Pharmacy & Medicines Optimisation Team - Supporting ENHCCG Primary Care HCPs PAULINE WALTON Assistant Director & Head of Pharmacy & Medicines Optimisation

Aim: right patients get the right choice of medicine at the right time improve their outcomes avoid taking unnecessary medicines reduce wastage of medicines improve medicines safety Ultimately medicines optimisation can help encourage patients to take ownership of their treatment.

Why medicines optimisation - 1? Medicines are the most frequent health care intervention in the NHS East and North Herts CCG’s primary care prescribing budget is £76.9M in 2015/16 (Approx 12% of the CCG’s budget) GP prescribed items growing at around 3.2% annually, nurse prescribing growing at 11% More, & more expensive drugs funded from Primary Care budget “Save to Spend”

2014/15 Spend per 1,000 ASO-Pus Localities vs CCG vs Area vs National

Why medicines optimisation - 2 ? Around 7% of all hospital admissions have been attributed to or associated with adverse drug reactions with up to 2/3 of these being preventable. Up to 50% of patients do not take their prescribed medicines as intended. Inappropriate use of antibiotics is a significant problem; implicated in C. diff and MRSA infections and increased resistance.

And that’s where we come in…

What support do we give in primary care - 1? Provide support to GPs, nurses and secondary care to ensure the safe and cost effective use of medicines to achieve value for money and improved outcomes for patients Pharmaceutical Advisors provide advice at individual practice level Locality Prescribing Forums Support ScriptSwitch© Approval of independent prescribers

What support do we give in primary care – 2? Provide professional leadership and advice to CCG on healthcare services or pathways involving medicines Support PCMMG/HMMC/Trust Formulary Committees Provide link to Community Pharmacy Services Provide link to Local Area Team (eg CDs) Provide link to NHS England Provide targeted pharmaceutical advice to intermediate care patients preventing readmission into secondary care and supporting early discharge North Herts and Stevenage based Intermediate care beds

Impact on safer prescribing - Team work in Antibiotic Prescribing

Looking forward Continued support for practices to achieve 2015/16 KPIs e.g. cost-effective blood glucose testing strips, low cost PDE5s, DuoResp prescribing Improvements and monitoring of antibiotic prescribing CCG Quality premium – total abs/restricted abs Commissioning framework 3 day prescribing in UTI Care home pharmacists and In-practice pharmacists for more Meds Optimisation.

Keeping in touch Get to know your locality Pharmaceutical Advisor Speak to any of my colleagues present today Get to know your locality Pharmaceutical Advisor Introduce Colin Sach

Local Decision Making for Medicines and Optimising Respiratory Prescribing Colin Sach Senior Pharmaceutical Adviser Pharmacy and Medicines Optimisation Team East and north herts ccg

Objectives of presentation Provide overview of local medicines decision making committee - Hertfordshire Medicines Management Committee (HMMC) Introduction to PMOT website Current methods of communication Ideas to support implementation of guidance Highlight respiratory issues, guidelines & recommendations .

HMMC Overarching medicines decision making group for both Herts CCGs Membership: GPs, consultants, pharmacists, CCG GP board members, lay representative, public health, independent pharmacologist. Providers represented: ENHT, WHHT, HCT, HPFT, RFH (BCFH) Workplan – horizon scanning for new medicines/ guidelines, QIPP initiatives, business cases: prioritise those having quality, safety, economic impact on local population Leaflets available on CCG website to explain process to patients and HCPs Primary care clinicians include a locality GP prescribing lead for each CCG and LMC representative. CONTEXT: CCGs have a statutory duty to break even; also to commission NICE technology appraisals within 3 months of publication. Other treatments need to be prioritsed according to CCG priorities and policies. NICE CGs are not mandatory for commissioning; they are best practice guidelines. The NHS Constitution for England (DH 2009, updated in 2012), defines the rights of patients to:Drugs and treatments that have been recommended by NICE, through its technology assessment process and where considered clinically necessary for the patient, in line with the criteria outlined by the NICE. To have access to local decisions on medicines (and treatments) that have not yet been considered by, or have not received a positive recommendation for use in the NHS, using a robust assessment of the best available evidence. The National Institute for Health and Care Excellence (NICE) Good practice guidance (GPG1) on developing and updating local formularies (2012), Defining guiding principles for processes supporting local decision making about medicines (2009) produced by the National Prescribing Centre and Department Of Health and the accompanying Supporting rational local decision-making about medicines (and treatments) (2009) produced by the National Prescribing Centre have all been considered in the development of the local process for decision making about medicines.

