1. health and fitness

DRAFT FOR CONSULTATION:
MEDICINES MANAGEMENT
and
PRESCRIBING
STRATEGY
2013-2015
Date: November 2012
Review Date: January 2015
Author: Jasmeen Islam, Head of Prescribing in collaboration with Prescribing Lead GPs, Dr
Darren Jackson & Dr Liz Hepplewhite
Consultation: North Charnwood, South Charnwood, Hinckley & Bosworth and North West
Leicestershire Localities, Patient Participation Groups, Finance and Performance
Committee, Quality and Governance Committee, Chief Pharmacists at UHL and LPT
Sponsor/COO: Angela Bright
To be signed off by: WL CCG Board
1
Contents
Section
Title
Page Number
1.0
Executive Summary
1.1
Introduction
1.2
Background & Strategic Context
2.0
Current Position
3.0
Future Position
 Vision
 Goals & Objectives
3.1
Goal 1: Strategic Overview
3.2
Effective Partnerships & Engagement
3.3
Commissioning
3.4
Medicines Oversight
3.5
Medicines Expertise
3.6
Supports and Develops people
4.0
Glossary
5.0
Key References
Appendix 1
Appendix 2
Appendix 4
Appendix 5
Appendix 6
NPC CCG guide Towards Authorisation
NPC Competency framework Evaluation and action plans
Annual report from previous financial year
Draft QIPP Areas for 13/14
Horizon Scanning for Budget setting 13/14
2
1. EXECUTIVE SUMMARY
1.1 The prescribing of medicines is the most common form of therapeutic
intervention in medicine, and therefore, the quality of the prescription is the
foundation stone for high quality patient care.
1.2 Medication costs currently makes up approximately 14% of the Clinical
Commissioning Group (CCG) budget, with increased pressure on the budget due to
emerging NICE technologies and appraisals and greater emphasis to treat patients
in primary care. Last year West Leicestershire CCG delivered on the QIPP
prescribing target of £1.7 million. Over 2012/13 the target has been set as £1.2
million and practices are demonstrating ownership in striving to working towards
delivering this target.
1.3 The prescribing of medicines in primary care is one of the most powerful tools we
have available to improve the health of patients. However, armed with such potent
drugs, there is always a risk that patients will be harmed. Hence, there is also a
need to define a strategy for optimising medicines prescribing across the local health
economy to ensure that the CCG’s prescribing framework is safe, evidence based,
high quality and excellent value within the budget available.
1.4 National Recommendations are that:
a. CCGs must have medicines management expertise to optimise medicines
usage and improve patient outcomes in all the services that they commission
on behalf of patients.
b. The National Prescribing Centre (NPC) published an ‘Organisational
competency framework to ensure the effective delivery of medicines
management functions and responsibilities’ in 2011
c. The resource provides CCGs with a framework of competencies that a CCG
needs to have, or have access to, to ensure the effective delivery of
medicines management functions.
d. CCGs can use the framework to:
 Help define medicines management needs in the CCG
 Assist with recruitment and development of service specifications for
medicines management services
 Identify gaps in CCG knowledge and skills and highlight development
requirements
e. The framework identifies the six competencies necessary to deliver effective
medicines management services and outcomes for patients. The six
competencies that CCGs need to develop are:
 Has a strategic overview
3




Established effective partnerships
Commissions services that optimise the use of medicines
Provides medicines oversight
Has medicines expertise
1.5 The strategy also document covers the following areas:
1.
2.
3.
4.
Financial overview
Quality Innovation Productivity Prevention prescribing – see below
CCG Priorities including areas of quality prescribing
Goals with agreed key performance indicators (based on the above 1-5)
1.6 This document has been developed together with East Leicestershire and
Rutland and Leicester City CCGs and is underpinned by a number of key National
documents including:
 An organisational competency framework to ensure the effective delivery of
medicines management functions and responsibilities – A guide for
commissioning consortia boards. NHS National Prescribing centre. June
2011
 The NHS Outcomes framework 2012/13. Department of Health
 The Mandate. A mandate from the government to the NHS Commissioning
Board. April 2013 – March 2015. Department of Health.
4
1.7 Quality Innovation Productivity Prevention Plans
QUALITY:
INNOVATION:
Productivity:

Reducing C Difficile
 Procurement of
 Prescribing efficiencies
through antimicrobial
medicines such as
as above through
prescribing
rebate schemes,
savings built to last and
stewardship
dressings and
sustaining the QIPP
appliances
prescribing productivity
 Reducing harm
areas embedding these
associated with Non • IT systems to
inform decision
into practice.
Steroidal Anti
making and
Inflammatory Drugs
 Identify new areas for
triangulate
disease
targetted efficiencies as
 Alternatives to
management eg
in Appendix XX
antipsychotics to
Scriptswitch,
manage behaviour in
 Making the most out of
Eclipse, risk
dementia to reduce
patent expiries and
stratification tools ,
stroke, mortality and
disinvesting in
real
time
falls
medicines that show
prescribing
reduced outcomes or
 Care home
information
limited efficacy
medicines processes
• Inheriting and
/ review
 Continue with reduced
understanding
growth in unlicensed
 Reducing medicines
strategies to
specials prescribing
incidence errors and
manage
high
cost
shared learning
 Quantify where savings
non
specialist
can be made on
 Medicines
drugs
with
a
focus
hospital admissions or
reconciliation to
on anti TNfs for
outpatient appointments
reduce errors across
rheumatology
for
through investing in
transfer of care
2013/14
specific medicines.
 Using Risk
 Ensuring that
Stratification where
medicines are
prescribing budget
implicated and
requirements meet the
therefore reducing
needs of the local
associated
population
unplanned
admissions
Prevention :
 Identifying long term conditions (LTC) earlier and targeting interventions to
identify more patients with LTC to treat to prevent the long term implications
of cost pressures and to reduce long term burden of disease and disability.
 Prevention of medicines errors and preventable medicines related
admissions
5
1.8 The strategy aims to support the continuous quality improvement of prescribing
and medicines management to secure better patient outcomes.
1.9 The strategy will provide assurance to the Clinical Commissioning Group Board
and facilitate performance management of the optimal use of medicines across West
Leicestershire
1.10 The aim of the strategy is to build on the clinical leadership and engagement
between primary and secondary care over previous years by supporting prescribing
safety, NICE implementation, horizon scanning and managed entry of new
pharmaceuticals for the benefit of the West Leicestershire population.
1.11 Patients in the NHS have a right to expect that the decision to prescribe any
medicine dispensed is based on the most accurate evidence and national guidance
and that the benefits outweigh the risks.
1.12 The strategy will need to ensure innovative use of IT systems and a highly
trained and flexible medicines management support resource to be available to
engage prescribers and deliver useful information and implementation on practice
prescribing patterns to achieve cost effectiveness, safety and quality.
1.13 Strategic clinical (medical and pharmaceutical) leadership of prescribing and
medicines management should facilitate continued clinical engagement from GP
practices and secondary care so ensuring the delivery of safety, quality and
medicines optimisation across the whole patient pathway.
1.14 The strategy implementation should ensure that sufficient attention is given in
the CCG prioritisation process for financial risks of new drug developments and
NICE technology appraisals so there is timely implementation to avoid statutory risks
and reduce patient safety, quality and outcomes.
1.15 Reducing medicines related admissions should be a focus of the strategy in
particular for the next two years. Medicines optimisation should occur to support
patients post discharge and to support those patient groups at high risk of admission.
1.16 The strategy aims address the issue of improving the safety, quality and
medicines optimisation for patients in residential and nursing homes and patients
receiving carer support in their own home. Failure to address this issue carries
financial risks to prescribing and activity budgets.
6
2.0 BACKGROUND
2.1 Nationally, primary care prescribing is a high priority area in recognition of the
fact that prescriptions are the most frequent therapeutic interventions in primary
care; medication costs make up approximately 14% of Clinical Commissioning
Group (CCG) budgets and cost the NHS in England approximately £8 billion.
Furthermore, 4-5% of all hospital admissions are preventable medicines-related
admissions1.
2.2 This document details the vision and strategic plan and direction of travel for
Medicines Management (MM) which is aligned to the vision and objectives of the
West Leicestershire CCG.
2.3 West Leicestershire CCG has agreed an emerging vision which includes:
 enhancing the quality of primary care
 reducing clinical variation and
 improving use of resources.
2.4 This strategy is aimed at significantly and continuously optimising the use of
medicines to maximise patient benefits through innovative and targeted
application of pharmaceutical and commissioning capability and thus engages
stakeholders to reduce variation in prescribing quality and expenditure to
optimise evidence based prescribing.
2.5 The Strategy aligns the medicines management goals and objectives to the
six competency areas proposed in the National Prescribing Centre (NPC) guide 2
for consortia boards titled “An Organisational competency framework to ensure
the effective delivery of medicines management functions and responsibilities”.
The six areas are: Strategic Oversight, Effective Partnerships, Commissioning,
Medicines Oversight, Medicines Expertise and Supporting and Developing
People.
7
3. INTRODUCTION
3.1 Medicines management is the term used to describe the system of processes
and behaviours which determines how medicines are used by patients and the NHS.
West Leicestershire CCG currently spends approximately £48 million per annum on
primary care prescribing.
3.2 Prescribing is the most frequent therapeutic intervention in primary care and a
commissioning decision is made every time a medicine is prescribed. Medicines are
integral to the majority of clinical services and are an important part of care for the
majority of patients, being delivered by a wide range of staff.
3.3 Nationally and locally there is increased focus on areas such as minimising
patient risk, improving patient safety, reducing admissions, long term care and
improving the quality of care of patients. There is a continued focus on improving
cost effectiveness with wider consideration of overall health costs for services as well
as treatments. The CCG’s medicine management team function is to set, influence
and steer medicines commissioning decisions and implementation according to best
practice to achieve the best health outcomes for the population we serve within a
finite prescribing budget.
4. STRATEGIC CONTEXT
4.1 The NHS has been undergoing a significant evolution since 2011 which has led
to the dissolution of PCTs and SHAs and the formation of: National Commissioning
Boards (NCB) and Clinical Commissioning Groups (CCGs) which are supported by
Clinical Support Services (CSS). The CSS is commissioned across CCGs. There is
a lot of staff movement; it is yet to be ascertained what impact this will have on
Medicines Management functions and responsibilities, in particular the medicines
governance functions which is currently responsible at Cluster PCT level.
4.2 Prescribing expenditure accountability has been delegated to the emerging
CCGs with full prescribing accountability and responsibilities when they become
statutory bodies in April 2013.The CCGs will be accountable to the Local Area
Teams (LATS) of the NHSCB which is currently under development. The CCGs will
have the responsibility to provide choice and access to high quality health care for
patients and to ensure that commitments to improving health, reducing health
inequalities and providing better health services are delivered for local people. They
will also become responsible for ensuring prioritisation and value for money in ways
which have maximum impact on health.
8
4.3 This strategy has been developed to complement the West Leicestershire CCG
objectives and values. Good medicines management is essential to support the
CCG’s vision of:
Patients, Practices and Partners working together to create the best value
healthcare for West Leicestershire to
1. Improve health outcomes by responding to the needs of the population
2. Improve the quality of healthcare services in terms of clinical effectiveness,
patient safety and patient experience and ensuring all patients are treated with
dignity and respect
3. Use our resources wisely by stimulating innovation and service
transformation
Goals and objectives: Our aim is to deliver significant and continuous
improvements to the use of medicines through innovation and the targeted
application of pharmaceutical and commissioning capability
4.4 This strategy sets the vision and strategic direction of travel for Prescribing &
Medicine Management over 2 years and will be revised annually in line with national
and local priorities. It draws on several key publications relevant to medicines
management:









