Meeting: Governing Body (Meeting in Public) Meeting Date 22 May 2019 Action Approve Item No. 6 Confidential No Title Over the Counter Medications for minor short term conditions Presented By Howard Hughes, Clinical Board Member Author Salina Callighan, Head of Medicines Optimisation Clinical Lead Nigget Saleem, Clinical Cabinet Lead-Medicines Optimisation Executive Summary In March 2018, NHS England issued guidance to CCGs: ‘Conditions for which over the counter items should not routinely be prescribed in primary care’. In December 2018 the Greater Manchester Medicines Management Group (GMMMG) Clinical Standards Board (CSB) approved a GM commissioning statement (appendix 1) to promote consistent adoption and implementation of the NHS England guidance across Greater Manchester. In February 2019, the Clinical Cabinet: Considered the GM commissioning statement and approved the adoption of the GM position which would supersede the local Prescribing for Clinical Need policy. Approved a local engagement process. A four week engagement period in relation to conditions for which over the counter items should not routinely be prescribed ran from Friday 15th March until Friday 12th April 2019. This paper summarises the findings of the feedback report ‘Engagement: Conditions for which over the counter items should not routinely be prescribed’ and makes recommendations to the Governing Body, for the full report see appendix 2. Recommendations It is recommended that the Governing Body: Consider the local engagement feedback report. Support Clinical Cabinet’s decision to align Bury’s current Prescribing for Clinical Need policy with the GM commissioning statement and commitment to support local clinicians to implement this policy. Links to CCG Strategic Objectives To encourage people so that they want to, and do, take responsibility for their own health and well-being. ☒ To drive and support system wide transformation. ☐ To commission joined-up health and social care for people in Bury through a ☐ Single Commissioning Framework. To achieve financial sustainability for the Bury health and social care economy. ☒ To support the Locality Care Alliance to deliver high quality services in line with ☐ commissioner intentions. To be a high-performing, well-run and respected organisation with an empowered ☐ workforce Does this report seek to address any of the risks included on the Governing Body Assurance Framework? If yes, state which risk below: [Insert Risk Number and Detail Here] GBAF Implications Are there any quality, safeguarding or Yes ☒ No ☐ N/A ☐ patient experience implications? Patients may be reluctant to self-care. It is a longer term strategic objective to change patients’ hearts and minds. Safeguarding and patient experience will be considered following the engagement. Has any engagement (clinical, stakeholder or public/patient) been undertaken in Yes ☒ No ☐ N/A ☐ relation to this report? A four week engagement period ran from Friday 15th March until Friday 12th April 2019. Have any departments/organisations who Yes ☒ No ☐ N/A ☐ will be affected been consulted? Clinical leads (Clinical Director and Clinical Cabinet Lead-Medicines Optimisation). Communications and Engagement Lead. Please note this proposal reflects a policy already in place in Bury since 2015. Are there any conflicts of interest arising from the proposal or decision being Yes ☐ No ☒ N/A ☐ requested? Are there any financial Implications? Yes ☒ No ☐ N/A ☐ Has an Equality, Privacy or Quality Impact Yes ☒ No ☐ N/A ☐ Assessment been completed? Is an Equality, Privacy or Quality Impact Yes ☐ No ☐ N/A ☒ Assessment required? Are there any associated risks including Yes ☒ No ☐ N/A ☐ Conflicts of Interest? Potentially, reputational risk if Bury does not align with the GM position and retains a slightly different policy and exceptions. Are the risks on the CCG’s risk register? Yes ☐ No ☐ N/A ☒ Governance and Reporting Meeting Date Outcome Clinical 06/02/2019 DC/03/06/02/19: Supported the GM commissioning statement in Appendix 1. Cabinet DC/04/06/02/19: Approved that a local engagement process be undertaken and the use of common implementation tools and communication materials. Over the Counter Medications for minor short term conditions 1. Introduction and Background 1.1 On 29th March 2018, NHS England (NHSE) issued guidance to CCGs describing 2 drug groups of limited clinical value and 35 conditions which are considered to be self-limiting and therefore suitable for patient self-care. Key themes are: encouraging self-care; stopping prescribing of drugs of limited clinical effectiveness and; where drugs are available over the counter (OTC) for the treatment of minor conditions, these should not routinely be prescribed. The guidance is condition–based i.e. it