Final Evaluation Report for Stort Valley and Villages (SVV) Locality In-Practice Pharmacist (IPP) Project: 1 year pilot June 2013 – June 2014

Executive Summary (unless specified savings are annualised)  Potential savings identified to date: £136,615  Current cost savings to date: £93,995  All GP Practices actively engaged with the project and the IPP regularly (usually weekly) attended all practices in the course of the year  Processes to agree and approve practice workload were established and reviewed during course of the year to address specific practice needs  Regular activity reports prepared and reviewed with prescribing leads  More prompt and tailored handling of individual patient prescribing queries facilitated by regular access to patient records  1201 quality/safety activities/ financial interventions made in the practices Summary Practice based pharmacist schemes have a history of improving practice prescribing activity. Transformational funding was agreed for acquiring an in-practice pharmacist for an initial 1 year project to assist in the delivery of medicines optimisation for the 5 GP practices in the SVV locality. The surgeries were supported by a 0.53 wte dedicated IPP who started on 11th June 2013. The IPP had senior support from the Hertfordshire Pharmacy & Medicines Optimisation Team (PMOT).

The first priority was to establish effective working practices with each of the five practices and agree immediate priorities for practice work encompassing cost effective prescribing, robust governance on prescribing processes and improved efficiency.

Practice priorities were identified based on:  Actions identified in the practice prescribing MOT reports  Achievement levels of 2013/14 prescribing Key Performance Indicators (KPIs)  Locality productivity and governance opportunities

At June 2014, direct forecast annualised cost savings achieved by the project (before cost of IPP post) was £93,995 – or 69% of the identified potential annualised cost savings of £136,615. Of the forecast cost savings £51,641were realised within the period June 2013 – June 2014.

Expected outcomes of scheme:

1. Financial & Productivity

Produced by Hertfordshire Pharmacy and Medicines Optimisation Team Hertfordshire, Bedfordshire and Luton Commissioning Support NHS Central Eastern Commissioning Support Unit Page 1 of 7  Support practices to implement cost effective prescribing and to a minimum deliver sufficient demonstrable savings to cover the costs of the service  Support practices/the locality in controlling prescribing spend  Improve practice achievement of medicines related KPIs, QIPP, QoF targets

2. Quality/Safety  Realise medicines optimisation opportunities and optimise prescribing choices within practices  Improve efficiency in prescribing processes/systems to reduce practice workload/increase capacity and reduce waste  Improve knowledge and understanding of practice staff and their contribution to increasing quality and safe medicines use

3. Innovation  Develop a model of in-practice pharmacist support to co-ordinate and deliver medicines optimisation activities within GP practices

4. Prevention  Improved medicines optimisation activities to reduce the number of prescribing errors, reduce the number of medicines related incidents, improve patient outcomes and reduce hospital admissions

Progress Update

1. Financial & Productivity

Support practices to implement cost effective prescribing

Total Direct Cost Savings from June 2013 to January 2014

SVV Central Church Much Parsonage South St Hadham Street Potential £136615 £23991 £12135 £40881 £7827 £51781 annualise d savings to date * Actual £93995 £21642 £10950 £21655 £3532 £36216 realised annualise d savings to date Realised 69% 90% 90% 53% 45% 70% as % of potential

*Includes potential cost saving i.e. those in the ‘system’, identified and awaiting action by the GP

Work has been initiated in the following areas to address cost effective prescribing objectives:  Dutasteride switch to finasteride

Produced by Hertfordshire Pharmacy and Medicines Optimisation Team Hertfordshire, Bedfordshire and Luton Commissioning Support NHS Central Eastern Commissioning Support Unit Page 2 of 7  Tadalafil switch to sildenafil  Pregabalin dose optimisation  Pregabalin use review  Opioid patches use review  Improving generic prescribing rates  Review of infant formula  Quetiapine MR  Omeprazole 40mg  Venlafaxine MR  Emollient prescribing  BGTS preferred choice

In the course of the year, ensuring the prompt actioning of the recommended switches was a priority for the IPP. Whilst clinical governance dictates that the final decision to switch patients must be approved by a relevant GP the IPP has taken steps to ensure that all approved recommendations are actioned in a more timely manner, thus releasing the maximum financial benefit within the prescribing budget:  Results of monthly monitoring on actual numbers of patients switched are discussed with individual practice prescribing leads and at locality medicines management meeting.  Individual prescribers are advised that, where appropriate, the default position will be that the switch will be adopted on an agreed date unless patient identified as not suitable  Increased familiarity of prescribers with the work of the IPP has resulted in more timely responses to requests to consider switch  IPP allocating necessary time to complete the switch. Although this is labour intensive it has ensured that the work is completed in a timely manner.  Utlising appropriate practice admin resource to carry out associated admin tasks eg patient letters