An Organisational competency framework to ensure the effective
delivery of medicines management functions and responsibilities2: A
guide for commissioning Consortia Boards.
The Mandate. A Mandate from the Government to the NHS
Commissioning Board: April 2013 to March 2015. Department of Health
The NHS Outcome Framework 2012/13. Department of Health
The NHS White Paper ‘Our Health Our Care Our Say’ (DoH 2006)3 aimed
at increasing patient choice, care outside hospitals and nearer to home,
resource allocation on prevention and focus on long term needs
High Quality Care For All (NHS Next Stage Review)6: supporting patients in
partnership medicines choices, clinical priority setting and standards (NICE,
NPSA), clinical evidence and best practice.
Pharmacy in England7: workforce, transfer of care, public and patient
awareness campaigns.
Moving Towards Personalising Medicines Management8 : responding to
national guidance, priorities for medicines management services,
incorporating medicines management into all services, training and education.
Health Act 2006 9: legislative duties to ensure the safe use of controlled
drugs.
Quality Commission: Essential standards of quality and safety Outcome 9
9
4.5 The annual primary care prescribing budget for WL CCG is around £50m. This
relates to around 15% of the total CCG budget. There are continued cost pressures
in prescribing, for example the advent of newer and relatively expensive drug
technologies, an increased focus on prescribing for disease prevention, and the
increasing numbers of patients with diseases identified through new services.
Published reports recommend a proactive approach to identifying new patients and
increasing prescribing for prevention.
4.6 With around 5 million prescriptions per annum there is always opportunity for
improved financial management of prescribing. Reports through the National Audit
Office and Department of Health have identified areas to improve cost effectiveness
and provide guidance. Key strategies include greater use of more cost effective
drugs (that are safe and effective), minimising drug wastage and providing more
support for patients with their medicines.
4.7 The value of unused drugs returned to community pharmacies for disposal has
been estimated to be £ 2 million per annum for this CCG. This level of drug wastage
is similar to other CCGs and in line with the national picture. Apart from the
considerable financial waste, patients who are not taking their medicines may not be
getting the best support and care that they need to prevent longer term illness.
Strategies that can address this issue include reducing medication waste through
improving medicines adherence (taking of medicines), creating better concordance
(a partnership in medicines-taking between the patient and clinician), and improving
systems for repeat prescribing.
10
5. Financial Health
5.1 Sound financial health is a key requirement for delivery against devolved
prescribing budgets and it is vital for the CCG to continue to build on previous
strategies to build on the achievements to manage prescribing resources effectively
as in previous years. The graph below illustrates that the prescribing cost per capita
across the CCG is one of the lowest in the East Midlands. With the advent of new
drugs and greater shared care arrangements of drugs to prevent hospital activity, it
is important that the prescribing budget in it’s entirety reflects the needs of the
population, whilst also ensuring that efficiencies continue to be delivered on
prescribing in key therapeutic areas where national evidence and local clinical
variation exists.
East Midlands Prescribing Costs Per Capita
Apr-12 to Sep-12
PCT NOTTINGHAM CITY
Locality North Charnwood
PCT LEICESTER CITY
Locality South Charnwood
PCT DERBY CITY
West Leicestershire CCG
PCT NORTHAMPTONSHIRE TEACHING
PCT LEICESTERSHIRE COUNTY & RUTLAND
Locality Melton Rutland Harbor
Locality Hinckley and Bosworth
East Leicestershire CCG
Locality Blaby and Lutterworth
Locality North West Leics
Locality Oadby and Wigston
EAST MIDLANDS
ENGLAND
PCT NOTTINGHAMSHIRE COUNTY TEACHING
PCT DERBYSHIRE COUNTY
PCT BASSETLAW
PCT LINCOLNSHIRE
£0 £10 £20 £30 £40 £50 £60 £70 £80 £90
Source: epact
11
5.2 Prescribing Budgets and Incentive Schemes
Locality Budgets/Spend –Year end 11/12 and current position
At year end, the prescribing budget position was £939K underspent against budget.
The budget setting methodology for the CCG is aimed at achieving
 a fair and adequate prescribing budget to meet the needs of patients
 an improvement in the cost and clinical effectiveness of prescribing
 a transparent approach
In deciding the level of affordable funding, the CCG would take a number of factors
into account. In deciding the level of affordable funding, the CCG would take the
following factors into account:


The DH budget setting toolkit
Horizon scanning for new agents
(This is detailed in the horizon scanning document in appendix XX
12

Other local factors that affect prescribing spend, such as demographic growth
and inflation
5.3 Over 2012/13 analysis of the Department of Health’s toolkit to disaggregate
prescribing budgets at practice level has been undertaken with representation from
clinical leads across all four localities and with the CCG. There will be a move
towards full fair share rather than prescribing fair share at practice level, that has
historically been implemented, due to limitations of the prescribing fair share
methodology that does not take into account a number of key factors that make
budget setting at practice level less accurate for the needs of the demography.
5.4 Any prescribing incentive scheme in the future will need to build on the
successes of previous schemes and incorporate actions required that will contribute
to achieving key prescribing actions. All schemes will be subject to consultation
across localities and practices.
5.5 Identification of variation in prescribing will enable targeted support through the
Prescribing Team and augmented by commissioned schemes to those practices that
require it.
6. QIPP Prescribing Efficiencies
6.1 Extensive implementation of Quality, Innovation, Productivity and Performance
(QIPP) on prescribing areas has been identified to release at least £1.2 million for
2012/13 through formulary implementation across the CCG; further efficiency
savings have been identified through volume reduction of prescribing within specific
therapeutic areas alongside ongoing commissioning support to practices. There is a
further £800K anticipated for savings based on patent expiry. These factors have
been incorporated into the budget setting allocation for 2012/13 whereby £2.2 million
has been removed from prescribing budgets in line with this predicted reduced
impact on expenditure. It is envisaged that a similar approach will be used during
the timescale of this strategy. For 13/14, prescribing efficiencies of at least £1.2
million has been identified. These areas are subject to consultation, and do not
include additional efficiencies through natural price reductions, such as patent expiry.
6.2 For 11/12 and 12/13, QIPP prescribing focus has primarily been based upon
productivity and some innovation with some quality focus. The prime quality focus
has been implemented through QOF medicines management 6 & 10 indicators. In
the future the agenda will need to focus on the other areas of QIPP and to build on
the successes and learnings from previous years. This is highlighted in the diagram
below.
13
6.3 Quality Innovation Productivity Prevention
QUALITY
 Reducing C Difficile through appropriate use of antimicrobials
 Reducing harm associated with Non Steroidal Anti Inflammatory Drugs
 Alternatives to antipsychotics to manage behaviour in dementia to reduce stroke,
mortality and falls
 Care home medicines processes / review and staff training
 Reducing medicines incidence errors and shared learning
 Medicines reconciliation to reduce errors across transfer of care
 Using Risk Stratification where medicines are implicated and therefore reducing
associated unplanned admissions
 Support for frail elderly medication reviews and /or targeted reviews
 Medicines input into CCG identified workstreams
 Effective medicines reconciliation to prevent harm
 Correlation of prescribing with admission and referral trends for a holistic view of patient
care and hence reduce variation
INNOVATION
 Effective procurement of medicines to benefit the whole of LLR, such as oral nutritional
supplements
 Effective use and management of rebate schemes schemes whilst adhering to national
and local guidance
 Use of NHS logistics and procurement eg for dressings and therefore enhancing value
chain. Evaluation of current scheme of dressings supply
 IT systems to inform decision making and triangulate disease management eg
Scriptswitch, Eclipse, risk stratification tools, real time prescribing information
 Effective inheritance and understanding strategies to manage high cost non specialist
drugs with a focus on anti TNfs for rheumatology for 2013/14
 Optimising benefits from Home care and adhering to DH recommendations
 Risk Stratification and prescribing to target medicines optimisation reviews to those most
at risk
 Medicines query database to build knowledge and shared learning
 Effective collaborative working with pharmaceutical companies in CCG relevant
workstreams
14
Productivity:
 Prescribing efficiencies as above through savings built to last and sustaining the
QIPP prescribing productivity areas embedding these into practice.
 Identify new areas for targeted prescribing efficiencies as in Appendix 4, without
compromising patient care
 Making the most out of patent expiries and disinvesting in medicines that show
reduced outcomes or limited efficacy
 Continue with reduced growth in unlicensed specials prescribing
 Quantify where savings can be made on hospital admissions or outpatient
appointments through investing in specific medicines.
 To understand where waste can be reduced via appliance contractors ordering
mechanisms and to define a work program around this.
 Ensuring that prescribing budget requirements meet the needs of the local
population
Prevention :





