1. Basildon and Brentwood CCG Prescribing Meeting
Whitmore Suite, Orsett Hall
22nd February 2017
Working for a better NHS for everyone

2. Agenda 12.15pm Buffet and Registration
13.00pm Welcome and Introductions Jonathan Andrews/Denise Rabbette
13.05pm Prescribing Update Jonathan Andrews
13.50pm Update on dietetic prescribing Judith Harding
14:15pm Medicines Management Current Issues Denise Rabbette
14.45pm Prescribing Incentive Scheme Jonathan Andrews
14:50pm Q & A
15.00pm Close
This event is being supported by the following Pharmaceutical companies:
Chiesi Aymes Ashfield Healthcare
Takeda GlucoRx

3. BBCCG Prescribing Update
Jonathan Andrews
February 2017
Working for a better NHS for everyone

4. Financial Performance December 2016
Prescribing Budget is £ million Forecast outturn is £ million Underspend is £532k QIPP projecting £1.6 million savings

7. BBCCG Prescribing Gain Share
Proportion of underspend shared with practices
Scheme is in addition to Prescribing Quality Incentive Scheme
CCG has significant underspend
80% of practices underspent

8. BBCCG Prescribing Gain Share
Prescribing gain share to continue in 2017/18? – comments welcome
Further information can be requested from

9. Prescribing Incentive Scheme 2016/17
% alogliptin – target 50% (template available) Branded ICS/LABA – target 90% ScriptSwitch uptake – target 45% Outstanding audits – support still available via

11. Prescribe ICS/LABA inhalers by brand name
Generic name
Branded products to prescribe
Fluticasone/Salmeterol Inhaler 500/50mcg
Seretide 500 Accuhaler or AirFluSal Forspiro 50/500mcg
Fluticasone/Salmeterol Inhaler 250/50mcg
Seretide 250 Accuhaler
Fluticasone/Salmeterol Inhaler 100/50mcg
Seretide 100 Accuhaler
Fluticasone/Salmeterol Inhaler 250/25mcg
Seretide 250 Evohaler or Sirdupla 25/250mcg
Fluticasone/Salmeterol Inhaler 125/25mcg
Seretide 125 Evohaler or Sirdupla 25/125mcg
Fluticasone/Salmeterol Inhaler 50/25mcg
Seretide 50 Evohaler
Budesonide/Formoterol Inhaler B/A 400/12mcg
Symbicort 400/12 Turbohaler or DuoResp Spiromax 320/9mcg
Budesonide/Formoterol Inhaler B/A 200/6mcg
Symbicort 200/6 Turbohaler or DuoResp Spiromax 160/4.5mcg
Budesonide/Formoterol Inhaler B/A 100/6mcg
Symbicort 100/6 Turbohaler
Beclometasone/Formoterol Inhaler
100/6mcg
Fostair 100/6 Inhaler
200/6mcg
Fostair 200/6 Inhaler
Beclometasone/Formoterol Breath Actuated Inhaler
Fostair 100/6 NEXThaler
Beclometasone/Formoterol Breath Actuated Inhaler 200/6mcg
Fostair 200/6 NEXThaler

13. ScriptSwitch “negative savings”
ScriptSwitch Negatives savings display because….
Unlicensed specials have no cost, so displays as Zero, making the replacement appear more costly
SystmOne, Emis, Vision and Microtest use Multilex data drug database which is not updated as fast as DM+D which is what we use
Safety switches such as diclofenac to naproxen tablets
MMT get a report of the negatives savings every month and review these
Prescribers can also feedback if unsure using the feedback button and we can double check

15. Medicines Management Committee
Updated vitamin D guidelines
Updated COPD guidelines
New drug approvals:
Toujeo®(insulin glargine 300units/ml)
Abasaglar® (insulin glargine biosimilar)
Trulicity® (dulaglutide)
NB Automatic switch away from saxagliptin