Improve practice achievement of CCG medicines-related KPIs, QIPP, QOF targets There has been a significant uplift in achievement of both KPIs targeted for additional in- practice pharmacist support in most recent data points:

Rolling 3 months comparing July 2013 to March 2014 KPI 1 Finasteride KPI 2 Sildenafil Practice Threshold Achievement Achievement Threshold Achievement Achievement % July 2013 % March 2014 % July 2013 % March 2014 % %

Central >=94.82 58.47 91.3 >=67.07 56.72 61.4

Church >=94.82 52.56 95.4 >=67.07 40.00 54 Street Much >=94.82 73.28 86.5 >=67.07 26.44 65.4 Hadham Parsonage >=94.82 75.31 97.5 >=67.07 65.38 73.9

South >=94.82 56.51 95.5 >=67.07 60.22 76.7 Street

Produced by Hertfordshire Pharmacy and Medicines Optimisation Team Hertfordshire, Bedfordshire and Luton Commissioning Support NHS Central Eastern Commissioning Support Unit Page 3 of 7 2. Quality/ Safety Optimisation of prescribing choices within SVV GP practices To date, 1201 patient medication records have been reviewed for medicines optimisation opportunities across the 5 practices. The interventions are predominantly the identification of more cost effective prescribing choices but also include patients on medications subject to recent safety alerts and patients on medications where a more appropriate alternative is available.

Total Interventions made from June 2013 to June 2014

No. of No of potential medication No of potential switch Dates quality/safety records interventions identified interventions identified reviewed June 2103 – June 1201 635 566 2104

 Attendance at the practices on a weekly basis has resulted in increased opportunities to address specific prescribing queries from a range of practice staff. The average rate of enquiry is approximately 8/week, across the locality. This is in addition to the enquiries that are handled by the SVV Pharmaceutical Advisor.  In the course of the year there has been a significant increase in queries relating to the prescribing of drugs based on the recommendation of hospital specialists. In conjunction with the SVV Pharmaceutical Advisor and with reference to the outputs of HMMC the IPP has been able to support prescribers in successfully challenging the use of:  Daily tadalafil for LUTS  Compression garments for lymphoedema  Unlicensed use of drugs  NOACs in AF  Timely actioning of individual patient recommendations from the High Cost Drugs and Specials reports provided by the SVV Pharmaceutical Advisor has resulted the identification of patients’ medications suitable for switching to a licensed/more cost effective option. Specific examples are outlined in the practice reports.

Improve efficiency in prescribing processes and reduce waste Work in the following areas has been initiated across all 5 practices with the objective of realising improvements in efficiency, governance and waste reduction. A lead practice was identified to assist with the development of robust procedures and subsequent roll- out across the locality has been taking place.

Repeat Dispensing – ‘RD’ Objective: To produce a robust practice protocol for future use and increase the number of appropriate patients offered the scheme

Produced by Hertfordshire Pharmacy and Medicines Optimisation Team Hertfordshire, Bedfordshire and Luton Commissioning Support NHS Central Eastern Commissioning Support Unit Page 4 of 7  Revised in-practice protocol written compatible with EMIS Web/SystemOne documents  Search criteria developed to identification of target population for service offering. Established rolling programme of targets to achieve 20-30 new patients a month for consideration  Meetings and practice documents used to communicate with GPs, practice staff and community pharmacy o Central Surgery – currently approximately 20 new patients per month being started on RD o Parsonage - RD flags created on 189 patient records. Prescribing and admin staff briefed on how to address alert o South Street – RD flags created on 300 patient records. Prescribing and admin staff briefed on how to address alert

Repeat Prescribing Objective: To develop a robust practice protocol for all stages of the repeat prescribing process, including medication review  An audit of current repeat prescribing and medication reviews has been carried out in 4 of the SVV practices to identify: o Areas for improvement in efficiency and clinical governance o Examples of best practice  Actions to address specific findings of audit have been developed in conjunction with practice staff  Revised processes in all practices now utilise the functionality of GP computer systems to ensure: o Improve efficiency of communication between practice staff o Improve audit trail of decisions and actions for individual patients

Prescribing of stoma/catheter appliances Objective: To produce a revised practice protocol for the processing of appliance repeat script requests that ensures appropriate clinical review of requests and identification of potential over-ordering issues  Revised in-practice protocol for stoma and catheter appliance prescribing developed in conjunction with practice staff, nurse specialist, community nursing team and patients for adaptation and use in SVV practices  Roll out meetings held in all SVV practices to update prescribing and admin staff. Patients and dispensing contractors notified of change  National audits suggest anticipated saving from reduced wastage approximately 10% of total appliance spend  Example of best practice – South Street Surgery: o Following completion of process practice have appointed a lead administrator and nurse prescriber to ensure review and monitoring of appliance scripts takes place in a timely manner and improved patient contact. o IPP review of prescribing of non-essential items on repeat realised estimated cost saving £300 per annum  SVV work has highlighted a significant issue with community nurse requests for catheter products. IPP requested that PMOT work with HCT colleagues to identify more appropriate system.