Identifying long term conditions (LTC) earlier and targeting interventions to identify
more patients with LTC
Ensure appropriate uptake on anticoagulation guidelines to prevent risk of harm
to optimise treatment to prevent the long term implications of cost pressures and to
reduce long term burden of disease and disability; including benchmarking
outcomes, prevalence and prescribing data.
o Diabetes mellitus
o COPD
o Frail and elderly
o Care homes
o Rheumatology
o Dementia
o Mental health
o Cardiovascular disease
o Prevention of medicines related falls and fracture
A significant number of patients do not present themselves early enough to primary
care medical services or respond to public health messages and so have acute or
long term conditions that go undiagnosed. In many cases such as diabetes,
rheumatoid arthritis and CHD the longer the length of time to diagnosis the poorer
the outcomes, the greater the complications and greater the cost to the NHS.
Improving the identification of unmet pharmaceutical need is a key to medicines
optimisation
The majority of the medicines related emergency admissions could be preventable
with improved medicines optimisation, improved safety and quality of prescribing and
targeted medicines management support for at risk patients.
15
7. Recently published National Guidance
The recently published Mandate for 2013-15 and the NHS Outcomes Framework
2012/13 identifies 5 key areas that the National Health Service’s strategic direction is
required to pursue for one of it’s objectives. The illustration below reflects four of
these areas and highlights where medicines optimisation has an influence in
ensuring these key areas are met:
16
Preventing
people dying
prematurely
• Supporting earlier diagnosis of illness and tackling risk factors such as high blood
pressure and cholesterol
• Ensuring people have the access to the right treatment when they need it,
including drugs and treatment recommended by the National Institute for Health
and Care Excellence (NICE)
• Reducing premature mortality from the major causes of death:
•under 75 mortality rate from cardiovascular disease
•under 75 mortality rate from respiratory disease
•under 75 mortality rate from liver disease
•Smooth transitions between care settings including primary and
secondary care and health and social care. *
•Ensuring people feel supported to manage their condition
Enhancing quality •Supporting the best treatments available for dementia
of life for people •Unplanned admissions for asthma, diabetes and epilepsy under 19s , by
with long term
optimising medicines use
conditions
•Helping older people to recover their independence after illness or injury
Helping people to •emergency readmissions (where medicines may be implicated**
recover from
episodes of ill health
or following injury
•Reducing incidence of healthcare associated C. difficile and MRSA
•Reducing incidence of newly aqcuired category 2,3 and 4 pressure
ulcers***
Protecting people •Reducing incidence or medication errors causing serious harm and to
from avoidable
create a culture of learning from patient safety incidents
harm
17
*this includes reducing medicines reconciliation errors and ensuring medicines and
medicines processes are optimised during transition, including nursing or residential
home or primary/secondary care transitions, to ensure seamless care.
** including reducing medicine errors across the interface between primary and
secondary care
***includes appropriate oral nutritional strategies within care homes and frail elderly
in their own homes and identifying medicines that are evidenced to have an impact
on nutritional status such as antipsychotics for behavioural symptoms in dementia
8. Medicines Governance
Currently the cluster governance team provides medicine governance assurance
and control to ensure that CQC standards are met. It is anticipated that the CCG
Prescribing & Medicines Management Team will be responsible for providing some
of these functions by April 2013. At present it is unclear whether responsibility for
medicines management governance functions, accountability and assurance would
be full or partial.
9. Non- specialised high cost drugs
9.1 Currently the East Midlands Specialised Commissioning Group manages the
non- specialised high cost drugs which may have implications of high risk to the
prescribing budget. It is supported by a multi-disciplinary commissioning team of staff
(the ‘Specialised Commissioning Team’), who plan, procure and performance
monitor the delivery of specialised services with a value of circa £600 million.
EMSCG has historically been responsible for commissioning specialised services on
behalf of all 9 PCTs in the East Midlands SHA area.
9.2 The CCG will need to understand resource implications in managing this to
ensure this area of prescribing is managed effectively but at the same time ensuring
that the right innovative medicines are available to those who need it. There may
also be some scope for QIPP efficiency savings through, for example, homecare,
rather than an IV method of administration that incurs additional cost in the
outpatient setting, as well as bringing treatment closer to home. The anticipated
budget is likely to be £14 million across LLR.
9.3 Position from April 2013: EMSCG functions have been included in the LAT of
the NCB, however not all current functions are included and some specialised drugs
have been designated for Primary Care to manage within the national reorganisation
18
of the NHS. This generally refers to excluded to tariff drugs however there is a need
to identify and determine that there are not charges been levied through the
specialised route for drugs included in tariff for different indications.
9.4 The majority of drugs will be managed by the NHS Specialised commissioning
board (NHSSCB) however there are some drugs that are designated to be managed
by CCGs. Estimated to be split 80% NCBSCG and 20% CCGs. The provisional list
of the drugs allocated to CCGs with approximate costs is included in Appendix xx
9.6 The function provided by the LLR pharmacists is not included in the function of
the NHSSCB so from April 2013 there needs to be arrangements in place to ensure
that this area of prescribing is appropriate and as agreed in the specialised drugs
budget allocated to CCGs and that fees are submitted correctly. This is currently
under agreement and discussion, and it is vital that a robust process is established
and implemented to take this forward.
10. Pharmacy Contractors
Currently the cluster medicines governance team provides chemist governance
assurance and control to ensure adherence to the pharmacy contract. It is expected
that pharmacy contracts management will be taken over by the Local area Teams in
April 2013. It is however, important to improve communication between GP practices
and Pharmacies to ensure seamless implementation of the agenda set out within this
strategy. Localities have highlighted that it is critical that pharmacy contractors
understand and are aligned to the objectives of the CCG; WL CCG general
practitioners have recommended that the strategy reflects this, in particular with
regards to reducing medicines waste and supporting the prescribing QIPP agenda.
11. Integration with CCG Clinical Priorities
Integration with the delivery of the CCG clinical priorities with the emerging
recognition of the potential to improve patient care by optimizing drug usage through
contribution to education and targeted medication use and clinical medication review.
An example of this is a pilot for level 3 clinical medication review undertaken by a
pharmacist through targeted intervention for proactive care referred by Clinical
Coordinators or GPs through the virtual ward scheme.
12. Localities
Locality forums are a pivotal arena for local decision making and peer discussion
about key prescribing subjects and comparative prescribing data discussions.
13. Seamless Medicines Care across the interface between primary and
secondary care
As more medicines are introduced into the local health economy, medicines
optimisation across primary and secondary care will need clinical leadership, use of
established due processes, good communication and robust shared care
19
arrangements. GPs across localities have cited that the process for shared care
agreements and requests needs further improvement and this will continue to be a
priority area over the next two years.
20
14. Goals
These are aligned with both the domains for CCG authorisation and the medicine
management competencies for Consortia boards towards authorisation as
highlighted by the National Prescribing Centre. Consequently, these goals have
taken into consideration the outcome and action plans developed following
evaluation of the CCG against the medicines management competencies as detailed
in Appendix 1.
The six areas are:
Strategic
Overview
Support and
Development of
People
Effective
Partnerships
Commissioning to
Optimise
Medicines Use
Medicines
Expertise
Provision of
Medicines
Oversight
21
14.1 Strategic Overview
Goal 1:
The CCG has a designated board level lead for
medicines management, and a clear strategy and
action plan for optimising medicines use across our
health economy. We have the medicines
management resource through which it can be
delivered and work closely with the prescribing Lead
GPs and Clinical Leads to realise the objectives.
Objectives
1. To develop and lead implementation of a medicines strategy for the entire
patient population
2. Provide specialised medicines and therapeutic advice to inform CCG
board and subgroups, as and when required, on medicines optimisation and
governance priorities and actions.
3. Achieve the vision and all CCG Medicine Management goals through monthly
Medicine Management Strategic Group
4. Improve medicines assurance, efficiency, governance and safety and reduce
variation through creating an LLR Medicines Optimisation committee for
joint decision making and working across all three CCGs and community
stakeholders
5. Deliver improved patient safety; reduce medicines risk and hospital
admissions to optimise the use of medicines
6. Integrate medicines management expertise in service redesign, patient
pathways and services
7. Improve medicines management and safety in care homes
8. Ensure integration of Medicine Optimisation within the CCG clinical priority
work streams.
9. Build on and improve relationships and systems to optimise the use of
medicines across the interface of primary and secondary care
10. Further develop links with community pharmacy to optimise the use of
medicines
Key Performance Indicators for Goal 1:
1
2
3
Key Performance Indicator for Goal 1
Clear strategy and action plan ratified by board
Monthly /quarterly papers to board subgroups as required
Evidence that MM6/10 audits are agreed to integrate with CCG and
national strategic objectives.
22
14.2
Established Effective Partnerships
Goal 2:
To identify all our partner organisations, make
contact, set up effective communication processes
and are working on areas of joint interest
Objectives
1. Provide Medicines Management support and expertise to all practices in the
CCG
2. Improve the use of information for patients in relation to medicines
services and medicines management and engage public representatives to
deliver the strategy eg medicines waste reduction campaign
3. Ensure good relationship and liaison with General practice teams through
allocation of designated Medicines Management locality pharmacist
/technician
4. Ensuring locality views represented in prescribing strategy and plans
5. Ensure good relationships and liaison with other CCGs through the creation of
an LLR Medicines Optimisation committee (LLR MOC) for joint decision
making and working across all three CCGs and community stakeholders
6. Deliver improved prescribing systems for patients in accordance with
national programmes.
7. Deliver effective systems to ensure safe and improved medicines
management across interfaces with acute and community hospitals e.g.
medicines reconciliation processes, LMSG and Interface pharmacist
8. Identify gaps and develop medicines management services for the most
vulnerable patients and patients at greatest risk of medicines related
problems.
9. Deliver organisational structures to support delivery of medicines
management across the local health area eg through integrated /proactive
care
10. Establish links and joint working with public health
11. Establish links and joint working with Councils eg to ensure Medicine
Management in care homes in line with CQC requirements
12. Further develop long term relationships and network working with Community
Pharmacy to improve patient care and safety .
13. Improve/establish joint working with relevant health care professionals eg
UHL specialist Pharmacist, specialist nurses, community specialists
Community pharmacy the LPC and the LMC
23
1
2
3
4
Key Performance Indicator for Goal 2
90% attendance of either Head of Prescribing or Prescribing lead GP at
LMSG
90% delivery of prescribing standing agenda item at all locality meetings
Input into yearly Community Pharmacy audit requirements to support the
CCGs plans around medicines optimisation.
Engagement in one CCG wide Patient participation group event per year
24
14.3
Commission services that optimise the use of medicines
Goal 3:
We have a good understanding of the needs and
service requirements of our patients with regard to
their medicines, all our contract specifications set out
our expectations for optimal use of medicines
Objectives
1. Ensure delivery of Quality, Innovation, Productivity and Prevention.
2. Improve assurance of medicines management and safety in relation to
Commissioning for Quality and Innovation (CQUIN) to Service level
agreements
3. Improve assurance of medicines management and safety in relation to local
enhanced services
4. Ensure availability of up-to-date and accurate prescribing data to provide
intelligence to plan work streams and inform practices by commissioning
appropriate data sources
5. Improve assurance of medicines management and safety and ensure
medicines expertise by commissioning medicines information services.
6. Improve assurance of medicines management and safety by commissioning a
real time decision support tool to practices (e.g. ScriptSwitch or equivalent)
7. Improve assurance of medicines management and safety in relation to all
other relevant locally commissioned services.
8. Commission services to ensure delivery of required Medicine Management
functions not covered by the medicine management structure.
Key performance Indicators for Goal 3
1
2
3
4
Key Performance Indicator for Goal 3
Input to Prescribing CQUIN /Quality Schedule for UHL and LPT
Evidence of KPIs delivered for commissioned schemes
Monthly QIPP progress reports to Finance and Performance Committee
Monthly prescribing updates on QIPP areas to localities and practice
access to monthly QIPP reports
25
14.4
Provision of Medicines Oversight
Goal 4:
Provision of medicines oversight, governance and
assurance of safe, effective and affordable medicines
usage in provider services.
Objectives
1. Establish assurance processes for medicines Governance within the CCG
2. Deliver improved prescribing systems for patients in accordance with
national programmes.
3. Deliver a systematic assessment and shared learning process for medicines
related events across LLR.
4. Consult and agree robust QOF MM10 audits and ensure sign up by all
practices
5. Liaise with accountable officer to ensure safe and secure handling of
controlled drugs within CCG
6. Manage Patient Group Directions used within the CCG
7. Deliver NICE guidance and local and national medicines related Indicators
8. Improve assurance processes by ensuring that up to date standard
operating procedures are available and implemented
9. Improve provider medication handling assurance processes by managing
auditing Medicines policy
10. Improve assurance by ensuring provider standard operating procedures for
patients receiving support with medicines including clinical trials and sharing
concerns about handling and access to pharmaceutical advice
11. Ensure Medicines safety through input and output from LMSG
12. Ensure Medicines safety through provision of Medicine governance
information in the monthly locality prescribing updates
13. Ensure Medicines safety through effective use and commissioning of
Medicines Information Services
14. Ensure Medicines safety through targeting medicines optimisation to patient
groups on polypharmacy eg integrated care pharmacist, care home patients
15. Establish systems to confirm communication of and adherence of LMSG
decisions within UHL
26
Key performance Indicators for goal 4
Key Performance Indicator for Goal 4
Evidence of safety/ quality considerations in QOF audit
recommendations
Log of Standard Operating Procedures and Audit tools for prescribing
team and GP practices
Input into decision making for yearly prescribing audit for community
pharmacists
1
2
3
14.5
Provision of Medicines Expertise
Goal 5:
Understand the need for and having access to the
full range of skills, expertise and knowledge
necessary to ensure the safe, legal and effective use
of medicines for our population.
Objectives
1. Actively input into and disseminate guidance from the local area
prescribing Committee (LMSG) and affiliated groups
2. Liaise with LLR specialists and GPs with specialist interests as required to
develop and disseminate guidance in relation to prescribing
3. All new shared care guidance to have primary care a CCG prescribing lead as
co-author
4. Ensure availability of up to date medicines information by ensuring access
to Medicines information services and develop a signposting directory for
clinical queries
5. Commission services required to ensure access to the required expertise to
ensure safe, legal and effective use of medicines
6. Ensure the appropriate medicine management and prescribing team
structure to meet the needs of the CCG and population
7. Develop systems and processes to keep abreast of new medicines related
guidance and legislation
8. Commission services not covered by the CCG prescribing & Medicines
Management Team
1
2
Key performance Indicators for Goal 5
100% CCG representation at LMSG
Dissemination of LMSG updates through monthly localities
27
14.6
Supports and Develops people
Goal 6:
Have processes to ensure that people who are
working with, or for us, in medicines management are
competent, and we support and develop individuals to
carry
out
their
roles
effectively
Objectives
1. Deliver organisational structures to support delivery of medicines
management across the local health area.
2. Development of local workforce and education and training to support
delivery of this strategy.
3. Put mechanisms in place to demonstrate and provide evidence of our
commissioning function and effectiveness.
4. Introduce a SharePoint database for the medicines management enquiry
answering facilitators will facilitate sharing of information and learning.
5. To be proactive in celebrating success and to share best practice both within
the organisation and externally.
6. Support team members through quarterly one to ones and to develop
expertise in specific lead areas
1
2
3
Key performance Indicators for Goal 5
Completed PDR plans with Personal Development plans
Interactive database of queries developed and active by December
2013
Annual log of GPhC registrations for the Prescribing Team
28
15. GLOSSARY & ABBREVIATIONS
WL CCG
LLR
CQINS
QIPP
QOF
MM
PDR
NPC
NICE
NPSA
PGDs
DH
NHS
PCTs
APC
LMSG
West Leicestershire CCG
Leicester Leicestershire & Rutland
Commissioning
for
Quality
and
Quality, Innovation, Productivity and Performance
Quality & Outcome Framework
Medicines Management
personal development review
National Prescribing centre
National Institute of Health and Clinical Excellence
National Patient Safety Agency
Patient Group Directives
Department of Health
National Health Service
Primary Care Trust
Area Prescribing Committee
Leicestershire Medicines Strategic Group
Innovation
16. REFERENCES (further work needed here)
1) Pirmohamed M et al 2004. Adverse drug reactions as cause of admission to
hospital: prospective analysis of 18,820 patients. BMJ 329:15-19
2) The Mandate. A Mandate from the government to the NHS Commissioning
Board: April 2013 to March 2015
3) The NHS Outcomes Framework 2012/13. Department of Health
4) National Prescribing Centre 2011. An Organisational competency framework
to ensure the effective delivery of medicines management functions and
responsibilities; A guide for commissioning Consortia Boards.
5) Department of Health 2006. Our health, our care, our say, a new direction for
community services.
6) Darzi 2008. High Quality Care For All. NHS Next Stage Review. Final Report
June 2008.
7) Department of Health. World Class Commissioning. Commissioning
Assurance Handbook. June 2008.
8) Department of Health. High Quality Care for All. NHS Next Stage Review
Final Report. June 2008.
9) Department of Health. Pharmacy in England: Building on strengths –
delivering the future. April 2008.
10) The National Prescribing Centre. Moving towards personalising medicines
management. April 2008.
11) Department of Health. The National Health Service Act 2006
29
Appendices
30
APPENDIX 1
Delivery of Prescribing and Medicines Management Services in Leicester Leicestershire and Rutland
The proposed content of the authorisation process for CCGs is built around six domains – six areas which are most likely to act as
pre-conditions of success for a CCG. The process will also need to reflect the final composition of legislative requirements. To be
authorised, CCGs should be able to demonstrate an adequate level of competence across all these areas and the potential to
achieve excellence in future.
Domain
A strong clinical and
professional focus which
brings real added value
Description
A great CCG will have a clinical focus perspective threaded through everything it does, resulting in having quality
at its heart, and a real focus on outcomes. It will have significant engagement from its constituent practices as
well as widespread involvement of all other clinical colleagues; clinicians providing health services locally
including secondary care, community and mental health, those providing services to people with learning
disabilities, public health experts, as well as social care colleagues. It will communicate a clear vision of the
improvements it is seeking to make in the health of the locality, including population health.
P&MM services ensure collaboration across the health community through:
 Shared decision-making, to avoid unacceptable variations in access to services and medicines;
 Making sure that the information necessary to underpin these processes, either on an individual level or
through local decision-making groups, is available and understood;
 Pooling of expertise to avoid duplication of effort;
 Sharing good practice to speed up adoption and avoid reinventing the wheel;
 Leadership/facilitation of professional networks to support collaboration.
Relevant P&MM work streams –
 Therapeutic Advisory Service (TAS) is a sub group of Leicestershire Medicines Strategy Group (LMSG)
and evaluates the requests for use of new medicines or new indications for existing medicines. Medicines
31
Management representation ensures that a primary care point of view is considered with each
submission. The service coordinates the new drug assessment agenda and pools expertise across the
interface to ensure that only one assessment of each new drug of significance is done for LLR with
recommendations being fed into the LMSG agenda.
Meetings occur every 6 weeks.


