1. Supporting Realistic Medicine through the delivery of a Single National Formulary

2. Welcome

3. Today’s session
In this interactive session, delegates will take part in group discussions to consider how to implement the new approach throughout Scotland by considering current practice and what will help facilitate the roll- out of the national formulary and how it can be embedded.

4. Realistic Medicine and the development of the Scottish Formulary

5. What is Realistic Medicine?

6. Aims of Realistic Medicine

7. Benefits of the Scottish Formulary
Support the reduction of unwarranted variation in prescribing practice, reducing medicine harm and continuing to improve patient outcomes.
Help to achieve more equitable, greater value-based care so that the potential population benefit from medicines can be maximised.
Supports the principle that services and functions of the health service which can be delivered more efficiently at national level will be done on a ‘Once for Scotland’ basis

8. Current position 11

9. Defining the Scottish Formulary
How do the existing formularies describe themselves?
“list of medicines approved for local use”
“promoting high quality, safe and cost-effective prescribing”
“evidence-based formulary ”
“drug prescribing guidance”
“provide appropriate treatment for the vast majority of patients”
“a tool to assist”
“based on local expert opinion and practice”
“primary and secondary care”

10. Business As Usual Arrangements
Development approach
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Chapter
Business As Usual Arrangements
Development Process
Chapter
Groups
Evidence & Guidance
Analysis
Data
Platform IT
Comms & Engagement
SMC Decisions
Appeals Process

11. Development process 1. Preparation 2. Development 3. Peer Review
4. Completion

12. A consultant’s perspective on the Scottish Formulary

13. A national approach to realising realistic medicine in antimicrobial prescribing
Dr R. Andrew Seaton
Consultant in Infectious Diseases, NHS GGC
Chair of the Scottish Antimicrobial Prescribing Group
@raseaton66

14. SAPG INDIVIDUAL POPULATION CONSORTIUM OF EXPERTS/HB AMTs
Delivering a National Antimicrobial Stewardship Programme
INDIVIDUAL
POPULATION
OPTIMISE USE AND OUTCOME
CONSORTIUM OF EXPERTS/HB AMTs
ANTIMICROBIAL PRESCRIBING
SURVEILLANCE
QUALITY IMPROVEMENT
EDUCATION

15. ANTIMICROBIAL PRESCRIBING
SAPG
NATIONAL FORMULARY
CONSENSUS
GUIDELINES
REDUCE VARIATION
REDUCE HARM (AMR+)
& OPTIMISE OUTCOME
ANTIMICROBIAL PRESCRIBING
OPTIMISE USE AND
OUTCOME
UNNECESSARY OR REDUNDANT
REDUCE WASTE
AMR, CDI, SAB GaV
PEN ALLERGY
REDUCE HARM
PERSONALISE/ INDIVIDUALISE
RISK-BASED DECISION SUPPORT VIA MOBILE APP.

16. SAPG: Reducing Variation and Waste

17. SAPG: Reducing Harm
VoL outbreak

18. Delivering a National Antimicrobial Stewardship
SAPG
Delivering a National Antimicrobial Stewardship
Programme
NATIONAL FORMULARY
CONSENSUS
GUIDELINES
REDUCE VARIATION
REDUCE HARM (AMR+)
& OPTIMISE OUTCOME
ANTIMICROBIAL PRESCRIBING
OPTIMISE USE AND
OUTCOME
UNNECESSARY OR
REDUNDANT
REDUCE WASTE
AMR, CDI, SAB GaV
PEN ALLERGY
REDUCE HARM
PERSONALISE/ INDIVIDUALISE
RISK-BASED DECISION SUPPORT VIA MOBILE APP.

19. Advantages of a Single National Approach – Antimicrobial Perspective
SAPG - National engagement and process for change
In line with SAPG work to date
Reducing harm, waste and unnecessary variation through consensus
“Working across borders” during training
Amplifying best practice
Avoiding duplication of effort

20. Challenges of a Single National Approach – Antimicrobial Perspective
Local autonomy and cross speciality consensus
Local initiatives to enhance AMS
Contingency/flexibility/response
To supply issues
To outbreaks
To new evidence
Governance of “Business as usual”
Local responsibility for guidance

21. % commonality BNF Chapter – Formulary is not the same as guidance
NHS Board Range
96% - 97%
67% - 78%
49% - 91%
Formulary is not the same as guidance
(or practice)
Effective Prescribing &

22. Primary Care 80% of antimicrobials are prescribed within PC
PHE guidance agreed/adopted by SAPG and AMTs
De facto national consensus