17. Requests to prescribe in primary care?
Drug
Indication
GP prescribing?
Regorafenib 160mg
Metastatic colorectal cancer
Exjade
Chronic iron overload
CBD patch
Fibromyalgia
Entresto
Heart failure
Etilefrine
Priapism in sickle cell disease
Linezolid
Resistant infections
Tenofovir
Chronic hepatitis B
Macitentan
Pulmonary Arterial Hypertension
Drugs for fertility
IVF
Apixaban
AF (in patient on dialysis)
Mexiletine
Muscle stiffness in Myotonia Congenita
Trimetazidine
Stable angina, vertigo

18. Requests to prescribe in primary care?
Check traffic lights
Check ScriptSwitch
Contact Medicines Management Team
If already prescribing, please do not stop prescribing if on “red list”
Standard letter available shortly

19. Respiratory Guidelines
Basildon Hospital reviewing prescribing of Seretide
For patients identified as using an unlicensed Seretide Evohaler and Seretide Accuhaler for COPD, the following switch is being undertaken
Seretide 250 Evohaler, 2puffs BD Fostair 100/6, 2puffs BD
Seretide 500 Accuhaler, 1 puff BD Fostair 100/6, 2puffs BD

21. Guidelines for the Management of COPD
Treatment choices: adapted from GOLD ABCD assessment (2017 Report)
-Initiation and escalation of treatment based on symptoms (mMRC and CAT) and risk of exacerbations. mMRC-Modified British Medical Research Council dyspnoea scale. CAT- COPD Assessment Tool.
-Patients can start in any group, and change between groups, therefore regular assessment required.
SABA-short acting β2 agonist. SAMA-short acting anti-muscarinic antagonist. LABA-long acting β2 agonist. LAMA-long acting muscarinic antagonist. ICS-inhaled corticosteroid. Continue SABA in each group.
Patient Group
Risk and symptoms
Symptoms
Exacerbation history (in last 12 months)
Initial treatment
Further treatment
Comments
CAT score
mMRC A
Less symptoms
Low risk
<10
0-1
0-1 (not leading to hospital admission)
SABA (or SAMA)
LAMA or LABA B
More symptoms
≥10 ≥2
LAMA (or LABA)
Persistent symptoms:
LAMA + LABA C
High risk
≥2 or ≥1 leading to hospital admission
Further exacerbations:
Or LABA + ICS, but ICS increases risk of pneumonia D
Further exacerbations: LABA + LAMA + ICS
Or switch to LABA + ICS, but no evidence of better prevention of exacerbations
SABA
SAMA
LAMA
LABA
LAMA+LABA
LABA+ICS
First choice inhaler
Salbutamol MDI 100 mcg
1-2 puffs up to QDS PRN
Ipratropium MDI
20 mcg
Aclidinium bromide (Eklira Genuair) 322mcg (DPI)
1 puff BD
Formoterol Easyhaler 12 mcg (DPI)
Duaklir Genuair (formoterol/
aclidinium) 340/12mcg (DPI)
Fostair 100/6 MDI or Fostair NEXThaler (beclometasone/
formoterol)
2 puffs BD
Second choice inhaler
Salbutamol 100mcg Easyhaler 1-2 puffs up to QDS PRN
Tiotropium (Spiriva) Respimat 2.5mcg
2 puffs OD
Relvar Ellipta 92/22mcg
1 puff OD
Prescribe inhalers by brand name to ensure device continuity.

22. Antimicrobial stewardship
Appropriate antibiotic prescribing in primary care is a CCG priority
Monthly Rag reports
Further resources available at:
Volume of prescribing is a CCG Quality Premium for 2016/17 and 2017/18

25. Antimicrobial stewardship. NHSE Quality Premium 2017/18
CCG targets are as follows:
10% reduction (or greater) in the Trimethoprim: Nitrofurantoin prescribing ratio based on CCG baseline data (June15-May16) for 2017/18.
a 10% reduction (or greater) in the number of trimethoprim items prescribed to patients aged 70 years or greater on baseline data (June 15-May 16) for 2017/18.
items per STAR-PU must be equal to or below England 2013/14 mean performance value of items per STAR-PU.
NB Guidance around treatment of UTI currently being reviewed locally.