Leicester Partnership Trust Prescribing Group (LPTPG) also feeds into TAS with Mental health related
prescribing issues. Meetings occur monthly
Leicestershire Medicines Strategy Group (LMSG) is a joint LLR wide committee between NHS Leicester
City and Leicestershire county and Rutland , the three shadow CCGs and University Hospitals of
Leicester and Leicester Partnership Trust with Clinician and pharmacist representation from all member
organisations and representation from the LPC and LMC. The committee agrees the use of medicines as
a heath community and provides information on the appropriate and safe use of medicines including
traffic light classification. Meetings occur monthly.

Communication. LMSG decisions and messages are made available to all LLR prescribers and other
stake holders through the LMSG Bulletin that is sent directly to individuals and accessible through the
LMSG website ( www.lmsg.nhs.uk ). e. TAS submissions and minutes are also accessible on the TAS
website (http://www.tas-leicester.org/ )

The LMSG Traffic Lights List summarises all traffic light decisions to date and is also available on the
website

Full and Simple Shared Care Agreements are developed with input from all member organisations and
then ratified at LMSG with agreement of all parties.

The introduction of the shared Interface pharmacist role consolidates information from LMSG and across
the interface addressing issues raised by both primary and secondary care clinicians.This role also liaises
32
with other areas to ensure that we have as near a consistent approach to prescribing across the SHA
Meaningful engagement
with patients, carers and
their communities
Clear and credible plans
which continue to deliver
the QIPP (quality,
innovation,
CCGs need to be able to show how they will ensure inclusion of patients, public, communities of interest and
geography, health and wellbeing boards and local authorities in everything they do, especially their
commissioning decisions. They should include mechanisms for gaining a broad range of views then analysing
and acting on these. It should be evident how the views of individual patients from the consulting room are
translated into commissioning decisions and how the voice of each practice population will be sought and acted
on.
Relevant P&MM work streams –
 Patient engagement and communication. The P&MM team engage regularly with patients particularly in
relation to patient queries and with regard to therapeutic switches in practice necessitating patient
communication and reassurance.

Patient complaints. The Head and of P&MM respond to specific patient complaints on request from the
complaints department and LLR PALS.

Freedom of Information. The Head of P&MM respond to Freedom of Information requests from the public
and wider population.

Patient Education. The P&MM team provide educational support to patient participation groups on
request.
CCGs should have a credible plan for how they will continue to deliver the local QIPP challenge for their health
system, and meet the NHS Constitution requirements. These plans will set out how the CCG will take
responsibility for service transformation that will improve outcomes, quality and productivity, whilst reducing
unwarranted variation and tackling inequalities, within their financial allocation. They need a track record of
33
productivity and prevention)
challenge within financial
resources in line with
national outcome standards
and local joint health and
wellbeing strategies
delivery and progress against these plans, within whole system working, and contracts in place to ensure future
delivery. CCGs will need to demonstrate how they will exercise important functions, such as the need to promote
research.
Relevant P&MM work streams –
 QIPP processes. QIPP has been central to the P&MM function since its inception. Reporting has been
reconfigured so that all QIPP related initiatives have been identified for each practice, quantified in terms
of potential savings and, where action is agreed, monitored in order to determine the scale of
accumulated savings achieved. This has enabled us to better inform practices, LLR Directors, Chief
Executive and East Midlands Strategic HA of QIPP priorities and progress. This work has been developed
further as part of the Quality and Outcomes Framework and Prescribing Incentive scheme for general
practice.

Key messages for QIPP delivery. The MMT develops an annual Framework of Key Prescribing Messages
which identifies potential areas for action which are rational, clinically evidence based and cost effective.
This is as a collaborative approach across the three CCGs and using jointly developed information from
LMSG and Medicines Information

Investment and disinvestment. MMT regularly identify investment/disinvestment opportunities which are
promoted through the MM team, locality meetings and newsletters and ScriptSwitch. Additional ideas
come from the centre, for example through NICE and the National Prescribing Centre. The NPC has been
influential on the QIPP priorities both locally and nationally. Increasingly, CCG led initiatives are becoming
part of the LLR QIPP agenda.

Strategic planning and implementation support. P&MM have been involved in the development of CCG
strategic plans for P&MM on request. A large proportion of the available P&MM resource for the first half
34
of 2011/12 was dedicated to the support of the new QP QOF agenda in CCGs.
Proper constitutional and
governance arrangements
with the capacity and
capability to deliver all their
duties and responsibilities,
including financial control,
as well as effectively
commission all the
services for which they are
responsible

Better Care Better Value performance. BCBV performance is monitored monthly and poor performance
flagged to individual practices by MMT members. Monitoring of key performance indicators across a
range of therapeutic areas is a longstanding part of the P&MM service supported by a dedicated
Prescribing Analyst.

The P&MM Team have been central to the successful adoption of the prescribing Quality Productivity
indicators as part of the GMS Contract. Driving quality and productivity through the Contract has raised
the profile of QIPP in general practice to an unprecedented degree.

The regular updating of the ScriptSwitch profile and Practice system based formularies to deliver
prescribing advice at the point of prescribing requires considerable P& MM resource and expertise to
update and maintain accurate information
CCGs need the capacity and capability to carry out their corporate and commissioning responsibilities.
This means they must be properly constituted with all the right governance arrangements. They must be able to
deliver all their statutory functions, strategic oversight, financial control and probity, as well as driving quality,
encouraging innovation and managing risk. They must be committed to and capable
of delivering on important agendas included in the NHS Constitution such as equality and diversity and
safeguarding. They must have appropriate arrangements for day to day business, e.g. communications.
They must also have all the processes in place to commission effectively each and every one of those services
for which they are responsible, from the early health needs assessment through service design, planning and
reconfiguration to procurement, contract monitoring and quality control.
Relevant P&MM work streams –
 Local Decision Making (LDM). LMSG ensures rational decision making about the funding of medicines
and treatments on a population basis
35

Policy development. P&MM contribute to the maintenance and development of a raft of policies to
ensure compliance with the legal frameworks governing medicines usage, including:
-Safe and secure handling of medicines
-Controlled drugs legislation
-Prescription forms handling
-Waste management legislation.

Protocols and Procedures. The three CCG MMT develops protocols and Standard Operating Procedures
(SOPs) for use by the whole P&MM team to ensure a uniform and safe approach to all implemented
prescribing changes across LLR. This speeds up adoption of new prescribing messages as they arise and
manages risk by avoiding individual advisers and technicians developing individualised approaches to
complex prescribing areas.

Education and Training. The P&MM Team are able to provide education and training to health and social
care staff on all aspects of the legal, safe and effective use of medicines.

Controlled Drugs Legislation. A specific policy relating to the handling of Controlled Drugs is in place and
is regularly updated to keep guidance in line with this rapidly changing area. P&MM answer queries from
GP practice staff to support them to work within the legislation. Although this role is currently delivered by
the Cluster team CCG P& MM also provide advice in this area.

P&MM work closely with Clinical Governance and Risk and Practitioner Performance to inform on all
aspects of incidents and complaints that arise in relation to medicines management and pharmacy issues.

P&MM work collaboratively for mutual benefit working with the Pharmaceutical Industry. Working to
ensure PI influences are constructive and not destructive and ensuring that decision making remains as
objective as possible and uncluttered by misinformation and incentivisation linked to dispensing deals.
36
Collaborative arrangements
for commissioning with
other clinical commissioning
groups, local authorities and
the NHS Commissioning
Board as well as the
appropriate external
commissioning support

Budget setting and Monitoring. Working alongside Finance colleagues on the Prescribing Budget Setting
Methodology each year. Prescribing growth in terms of both cost and volume is also closely monitored
with P&MM reports informing decision making around uplifts and growth, including horizon scanning for
the impact of new technologies and drugs.

Budgetary management in general practice is supported through monthly updates and targeted
prescribing advice delivered by MMT.

Incentive Schemes. Developing, managing and evaluating incentive schemes for general practice and
other providers as appropriate. Development, support and administration of such a Reward Scheme is
extremely demanding of P&MM resource, and has demonstrated proven benefit over 2011/12.
CCGs need robust arrangements for working with other CCGs in order to commission key services across wider
geographies and play their part in major service reconfiguration. They also need strong shared leadership to
develop joint health and wellbeing strategies, and strong arrangements for joint commissioning with local
authorities to commission services where integration of health and social care is vital and the ability to secure
expert public health advice when this is needed. They also need to have credible commissioning support
arrangements in place to ensure robust commissioning and economies of scale. They need to be able to support
the NHS Commissioning Board in its role of commissioner of primary care and work with the Board as a partner
to integrate commissioning where appropriate.
Relevant P&MM work streams –
 Safe and Secure Handling of Medicines in Care Homes. Development, in conjunction with Local Authority,
of contractual standards to ‘hold’ Providers to and Policy and Procedure Guidance to guide Providers to
safe and secure handling and administration of medications in Care Homes.

Horizon scanning. Horizon scanning is incorporated into regular updates to LMSG compiled from
nationally produced resources.
37

Formularies. There is a well-established Net formulary available in LLR which is available to all who have
access to an N3 connection this includes links to NICE guidance, local guidance developed by UHL and
LMSG and reference to shared care agreements

Service Specification. Providing medicines specific input into service specifications and the contracting
process. Senior P&MM staff input into the development of service specifications such as those to support
the delivery of anticoagulation and DVT services and improving respiratory disease outcomes services
from GP practices and Community Pharmacies.
38
APPENDIX 2
ANNUAL REPORT FOR PRESCRIBING
WEST LEICESTERSHIRE
CLINICAL COMMISSIONING GROUP
2011-2012
Report Prepared By:
Jasmeen Islam, Head of Prescribing, West Leicestershire Clinical Commissioning Group
Data Analysis: Sally-Anne Crawford, Prescribing Support Officer, West Leicestershire Clinical Commissioning
Group
June 2012
39
SUMMARY
2011 /12 was the first year of delegated prescribing budgets within the
Clinical Commissioning Group (CCG) and hence managing a ‘real’ budget
for this whilst maintaining high quality prescribing was a challenge that
was set out at the start of the year.
It is with the combined hard work and dedication of all practices on
working to manage prescribing expenditure against budget that the CCG
is pleased to report an underspend of just under £940K and achievement
of the QIPP (Quality, Innovation, Productivity, Performance) target of
£1.7 million as embarked on at the start of the financial year.
1. Clinical Leadership
Strong Clinical Leadership has resulted in a clear vision and direction for the
prescribing agenda with a pragmatic approach.



Dr Darren Jackson and Dr Liz Hepplewhite, CCG Prescribing Leads, have
been instrumental in making the achievements on the prescribing agenda
happen.
Monthly prescribing lead meetings with Dr Jackson and Dr Hepplewhite have
ensured that the strategies implemented are robust and with strong clinical
input.
The Locality Chairs have provided substantial input in the prescribing
approach to their respective localities, enabling approaches to be tailored
accordingly.
2. Prescribing Performance Against Budget
This was a year of considerable change for prescribing, as increased ownership in
the form of QP prescribing for QOF of which 28 points were allocated. This, together
with the prescribing incentive scheme for 2011/12 supported the stimulus for aspired
achievement of financial balance. Practices chose not to work on individual target
areas as part of the incentive scheme, but work towards achievement of financial
balance in a less prescriptive form, following consultation at all 4 localities at the start
of the financial year. The result is that 60% have achieved the full payment for the
incentive scheme, 14% have achieved the payment of the first 50%. This is subject
to appeals that are made.
The financial position over 2011/12 for prescribing at year-end is
an under-spend of approximately £940K*.
40
Table 1: Performance against budget 2011/12
Locality
North West
Leicestershire
South Charnwood
Hinckley & Bosworth
North Charnwood
West Leicestershire
CCG
Budget Year
to Date
Expenditure
Year to
Date
£14,382,813 £13,530347
Balance
% Variance
2011/12
-£852,466
-5.93%
£9,699,014
£9,411,820
-£287,194
-2.96%
£14,443,599
£14,45588
£12,289
0.09%
£9,757,284
£9,945,184
£187,900
1.92%
£48,282,710 £47,343,199
-£939,511
-1.94%
The above table includes the impact of the Nutricia rebate.
Performance against budget 2010/11
West Leicestershire CCG
North Charnwood
Hinckley and Bosworth
North West Leicestershire
South Charnwood
Budget
Year to
Date
£46,669,186
£9,451,972
£13,814,045
£14,039,952
£9,363,216
Expenditure
Year to Date
Variance
£
£48,200,410
£10,236,598
£14,749,536
£13,541,312
£9,672,965
£1,531,225
£784,626
£935,491
-£498,640
£309,749
Variance
%
3.3%
8.3%
6.8%
-3.6%
3.3%
The above tables demonstrate that the localities that were overspent in 2010/11
have reduced their respective expenditure and variance against budget
considerably.
3. Prescribing Support to Practices
There has been a shift in prescribing support this year due to restructuring. Support
reduced from 4 x 0.5 WTE locality Prescribing Advisors to 1 x 0.5WTE, of which this
became vacant in the Summer of 2011; we were unable to recruit to due to a
shortage of applications.

