1. Improving prescribing quality Richard Seal Programme Director National collaborative medicines management services programme

2. Every system is perfectly designed to get the results it achieves ! Don Berwick, Institute for Healthcare Improvement

3. Unwanted medicines ?

4. Unwanted effects !

5. Brain-shakers  The majority of your problems derive from your systems, processes and methods, not from the workers  Changing the system will change what people do, changing what people do will not change the system  The majority of changes in organisations have nothing to do with improvement

6. Quality in prescribing ?

7. Prescribing with EASE  E ffectiveness  A ppropriateness  S afety  E conomy Parish PA Drug prescribing – the concern of all J Roy Soc Health 1973;4:213-217

8. Looking at it another way Respecting Patient Choices Minimising Cost Minimising risk Maximising benefit Barber N What constitutes good prescribing ? BMJ 1995;310:923-925 (8 April)

9. Problems with prescribing Inefficient management systems Inappropriate variation Irregular review Knowledge of the evidence Risks vs benefits Lack of patient involvement in decision-making Medication errors

10. What’s a collaborative ? “A proven improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common goal.”  …hence it is not  a research project  a passive exercise

11. The collaborative programme

12. Key elements of a collaborative  Challenging aims  Identifying and sharing ideas which lead to successful changes  Testing and refining small changes  Measuring progress  Implementing and sustaining change found to work

13. Goal and aims “…optimise prescribing and improve health outcomes and patient experiences, where medicines are involved” –Identify and address unmet pharmaceutical need –Help patients get more help with their medicines, thereby achieving real improvements in health –Improve efficiency and reduce waste –Better access to a range of medicines management services which make better use of skills of pharmacists

14. Collaborative Structure Each organisation will work towards the collaborative objectives by developing and implementing their own locally acceptable models of work ‘EXPERT’ Panel 0 4 1 to 3 Report & Rollout Five Learning Sessions Local Actions Local Actions Local Prep Support from core team

15. 3 waves of activity Wave 1 site Wave 2 site  Wave 3 site London Region

16. Improvement measures  Improvement not performance management  Reflect improvement activities in a number of areas  Teams develop additional local measures  4 practice level –Polypharmacy (med reviews from wave 2), equivalence and compliance, safety, satisfaction  3 PCT level –Med review in NH, VFM & health improvement, discharge,

17. Practice level Collected monthly from the 5 practices initially involved in the programme

18. Wave 1 -Average number of repeat items in over 65s on 4 or more

19. Wave 2 - % over 65s with documented medication review in past 12 months

20. % scripts each month where not all regular items are requested

21. % scripts leaving surgery without specific dose instructions

22. % patients experiencing problems with repeat medicines

23. PCT level Collected monthly from practices across the PCT

24. % nursing home residents with documented med review in past 12 months

25. Receipt of discharge info for 90% of patients before next request for medicines

26. Areas of improvement activity General Practice Community Pharmacy PCT Repeat prescribing processes Medication review Drug monitoring Practice staff empowerment Telephone consultations Medicines managers Incentivised medicines management Formulary development Practice-based pharmacists HIMP & NSF priorities Care home services Interface issues Multidisciplinary teams Patient involvement Workshops Prescription interventions Medication review Minor ailments Services to practices Enhanced DUMP campaigns Patient education Case-finding

27. What next  Range of spread activities –Regional events and networks –Partnership working  Wave 4 planning  Evaluation  Identification of key improvements for roll-out –Medication review –Prescription intervention schemes –Minor ailment schemes –Repeat prescribing systems –Medicines management in NSFs

28. Things to think about  All improvements require change but not all changes lead to improvement  Changes travel through conversation and interaction between trusted peers  Ideas that spread more rapidly –Relative advantage – “better than it is now” –Compatible with existing beliefs and values –Simple to understand and implement –Easily tested before committing fully –Observable difference

29. Final thought “Great discoveries and improvements invariably involve the co-operation of many minds” Alexander Graham Bell