23. Secondary Care SAPG guidance Variation in empirical guidance
Principles of AMS
Surgical Prophylaxis
Gent and Vanc guidance
Variation in empirical guidance
Evolved over time
Reviewed annually/2yearly by HB AMTs

25. Promotion of Gentamicin-based
Empirical Hospital Guidance
(Sepsis)

26. Preservation of our most valued agents
AMTs

27. Guideline survey May 2017 NHS HB UNDIFFERENTIATED SEPSIS GGC Gent Amox
+/- Fluclox
Lothian
Met
Lanarkshire
+/-Met
Grampian
+/- Met
Tayside
Forth Valley
Co-amox
Borders
Dumfries
Met +/- Fluclox
Highland
Fife
Ayr and Arran
Fluclox +/-Met

28. Guideline survey June 2018 NHS HB UNDIFFERENTIATED SEPSIS GGC Gent
Amox
+/- Fluclox
Lothian
Met +/- Fluclox
Lanarkshire
Met
Grampian
+/- Met
Tayside
Forth Valley
Borders
Dumfries
Highland
Fife
Ayr and Arran
Fluclox +/-Met

29. STEWARDSHIP INITIATIVES - Learning from variation to generate change

30. Guideline survey June 2018 NHS HB UROSEPSIS GGC Gent Amox Lothian
Lanarkshire
Grampian
Tayside
Forth Valley
Borders
Dumfries
Highland
Fife
Ayr and Arran

31. Guideline survey June 2018 NHS HB CONSENSUS INTRA-ABDOMINAL SEPSIS
CNS INFECTION
SEVERE CAP
ASP PNEUMONIA
NON-SEVERE HAP
SEVERE HAP
IECOPD
LOWER UTI
NON SEVERE CELLULITIS
SEVERE CELLULITIS

32. Other considerations in national guidance in antimicrobial prescribing
Restricted/Protected status of antimicrobials:
Consensus
Duration of therapy:
Some minimal variation
IV to Oral Switch Therapy (IVOST):
Work ongoing
Approach to penicillin allergy:
National work underway

33. Penicillin Allergy De-labelling
10% of inpatients “labelled”
Mislabelling in c. 80% + associated with increased Rx cost, admission length, AMR and poorer outcomes
Teicoplanin 17 xs increased risk of anaphylaxis cf other antibiotics
De-labelling complicated

34. Single (Scottish) National Formulary Infections Chapter
Phase 1:
Primary care (80% of antibiotic prescribing) – SAPG/AMTs
Are we there already?
HIV (HIV leads group, Rak Nandwani)
HCV (National group, John Dillon)
Phase 2:
Hospital prescribing – SAPG/AMTs

35. Conclusions SAPG provides a national framework for AMS
Excellent engagement with board AMTs
Work programme is aligned to Realistic Medicine
Consensus in best prescribing practice in both primary and secondary care is fundamental to reducing waste, harm and unnecessary variation in practice
Good progress to date towards these goals
Needs flexibility and ability to respond to emerging challenges

36. Acknowledgements SAPG SNF Group
Health Boards Busi Mooka (Tay) , Ursula Altmeyer (A&A), Anne Duguid (Borders), Bryan Marshall (D&G), Niketa Platt (Fife), Robbie Weir (FV), Sandy Mackenzie (Gramp), Brian Jones (GGC), Gail Haddock (Highland), Adam Brown (Highland), Stephanie Dundas (Lanark), Morgan Evans (Lothian),
Professional Groups: Anne Thomson (National Prescribing Adviser group), Suzanne Clark (Public Partner), Mairi MacLeod (SMVN) Jacqueline Sneddon (SAPG) and Deirdre O’Driscoll (IPCN),

37. A GP’s perspective on the Scottish Formulary

45. Group discussions

46. 19 20 21 18 17 14 15 16 22 23 28 29 30 27 26 24 25 12 13 4 5 2 1
End 6 3 10 7 9 11 8
Group discussions
Time remaining:
People
Promotion
Processes
Patients
Minutes
Which roles within your Board should we be directly communicating with regarding the implementation of the Scottish Formulary?
(prioritise your suggestions)
Which communication methods should be utilised when engaging with Board colleagues around implementation?
(prioritise your suggestions)
Which existing processes within your Board should we be considering as part of the implementation plans?
(consider what happens now and what processes you feel will change when the Scottish Formulary is introduced)
What do you feel are the key points to be considered in communications with patients around the Scottish Formulary?
(prioritise your suggestions)

47. Feedback from group discussions

48. Thank you for your contribution Keep up to date at: http://www