Outputs and RAG ratings Outputs include treatment guidelines & recommendations for medicines Allocated RAG (red; amber; green) rating: DOUBLE RED – Not recommended for prescribing by Secondary or Primary care RED – Not recommended for prescribing in Primary Care AMBER (with shared care) – Recommended for initiation by Secondary care specialists and continuation in Primary care GREEN – Recommended for prescribing; Primary or Secondary care initiation

Link to PMOT website http://www.enhertsccg.nhs.uk/local-decisions

Communication to Primary care Recommendations uploaded to CCG websites Summary and links emailed to locality PhAds for onward dissemination to GP Prescribing Leads Email to Practice Managers for circulation in practice Messages added to ScriptSwitch© by PMOT Recommendation spreadsheet emailed to community pharmacists

Verbal communication & peer discussion Discussed with locality GP Prescribing Leads, PhAds, LPC at PCMMG Identify potential implementation issues Discussion led by PhAds at locality prescribing meetings attended by practice GP Prescribing Leads: GP Prescribing Leads feed back at practice level Involvement of nurses at prescribing meetings?

How do we improve communication and implementation? Do you receive copies of updated guidance on a regular basis? Is new guidance discussed at practice level? To what extent is new guidance implemented in practices? What are the challenges facing successful implementation? Ideas to aid implementation of recommendations? Nurse involvement with locality prescribing meetings Locality nurse forums Nurse specialist contact details Feeding back to PhAds, Prescribing Leads

Medicines Optimisation and Respiratory Prescribing Rationale for & examples of recent HMMC guidance on treating COPD and asthma Stepping down inhaled corticosteroids in asthma Seretide 250 Evohaler – review & switch algorithm DuoResp Spiromax for asthma/COPD

Why target respiratory prescribing?

Primary Care prescribing – Top 5 drugs by cost BNF Name Prescriptions/year Cost/year Seretide 94,021 £3,827,797 Enteral Nutrition 82,153 £2,342,684 Glucose Blood Testing Reagents 61,090 £1,675,672 Symbicort 40,162 £1,504,863 Tiotropium 44,719 £1,458,088 3 of the top 5 drugs by cost for both CCGs are inhalers These 3 medicines account for approximately 10% of total primary care prescribing spend (£70m) 60% of prescribing costs for Seretide are for the highest strength products (250 evohaler and 500 accuhaler) Note cannot differentiate between asthma and COPD prescribing from Epact data

Inhaler costs ICS/LABA Inhaler Dose Annual cost Seretide 250 Evohaler* Two puffs BD £725 Seretide 500 Accuhaler One inhalation BD £500 Symbicort 200/6 and 400/12 Turbohaler Two inhalations BD £460 DuoResp 160/4.5 and 320/9 Spiromax £365 Fostair 100/6 MDI £355 Flutiform 250/10 MDI* £555 The main inhalers prescribed are all relatively high cost ranging from approximately £355/year to £725/year (that’s £30-£60 per inhaler) Note cost differences between Evohaler and accuhaler devices (only accuhaler licensed for COPD) Costs are obviously higher still when combinations of inhalers are used and the cost of triple therapy can be over £1,000/year *’0ff-label’ for COPD

Seretide prescribing breakdown 50% of prescriptions and 60% of costs are for highest strength Formulation Strength Prescriptions % Prescriptions Cost % DPI (Accuhaler) 100/50 micrograms 4,417 5% £88,363 2% 250/50 micrograms 8,007 9% £312,360 8% 500/50 micrograms 18,153 21% £735,345 19% MDI (Evohaler) 50/25 micrograms 7,434 £142,573 4% 125/25 micrograms 24,544 28% £945,826 25% 250/25 micrograms 24,705 £1,603,328 42% Note cannot differentiate between asthma and COPD prescribing from Epact data

