NSAID/valproate/lithium audit)

DSQS NSAIDs/valproate/lithium

3. Medication review (proactive 3-6 monthly) of at risk patients:

Utilising the multidisciplinary team, PCN pharmacist support

4. Systems and practice:

Using the evidenced PINCER interventions (PRIMIS – National Roll Out)

Eclipse RADAR Safety Alerts (‘UKMI Drug Monitoring in Adults in Primary Care’)

https://apps.nhsbsa.nhs.uk/MOD/MedicationSafety/atlas.html

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Will it be prescription growth or decline in 10 years time?

Overview of the UK population: July 2017Office For National Statistics

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