Agenda Item No: 13 Date of Meeting: 28th January 2016 Governing Body Meeting in Public Paper Title: Prescribing Report Decision Discussion Information Follow up from last meeting Sue Russell – Lead Pharmacist, Pharmacy & Medicines Report author: Optimisation Team (PMOT), East & North Hertfordshire CCG Pauline Walton- AD of Pharmacy & Meds Optimisation. Dr Ash Shah (Lead GP for Medicines Optimisation) Report signed off by: Harper Brown (Director of Commissioning) Purpose of the paper: To inform the Governing Body of: the financial position of ENHCCG practices against their respective budgets at October 2015. progress against the local medicines optimisation agenda to date of meeting. Appendix 1a, b– Locality-level Prescribing Report to Board: These present an overall summary of all the key performance indicators and QIPP projects related to prescribing at year-end including GP prescribing costs, ScriptSwitch® activity, and Prescribing Key Performance Indicators (KPIs) including anti-bacterials usage. (Each element is available to practice level to support local monitoring, and this data is shared with each Locality and practice prescribing lead by their Pharmaceutical Adviser regularly throughout the year). Dr Shah is a partner in Wrafton House Surgery, Welwyn & Conflicts of Interest Hatfield Locality. involved: Recommendations to the To note the financial position at October 2015 Board / Committee (prescribing) & December (oxygen), and the work undertaken to date this year by practices & PMOT. 1 Prescribing Report Meeting Date 28th January 2016 1. Purpose of the Paper 1.1 The prescribing finance, performance and pharmacy & medicines optimisation report for East & North Hertfordshire CCG is presented, using October 2015 ePACT Data, December 2015 oxygen data (CCG level only), and December 2015 ScriptSwitch® (SS) information. The report includes activity within the Pharmacy & Medicines Optimisation Team. 2. Terms / Acronyms Used in this Report not otherwise defined Initials In full PMOT Pharmacy & Medicines Optimisation Team of CCG HCT Hertfordshire Community Trust HVCCG Herts Valleys CCG HMMC Hertfordshire Medicines Management Committee HPFT Hertfordshire Partnership Foundation Trust QIPP Quality, Innovation, Productivity and Prevention initiatives PCMMG Primary Care Medicines Management Group NHSE NHS England UTI Urinary Tract Infection KPI Key Performance Indicator A & E Accident and Emergency Department 3. Executive Summary At October 2015 the CCG shows an overspend against its prescribing allocation of £607,991 (0.8%). This is an improvement on earlier months of 2015-16The rate of growth overall in spend (4.25%) is still above that nationally which is at 3.66% and the increase in item numbers is being analysed. The domiciliary oxygen budget is forecasted to underspend by approximately. £11K. Practice progress against prescribing KPIs remains encouraging across the board. The CCG and all Localities have either achieved target thresholds or shown improvement towards them. The period since the last report in September 2015 has seen a considerable number of PMOT initiatives in respect of promoting antimicrobial stewardship. Data is included showing the successful widespread uptake of the community pharmacy emergency medicine supply service as part of winter resilience. Engagement with secondary care continues including senior pharmacist support for the integrated care programme board agenda. The decisions of HMMC from July & September have been ratified by Governing Body workshops. A timeline has been agreed to streamline the process to bring these decisions to the board in a more co-ordinated and timely fashion allowing PCMMG comments where appropriate. An update on potential resource and clinical risk areas is given. 4. Risks & Mitigating Actions 4.1 Primary Care Prescribing Expenditure As at October 2015 ENHCCG had spent £46,824,981and the forecast spend for the year after adjustments is £77,059,930. This predicts a forecast overspend of +£607,991 on primary care prescribing. Prescription items numbers were up by 1.99% in the period April to October. Although our number of items per 1000 ASO-PUs has increased to almost the national average, our cost per item is almost 7% lower than the national average item cost. Forecast annual growth in spend is 4.25%, but national growth is currently only 3.66% so PMOT continues to work on understanding this difference. Early indications appear to suggest that this may be due to volume of prescribed items. The biggest individual growth in cost was for the oral anticoagulants apixaban and 2 rivaroxaban. Forecast increased spend for the category this year is +£600K. Overall growth in the year to October 2015 for newer anti-diabetic medicines was £430K (+27% on comparative