The perils of passive medicines optimisation – and how to overcome them

The importance of medication management cannot be underestimated – the NHS has released guidance on the management of prescribing costs as a result of the burden it’s placing on budgets.

David Englefield, managing director of Spirit Healthcare, outlines a simple way for CCGs – and, consequently, general practices –  to save money on their prescribing budget.

There isn’t a CCG in England that’s not actively focused on getting the most from its prescribing budget. But it’s a race that never ends. Medicines optimisation is a hostage to the dynamics of modern-day healthcare, with the ever-increasing demand for medicines and the cost of new innovations often combining to neutralise the impact of cost-saving strategies.

The figures speak for themselves. In 2016, the number of primary care prescriptions dispensed in the community passed 1 billion for the first time. It increased again last year. And though the cost of primary care prescribing fell fractionally by 0.4% in 2017, it still exceeded £9bn and was higher than every year bar one since 2010.

Battle of the budget

As the average number of prescription items a year per person in England continues to climb – it has grown from 15 to 20 since 2006 – the battle to trim the prescribing budget gets ever more difficult. The subsequent pressure on medicines management teams is as intense as it is relentless. However, with a targeted approach to formulary management and a laser focus on implementation, there are simple, sustainable savings that can be made without compromising patient outcomes.

Minimal costs maximum care

The focus on minimising prescription costs whilst maintaining the quality of care has seen CCGs deploy a range of strategies to unlock savings. But, as research published in the BMJ earlier this year highlights, there’s limited evidence of a definitive model that works. The majority of strategies have focused on drugs, with a natural emphasis on encouraging generic prescribing. There have been some successes, but the outcomes have largely been variable.

According to the BMJ study, which described a new method of identifying potential cost-savings in community prescribing due to large variations in cost, the biggest opportunity for savings is in glucose blood testing reagents. Spending on glucose blood testing agents, which accounts for around a fifth of all diabetes prescribing costs in England, has increased by more than 30% since 2005, exceeding £180m in 2016/17.

The BMJ study identifies possible savings of around £12m in this key area, approximately half of which, it says, are ‘practically achievable’.

Making savings ‘eminently possible’

In fact, those savings are eminently possible – and the evidence is there to prove it. For example, two CCGs in Greater Manchester Medicines Management Group (GMMMG) – Bury CCG and Heywood, Middleton and Rochdale (HMR) CCG – realised combined annualised savings of almost £240,000 when their GP practices switched appropriate type 2 diabetes patients to a preferred system of blood glucose monitoring in 2015/16. This simple change alone yielded cost reductions of around £10,000 a month in each CCG.

Certainly, the GMMMG experience shows that medical devices can provide low hanging fruit for medicines management teams looking to save money without diminishing patient care. Formularies often list a range of products that fulfil an identical purpose and demonstrate equivalent clinical outcomes – but those products typically have huge variation in price. By consolidating formulary choice to a preferred system, significant reductions – and indeed more effective patient utilisation – are achievable.

However, revising the formulary – on its own – is not enough. Formulary decisions need active implementation if they’re to realise anticipated gains. Changing a formulary, then leaving GP practices to their own devices – no pun intended – simply does not work. In Bury and HMR CCGs, for example, the savings achieved were almost 700% greater when change was actively implemented.

So how can you reduce the unnecessary and avoidable costs that are eating into your prescribing budget? It’s all about evaluation, collaboration and implementation – in a pro-active way. Here’s a simple step process to achieve rapid and sustainable medicines optimisation.

Step 1: Identify the opportunities

Examine your formulary to identify any high-cost areas of prescribing where you have multiple products in the same classification that offer clinical equivalence but at variable cost. Self-monitoring blood glucose systems (SMBG), which link to prescription-only SMBG strips required in high-volume, are often a common example. Typically, formularies contain multiple options where the pricing is not relative to any clinical advantage.

Step 2: Rationalise your formulary

Evaluate all products in the classification for clinical effectiveness, utility and cost – and select a preferred option based on your own value criteria. Then consolidate your formulary to list only the preferred choice. The rationale here is simple: ‘shopping basket’ formularies that list multiple ‘clinically-neutral’ items at variable prices risk prescribers choosing high-cost products that do not provide any clinical advantage. If CCGs wish to save money and optimise the prescribing budget, these high-cost items need to be removed from the shopping basket. This is one of the few areas where choice can be costly.

Step 3: Implement the change

Evidence suggests that adopting a passive approach to medicines optimisation rarely succeeds; changing prescribing behaviours does not happen by chance. Active implementation, which can be delivered through collaboration with third parties with proven success rates, is the most effective means of realising cost-savings quickly and sustainably.

The active implementation process itself breaks down into four key steps:

  1. Communicate the change. It’s vital that all GP practices within a CCG are made aware of the formulary change and the reasoning behind it. Through proactive engagement, primary care organisations – including GP practices and community pharmacies – can establish a good understanding of what the CCG is hoping to achieve and prepare for the next stage of implementation.
  1. Identify the right patients. This step is crucial. It may not be appropriate to switch every patient in the target therapy area of your chosen product. It is therefore important to carry out transparent audits of practice lists to identify suitable patients. Audits are typically conducted by nurses working on behalf of the implementation team, who apply strict criteria to patient selection. The final list should be validated and authorised by the specialist lead at the practice.
  1. Train and educate patients. The next step is to introduce the new product to patients and train them on how to use it. This is normally carried out via nurse-led ‘switch clinics’, held at the practice, where small groups receive practical training with the new product and are asked whether they would like to be switched to it. The clinics also present a valuable opportunity for nurses to provide education that can help patients better manage their condition.  With adherence still a major barrier to medicines optimisation, switch clinics provide high-value patient engagement that can support the long-term utilisation of treatments.
  1. Switch. The final step is to physically make the switch. This typically involves an implementation team nurse updating practice data so that the repeat prescription details of every consenting patient can be amended accordingly.

The targeted approach to formulary management, underpinned by a collaborative focus on active implementation, is certainly worth considering. Evidence shows that in the areas where the model has been applied, CCGs have been able to realise rapid cost-savings. With implementation teams able to conduct multiple clinics across a day, practices can quickly switch large numbers of patients to more cost-effective products – and make immediate savings that may otherwise take months to achieve if they adopted a more passive approach.

That’s why, as CCGs battle the enduring challenge of medicines optimisation, the most effective medicines management teams will be those who work with implementation partners that can help them drive targeted and productive formulary change.

Effective formulary management can make a huge difference to prescribing budgets – but only if strategies are actively implemented. Because left to their own devices, prescribing habits won’t change by chance.

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