Given the rising cost of medicines as a share of the NHS budget in England, the establishment of ICSs provides a timely opportunity to take stock on delivering medicines optimisation at local level, learning from the prior expertise of clinical commissioning groups. Ellen Rule provides insight from her new report, co-authored with the NHS Confederation’s Senior Policy Advisor, Edward Jones
Medicines optimisation aims to improve health outcomes, service quality, and sustainability by ensuring patients are taking their prescribed medicines as recommended to derive the intended benefits and avoid incurring harms. As the most common healthcare intervention in the world - and the one with the greatest risk of avoidable harm - optimising medicines usage is a priority to improving healthcare. However, with medicines spending consuming a significant share of the overall NHS budget in England, it is also vital to the sustainability of the health service.
A changing healthcare landscape
Since their inception in 2013, clinical commissioning groups (CCGs) have led medicines optimisation efforts at local level. With statutory integrated care systems (ICSs) taking over these functions, there is an opportunity to galvanise medicines optimisation efforts, taking advantage of the deepening of integration and collaboration that ‘system-working’ facilitates.
This is important work given the scale of the challenge. Half of all UK adults take at least one prescribed medicine and 30 to 50 per cent of the medicines prescribed for long-term conditions are not taken as intended. Between 5 and 10 per cent of all hospital admissions are medicines-related and around two-thirds of these are preventable.
While data can be improved to account for confidential discounts negotiated with industry, current data suggests that medicines are the second highest cost to the NHS after staff.
Based on the expertise of stakeholders across the healthcare system involved in medicines optimisation – from commissioners to primary, community and acute providers – the report I’ve co-authored, published by NHS Clinical Commissioners, which is part of the NHS Confederation, sets out recommendations across five areas to enable the systemisation of medicines optimisation: workforce, governance, national leadership, pathways and technology.
Building a ‘one medicines team’
The NHS is its people and the success of medicines optimisation efforts in systems depends on local teams working together effectively: medicines are everyone’s business as an integral component of many patient pathways. Building a ‘one medicines team’ requires workforce development across community pharmacists, PCN pharmacists, acute pharmacists, as well as all those engaged in prescribing and closest to patients taking medicines.
The successful systematisation of medicines optimisation can improve both the quality of care and the sustainable use of NHS resources
Some ICSs have set up local pharmacy workforce development groups, developing shared goals, relationships, rotations and cross-setting career pathways. In Sussex, for example, ICS, CCGs and primary care networks support care home staff to deliver medicines optimisation in care homes. This has improved residents’ medicines usage and released savings to be re-invested in patient care.
Local medicines teams stressed the opportunities of giving systems greater agency to build their own, locally tailored medicines optimisation strategies. Medicines are a cross-cutting function and need leadership within ICSs, with clear accountability at board-level, carrying on CCGs’ valuable work. In line with the NHS Long Term Plan, systems should be the nucleus for tailored medicines optimisation strategies to advance national goals, with tactics adapted to local needs at place-level.
But in some areas of prescribing national leadership is needed to accelerate and support local systems’ medicines optimisation efforts. Promoting automatic substitution of, for example, biosimilars on formularies and registers could accelerate conversion to use of biosimilars, releasing significant financial savings.
Enhancing patient pathways
Medicines are a core component of patient pathways. Ensuring medicines are prescribed at the optimal point and in the optimal setting, can improve patient outcomes and reduce medicines wastage. Systematisation provides an opportunity to review where medicines can be most effectively prescribed to optimise the use of those medicines.
In my own ICS in Gloucestershire, we identified significant challenges for people living with dependence medicines (similar to the challenges highlighted in Public Health England’s review on ‘dependence medicines’) and set out to co-design and implement our ‘Living Well with Pain’ Programme with our local community. This has changed the way people with persistent pain are supported through a whole-system pathway transformation approach, resulting in measurable morphine prescribing improvements, with significant financial savings.
Technology can also join up and improve services. The Royal Devon and Exeter NHS Trust has used electronic medical records to document and share medicines decisions with GP practices and community pharmacies. Better sharing of information has enabled acute, community and general practice pharmacy teams to communicate directly to manage patients’ care in the community after discharge, which may lead to reduced re-admissions.
Meanwhile, Derby and Derbyshire CCG’s Appliance Project has improved the prescribing of stoma and continence appliances. By extending their Medicines Order Line and auditing to devices, more patients are getting the right devices at the optimal time, reducing waste and improving patient experience – one patient described it as the “best service the NHS has offered yet”.
The successful systematisation of medicines optimisation can improve both the quality of care and the sustainable use of NHS resources. However, this will require effective approaches at national, systems and place levels – as well as patience. April 2022 is the start, not the end of the systematisation journey. It will still take three to five years to deliver real benefits for population health, clinical quality and value. We hope our report will give ICSs a roadmap to realising those benefits.
Ellen Rule is director of transformation and service redesign at NHS Gloucestershire CCG and the Gloucestershire ICS programme director.
This blog was first published in pharmaphorum.