Produced by Hertfordshire Pharmacy and Medicines Optimisation Team Hertfordshire, Bedfordshire and Luton Commissioning Support NHS Central Eastern Commissioning Support Unit Page 5 of 7 Monitored Dosage Systems Objectives: To ensure that practices and community pharmacies are operating a consistent protocol for approving requests for monitored dosage systems & to ensure that all new requests are assessed against best practice guidance.  All practices notified of current guidance on when 7 day prescribing is appropriate. Information also circulated to all locality based community pharmacies.

Adherence to local medicines management guidance The practices were supported on a weekly basis to more effectively implement local medicines management decisions. This is particularly challenging for the locality as the majority of patients attend non-Hertfordshire Trusts – Princess Alexandra Hospital, Addenbrookes. Prescribing recommendations from West Essex and Cambridge are not always consistent with decisions from HMMC/PCMMG. The work to address these issues is a combined effort from the IPP, locality Pharmaceutical Advisor and Lead Commissioning Pharmaceutical Advisors. Examples of successful challenges to secondary care prescribing choices:  GP prescribing of HIV therapy  Duplicate prescribing by GP and HPFT of donepezil  Nafarelin® nasal spray for endometriosis  Dabigatran for DVT prevention  Ciclosporin eye drops  Lisdexamfetamine for eating disorders  Growth Hormone outside of shared care and funding arrangements  Daily tadalafil for LUTS  Testosterone patch for female ACTH patient  First line use of Nuvaring

3. Innovation  All SVV practices have actively engaged with the IPP during the course of the year.  Presentations by the IPP on work streams given at: o SVV TARGET day to practice and community nurses o SVV Patient liaison meeting  Regular contact throughout the year with practice prescribing leads has been carried out by face: face time, email, GP system tasks and monthly locality medicines management meetings.  A wider range of practice staff are familiar with the work of the IPP and have engaged on a weekly basis with her.

Activity Analysis (June 2013 – June 2014)

 83% of the in-practice pharmacist time has been spent on activities within the SVV GP practices or on support for SVV locality initiatives. This equates to approximately 800 hours of IPP time working in and supporting the SVV practices in the course of the year.  The remainder of the time has been used for weekly admin tasks, training or engaging with, or getting support from, the wider PMOT to address specific practice issues. Produced by Hertfordshire Pharmacy and Medicines Optimisation Team Hertfordshire, Bedfordshire and Luton Commissioning Support NHS Central Eastern Commissioning Support Unit Page 6 of 7 4. Prevention Specific activities to address the improved use of preventative medicines optimisation activities i.e. reducing the number of prescribing errors, reducing the number of medicines related incidents, improving patient outcomes and reducing hospital admissions have been initiated. Examples of audit work undertaken in support of these objectives include:  Duplicate supplies of donepezil from practice and HPFT  Elderly patients with cognitive decline prescribed oxybutynin  Co-prescribing of clopidogrel and omeprazole  First line prescribing of minocycline  Ketoconazole prescribing  Inappropriate prescribing of Ensure® oral nutritional supplements  Auditing use of medication review systems

5. Feedback from practices

A questionnaire was developed and circulated to GP prescribing leads and practice managers to provide feedback on the IPP role. 3 questionnaires were received from GP prescribing leads and 1 from a practice manager. The completed questionnaires were generally very supportive of the role and highlighted the benefits that GPs and other practice staff found the role to demonstrate.

GP prescribing lead feedback: • 100% felt benefit or significant benefit of IPP in drug switch process • 100% felt the IPP helped practice to save money • 100% agreed the practice would benefit from continued IPP support • 100% had at least fortnightly contact with IPP across a wide range of media • 100% reported <10% switched medication had to be changed back

Practice manager feedback: • No disadvantages or problems in providing the relevant space and IT access within practices • found there to be advantages of the IPP presence at practice level, and was available to staff for just the right amount of time. Comments: (GP) ‘’Excellent – has made a huge difference. I hope the role will continue’’ ‘I think this role has been very successful, as above - helped with specific queries and always came back with an answer/suggestion.’ (GP) ‘Very useful…..one of the best ways of helping practices to do safe prescribing and at the same time saves some money.’ (PM) ‘..…has been a pleasure to work with and undoubtedly has been an asset with the various projects undertaken.’

Report Prepared by Julie Sampson, Stort Valley and Villages IPP and reviewed by Colin Sach, Senior Pharmaceutical Adviser NHS & Sue Russell Lead Pharmacist NHS Central Eastern CSU

Produced by Hertfordshire Pharmacy and Medicines Optimisation Team Hertfordshire, Bedfordshire and Luton Commissioning Support NHS Central Eastern Commissioning Support Unit Page 7 of 7