Supporting Realistic Medicine through the delivery of a Single National Formulary

Welcome

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.

Realistic Medicine and the development of the Scottish Formulary

What is Realistic Medicine?

Aims of Realistic Medicine

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

Current position 11

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”

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

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

A consultant’s perspective on the Scottish Formulary

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

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

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.

SAPG: Reducing Variation and Waste

SAPG: Reducing Harm VoL outbreak

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.

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

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

% 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 &

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

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

Promotion of Gentamicin-based Empirical Hospital Guidance (Sepsis)

Preservation of our most valued agents AMTs

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

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

STEWARDSHIP INITIATIVES - Learning from variation to generate change

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

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

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

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

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

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

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),

A GP’s perspective on the Scottish Formulary

Group discussions

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)

Feedback from group discussions

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