26. Controlled Drugs Many responsibilities transferred to CCG including:
1) Witnessing destruction of expired stock
2) Monitoring (quantities especially)
3) Investigations
Policy recently circulated and on website:
NB all CD incidents must be reported to:

27. Travel vaccines
Hepatitis B vaccine should not be prescribed on FP10 prescription for travel purposes.
Prescribing of combined Hepatitis A & B is not supported by BBCCG & TCCG for patients travelling abroad
Hepatitis A single vaccine can be
provided on the NHS, with hepatitis B
being funded privately for patients
requiring both vaccines for travel
purposes

28. Paracetamol
Paracetamol should not be routinely prescribed for short term use, packs of 32 or less are readily available to purchase.
Regular prescriptions of paracetamol for the treatment of long term conditions should be reviewed and large quantities of tablets/capsules/suspension should be discouraged.
The use of paracetamol in care homes should be prescribed on a when required basis rather than regularly.
If a liquid formulation is needed the 250mg/5ml strength of paracetamol is prescribed or the soluble tablets. The use of paracetamol 500mg/5ml oral suspension or solution is
not licensed for use in children, and not recommended for
for routine use in adults for cost effective reasons.

29. Summary ICS/LABA combinations
Prescribe 90% by brand by end of March 2017
Gliptins
Prescribe 50% as alogliptin by end March 2017
Other Incentive Scheme audits
Complete by end March 2017
Require support to do audits?
Contact
Unusual requests to prescribe?
Check traffic lights/ discuss with MMT
Prescription clerk training event
Ask prescription clerks for subject ideas
Travel vaccines
No Hep B, or combined Hep A/B for travel
Controlled drugs
Report incidents to
Review quantities prescribed
Paracetamol
Review quantities of paracetamol
Antimicrobial Stewardship
Access PrescQIPP resources/ webinars

30. Update on dietetic prescribing
Judith Harding
Dietetic Prescribing Advisor
22 February 2017
Working for a better NHS for everyone

31. Gluten free prescribing
Update on dietetic prescribing
Judith Harding
22 February 2017
on dietetic prescribing
Judith Harding
22 February 2017

32. Lactose intolerance (page 11)
FOR PURCHASE NOT PRESCRIPTION - Lactose free formula from supermarket - Over 1 year – Lactofree full fat milk from supermarket

33. GORD (page 9-10)
FOR PURCHASE NOT PRESCRIPTION Anti-reflux formula from supermarket or pharmacy Thickener, Carobel from pharmacy Supermarket Pharmacy

35. Post discharge pre-term formula
Nutriprem SMA Gold Pro Prem Please prescribe powders NOT liquids Please stop at 26 weeks corrected age at the latest

36. CMPA – Similac Alimentum £9.10p Adult ONS – Aymes Shake 61p
First line names to remember!
CMPA – Similac Alimentum £9.10p Adult ONS – Aymes Shake 61p

37. Working for a better NHS for everyone

38. Current Issues BTUH commissioning issues PbR excluded drugs Tadalafil
Liothyronine
NOACs/warfarin
Shared care
Other commissioning issues (NELFT, PH and gender dysphoria)
Any others?

39. BTUH commissioning arrangements

40. HCD and PbR excluded drugs

41. Policies/Guidelines Informed by….

42. Drugs for erectile dysfunction

44. Progress so far……

45. Liothyronine Liothyronine 20mcg costs £258.20 for 28 tablets
Not recommended for routine use as insufficient evidence for combination therapy superiority over L-T4 alone(British Thyroid Association)
Subset who may benefit from a trial – Endocrinologist initiated and reviewed after 3/12
BTA stated that there is no convincing evidence for LT-3 monotherapy, Armour Thyroid etc

46. Liothyronine continued

48. Liothyronine items Jan – Dec 16

49. NOACs/Warfarin

52. Key issues

53. In practice…..

54. Shared Care

55. Other commissioning issues

56. Prescribing Incentive Scheme 15/16
All claims must be processed by 31st March 2017 in order to receive payment of the award.  If the practice is unsure of the value of the outstanding award or how to claim the award, please contact Leigh Ann Paterson for further information: or

57. Medicines Management Webpage
The Medicines Management Webpage is available at:

58. Medicines Management Contact Details
Medicines Management Team
Civic Offices
2nd Floor
New Road
Grays
RM17 6SL
Tel:
Fax: