1. The Specials Trajectory Richard Jones, Head of Medicines Management Team & Accountable Officer for Controlled Drugs 8 th February 2011 12/13/20151

2. NHS Spend - historic  NHS Luton spend on ‘specials’ for 2009/2010 was £1,454,954.  This represents an increase of 62% in cost on 2008/2009 and a 1.3% decrease in number of items for the same time period and a variance of over £750,000 compared to SHA. Medicines Management Team 12/13/20152

3. Growth in Luton spend/National and SHA Medicines Management Team 12/13/20153

4. Total overcharge Medicines Management Team 12/13/20154

5. 5 Medicines Management Team No. of prescriptionsPercentageCostPercentage Specials with no licensed alternatives75722% £256,92024% Specials with a suitable alternative266678%£802,10276% Using such reference sources and the prescribing data for 2009-10 the following figures were derived: Note: 76% of specials cost could have been avoided.  Total cost of pharmacy overcharge: £654,050.51 (62% of total spend on specials)

6. Ongoing interventions 12/13/20156 Medicines Management Team  Practice Visits ongoing/ including nursing/care homes  NHS Pharmaceutical services Regulations 2005 – Fitness to Practice Guidance Efficiency: These grounds may be used when the inclusion of the chemist on the PCT’s pharmaceutical list could be “prejudicial to the efficiency on the service). This relates to issues of competence 9bad practice and repeated wasteful resources or actions or burdens of others in the NHS.

7. Monthly spend on specified & unspecified items Medicines Management Team 12/13/20157

8. Variance in spend to SHA Medicines Management Team 12/13/20158

9. Background  Growth in Luton spend/National and SHA  Examples of 10 most commonly prescribed  Highest charge of specials  Top 10 breakdown of community pharmacies average spend per item)  Community pharmacy charges over 12 months. Medicines Management Team 12/13/20159

10. Specials timeline  Specials QiPP Project (March 2010- Jan 2011)  NEWT guidelines - information to GP practices (April 2010)  Practice pharmacists to identify specials patients (April 2010)  Practice visits (April –May 2010)  Practice pharmacist educating GPs (May 2010)  Practice pharmacist targets high spend Good practice dissemination & ongoing practice visits (June 2010)  Nursing & care home visits (Aug 2010) Medicines Management Team 12/13/201510

11. Specials prescribing? Medicines Management Team 12/13/201511  These are unlicensed medicines which do not have a fixed tariff price an do not provide the same guarantees of effectiveness and safety as associated with licensed products. They are occasionally necessary.  NHS Luton spend on specials was £1 million in excess of expected cost in 2009-10.  April 2010 spend was £114K (before)  Significant reductions in spend and number of items prescribed has been made in recent months.  November 2011 spend was £53K (after)

12. Medicines Management Team 12/13/201512 Total Actual Cost Specials excluding unspecified cost – highest March 2010 over £120K

13. 10 most commonly prescribed - No alternative available. Medicines Management Team 12/13/201513 BNF NameTotal ItemsTotal Act Cost Tacrolimus_Liq Spec 5mg/5ml34£45,110.23 Midazolam_Liq Spec Oromucosal 10mg/ml100£37,659.15 Tetrabenazine_Liq Spec 25mg/5ml18£23,419.41 Azathioprine_Liq Spec 50mg/5ml74£20,636.72 Ergocalciferol_Soln 3,000u/ml36£16,759.39 Tacrolimus_Liq Spec 2.5mg/5ml17£15,175.59 Glycopyrronium Brom_Tab 1mg22£11,925.54 Diltiazem HCl_Crm 2%48£11,341.41 Sod Chlor_Eye Dps 5%62£10,072.51 Mag Glycerophos_Tab 97.2mg70£9,606.87

14. 10 most commonly prescribed – DID NOT need to be prescribed as specials/alternatives available Medicines Management Team 12/13/201514 BNF NameTotal ItemsTotal Act Cost Clobazam_Liq Spec 5mg/5ml93£58,790.57 Simvastatin_Liq Spec 20mg/5ml117£42,849.92 Omeprazole_Liq Spec 20mg/5ml110£42,308.16 Amisulpride_Liq Spec 25mg/5ml108£34,515.40 Melatonin_Cap 3mg214£30,461.31 Quetiapine_Liq Spec 12.5mg/5ml61£28,554.41 Gabapentin_Liq Spec 250mg/5ml18£26,037.49 Amlodipine_Liq Spec 5mg/5ml82£24,772.39 Dipyridamole_Liq Spec 100mg/5ml37£23,078.21 Clobazam_Liq Spec 10mg/5ml43£21,753.94

15. Medicines Management Team 12/13/201515 PHARMACY Average Spend per item A£1,287.34 B£1,016.69 C£872.59 D£641.56 E£638.65 F£622.56 G£548.69 H£497.67 I£465.20 J£459.61 Top 10 Community pharmacy average spend per item

16. Average Cost Average cost of special and unspecified items are £309.47 and £106.46 respectively:  Vs £8.85 - for all other items prescribed in 2009-10 (excluding specials and unspecified items)  Vs £172.68 -average cost of special in SHA  Vs £118.31 -average cost per special at most cost-effective prices Medicines Management Team 12/13/201516

17. Local interventions and timeline  Discussions with LPC  Discussions with GP practices  Sourcing different prices  Meetings with community pharmacy contractors  Discussions with hospital specialist prescribing specials Medicines Management Team 12/13/201517

18. Actual>Planned QiPP Financial savings (Month 8) Actual>Planned Reduction in Net Ingredient Costs per ASTRO PU Medicines Management Team 12/13/201518 Planned Savings for 2010/2011 Planned Savings to Date Actual Savings to Date £ 342,886£132,213£198,985

19. Luton’s success….thanks to team!! Telephone 01582 53 2114 QiPP Medicines Management Team & PBC Finance Lead Medicines Management Team 12/13/201519

20. Agenda  Background to trajectory & proposed QiPP plan.  Steep increase in growth June 2009 & Pharmacist recruited in April 2010 to tackle spend.  Action plan and Community Pharmacy visits.  Monitoring growth  Savings to date Medicines Management Team 12/13/201520