Hands-on support for therapeutic interventions and in the form of promoting
regular prescribing discussions at practices has therefore been significantly
reduced this year.
41



The existing team have been targeting high impact QIPP prescribing
interventions, of which a summary of these savings are provided in table 2
and in Appendix 3.
QIPP therapeutic interventions are only one aspect of the team’s work
streams, as support is also provided in the form of expert prescribing advice,
support with prescribing data, annual visits, and implementing other
prescribing strategies, such as input to guidelines and formulary
development.
Below is a selection of feedback received about the prescribing team
Comment from Dr McGhee to Sylvia Otter, Practice Pharmacist: ‘Thank you for all your work and
support and I will start to look at the forthcoming audits soon. We are indebted to you…’’
Comment from Dr Nic Rushman at May 2012 Locality Forum (NWL): ‘Sylvia seems to wave her
magic touch in getting us to choose areas to work on …she’s brilliant.’
Comment from Dr Maini, Desford Medical Practice: ‘I really value the team’s support. Lisa (Lisa
Cook, Prescribing Support Technician) has helped us with our prescribing so much and her
approach has been wonderful- we are truly grateful’
Comment from Professor Lakhani to Sally Anne Crawford, Prescribing Support Officer about
prescribing data for QP indicators: ‘this is very good and useful format, love the number needed to
change …well done’.
At a locality forum South Charnwood Professor Lakhani addressed the forum saying: ‘this is the
greatest support we’ve had for prescribing.’
4. Delivered QIPP Savings
The table below summarises the savings delivered as part of the QIPP program
across the CCG.
42
Table 2: QIPP Savings Achievements
£346,663.18
£732,326.12
CCG Prescribing Team Interventions
Practice QP Actions (targeted)
Care Homes Interventions –
commissioned
Commissioned Private Providers
Not Dispensed Scheme ^
Total (ANNUALISED)
Total Savings on this year's budget
(in year savings)**
£40,000.00
£329,800.28
£23,822.98
£1,472,612
£754K
*£225K
Plus Formulary adherence to 5areas not
chosen as QP Prescribing options
(in year savings)
Subtotal : £979K
*** Grand Total (IN
YEAR): £1.1 million
ANNUALISED GRAND TOTAL: CIRCA £1.7 MILLION
*minimum estimate
** In year estimations based upon when work was completed and the proportional impact on savings
within the financial year only.
***A rebate for 20% discount for Nutricia nutritional supplements has historically been paid to
Leicestershire Partnership Trust instead of the PCT/CCG. The CCG has secured the rebate back to
practice expenditure and the rebate will apply back to practices spend against budget for Nutricia
products for 2011/12 and for 2012/13. This contributes to the QIPP performance for oral nutritional
supplements and is included in the financial position for 2011/12.
^ Not dispensed scheme relates to medicines and appliances not dispensed at pharmacies through
incentivisation.
4.1 QP Prescribing for QOF
Practices are to be commended on the remarkable achievement for QP prescribing
of which there has been significant prescribing change evidenced as a result of this.
There was a national directive to use 12 indicators for QP, of which practices were
already achieving the targets for in the majority of cases, locally. Therefore we were
successful in negotiating with BMA Employers to agree bespoke QP indicators for
prescribing based on individual practice choice and greatest potential savings
following a series of practice visits in the spring of 2011 by the prescribing team.
This was supplemented with peer review for all localities of which speakers
presented on the following subjects of QIPP prescribing for:
43





Respiratory disease
Long acting insulin analogues
Ezetimibe
ACE inhibitors/ ARBs
Specials
A reporting tool was developed and provided to practices on a monthly basis to
provide progress against indicators and their targets
Table 3: QIPP Savings Delivered through QOF QP Prescribing 2011/12
Hinckley & Bosworth
North Charnwood
North West Leicestershire
South Charnwood
Grand Total
Points
Practice
%
Available Points
Points
195
166.21 85.24%
135
118.56 87.82%
225
209.15 92.96%
195
172.41 88.42%
750
666.33 88.84%
Actual
Savings on
QP Indicator
£238,946.77
£230,644.07
£128,368.71
£134,366.57
£732,326.12
5. Commissioned Prescribing Support
a) Practice deployed
Targeted commissioned prescribing support to augment the capacity of the practice
based prescribing team meant that additional input was provided to the top 10 overperforming practices, with an emphasis on QIPP delivery. Three providers were
commissioned, all of whom delivered at least a two for one return on investment.
Further detail is provided in Table 2 and Appendix 3.
Furthermore, Hinckley and Bosworth used locality funds to provide additional
prescribing support to all practices. Practices chose providers, which resulted in 3
providers being commissioned to the locality, all with a return on investment of at
least two for one. Please see Appendix 2. Feedback from practices for all 3
providers have been very positive.
b) Care Homes
Slippage funds were used to commission care homes medication reviews and
contribution to the QIPP savings agenda and to understand the implication of
potential wider roll out for future years. Appendix 1 highlights key interventions that
were made. The interventions resulted in a return on investment of 2 for 1, and in
44
addition, training elements for medicines administration storage and supply were
delivered.
Feedback from Dr Cannon, Bridge Street Surgery: ‘I am emailing to say how impressed I have been
with the scheme in general … Rupinder’s efforts have been first class and done with a smile and
pleasant attitude’.
c) Software / IT Systems
‘Medman’ was commissioned and targeted to the top 10 overspent practices to
enable practices to identify savings potentials quickly direct from clinical systems.
There has been some anecdotal feedback from practices about the software and the
feedback is being used to inform future commissioning of this software. The CCG
has now also commissioned the software ‘Eclipse’ which has been recommended by
National QIPP Leads.
d) Formulary implementation
The CCG commissioned a pharmacist to integrate the LLR formulary on clinical
systems as a result of feedback from practices prior to the financial year and as part
of the Paperlite Program. All practices across the CCG except two that have their
own formulary have had the formulary installed. The commissioned pharmacist built
the formulary for compatibility with Emis Web, Emis LV, EMIS PCS and Vision in
addition to System One of which the formulary had already been developed via CCG
input. The CCG is developing an approach to ensure sustained updating of the
formulary on clinical systems.
6. Locality forums
Locality forums have allocated a standing item for prescribing at each of the
meetings. This has generated substantial discussion, consultation and agreement
for strategies on prescribing. The locality planning and engagement team have
supported this process together with the locality chairs. 87% of monthly forums over
the year across all 4 localities have had pro-active prescribing team representation.
7. Prescribing queries
Over 2011/12 there has been a significant number of medicines queries of which the
team provide a response to practices and other healthcare professionals. Many of
the queries are complex in nature. The team have logged at least 100 clinical
queries over the last 6 months of the financial year. This is a conservative estimate
45
as queries obtained verbally at practices, meetings or over the phone may not also
be logged.
8. QOF MM 6 & 10 Indicators
100% of all practices achieved QOF MM 6 and 10 indicators within the allocated
timescale
9. Managed entry of new drugs
The CCG has pro-active representation at the Leicestershire Medicines Strategy
Group, the chair of whom is also the CCG’s Prescribing Lead GP. This group
manages the entry of new drugs into the local health economy.
10. Budget setting for prescribing
The CCG undertook horizon scanning for new drugs to understand the implications
for budget setting. A working group across all 4 localities identified options for the
budget setting methodology for 2012/13 financial year. An agreement was reached,
and further work is needed over 2012/13 to take this further forward for the future.
46
APPENDIX 1
Summary of Outcomes of the Care Home Review
Pilot
Author: Rupinder Gill, Pharmacist
Commissioned Service Provided by Prescribing Support Services
Total savings made on the project:
£50,224.14
Total spend:
£20k
Cost savings achieved:
2:1
Length of frame work:
01/03/2012 – 30/04/2012
Project delivered by 2 Care home
pharmacists:
Rupinder Gill
Prescribing support services
Sandeep Khokhar
Prescribing support services
Intervention Summary
Examples of Key findings:
Number of patients reviewed: 148
1) Medications not updated or delayed to be
updated at the surgery following a
resident’s hospital admission.
2) Stock pile – poor ordering process by the
care homes: 22 Lantus pens found for 1
resident. 140 fortisip multifibre ordered for
the same patient in one month.
3) Test strips prescribed and ordered for all
diabetic patients even non-insulin
dependant
4) Carers observed to be unable to operate
auto haler correctly, unaware of how to
administer eye drops correctly, unable to
calculate BMI, unaware of what volume of
liquid to make laxido sachet in. Lack of
Number of interventions made: 578
Number accepted and implemented: 437
Acceptance rate by the GPs: 76%
Changes implemented by the pharmacists:
47
47%
knowledge on how to interpret BM
readings. When to challenge if a prn
medication is really needed i.e. laxative
given to someone with loose stools.
5) Covert medication: patients refusing
expensive liquid preparations. Treatment
review required
6) Swallowing needs of the patients can
change frequently yet they continue to
stay on the expensive preparations.
7) All PRN medication blistered and returned
to the pharmacy after 3 months.
8) Incomplete medication record on system
one at Forest House surgery
Quality outcomes:
Examples of interventions made:
(All the interventions are documented on the
data sheet)
Number of sedatives stopped or reduced:
15/26 (58%)
Number of Sip feeds stopped: 7/15 (47%)
Number of patients started on Calcium and
Vit D: 20 (13%)
Number of dementia reviews conducted: 44
1) Dementia reviews with Dr Noble
consultant Psychiatric: as the dementia
prescribing is initiated in secondary care
most GPs preferred referrals made
directly to them therefore these
interventions were made when he visited
Charnwood on the 12/4/12
2) Of the 11 intervention made, 5 were
accepted and implemented and 3 are
pending
Number of Dementia medication
interventions: 11 (25%)
Training provided on:
Number of dementia reviews accepted: 5
(45%)
Training issued to the care homes:
Attended by 6 at Beaumanor nursing home





48
BMI calculations
Inhalers
Best practice on ordering medication
Steroid creams/skin care
Swallowing problems/covert medication
Attended by 7 at Charnwood nursing home




