National Do Once Programme – Making national PGDs a reality Tracy Rogers

Key Drivers Carter 1 report recommendations based around efficiency and productivity Carter 2 report: Recommendation 11 – Medicines and Pharmacy Optimisation states: NHS England’s Specialist Pharmacy Services and the regional medicines optimisation committees developing a national ‘do once’ system for organisational medicines governance, including national standardised medicines policies, patient group directions and other essential organisational governance documents during 2018/19. Medicines Value Programme Carter 1 set the scene for improving both efficiency and productivity across NHS acute hospitals Carter 2 report builds on Carter 1 work and recommends that is an opportunity to improve both efficiency and productivity in the NHS by standardising the development and distribution of PGDs, medicines policies and other essential organisational governance documents across NHS organisations. Thus, a ‘do once’ approach to develop quality assured PGDs and essential medicines governance documents which are adopted and authorised locally has been proposed. This would release significant local resource to be redeployed on optimising outcomes from medicines use. Change is essential to support and deliver the Medicines Value Program, so we can improve health outcomes from medicines and ensure we are getting the best value from the NHS medicines bill.

Experience from Practice PHE immunisation PGD templates – introduced in 2013 Pan-London initiative – standardisation of PGDs for sexual health services Specialist Pharmacy Service scoping exercise of PGDs used for administration/supply of antimicrobials So why do we need to do this? and how do we know that a do-once system can lead to delivering on the recommendation in Carter 2 report? Firstly the PHE immunisation PGD templates have been used now since 2013. The concept has been established and the PGDs have been widely adopted Secondly the pan-London initiative produced PGD templates for sexual health services and found that standardisation provides a consistent and high standard of care no matter where a patient presents. These templates have been in place for several years for Trusts within London to adopt and have been well received. No longer funded so no longer updated. SPS undertook a scoping exercise earlier this year – looking at the provision of antimicrobial therapy across acute, community and mental health trusts.

Background to abx PGD scoping Scoping exercise undertaken to explore the extent to which PGDs are used to supply antimicrobials within NHS services and determine whether there are areas of duplication that would meet the principles of operational productivity and performance in the NHS. Requests made to 44 NHS organisations between November 2017 and February 2018 – spread of organisation type and geography. 22 organisations responded (acute, community and mental health trusts), 18 of whom used antimicrobial PGDs submitting a total of 199 PGDs. Keep in mind what NICE say about abx and PGDs…. 4

Variation There was significant variation in the quality of PGDs across the organisations in the cohort. Examples included: a single PGD for the supply and administration of ‘sexual health medication’ to treat multiple clinical conditions. a PGD for multiple treatments is not in line with NICE guidance. incomplete information relating to the antimicrobial agent such as strength and quantity to supply. inclusion criteria made reference to internal organisation guidelines and therefore relied on the guidelines and PGD being updated simultaneously.

Duplication Across the responding 18 Trusts who had antimicrobial PGDs there were 199 PGDs for provision of antimicrobial therapy. By removing duplication this could be reduced to 33. Highlights the significant operational burden of PGDs.

Standardisation of PGDs – the options Three options outlined in the report: Option 1 - do nothing Option 2 - develop a repository of quality assured example PGDs that are made available to organisations via the SPS website Option 3 – develop national PGD to standardise treatment and practice in line with national guidance. Report published before Carter 2 report – option 3 reflects Carter recommendations

Progress to date Paper to RMOC to agree the governance structure The MGDO Secretariat is accountable to the RMOC who will approve all output prior to release. Initial focus PGDs PGDs will be developed by Short Life Working Groups (SLWG) made up of nationally recognised subject matter experts (SMEs) What have we done so far? Carter 2 came out in May We have established the Medicines Governance Do Once (MGDO) Secretariat and submitted a paper to the RMOC to agree the governance process. That Paper was shared with the programme for today This secretariat provides the oversight for the whole project and is made up of SPS and NHS Improvement. It is the group that will ensure the programme is delivered We have based our governance processes on those used by PHE, so have benefitted from their learning. In year 1 of the 3 year programme we will initially focus on PGDs as we believe that this is the area where we can have the biggest impact in improving efficiency and productivity. We, SPS, are not the clinical experts and we need the PGDs to be developed in Short life working groups which have the Subject matter experts, and those working in the clinical environment in which the PGD will be used in.