is treatment of the conditions listed which may be suitable for self-care. 1.2 In August 2018 the Greater Manchester Medicines Management Group (GMMMG) Clinical Standards Board (CSB) approved a proposal that CCGs implement the NHSE guidance. CCG Medicines Optimisation leads expressed a desire for a GM approach and subsequently a ‘commissioning statement’ (similar to an Effective Use of Resources commissioning statement) was drawn up and approved at the December 2018 CSB. “For equity of patient experience, this is strongly recommended to be adopted across all GM CCGs, with an intention to engage CCG Communications and Engagement Leads and those at the Health and Social Care Partnership in the delivery of a GM-wide approach to implementation”. 1.3 NHS Bury CCG introduced the Medicines Optimisation Prescribing for Clinical Need policy in September 2015, which was actively implemented during 2016. This policy differs marginally from the GM commissioning statement in the following areas: Conditions included in the Bury policy Scabies; vaginal thrush but not included in the GM statement Conditions included in the GM Haemorrhoids; mild cystitis; contact statement but not in the Bury policy dermatitis; hyperhidrosis; infrequent constipation; infrequent migraine; minor burns and scalds; oral thrush; ringworm; travel sickness; fungal nail infection The GM statement also includes ‘exclusion criteria’ (in line with the NHSE guidance) which will require further definition. The Bury policy does not include exclusions other than those related to the OTC licensing restrictions of certain products. 1.4 A period of engagement ran from Friday 15th March until Friday 12th April 2019, to gather views on the proposed changes i.e. where the commissioning statement differs from our existing Prescribing for Clinical Need policy. 2. Summary of the Feedback report. Engagement: Conditions for which over the counter items should not routinely be prescribed 2.1 Summary of feedback: There were 262 responses to the survey, from patients and health professionals. There was a good amount of support for the approach (current local policy and the current proposal, though feedback that the current policy isn’t consistently applied) to ensure that NHS monies are only spent on medicines that are safe, clinically effective and provide a clear health benefit, to free up resources to be spent elsewhere to improve health in Bury. Despite not being included in new guidance and some concerns including affordability and the about the risk of scabies spreading, the majority of respondents agreed with the intention to retain scabies and vaginal thrush in our local policy as conditions for which over the counter items should not routinely be prescribed. In relation to the 11 conditions included in the new guidance that are not currently included in our local policy, there was support for this change to the local policy, however, there were concerns about affordability, eligibility, self-diagnosis/mis-diagnosis and potential complications if conditions aren’t treated appropriately. There was also concern that vulnerable individuals, people on a low income (affordability), children and those living with a long term condition may be disadvantaged by the approach. 2.2 Through the engagement approach, we tried to provide assurance that whilst our local policy includes a wide range of conditions for which over the counter items for minor conditions are not routinely prescribed by Bury GPs, if it is felt there are exceptional circumstances, the decision will always remain with the prescribing clinician. 2.3 Feedback included “Information and education would be needed to support people to make a decision on when to self-care and when to make an appointment”. CCG will utilise the implementation tools and communications materials developed for GM to support consistency of message to patients and other stakeholders. 2.4 There was a suggestion for the changes to made on a trial basis to assess the impact before full roll out. With this approach Bury would not support a GM wide position. This may negatively affect patient experience, adherence to the policy and ability to positively promote self-care. 2.5 A suggestion to re-evaluate the minor ailment scheme was made. Bury commissions a Greater Manchester Minor Ailment Scheme, and will work to ensure it supports decisions made at a local level. 3. Next steps 3.1 Align Bury’s current Prescribing for Clinical Need policy with the GM commissioning statement as outlines in 1.3 3.2 Where appropriate CCG utilises the implementation tools and communications materials developed for GM to support consistency of message to patients and other stakeholders. 4 Recommendations 4.1 Support Clinical Cabinet’s decision to align Bury’s