1. Medicines Optimisation How can data help us to get it right?
Clare Howard FFRPS FRPharmS

2. Medicines Optimisation Principles
In May 2013 the RPS produced their principles of MO.
NHS England has publicly committed to the principles and Bruce keogh and Jane Cummings and Keith signed up to the principles.

3. Medicines Optimisation – The Strategic Context
PPRS - NHS England response to PPRS agreement
“Ensuring medicines use is patient centred and focused on value, quality and outcomes will help seize the opportunity of the 2014 PPRS agreement”
Kings Fund Poly Pharmacy and Medicines Optimisation
NICE short clinical guideline published 2015
The challenge is why should CCGS and trusts do this on “ top of their day jobs” The reality is that if they don’t put strategies in place to support patients to get the most romtheir medicines ( reduce waste, reduce unplanned admissions etc) then they will never have the financial headspace for new medicines and ultimately that may cost a lot more in the long term.
Respiratory is a great example. How can we reduce premature mortality fro resp conditions when 94% of patients ant us ehtier inhalers properly. Where we have had programmes in place to improve this patient outcomes have improved.
I would also argue that gven the current issues with GP access that this area must capitalise on its relationship with community pharmacy. They can use the CPCF to support patietsn better and reduce burden on general practice. But needs to be signalled from the practice.

4. What key messages do they have?
NICE GUIDANCE (NG5)
Kings Fund
Between 2003 and 2013 the average number of prescriptions for any one person per year in England rose from 13 to 19
Better use of data
Patient centered care ( including shared decision making )
Transfer of care
Medication safety
In problematic polypharmacy, there can be increased risk of drug interactions and ADRs, impaired adherence and QoL for patients
One of the big themes was around polypharmacy.

5. The role of data
NICE says “The better use of data and technology can give people more control over their health and supports Medicines Optimisation”
Data sources include:
NHS England MO dashboard.
MHRA yellow card scheme
National Reporting and Learning System
NHS Safety Thermometer

6. What have patients told us?
Improve national awareness amongst patients, the public and professionals of the services available to support patients in their medicines-taking 
Enrich ‘consultations’ (in all care settings) to support health and care professionals to more closely consider the life stage/ patient perspective (see NICE Guidance)
Encourage patients to be more responsible and honest about their attitudes and behaviours around medicines-taking, including not wishing to take them
Encourage the provision of better information & support to enable patients/ carers to get the best from their medicines
Ensure that the view of patients and the public around waste, repeats, and broader system improvements on medicines-taking are incorporated into the Value for Money element of any strategy.
These are the key themes from the patient workshop. NHS England is developing a patient panel to take this forward and make sure MO is in line with patients wishes for better support for their medicines taking.

7. So what does the data tell us about NEL, Anglia, Bedfordshire, Hertfordshire and Luton?
Nobody has cracked this. Lots more opportunities to use community pharmacy. London area doing a lot with Repeat Dispensing Everyone is waiting for something that will fix this but many of the tools are already in the box but we’re not using them!

8. Use of tools proven to improve medication safety
This software is free to practices and we could easily work with Nottingham Uni to get a workshop for local practices.
Findings
72 general practices with a combined list size of 480 942 patients were randomised. At 6 months' follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0·58, 95% CI 0·38—0·89); a β blocker if they had asthma (0·73, 0·58—0·91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0·51, 0·34—0·78). PINCER has a 95% probability of being cost effective if the decision-maker's ceiling willingness to pay reaches £75 per error avoided at 6 months.

9. Use of tools proven to improve medication safety
This software is free to practices and we could easily work with Nottingham Uni to get a workshop for local practices.
Findings
72 general practices with a combined list size of 480 942 patients were randomised. At 6 months' follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0·58, 95% CI 0·38—0·89); a β blocker if they had asthma (0·73, 0·58—0·91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0·51, 0·34—0·78). PINCER has a 95% probability of being cost effective if the decision-maker's ceiling willingness to pay reaches £75 per error avoided at 6 months.