period to 2014. It is anticipated that cost pressures will ease in Q4 as the Department of Health has reduced the price payable for category M drugs in order to recover an overpayment nationally to community pharmacists of £45m.This is estimated to be approximately £430k for EN Herts CCG. 4.2 Domiciliary Oxygen There is currently a forecast underspend of approximately £11,000 on the oxygen budget as we move into the coldest winter months when respiratory problems peak. All CCGs across England procured Home Oxygen services on a regional basis under a National Framework Agreement put in place by the Department of Health. The East of England contract is with BOC and is for a 5-year period. It began September 2011 and expires September 2016. A process of re-procurement is complete and the subject of a separate paper for this meeting. 4.3 ScriptSwitch® electronic messages at the point of prescribing Only 3 practices do not have ScriptSwitch® currently. This decision support software profile is shared with HVCCG. Different CCG prescribing priorities can be problematic. This has been raised with colleagues to ensure messages are clearer. 4.4 KPIs Appendix 1b sets out Locality performance against the five key prescribing metrics agreed by PCMMG in June. Two are carried over from last year, with another new financially-driven KPI. Two KPIs are related to antimicrobial prescribing and are based on the targets set for the CCG to achieve part of the Quality Premium payment for 2015-16. At October the CCG is still on target against these. Progress continues to be made on the other KPIs. All Localities discuss performance as a standing item at their Prescribing Forums, sharing tips and ideas. The savings possible from the brand-switch to a more cost-effective budesonide/formoterol combination are only slowly being realised. However PMOT identified another savings opportunity with the launch of a generic fluticasone/salmeterol combination in the summer which has the potential to generate savings whilst also not meaning a change of device for the patient to use. This switch is being focussed on preferentially by some practices instead. 4.5 Community Pharmacy Local Community Pharmacies have been administering flu vaccines under the national scheme for eligible patients since October. The scheme runs until February 29th. The CCG commissioned a local service for the Emergency NHS Supply of Regular Medication as part of winter resilience projects. This has been running since November 1st 2015. Key outputs to date: Most requests received on Saturdays & Mondays 44 Pharmacies including eight 100-hour pharmacies have made supplies to 589 patients 6.9% (n = 43) were referrals from NHS 111 62% (n = 385) were patient requests direct to pharmacy 29% supplies to patients >75 years Most supplied medicine (4.8%) – Ventolin 100micrograms/dose Evohaler Top 3 supplies per practice: The Medical Centre Buntingford, 45 (7.3%), 2. The Nevells Road Surgery, Letchworth 39 (6.3%), 3. Potterells Medical Centre, North Mymms 38 (6.1%) In absence of the service patients reported that they would have: • Gone without medication (42.4%) • Contacted GP practice (34.5%) • Contacted the Out of Hours service/NHS 111 (13.7%) • Visited A&E (3.8%) • Visited an urgent care centre or walk-in centre (3.1%) • Other (2.5%) 4.6 ‘Specials’ – medicinal products produced to order and/or unlicensed products 3 Prescribing costs of ‘specials’ continue to decrease, with a 27% drop to the end of Q2 of over £142K compared to the same period in 2014/15. This was the highest reduction in our demographic cluster (defined by NHSE ‘Commissioning for Value’) and ENHCCG is in the bottom (best) quartile nationally for ‘specials’ spend which reflects the continued work PMOT undertakes to support patient safety and reduce costs. 4.7 Improving Prescribing of Antibacterials (‘Antimicrobials Stewardship’) including self- care Most practices have submitted their first UTI audit and action plan as part of the enhanced commissioning framework. Practices are now starting to submit their 2nd set of audit data. The CCG remains ‘green’ for both of the Antibiotic quality premium targets. Latest data available from NHSE validates that produced in-house, & shows that total antibiotic prescribing for ENHCCG has a value of 1.162 items/STAR PU. This is a decrease from September 2015 and below the target of 1.185 set for the CCG. Broad spectrum antibiotic prescribing shows a value of 8.3% items out of total prescribing, which is the same value as September but below the target of 11.3% set for the CCG in order to receive the payment. Prescribing data is distributed to all practices on a regular basis and discussed at locality medicines optimisation meetings. Latest data (October 2015) shows on a