Governance Structure This Governance structure is shown pictorially The PGD Service Board which is already in existence will give support on matters of policy/regulation/legislation etc and consists of stakeholders such a CQC, MHRA, NICE PHE, DHSC

Work Plan Look at areas where PGDs are not required: Supply of medicines that are GSL Administration of GSL and P medicines Schedule 19 exemptions Schedule 17 exemptions for healthcare professionals Initially the focus will be: Ambulance trusts Antimicrobials Sexual health/family planning In year 2 – medicines policies One of the first things we want to do is look at supporting organisations to remove unnecessary PGDs and will develop tools to enable this. Why these 3 areas: Ambulance trusts had indicated that they wanted to work together on PGDs. The amount of professional pharmaceutical advice to these organisations is minute and PGD development takes a disproportionate amount of this resource. There are only 10 ambulance trusts who are used to working together through the medical directors NASMeD and they have over-arching clinical advice from JRCALC. They have all agreed to work with us and we have made significant progress. Antimicrobials – we have started the work, based on our scoping work we identified a need, but we have found it challenging. The sexual health/family planning PGDs will build on the PAN London work and our only limitation at the moment is capacity

How will it work? (1) Call for existing PGDs MGDO secretariat produce first draft of national PGD from examples shared Full SLWG consultation (largely remote communication envisaged). SLWG made up of SMEs (recognised national clinical leaders and full stakeholder engagement) Comments collated by MGDO secretariat We will put out a call for existing PGDs We are going to call in all the good practice that is out there and from those produce a first draft of the examples shared in the national template. We will then conduct a full consultation with the SLWG using email The SLWG needs the appropriate clinical personnel around the virtual table. We will then collate all the comments www.sps.nhs.uk

How will it work? (2) Comments reviewed by core members (doctor, pharmacist and healthcare professional working under PGD appointed by SLWG), changes agreed and made by MGDO secretariat Repeat (Where consensus is not obtained this is reported to the full SLWG) PGD clinical content signed by core members Within each SLWG there will be 3 core members (doctor pharmacist and paramedic. Please note that is not an SPS pharmacist) who discuss and agree which changes should be made and we SPS make the changes Then we repeat, and aim for consensus. The PGD clinical content is signed by the core members. It is then locked and no changes can be made by organisations. www.sps.nhs.uk

How will it work? (3) MGDO secretariat ensure documentation of process, legal requirements and agreement of SLWG PGD submitted to RMOC for ratification PGD published on SPS website and other appropriate portals PGD authorised by individual trusts. Legal requirement (HMR 2012). We will then submit for ratification. We will then publish on our website and other appropriate portals For example for the ambulance trusts the PGDs will go on the JRCALC app The PGDs will need to be authorised by individual ambulance trusts as this is a legal requirement within the regulations www.sps.nhs.uk

Benefits? Deliver consistent care across England Reduce variability in PGDs Reflect national guidance Deliver increased organisational capacity Release significant local resource to be redeployed on optimising outcomes from medicines use Support organisational Governance arrangements What are the benefits? Consistency Reduced variability Alignment with national guidance Increase organisational capacity Release local resources to work on other medicines optimisation areas Support ambulance trust organisational governance arrangements www.sps.nhs.uk

Constraints? The programme will not develop PGDs for everything Local PGDs may still be necessary It will take time to develop national PGDs What are the constraints? www.sps.nhs.uk

Summary National ‘do once’ system Standardise PGDs and medicines policies SLWG with SMEs Collaborative programme with all stakeholders Release resource for other medicines optimisation activities Not the end of local PGDs