10. Use of services proven to support patients’ access to medicines and reduce GP workload
An increase wouldn't’t cost the CCGs anything and we could run workshops ( using Portsmouth to show how they have done it).
In 2002, it was estimated that up to 80% of all repeat prescriptions could be replaced with repeat dispensing over time, “yielding savings of up to 2.7 million hours of GP and practice time”. Feedback from areas that have implemented repeat dispensing is that patients find the system more convenient.
This opportunity was recently highlighted in the Transforming Primary care document published by DH and NHS England.
ile/304139/Transforming_primary_care.pdf
There is significant variation in the proportion of prescriptions managed in this way with some GP practices not making this service available to their patients. The use of this metric aims to increase the proportion of items provided this way and to ultimately free up GP and practice time.
The number of repeat items offered to patients in this way (as a percentage of all items) is currently just below 7%. However, CCGs vary in their use of repeat dispensing from 0 to 37%
Implementation of EPS2 will support practices in their roll out of repeat dispensing.

11. Use of services proven to support patients’ access to medicines and reduce GP workload
An increase wouldn't’t cost the CCGs anything and we could run workshops ( using Portsmouth to show how they have done it).
In 2002, it was estimated that up to 80% of all repeat prescriptions could be replaced with repeat dispensing over time, “yielding savings of up to 2.7 million hours of GP and practice time”. Feedback from areas that have implemented repeat dispensing is that patients find the system more convenient.
This opportunity was recently highlighted in the Transforming Primary care document published by DH and NHS England.
ile/304139/Transforming_primary_care.pdf
There is significant variation in the proportion of prescriptions managed in this way with some GP practices not making this service available to their patients. The use of this metric aims to increase the proportion of items provided this way and to ultimately free up GP and practice time.
The number of repeat items offered to patients in this way (as a percentage of all items) is currently just below 7%. However, CCGs vary in their use of repeat dispensing from 0 to 37%
Implementation of EPS2 will support practices in their roll out of repeat dispensing.

12. Medicines Reconciliation
The point of this is to show that you as commisioniners should know where your local trust score with Meds rec rates. NICE says MR as defined by the IHI is the process of identifying an accurate list of a person meds, comparing them with current use, reconginsing discrpenacies and documenting changes. Organisations hould make sure that meds rec is carried out by a trained and competant helath care professiona ieally a pharmacist, pharmacy tech, nurse or doc

13. Medicines Reconciliation
The point of this is to show that you as commisioniners should know where your local trust score with Meds rec rates. NICE says MR as defined by the IHI is the process of identifying an accurate list of a person meds, comparing them with current use, reconginsing discrpenacies and documenting changes. Organisations hould make sure that meds rec is carried out by a trained and competant helath care professiona ieally a pharmacist, pharmacy tech, nurse or doc

14. NHS Safety Thermometer

15. Medication safety – a reporting culture

16. Medication safety – improving harm free care

17. Use of services known to increase adherence to medicines
MEDICINES DON’T WORK IN PEOPLE THAT DON’T TAKE THEM!
NMS demonstrated a 10% increase in adherence rates compared to the control. Why would you not increase this???
We have good links to LPC.

18. Use of services known to increase adherence to medicines
NMS demonstrated a 10% increase in adherence rates compared to the control. Why would you not increase this???
We have good links to LPC.

19. Use of services known to support patients in their medicines taking

20. Use of services known to support patients in their medicines taking

21. Access to Summary Care Record
May be Hampshire Healthcare record???

22. Prescribing of antibacterials

23. Use of antibiotics known to increase the risk of C. Diff by CCG

24. Adoption of NICE approved medicines
Need to get the fundamentals right to create the space for this. I believe that if our practices used the tools suggested and the CPCF more they could increase the adoption of NICE approved meds,

25. So what’s the answer? There isn’t one - There are lots
PRACTICE PHARMACISTS?
CCGs and CSUs role in making sure GP practices are aware of PINCER, PRIMIS etc
Joining up the system - refer to Pharmacy, Discharge MURs, NMS
Greater use of the Community Pharmacy Services already available
Patient awareness of the services they should expect as routine
Use of the STOPP START tool to reduce inappropriate polypharmacy

26. and finally.. Data is key to all of this.
Eventually if we don’t put all this in place we wont have the assurance that medicines are being used well, so investment in new medicines that help patients will be much riskier. This is unfair to patients who could benefit those medicines.
Or if we do get it right, we can be assured that patients will use medicines well and therefore the price tag becomes less of a focus.