Changes to processes within the practices
and care homes:
1) Forest house surgery has written a policy
for Charnwood nursing home about
monitoring for diabetic patients.
Eye drop administration
Control drugs
Communication with the GPs
Challenging what’s best for the patient
2) Forest house practice has started to add
the dementia medication prescribed in
secondary care to the repeat template.
Only one tablet is prescribed and the
carers know that they don’t order it.
3) The care home manager from the Willows
NH (Sonya) is to liaise with Dr Watson
regarding getting a protocol for monitoring
patients with a history of hypertension and
to get a homely medication box in place to
try and reduce the number of prn
analgesics and laxatives prescribed.
4) All blistering of PRN medication has been
requested to stop by the pharmacy.
5) All prn medication not in the original
container has the expiry and batch
number added on to it. The carers at
Charnwood have been informed not to
destroy any medication still in date.
6) The GPs at Bridge street surgery are
reviewing the prescribing of calcium and
vit D/biphosphonates in the patients with
deteriorating renal function.
Nursing homes involved in the pilot:
Charnwood Oaks
Care home manager: Sylvia
Beau manor Nursing home
Care home manager: Lyn
Surgeries involved in this pilot:
Forest House Practice:
Dr Rao
Dr Watson
Field Street surgery:
Dr Ghatora
49
The Willows nursing home
Care home manager: Sonya
Pinfold gate surgery:
Dr Brockhurst
Bridge street surgery:
Dr Cannon
Parkview Surgery:
Dr Baker
Storer Road Surgery:
Woodbrook Medical
Maxwell Drive Surgery
50
HINCKLEY AND BOSWORTH COMMISSIONED PRESCRIBING SUPPORT
Note: individual savings
potential will have been
variable due to size of
practice and number of
practices covered
51
CCG Wide Medicines Management Commissioned Support
Hinckley & Bosworth
ICS Total
Station View Health Centre
MMS Total
Burbage Surgery
Desford
Maples Surgery
Newbold Verdon
Old School Surgery
North Charnwood
ICS Total
Charnwood Medical Group
Forest House Surgery
Pinfold Gate Medical Centre
Rx Advisor Total
Dishley Grange
Field Street
North West Leicestershire
Rx Advisor Total
Dr Shepherd
South Charnwood
ICS Total
Barrow Health Centre
Rx Advisor Total
Alpine House
The Banks
Grand Total
APPENDIX 4
Annualised Savings
£31,613.04
£7,714.04
£7,714.04
£23,899.00
£7,484.00
£0.00
£9,037.00
£6,546.00
£832.00
£78,180.26
£68,595.00
£29,080.00
£23,256.00
£16,259.00
£9,585.26
£5,940.02
£3,645.24
£689.72
£689.72
£689.72
£48,871.01
£25,927.00
£25,927.00
£22,944.01
£20,226.76
£2,717.25
£159,354.03
Cost
£18,000.00
£3,000.00
£3,000.00
£15,000.00
£3,000.00
£3,000.00
£3,000.00
£3,000.00
£3,000.00
£15,000.00
£9,000.00
£3,000.00
£3,000.00
£3,000.00
£6,000.00
£3,000.00
£3,000.00
£3,000.00
£3,000.00
£3,000.00
£9,000.00
£3,000.00
£3,000.00
£6,000.00
£3,000.00
£3,000.00
£45,000.00
Annualised Return On Investment
175.63%
257.13%
257.13%
159.33%
249.47%
0.00%
301.23%
218.20%
27.73%
521.20%
762.17%
969.33%
775.20%
541.97%
159.75%
198.00%
121.51%
22.99%
22.99%
22.99%
543.01%
864.23%
864.23%
382.40%
674.23%
90.58%
354.12%
Note: individual saving
have been variable du
practice and number o
covered
EXAMPLES OF TARGETTED THERAPEUTIC INTERVENTIONS UNDERTAKEN BY THE CCG PRACTICE BASED PRESCRIBING TEAM
52
Scheme
ARB formulary choice
Arimidex to generic
BCBV Statins
Black Drugs Flomaxtra to Tamsulosin
Clopidogrel
Dose Optimisation
Doxazosin MR to plain
Doxazosin XL
Generic Savings
Glucosamine
Imigran to generic
Liquids to Tablets
Meds reconciliation error
Mesalazine to Mesren
Metformin MR
Movicol
Nizatidine to Ranitidine
Not Dispensed Intervention
Ondansetron
Oral Nutritional Supplements
Prednisolone E/C
Prednisolone EC to plain
Prescribing error
Red & Black
Rosuvastatin
Specials
Statins
Venlafaxine
Grand Total
Grand Total
£10,613.00
£30,855.00
£361.15
£69.42
£1,124.00
£2,478.00
£195.45
£23,694.41
£7,609.00
£11,204.00
£325.00
£2,922.66
£143.00
£220.83
£1,184.56
£704.51
£5,631.00
£1,972.08
£125.00
£3,025.80
£3,249.00
£6,985.00
£431.00
£2,809.68
£2,820.87
£209,468.56
£1,108.68
£15,331.00
£346,663.18
Practice Based Prescribing Team:
Pharmacists: 1.1 WTE
Technicians: 0.5WTE (reduced
from 2WTE from August 2011)
53
APPENDIX 5
Examples of CCG Wide Changes in Prescribing
Aim for decrease
Aim for increase
Specials
Special Order Products as a % of all Items
Angiotensin II Receptor blocker formulary adherence
Oct 10 to Mar 12
ARB Formulary Adherence
Decrease
↓
(All)
0.1800%
70.0000%
0.1692%
0.1575%
0.1600%
0.1445%
0.1200%
Increase
↑
(All)
80.0000%
0.2000%
0.1400%
Oct 10 to Mar 12
60.0000%
0.1449%
0.1426%
0.1355%
50.0000%
0.1181%
0.1125%
0.1044%
0.1022%0.1042%
0.0991%
0.1000%
40.0000%
0.0907%
0.0869%
0.0894%
0.0897%
0.0821%
0.0764%
0.0800%
30.0000%
0.0600%
20.0000%
0.0400%
10.0000%
0.0200%
0.0000%
0.0000%
Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11
TARGET: To reduce Special Order Products as a % of all BNF Items
Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11
Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12
Target:
TARGET: To increase formulary choice Losartan and Candesartan as a % of all ARBs
0.1733%
54
Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12
Target:
67.9188%
Aim for increase
Aim for increase
NSAID Formulary Adherence
Ibuprofen & Naproxen as a % of all NSAIDs
Oct 10 to Mar 12
Prednisolone Plain Tablets
(All)
#N/A
30.0000%
Prednisolone Plain
Oct 10 to Mar 12
(All)
#N/A
90.0000%
80.0000%
25.0000%
70.0000%
20.0000%
60.0000%
50.0000%
15.0000%
40.0000%
10.0000%
30.0000%
20.0000%
5.0000%
10.0000%
0.0000%
0.0000%
Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11
#N/A
Jul 11
Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12
Target:
24.9392%
Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11
#N/A
55
Jul 11
Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12
Target:
65.9917%
DRAFT QIPP PRESCRIBING EFFICIENCY ASPIRATIONS FOR WEST
LEICESTERSHIRE CCG 2013-14
PPI Formulary
Ezetimibe
Rosuvastatin to Atorvastatin
ARB Formulary
Opioid Patches to Capsules
Nitrofurantoin
CCB Formulary
High Dose Combo ICS
5HT1 Receptor Agonist
Tramadol
Doxazosin MR
Escitalopram
Coxibs
Dutasteride
Generic Pioglitazone
Nasal Sprays
Venlafaxine XL
Generic Latanoprost
Low Cost Statins
Nystatin
Melatonin
Formoterol
Prednisolone EC
Omeprazole Tabs to Caps
Erectile Dysfunction
Generic Clopidogrel
Generic Indapamide & MR
Generic Perindopril
Generic Risedronate
Grand Total
Potential Saving if National
Potential Saving if CCG
75th Centile reached
75th Centile reached
£301,065.35
£123,122.16
£355,194.69
£119,936.78
£137,635.06
£119,280.34
£69,217.73
£76,753.90
£53,200.85
£76,318.15
£87,071.78
£63,641.40
£95,384.87
£62,520.20
£90,835.77
£59,818.41
£87,504.36
£56,006.12
£70,614.20
£49,562.89
£41,002.83
£41,688.43
£58,237.48
£40,805.16
£71,497.11
£39,998.39
£55,240.41
£35,365.17
£35,793.10
£31,020.69
£18,731.03
£27,056.43
£3,738.70
£23,830.40
£30,335.32
£22,470.93
£24,285.15
£21,047.13
£22,509.90
£19,564.74
£20,529.06
£18,489.92
£4,453.87
£16,291.99
£16,988.31
£15,717.12
£15,602.24
£13,753.44
£15,438.14
£10,505.98
£11,728.36
£10,164.58
£8,123.21
£8,040.97
£8,829.39
£7,652.14
£6,104.96
£5,290.96
£1,816,893.22
£1,215,714.92
56
DRAFT PRESCRIBING QIPP EFFICIENCY RATIONALE
FOR CONSULTATION.
Standard operating procedures and audit tools will be developed for
these areas, based upon National and LLR wide guidance
1.Ezetimibe
Objective:

To ensure that Ezetimibe is prescribed as recommended in the drug
licence and as per the NICE guidelines.
 To reduce the overall prescribing of Ezetimibe as a percentage of all
statins.
Rationale:
Ezetimibe is only licensed for use in heterozygous-familial and non- familial
hypercholesterolaemia i.e. patients with high cholesterol concentrations not
due to an underlying cause (NICE states serum cholesterol >7.5 mmol/l)
Statins remain the treatment of choice in most patients. Ezetimibe only has a
role, as supported by NICE guidance, for those with primary
hypercholesterolaemia (ie have had a serum cholesterol >7.5mmol/l) who are
truly intolerant of statin treatment or where statins are contraindicated; or for
those whose cholesterol levels are still high despite being prescribed an
appropriate dose of a statin.
Potential saving if CCG 75th Centile reached: £119,936.78
2.Rosuvastatin to Atorvastatin
Objective:

To switch any patients currently prescribed rosuvastatin for primary or
secondary prevention to atorvastatin where appropriate.
Rationale:
Atorvastatin went off patent in May 2012 and dropped in price soon after
wards. There will be opportunistic savings for CCGs but further savings can
be made by switching rosuvastatin to atorvastatin.
Atovastatin has a large evidence base for efficacy and safety and until now
the only reason for not choosing it as a first line statin has been cost.
Potential savings if CCG 75th Centile reached: £119,280.34
57
3. PPI Formulary
To switch patients on branded PPIs to generic and use formulary
Omeprazole,Pantoprazole and Lansoprazole
The specific objectives are;
1.
To identify all patients prescribed PPIs as repeat medication.
2.
In each patient to determine the reason for the prescription.
3.
To identify patients where their PPI can be switched from pantoprazole
or rabeprazole to lansoprazole or omeprazole.
4.
To identify those patients in whom it would be appropriate to step down
treatment from a high dose (omeprazole 40mg, 20mg, pantoprazole 40mg,
lansoprazole 30mg, esomeprazole 40mg, 20mg and rabeprazole 20mg), to a
maintenance dose (omeprazole 10mg, pantoprazole 20mg, lansoprazole
15mg or rabeprazole 10mg).
Potential saving if CCG 75th Centile reached £123,122.16
4. ARB Formulary
To use the generic formulary Angiotensin –II Receptor agonists (Losartan,
Candesartan, and Valsartan) and prescribe any combinations with a diuretic
or calcium channel blocker as separate agents.
Potential savings made if CCG 75th Centile reached £76,318.15
Brands to generic –to make the most out of patent expiry , outwith
natural price drops
Objective:


To find any patients on a brand description of their medication and
change it to the generic description where possible.
To encourage all prescribing to be the generic name.
Rationale:
In the BNF ‘guidance on prescribing’ it states that ‘non-proprietary’ (or
‘generic’) titles should be used where given to enable any suitable product to
58
be dispensed saving delay to the patient and frequently expense to the health
service.
By using the generic name it is clear to all health care professionals which
drug is prescribed.The BNF states that the only exception to this should be
where bioavailability problems are so important that the patient should always
receive the same brand:
For example:
Beclomethasone cfc-free inhalers must be prescribed by brand to ensure the
correct dose is delivered (Qvar and Clenil have different potencies and drug
deposition)
Carbamazepine
Phenytoin
(NB many practices use the brand description for all antiepileptics to avoid
confusion. Tablets as capsules are not bioequivalent)
Transplant rejection drugs e.g. ciclosprorin, tacrolimus
MR diltiazem
MR nifedipine
MR morphine oral preparations
Oral mesalazine
5. Generic Pioglitazone
To switch patients from the brand Actos to generic drug Pioglitazone.
28 Actos 15mg costs £25.83
28 Pioglitazone 15mg costs £6.61
Potential saving if CCG 75th Centile reached £ 31,020.69
6. Generic Latonoprost
To switch patients from the brand Xalatan to generic drug Latanoprost 2.5mls
Potential saving if CCG 75th Centile reached £22,470.93
59
7. Low cost statins
To reduce usage of branded Pravastatin, Simvastatin, Fluvastatin and
Atorvastatin in favour of low cost generic statins and Simvador (prescribe new
patients as Simvastatin generic). 80mg MR Fluvastatin to be prescribed as 2 x
40mg tablets twice a day.
Potential saving if CCG 75th Centile reached £21,047.13
8. Generic Clopidogrel
To switch patients from the brand Plavix to generic drug Clopidogrel.
28 Plavix costs £35.64
28 Clopidogrel costs £1.95
Potential saving if CCG 75th Centile reached £10,164.58
9. Generic Perindopril
To switch patients from the brand Coversyl (Perindopril Arginine) to the
generic drug Perindopril Erbumine.
28 Coversyl costs £8.27
28 Perindopirl Erbumine costs £1.67
Where patients are on Coversyl Plus (Perindopril Arginine 5mg + Indapamide
1.25mg) to prescribe as separate agents (Perindopril erbumine 4mg and
indapamide 1.5mg)
Please note that: Perindopril Arginine 2.5mg is equivalent to Perindopril
Erbumine 2mg.
Potential saving if CCG 75TH Centile reached £7,652.14
10. Generic Risedronate
To switch patients from the brand Actonel weekly to the generic drug
Risedronate weekly.
4 Actonel 35mg costs £19.12 4 Risedronate 35mg weekly costs £1.12
Potential saving if CCG 75th Centile reached £5,290.96
60
11. 5HT1 Receptor Agonist
To switch patients from the brand Imigran to the generic drug Sumatriptan. To
prescribe sumatriptan in favour of other 5HT1 receptor agonists where
appropriate
6 Imigran 50mg tabs costs £26.54, Imigran 100mg tabs costs £42.90
6 Sumitriptan 50mg costs £1.66
6 Sumitriptan 100mg costs £2.15
Potential saving if CCG 75th Centile reached £56,006.12
Modified release to standard release preparations
Objective:

Whether patients prescribed modified release preparations could be
offered treatment with an immediate release formulation. The patient
will still get the same total daily dose however the frequency may alter.
Rationale:
These preparations are significantly more expensive than the immediate
release formulations and restrict the up or down titrations according to the
patients’ symptoms.
12. Tramadol reviews
1)
Whether patients prescribed Tramadol MR could be offered treatment
with immediate release Tramadol. If this is not appropriate the most cost
effective brand of Tramadol MR will be offered.
2)
To review all patients currently treated with Tramadol with a view to
step down to an alternative analgesic or stop if possible, based on risk of
harm.
Potential saving if CCG 75th Centile reached £49,562.89
61
13. Doxazosin MR to plain Doxazosin
To switch the modified release preparation to standard release.
Please note that the dose needs to be halved when switching from MR to
plain tablets as they are NOT equivalent.
Potential saving if CCG 75th Centile reached £41,688.43
14. Indapamide MR to plain Indapamide
1)
To switch patients from Indapamide MR 1.5mg tablets to Indapamide
2.5mg tablets
2) To switch patients from the brand to the generic drug indapamide.
Potential saving if CCG 75th Centile reached £8,040.97
Most cost effective formulations
Objective:
 To switch patients on to the most cost effective formulation
Rational;
Making simple changes to the formulation of a drug for example switching
from tablets to capsules can make significant cost savings without much
disruption to the patients therapy or the overall treatment outcome. Changes
in drug prices may be due to loss of patent, category M, or change of
manufacturers etc.
15. Prednisolone EC 5mg tablets to plain prednisolone
There is no clinical justification for using enteric coated prednisolone which is
more expensive as no extra gastric protection is gained. Therefore all patients
on the EC preparation can be switched to the plain prednisolone tablets
without any change to their overall therapy.
Potential saving if CCG 75th Centile reached £15,717.12
62
16. Nitrofurantoin 50mg tablets to Macrodantin
A pack of 100 Nitrofurantoin 50mg tablets costs £102.03 compared to a pack
of 30 Macrodantin capsules which costs £6.91 therefore it is more cost
effective to prescribe the capsule form or to switch to 100mg tablets.
Potential saving if CCG 75th Centile reached £63,641.40
17. Omeprazole tablets to capsules
To switch patients on omeprazole tablets to capsules and to prescribe all
omeprazole as the generic.
28 Omeprazole 10mg tabs costs £5.26 28 Omeprazole 10mg capsules costs
£1.24.
Potential saving if CCG 75th Centile reached £13,753.44
18. Nystatin formulation
To switch all patients on Nystatin to the brand Nystan.
Nystan costs £1.80 compared to the generic Nystatin oral suspension which
cost £22.85.
Potential saving if CCG 75th Centile reached £19,564.74
19. Opioid Patches to capsules
Objective:

To reduce prescribing of Buprenorphine and Fentanyl patches in favour
of Morphine capsules (Zormorph) only where appropriate
Rationale:
Fentanyl is a strong opioid similar to morphine, though it is much more potent.
Patches containing fentanyl cost much more than oral morphine. Reserve
fentanyl patches for patients who are intolerant of morphine or who have
swallowing difficulties.
Buprenorphine patches at lower doses are broadly as effective as codeine or
tramadol but much more expensive. Oral analgesics should generally be
preferred as first line therapy in chronic non-cancer pain. Although it has both
63
opioid agonist and antagonist properties this makes little difference to its
clinical use. It is generally used like other opioids in chronic pain.
Buprenorphine patches cost several times more than oral morphine in
equivalent doses.
Potential saving if CCG 75th Centile reached £76,318.15
20. Calcium channel blockers
Objective:
 To switch patients on a CCB to the drug Amlodipine.
Rationale:
As generic amlodipine is now included in category M of the Drug Tariff it
should be the first choice for patients requiring a calcium channel blocker, it is
also the formulary first choice.
Excludes patients on Verapamil, Diltiazem, Nifedipine and Nimodipine.
Potential saving if CCG 75th Centile reached £62,520.20
21. Escitalopram to Citalopram
Objective:

To review escitalopram prescribing in line with LSMG formulary status
Rationale:
There is insufficient evidence to recommend routine use of escitalopram in
primary care as an alternative to citalopram.
Cost effective prescribing. Escitalopram is considerably more expensive than
citalopram. Monthly costs of usual doses from Drug Tariff November 2012:
Escitalopram (10-20mg) £14.91-£25.20
Citalopram (20-40mg) £0.86 - £1.06
Potential Saving if CCG 75th Centile reached: £40,805.16
64
22. Coxib reviews
Objective:


To switch patients from Cox IIs to generic Ibuprofen and Naproxen.
To reduce overall volume of Cox II prescribing.
Rationale:
Coxibs, as a class, are associated with a small excess risk of thrombotic
events compared with no treatment (~3 per 1000 users treated for one year),
and are contraindicated in patients with established CV disease.

Low-dose ibuprofen (≤1200mg/day) and naproxen 1000mg/day
appear to be associated with a lower risk.
Coxibs, as a class, are associated with a lower GI risk than traditional
NSAIDs. However, their GI safety advantage is diminished when they are coadministered with aspirin.


Of the traditional NSAIDs, low-dose ibuprofen is associated with a
lower GI risk than diclofenac or naproxen.
Use of a proton pump inhibitor (PPI) with any NSAID significantly
reduces the risk of GI side effects.
Potential Saving if CCG 75th Centile reached £39,998.39
23. Dutasteride
Objective:

Identify male patients currently prescribed dustasteride 500mcg daily
for benign prostatic hyperplasia and identify whether they could be
switched to finasteride 5mg daily in line with the local pathway for
treatment, if the drug has not been tried prior.
 To switch patients on the brand Proscar to the generic finasteride.
Rationale:
Dutasteride 500mcg costs £29.77* for a box of 30 where as finasteride 5mg
costs £1.68* for a box of 28. Prices correct as of November. LMSG
prescribing pathway places finasteride ahead of dutasteride for prescribing
Potential Saving if CCG 75th Centile reached £35,365.17
65
24. Nasal sprays
Objective:


To switch patients to formulary first choice Beconase.
To prescribe in line with LLR formulary choice
Rationale:
The brand beconase is the cheaper than the generic in this case and it is also
the formulary first choice drug. Beconase costs £2.19 where as the generic
beclometasone nasal spray costs £2.34. There is much prescribing outside of
formulary choice at present.
Potential Saving if CCG 75th Centile reached £27,056.43
25. Melatonin reviews
Objective:

To use cost
preparations.
Rational:
effective
brand
Circadin
over
other
unlicensed
Circadin® is considered first line on the basis of licensing, cost and quality of
the product. As Circadin® is licensed in the UK, its quality is assured and
therefore it is safer than using an unlicensed product. Also to review
indications and efficacy for individual patients
Potential Saving if CCG 75th Centile reached £18,489.92
26. Formoterol increased uptake
Objective:
 To switch patients from Salmeterol and Indacaterol to Formoterol.
Rational:
Formoterol is a long acting beta2 agonist (LABA), pharmacologically different
from salmeterol. Both agents are selective agonists at the beta2 receptor;
however formoterol is a full agonist whereas salmeterol is a partial agonist.
Clinically formoterol has a rapid onset of action (3-5 minutes; similar to
66
salbutamol) and a wide dose range (6-72 mcg/day). It is the preferred LABA in
the Leicestershire Medicines Formulary
Easyhaler® is currently the cheapest formoterol formulation (£24.40 for 120
doses of 12mcg device), and based on this and the favourable characteristics
of the Easyhaler® dry powder device (ease of use, particle size) this is the
recommended formulation in the Leicestershire Medicines Formulary.
Salmeterol has a monthly cost of £33.65 and is not included in the
Leicestershire formulary due to this, its slower onset of action and
unfavourable dose response curve
Potential Saving if CCG 75th Centile reached £16,291.99
27. Erectile dysfunction
Objective:
 To switch patients to Sildenafil ready for patent expiry
Rational:
Sildenafil is due to go off patent in June 2013 and will drop in price soon
afterwards. There will be opportunistic savings for the CCG but further savings
can be made by switching patients currently managed on other
Phosphodiesterase type – 5 inhibitors or from the brand Viagra to sildenafil.
Potential Saving if CCG 75th Centile reached £10,505.98
28. Blood glucose testing strips
Objective:

To switch patients to the low cost blood glucose testing strips: Glucolab
or Omnitest. (this is subject to a workstream on going in this area
across primary and secondary care & with patient involvement)
Rational:
50 Glucolab test strips costs
£9.89
50 Omnitest 3 test strips costs £12.00
Compared to the current formulary suggested testing strips:
Acc-chek Compact
£15.83
67
Contour
£14.85
Freestyle lite
£15.16
Medisense Optimum plus
£14.80
Potential Saving if CCG 75TH Centile reached £…………………..
29. High dose combination, inhaled corticosteroid reviews
Objective;

Patients or regular high dose inhaled corticosteroids should be
reviewed every 3 months; if control achieved, step wise reduction may
be possible.
 Reduce dose of inhaled corticosteroid slowly; consider reduction every
3 months, decreasing dose by up to 50% each time.
Rationale:
Stepping down therapy once asthma is controlled is recommended, but often
not implemented leaving some patients over-treated. There are few studies
that have investigated the most appropriate way to step down treatment. A
study in adults on at least 900 micrograms per day of inhaled steroids has
shown that for patients who are stable it is reasonable to attempt to halve the
dose of inhaled steroids every three months. (British Thoracic Society
guideline)
Potential Saving if CCG 75th Centile reached £59,818.41
Other potential areas include:
 Oral contraceptives - formulary choice
 Drug holidays for patients taking bisphosphonates to reduce harm
 Reduced triple therapy prescribing for COPD in line with NICE ,
national and regional guidance.
 Continue with work on red and black drugs
 Continue with unlicensed specials reviews
68
WEST LEICESTERSHIRE CLINICAL COMMISSIONING GROUP
DRAFT 1 PRESCRIBING GROWTH AND
QIPP ASSUMPTIONS FOR 2013/14
Note: the calculations used to ascertain the assumptions for horizon scanning
will be approved at LMSG in November 2012. The cost calculator produced
nationally will not be published until December 2012; therefore the cost
calculator for 2011 has been used where relevant.
Paper prepared by Jasmeen Islam, Head of Prescribing. This document has been adapted
from a draft paper developed by the LMSG Horizon Scanning Group 2012.
Summary:
Category
New Drugs and Shared Care:
Dementia drugs
Move to ‘Green’ status:
QIPP Savings for 13/14
Patent expiry
Total
Impact for
WLCCG
£2.079million
£400K
£50K*
£1.2 million
£375K
£954K
*arbitrary figure –detailed estimate to follow
:
Note: Additional budget will be required for the management of specific
High Cost Drugs, that will be handed over by East Midlands Specialised
Commissioning Group in April 2013.
1. Basic growth required due to inflation and demographics
To be confirmed
2. Drugs with potential highest cost impact on prescribing budgets
2013-14
Drug / Indication
Indication
Impact
2013-14
Impac
t long
term
H
Dabigatran,
Rivaroxaban /
Apixoban
DVT,VTE
treatment
Secondary
prevention
M
Insulin Degludec
Diabetes
M
H
Dapaxetine
Premature
M
H
Comment /
Action
required
NICE
commissioning
guide for NOA
due April 2013
Price not
determined yet
but likely to
have
significant
implications in
primary care
for type 1 and
type 2
diabetes.
? develop
Estimated
cost for
WLCCG
£50K £100K
£20K
£26K
69
? Phentermine /
Lorcaserin
Dapagliflozin
ejaculation
Obesity
?
?
Diabetes
L
M
Donepezil,
galantamine,
rivastigmine and
memantine
Treatment of
Alzheimer’s
disease
Denosumab
Post
menopausal
osteoporosis
guidance
NICE TAs in
production
NICE TA Mar
13
Review for
2014/15
To include
20% growth.
Current spend
is £80K per
month across
LLR.
tbc
£5K
£ 400K**
£12K
*CCG to consider risk sharing across health economy across primary and secondary care for
new oral anticoagulants, as the volume and cost of the drugs have significant implications.
Although amber/ shared care status, only one month’s treatment is expected in primary care
although in the majority of cases it will be started in secondary care. Service redesign locally
may alter the prescribing status of the drug, with a greater potential impact in primary care
anticipated. This is yet to be discussed / agreed.
**Agreed that funds will follow this drug from LPT through implementation of Dementia
Strategy. Finance to confirm if this is the case. Exact figure to be determined.
3. Drugs identified last year / supported in year with significant impact for 2013-14
Drug / Indication
Indication
Impact
2013-14
Comment / Action required
Dabigatran,
Rivaroxaban /
(Apixoban)
AF prevention
and treatment
H
Rivaroxaban
Treatment of DVT
and prevention of
recurrent DVT
and PE following
acute DVT
M
Minimal prescribing to date (<£1k per annum)
but will increase as patients not at target are
identified in primary and secondary care. See
above. £300K - £792K
Prescribing starting October 2012. Likely to
request extension to other patient groups
covered by NICE TA. TBC
Tapentadol SR
Chronic pain
H
Ticagrelor
ACS NSTEMI
M
Ivabradine
Chronic Heart
Failure
M
Minimal prescribing to date in primary care
(<£1k per annum) as still RED but likely to
change as TAS audit due shortly. Small
numbers prescribed in UHL at present. High
impact possible when change to Green status
£200K - £564K based on 12% usage of 13%
population with chronic pain.
Prescribing to commence end 2012.
Additional indications (still within NICE) likely
to be requested in next year. £30K
Increase from £40k per annum 2010/11 to
60K 2011/12. If at same rate potential for
2013/14 estimate is £50K (+ £13K for this
year)
Recommendations
 New Drugs included in the summary above (Medium-High impact) should be
considered as part of Local Operational Plans for 2013-14.
70




