1. The future for prescribing of medicines & products with low/no clinical value
Introduction- whilst we are focussing on stopping the prescribing of medicines and prescribable products with low/ clinical value, we will also be looking at those medicines and products which although they have a demonstrable clinical effect they cost far more when prescribed on prescription- these are readily available from pharmacies and homecare stores/ supermarkets.

2. What do we mean by no or low clinical value ?
Did you know?
Dudley CCG spends over £1.8M on medicines that
have no or limited clinical value
Explain national figures and that painkillers are readily available in homecare stores and supermarkets, many painkillers are not intended for long term use
No clinical value- no proven benefit
Limited clinical value- some benefit in some types of patients
That is equivalent to about 75 community nurses
We have been working with NHS Clinical Commissioners at a national level to raise this issue and some of you will have seen the recent press
We want to use this time to get you as prescribers to contribute to the consultation on the introduction of a policy on the prescribing of products of no/ limited clinical value
Up to 22million prescriptions a year are being written for painkillers by GPs, costing clinical commissioning groups more than £80m. That is the equivalent of 58p for a pack that can cost 14p in shops.
See link

3. Match up the picture cards to the amount spent in Dudley in
Table Top Exercise:
Match up the picture cards to the amount spent in Dudley in
We need to talk about the implications of these efficiency savings at a national level and that this is one of a few initiatives we will be looking at to improve efficiency in prescribing, the other is in waste reduction and repeat prescribing

4. Answers Table Top Exercise:
Drug/product
Cost £
Dental items
14,758.08
glucosamine
1,634.06
lutein vitamins
1,356.85
omega 3 fish oils
25,437.86
Probiotics
1,595.85
Rubefacients
27,795.78
Sunscreen
1,695.80
Travel vaccines
41,849.15
Vaniqua
15,622.09
vitamins
825,263.30
Paracetamol
373,276.13
Ibuprofen
62,168.56

5. Background
Dudley CCG spends more than £1.8M on prescribing medicines & products which are of no or limited clinical value
The CCG is exploring with the public, GP and other stakeholders a policy which would stop this waste
12 week public consultation from the 1st February 2017 to the 24th April 2017
The CCG has estimated financial savings from this initiative of at least £1.1M which would go towards the efficiency saving required to be made for 2017/18
We need to talk about the implications of these efficiency savings at a national level and that this is one of a few initiatives we will be looking at to improve efficiency in prescribing, the other is in waste reduction and repeat prescribing
We spend in excess of 1.8M on such products
Back in September we started work with neighbouring CCGs in the STP- Walsall, Wolves and Sandwell to scope introducing such a policy, at the same time Duncan has been working with NHS CC on developing this policy at a national level
We decided that we wanted to consult with the public and so have worked with our comms team at the CCG to have a full public consultation
We expect that we could save at least 1.1M over the course of this new financial year

6. What are we proposing?
The prescribing of medicines & products of no or low clinical value is stopped
Patients on medicines classed as not suitable for routine prescribing will be reviewed and no new patient started on them
Patients will be supported to understand more about their medicines and to make choices about prevention, self-care and healthy living, where possible being directed to Community Pharmacy who can provide advice on medicines and supply either over the counter or via the Minor Ailments Scheme
It becomes routine practice to signpost patients to further help with their medicines and to local patient support groups
The CCG prescribing budget is utilised on evidence based medicines and interventions.

7. CCG Overview
Some practices may already be doing this to some degree, and the need/ dependence for accessing such products varies considerably across the localities and practices within the CCG- we would like to standardise this approach where possible
Actually the data show that the some of the more affluent areas are prescribing more of these medicines and products- is this down to patient expectation and attitudes

8. Examples of impact Stopping the use of some products Co-proxamol
Cough mixtures
Vitamins
Restricted List
Dosulepin – No new patient
Paracetamol – restricted volume
Hand out list of drugs and draw some examples
Co-proxamol
This product was withdrawn from the market in 2005 due to safety concerns.
Cough Mixture
These products have no clinical evidence of effectiveness.
 They over limited relief from the symptoms of a minor ailment and are available to purchase over the counter.
Vitamins
People may choose to take these supplements and vitamins as a lifestyle choice. The health benefits can be found from dietary adjustments.
Restricted List
Dosulepin
It should only be prescribed inline with NICE guidelines (NICE CG90.24).
New patients should not be started on this drug as it has risks of cardiac arrest.
Paracetamol
Paracetamol on prescription for short term use is not a good use of NHS resources. Many patients are prescribed paracetamol regularly for long term pain management and this is a recognised therapeutic and cost effective choice.