High dose Inhaled Corticosteroids – Safety Concerns Can cause local side effects eg sore throat, hoarse voice, oral thrush ↑risk non-fatal pneumonia (COPD) & T2DM may ↑ risk of fractures Prolonged use may lead to easy bruising, thinning of the skin especially in older people Rarely may temporarily reduce body’s ability to produce own steroids when under stress The systemic side effects of corticosteroids are well known. High doses of ICS are associated with clinically detectable adrenal suppression (Arch Intern Med 1999;159:941-55), increased risk of non-fatal pneumonia in patients with COPD (Arch Intern Med 2009;169:219-29), increased risk of type II diabetes (Am J Med 2010;123:10016), and may increase the risk of fractures (Thorax 2011;66:699-708) and tuberculosis (Chest 2014;145(6):1286-1297). It is recommended that all patients on high doses of ICS are made aware of the risks and given an ICS safety warning card (specific one developed.

High Dose Inhaled corticosteroids - Do the benefits outweigh the risks? COPD Appropriate for stage of disease - FEV1 ≥50% predicted - use of steroids indicated? Risks/benefits assessed if FEV1 < 50% Lower potency steroid is 1st line choice Asthma Appropriate for stage of disease – large number of asthmatics at step 4-5 of BTS asthma guidelines? Regular reviews must be undertaken to ensure the dose is indicated and stepped-down Clinical appropriateness and costs of high dose ICS Inhaled corticosteroids (ICS) are prescribed in asthma to improve control, reduce exacerbations and risk of death, and in those with severe to very severe COPD, to reduce the frequency of exacerbations. The benefits of an ICS outweigh the risks when used in clinically effective doses, however, long-term high doses (≥1000 micrograms beclometasone dipropionate (BDP) equivalent/day) may cause systemic side effects. A recent large Canadian observational study reported that taking ICS increases the risk of serious pneumonia in people with COPD and may be dose related. Study reinforces MHRA advice to be vigilant for the development of pneumonia and other lower respiratory tract infections when using LABA/ICS. A recent retrospective database analysis of 685 people with asthma in 46 GP surgeries in Scotland showed that, national guidelines were not followed. When using a combination to initiate treatment, there was widespread increase in ICS dose regardless of baseline ICS dose. If 10% of prescriptions for Seretide 250 evohaler were stepped down to a medium strength LABA/ICS or lower cost LABA/ICS savings of £50-100,000 could be realised

Respiratory Guidance – PMOT website COPD treatment Guidelines http://www.enhertsccg.nhs.uk/sites/default/files/content_files/COPD%20treatment%20flowchart%20update%20201411%28HMMC%29.pdf Seretide 250 Evohaler review and switch algorithm http://www.enhertsccg.nhs.uk/sites/default/files/content_files/Seretide%20250%20Evohaler%20%28fluticasone%20propionate-salmeterol%29%20for%20COPD%20Review%20%26%20Switch%20Algorithm%20201502%28HMMC%29.pdf Asthma Stepdown guidelines http://www.enhertsccg.nhs.uk/sites/default/files/content_files/Stepping%20Down%20Inhaled%20Corticosteroids%20%28ICS%29%20in%20Asthma%20Guidelines%20201502%28HMMC%29_0.pdf DuoResp recommendations for asthma & COPD http://www.enhertsccg.nhs.uk/sites/default/files/content_files/Budesonide%20-%20formoterol%20%28DuoResp%20Spiromax%29%20for%20asthma%20and%20COPD%20201411%28HMMC%29.pdf

Summary and key messages Familiarise yourself with local medicines guidance Local decisions/guidelines on website - summary spreadsheet Respiratory guidance Infection management guidelines Woundcare formulary Feedback on how to improve communication & successful implementation Identify potential issues/barriers Discuss with Pharmaceutical Advisor/Prescribing Lead