Drugs which are approved by NICE Technology appraisals during the year and
requested through the TAS process should be funded by PCTs within 3 months of
request
Further work needs to be done on those drugs with highest impact
Further consideration required on process for CCG management of excluded, non
specialist drugs e.g. Botulinum toxin
Cost savings from generic savings to be estimated / maximised by primary care
Shared Care Agreements 2012-13
Shared Care agreements supported November 11- Oct 2012. Impact ≤ £15k per annum
Drug
Hydroxychloroquine
Tredaptive
Midazolam
Ulipristal acetate
Indication
Inflammatory arthritides
Hyperlipidaemia
Seizures
Preop treatment uterine
fibroids
Full /
Simple
Date Approved
Annual Cost (£K)
F
Nov 11
4
S
S
Dec 11
July 12
4
5
S
Sept 12
2
TOTAL
15K
Other:
Discontinuation of epanutin & impact of alternative formulation: £50K
Hydrocortisone extended release for adrenal insufficiency: £ 20K
Mirabegron: £4K
Gliptin uptake for diabetes is increasing by £250K each year across LLR. Therefore predict a
£83K increase over 2013/14
Exanatide and Liraglutide: £250K due to QIPP schemes
Vitamin D as a result of Chief Medical Officer Guidance: £30K
71
Horizon Scanning 2013-14
Drugs Included:
 New Drugs / Indications included in Prescribing Outlook Sept 2012 with potential
additional cost impact. There are a variety of criteria for inclusion in this document, for
example drugs likely to provide a significant improvement in care, first in class, high
volume, significant effect on service delivery, media interest.
 Drugs launched late 2012-13 which have not been through TAS / LPT Prescribing
Group.
 All are drugs which are in tariff and therefore likely to be prescribed across the
Leicestershire community.
There may be other drugs launched in 2013-14 which
 individually have a low cost impact but which cumulatively may have a cost pressure
associated; or
 although not of significance nationally and therefore not included in Prescribing
Outlook may be relevant to the Leicestershire community.
Not included:
 PbR excluded drugs
 Cancer drugs (except hormone therapies)
Assumptions
 Drugs will only be prescribed for the indications stated
 All eligible patients treated unless otherwise specified
 Impact is based on the whole community – in practice there will be differences
between CCGs
 An estimate has been included for steady state prescribing. In the majority of cases
there will be a gradual uptake in new patients and throughout the year
For the purpose of this document cost impact, taking into account rate of uptake is
categorised as:
Low (L) = ≤ £15k, Medium (M) = £15-100K, High (H) = > £100k
72
Drug / Indication
Comment
Launch Date
(u=uncertain)
National
Population
Prevalence
Estimate
Leicestershire community per annum
No. Of patients
Likely
Cost
steady state
2013-14
impact
x cost =
2013-14
Cost impact steady state
Chapter 1 Gastrointestinal
10-15% but only
33-50,000
1/3 visit GP
TBC price unknown
Yes
??
Linaclotide
Irritable bowel
syndrome with
constipation
2012
PIII trials show response rate cf
placebo 12.7% vs. 3% on ≥ 30%
reduction abdominal pain
Apixaban
Stroke prevention in
atrial fibrillation
2012
AVERROES published –
ARISTOTLE trial
NICE anticipated April 13
As Dabigatran /
Rivaroxaban
Rivaroxaban
Treatment of PE and
prevention of
recurrent VTE
Non-inferiority to standard care shown
in PIII trial
PE
77 per 100,000
2012/13
NICE anticipated July
2013
Dabigatran
VTE treatment
2013
Apixoban
VTE Treatment
2013? May
Dabigatran
Long term secondary
prevention of VTE
2013
Apixoban
VTE prevention in
medically ill patients
2013
Prasugrel
ACS, Medical
management
VTE 132 per
100,000
Chapter 2 Cardiovascular
Will compete with Dabigatran /
Rivaroxaban
Local opinion is that this is
superior
Traffic
Light
Additional opportunity to
offset costs
Long term
Green
Cost of existing treatments but
they are likely to be lower than
linaclotide
Y
See
dabigatra
n/
rivaroxab
an
Green
As per Dab/ Riv – offset cost of
warfarin ( minimal) and Anticoag
monitoring
No
L
Amber
Reduced admissions / events
770 patients LLR
1,320
Likely to go with selected
groups as per other indications
? % - TBC
RE-COVER
Non-inferiority to standard care
NICE timeline tbc
AMPLIFY trial ongoing
As above
tbc
As above
tbc
RE-MEDY, RESONATE not yet fully
published
As above
tbc
ADOPT trail published
Superiority shown over enoxaparin
2013
Possible faster onset of action but
increased bleeding risk may limit use
TRILOGY trial still to be published
Cost £620 per year cf £710 ticagrelor
and £30 clopidogrel
Phentermine
topiramate
2013
CONQUER study – 62% of patients
>5% decrease in wt after 56/52 cf 21%
on placebo
Current views received from
cardiology indicate low
probability of use but may
change.
Chapter 4: Central Nervous System
2010 – 26% men Will compete with Orlistat but
and women >16
likely to be more expensive
obese
Current prescribing of Orlistat is
?
Amber /
green
73
Drug / Indication
Launch Date
(u=uncertain)
Obesity
Comment
National
Population
Prevalence
Estimate
Extension study SEQUEL 52/52 -10%
wt loss vs. -1.8% placebo
NICE appraisal anticipated July 2013
42% overweight
Liraglutide
Obesity
2013
Lorcaserin
2013
Likely to be used preferentially in
overweight diabetic patients
Dose higher than for diabetes
BLOOM – 47.5% lost >5% weight cf
20.3 % placebo NICE appraisal to
start end 2012
As Phentermine
Insulin degludec
Ultra long action Lower incidence of
hypos
4.45% in 2011
LLR higher than
this
About 10% have
Type 1 disease
Type 1 and 2 diabetes
2012
Insulin degludec /
insulin aspart
2013
Dapagliflozin
Type 2 Diabetes
Cost £183 month cf £32 month
Orlistat
?
likely to be more expensive than
Orlistat
?
Chapter 6: Endocrine
Likely to be up to 30% more
than current long acting
analogues
Based on 10% uptake price
+20% year 1 £40k, Yr 2 £80k
Yr 3 £120k
L
Traffic
Light
Additional opportunity to
offset costs
Long term
Amber
Yes
M
Green
Reduced hospital admissions
from hypos
Likely to be more expensive as
first in class
If 10% higher cost of gliptins
and based on gliptin uptake (
appendix)
Yr 1 + £5k
but £96k by year 5
Similar to Dapagliflozin
Yes
L/M
Green
Offset cost of gliptins /
exenatide
?
L
Green
Hydrocortisone 10 mg, net price
30-tab pack = £43.13
If price x2 and 20% patients =
£10k
Chapter 7
May be similar or higher at
approx £30 per month
similar to 3rd line choice
Solifenacin £14 per month
higher than first line choice
Based on 20% of 400 patients =
80
?
L
Amber
Y
L/M
Green
Combination
First in new class of drugs. Inhibits
renal-glucose reabsorption. Similar
HBA1c reductions to other classes of
new oral antidiabetic agents
4.45% in 2011
LLR higher than
this
Canagliflozin
Type 2 Diabetes
2013
Hydrocortisone oral
modified release
Adrenal insufficiency
2012
As above
As above
Mirabegron
OAB
2012
Alternative to antimuscarinic drugs.
Could be attractive if non response or
intolerant
2012
Leicestershire community per annum
No. Of patients
Likely
Cost
steady state
2013-14
impact
x cost =
2013-14
Cost impact steady state
reducing
2011/12 = £431k
2012/3 Q1+2 = £35k
100 patients LLR
Once daily formulation More expensive
than standard release but Generic
preps already increased in price
LLR 390 patients
+
74
Drug / Indication
Comment
National
Population
Prevalence
Estimate
Launch Date
(u=uncertain)
Dapoxetine
Premature ejaculation
Already available on private
prescription £76 for 3 tablets
Uncertain
Likely to be high media attention / high
demand unless prescribing guidance
issued
Strontium ranelate
Osteoarthritis
Uncertain
Add on therapy
Prevalence 2030%.
Prevalence
Lifelong 2-5%
Leicestershire community per annum
No. Of patients
Likely
Cost
steady state
2013-14
impact
x cost =
2013-14
Cost impact steady state
£13, 440
1% of male patients LLR =1000
?
L
x £79 = £79k
Traffic
Light
Additional opportunity to
offset costs
Long term
Green
Chapter 10 Musculoskeletal
By 65 10%
people have
major disability
due to OA
?
?
Green
The following drugs have been omitted as 1) cost likely to be equivalent / competitive with existing therapies; 2) place in therapy difficult to establish. 3) non
specialist excluded drugs will be included in MESCG bids for 2013/14 4) Low patient numbers
Drug
Vorapaxar (2)
Glycopyrronium bromide (1)
inhaler
Aclinidium inhaler (1)
Indacaterol (1)
Lisdex amphetamine dimesylate
Indication
atherosclerosis, secondary prevention of
CV events
COPD
Drug
Alogliptin (1)
Indication
Type 2 diabetes
Lixisenatide (1)
Type 2 diabetes
COPD
COPD
ADHD
Botulinum Toxin (3)
Tofacitinib (3)
Ingenol mebutate gel (1)
Lomitapide (4)
Overactive bladder
Rheumatoid arthritis
Actinic keratoses
Hypercholesterolaemia
See Prescribing Outlook for further details
NICE Guidance with potential primary care impact Due 2013-14
(Those in bold considered by group to be most significant)
Technology Appraisals
Acute coronary syndrome - rivaroxaban
Bipolar disorder (children) - aripiprazole
Bowel function – Methylnaltrexone
Diabetes (type 2) - dapagliflozin
Therapeutic Area
Cardiovascular
CNS
Digestive
Endocrine
Date due
Jul-13
Aug-13
Nov-13
Mar-13
75
Hepatic encephalopathy - rifaximin (maintenance)
Hyperuricaemia (symptomatic gout) - pegloticase
Obesity (with co-morbidity) - lorcaserin
Digestive
Musculoskeletal
Endocrine
Oct-13
May-13
Oct-13
Prostate cancer (castrate-resistant) - denosumab (bone metastasis)
Pulmonary embolism (acute treatment, VTE prevention) - rivaroxaban
Rheumatoid arthritis - adalimumab, etanercept, infliximab (TA130), certolizumab
pegol (TA186) and golimumab (TA225 part review) - review
Rheumatoid arthritis - tofacitinib
Schizophrenia or bipolar disorder - loxapine
Cancer/Urogenital
Cardiovascular
Nov-13
Sep-13
Musculoskeletal
Musculoskeletal
Mental Health
Jan-14
Sep-13
May-13
Stroke and systemic embolism (prevention, non-valvular atrial fibrillation) - apixaban
Cardiovascular
Apr-13
76
Potential Cost Savings
Patent Expiries of note
Drug
Dipyridamole + Aspirin
Rivastigmine hydrogen tart
Irbesartan
Tolterodine tartrate
Rabeprazole
Entacapone
Desogestrel
Montelukast sodium
Dorzolamide + Timolol
Zoledronic acid
Raloxifene HCl
Rizatriptan
Telmisartan
Memantine HCL
Escitalopram oxalate
Expiry Date
July 12
July 12
Aug 12
Sept 12
Nov 12
Nov 12
Dec12
Feb13
Mar 13
May 13
Aug 13
Aug 13
Dec 13
Apr 14
May 14
Further Considerations




Paediatric extension challenges may increase time
to expiry
Reduction in generic price may take 3-6/12 and
magnitude may vary – estimate 50-80%
Full year benefits will not be seen until 2014/15
Formulary Working Party will consider choices
where appropriate at meetings in 2013
Ackknowledgement: LMSG Horizon Scanning Group
Appendix 1: Gliptin uptake LCRPCT / Leic City PCT 2008- 2012
Year
Total Actual Spend Primary care
(epact data )
1
2008/9
£50k
2
2009/10
£125k
3
20010/11
£400K
4
2011/12
£740k
5
2012/13
£960k
Q1 x4
77