9. Myth Busting
We are not preventing the prescribing of medicines where there is clinical evidence for their use
We are not disproportionally impacting on patients in less affluent areas
We are not reducing access to medicines for minor ailments - we will be encouraging patients to think about self care
This will not happen over night
No decision will be made without a clinical review at patient level
Your health care professional will continue to be responsible for clinical decisions about your care including prescribing
This is not a ‘banned ‘list
Actually the data show that the more affluent areas are prescribing more of these medicines and products

10. Is Dudley CCG a lone voice?
As described work at national level through the NHS CC has raised the profile of our consultation, there has been some challenge – interestingly most of this challenge so far has been from Coeliac UK
If this piece of work is done at a national level this could release £400M which could be reinvested in other high priority areas, e.g. this is equivalent to the Cancer drugs fund
With this in mind, this is timely – we need to be honest with the population
We have a good opportunity to take this forward
Other CCGs in the STP and nationwide are looking at this topic, come have/ haven’t done a public consultation

11. What of our contracts and ethics?
Legal opinion broadly supportive
Central work stream with NHS England, GMC and others

12. Identity and accountability
Good Medical Practice (2013, updated 2014) (‘GMP’) describes what is expected of all doctors registered with the General Medical Council (‘GMC’).
GMP states that in providing clinical care all doctors must provide effective treatments based on the best available evidence.
It doesn’t say how…

13. Identity and accountability
This guidance should be read with the GMC’s explanatory guidance, in particular Good Practice in Prescribing and Managing Medicines and Devices (updated 2013) (‘GPPMMD’).
Paragraph 4 states ‘Prescribing’ is used to describe many related activities, including supply of prescription only medicines, prescribing, medicines, devices and dressings on the NHS, and advising patients on the purchase of over the counter medicines and other remedies.[Emphasis added].
Paragraph 27 reads ‘It is sometimes difficult, because of time pressures, to give patients as much information as you or they would like.
To help with this, you should consider the role that other members of the healthcare team, including pharmacists, might play.
Pharmacists can undertake medicine reviews, explain how to take medicines and offer advice on interactions and side effects.
You should work with pharmacists in your organisation and/or locality to avoid the risks of overburdening or confusing patients with excessive or inconsistent information.
Prescribing- includes supply , writing a prescription and providing advice which includes signposting

14. Who have we Consulted with?
Various Practice PPGs
Each CCG Locality
DPMA
Healthcare Forum
Health Overview and Scrutiny Committee
Health and Well Being Board
General Public
Neighbouring CCGs (STP approach)
NHSE and NHS Clinical Commissioners
You, our GP members
Over the last 12 weeks we have consulted with a range of individuals, groups etc…
This has included online questionnaire- obviously some of this is restrictive to those who are able to/ choose to access and participate however on the whole this has been positive

15. Findings from the consultation so far
Overwhelming support form organisations, groups and committees consulted
304 responses to the online questionnaire
Respondents felt that directing patients to community pharmacy would free up valuable GP time which they were in favour of
Clinician support for the general principles
Support for communications to be shared with schools and nurseries who can align policies accordingly
Support for publicity campaign once the Policy is finalised and ready to be rolled out
Support for further development of the community pharmacy minor ailments scheme
Support from DWMHPT and DGH so far!!!!
Impacts- Many of those who have responded so far to the consultation are expecting this initiative to free up general practice resources and NHS funds to manage patients more effectively, thus having a positive impact on both themselves and the healthcare system. The positive impacts most widely reported are improved access and freeing up valuable NHS money.
The most common concerns received so far have been about the impact on accessing minor ailments services by those on low incomes, at the moment the current NHSE minor ailments scheme is restrictive and hasn’t been publicised widely

16. Key issues raised through the consultation- so far
What happens when minor ailments become chronic?
What about prescribing for palliative care?
Where and how do community pharmacies fit in to the MCP model?
What if some GP Practices don’t follow the policy?
How do we reach the public who don’t have access to the internet or haven’t attended the engagement events?
What about me???

17. How can I find out more? http://www.dudleyccg.nhs.uk/pharmacyconsult/
Read our information leaflet available in your GP practice
Complete survey

18. Table top exercise
Completing the Survey

19. Next steps…
Once views have been sought, these will be taken to the prescribing Sub Committee in May who decide on the best policy for Dudley and how this will be implemented
This paper will include an impact assessment on all the options being proposed
Once a decision has been made on the outcome this will be published on the CCG website, newsletters and GP Practices- only when published will implementation start!
Resources will be available to support these messages
We will work with members of the public to develop any public information on any changes- Communications Team will lead this
Essential there is a unified message and GPs don’t go off and do their own thing

20. Table discussions How should we approach the self-care agenda?
How should we avoid penalising those with low income?
What support will you need to make this happen?
What will be the implementation challenges for GPs?
Essential there is a unified message and GPs don’t go off and do their own thing

21. Challenges for General Practice in implementing this Policy
Table top exercise
Challenges for General Practice in implementing this Policy

22. What support does General Practice need to make this happen?
Table top exercise
What support does General Practice need to make this happen?

23. Questions
Thank you expand
Support
Survey
Fortunate position