Items which should not be routinely prescribed in primary care Review and update Julie Wood, Chief Executive, NHS Clinical Commissioners Bhavana Reddy, Specialist Pharmacist Advisor, NHS England www.nhscc.org
Aim of the meeting To provide an overview of: • Overall objective of the consultation • Proposals for Clinical Commissioning Group (CCG) commissioning guidance - 9 items • To provide an opportunity for you to share your views and ask questions about the proposals. www.nhscc.org
Agenda - webinar 10:00 – 10:05 Introductions and aims Julie Wood Chief Executive, NHSCC 10:05 – 10:30 Overview - Items which should Julie Wood not be routinely prescribed in primary care Bhavana Reddy, Specialist Pharmacist Advisor, NHS England 10:30 – 11:00 Questions & feedback www.nhscc.org
Overall objective • Last year 1.1 billion prescription items were dispensed in primary care at a cost of £9.2billion. • It is important that the NHS achieves the greatest value from the money that it spends. We know that across England there is significant variation on what is being prescribed, at what price and to whom. • In addition, patients often receive medicines which have been proven to be ineffective, or for which there are other more effective and/or cheaper alternatives This object of this work is to support CCGs to remove unwarranted variation where it exists, and to provide consistent national clinical commissioning advice to inform local decisions which need to be taken to support effective prescribing practices www.nhscc.org
Background The Low Priority Prescribing project have published the following CCG guidance jointly with NHS Clinical Commissioners (NHSCC): Wave 1 - Nov 2017 Items which should not be routinely prescribed in primary care Recommendations on 18 items Wave 2 - March 2018 Conditions for which over the counter items should not routinely be prescribed in primary care Recommendations on 35 minor conditions + vitamins, minerals and probiotics Wave 3 - current Items which should not be routinely prescribed in primary care Review and update of 1 of the 18 items + 8 new items www.nhscc.org
Wave 1 – evaluation (18 items) From April to Sept 2018 prescribing data was reviewed for the 18 items included in wave 1 CCG guidance • From April to Sept 2018 spend on the 18 items has reduced by £12.7m from £61.4m in 2017/18 to £48.7m, a reduction of 20.7%. • Volumes prescribed have reduced by 21.5%. • An estimate in number of patients in receipt of prescriptions is Percentage change in spend April to September 2018 20.2%. compared to April to September 2017
Evaluation continued… • In 2017/18, seven of the items accounted for 81% of the total spend of all 18 items. • These are the products that will have biggest impact on savings: Liothyronine; Lidocaine Plasters; Trimipramine; Once daily tadalafil; IR fentanyl; Doxazosin; Co-proxamol. • Together these accounted for £4.7m or 74% of the £6.4m reduction in spend between July – Sept 2018. • There are safety concerns with co- proxamol and dosulepin and so it’s important to track change in patient numbers. • Between July – Sept 2018 there were 1,391 fewer patients in receipt of prescriptions for co-proxamol and 10,329 fewer patients in receipt of for dosulepin. www.nhscc.org
Evaluation continued... • A CCG survey and visits are currently underway to understand the challenges and barriers to implementation of the guidance and consider additional support to CCG if required. • Unintended consequences (actions that are not for seen or intended by the recommendations) are being monitored and the clinical working group will revisit these in Jan 2019. e.g. Interactions with secondary care and consequent costs www.nhscc.org
Wave 3 - how we arrived at the list of new items • Feedback from CCGs demonstrates that a national co-ordinated approach and CCG guidance, outlining national recommendations, has been a helpful lever to initiate and support local decision making and to implement changes. • As with previous waves of the Low Priority Prescribing Project, PrescQIPP & NHSCC identified further items - in conjunction with member CCGs - that they consider need not be routinely prescribed in primary care. • The NHS England and NHSCC joint clinical working group developed recommendations to support the proposals from member organisations. • The intention is to coordinate a national consultation on these recommendations which will support but not replace local engagement, consultation and decision-making, reduce duplication and reduce variation. www.nhscc.org
How we arrived at the list of new items As with previously published CCG guidance the joint clinical working group reviewed the recommendations for the 18 items included in the wave 1 and considered 8 new items based on the existing criteria: • Items of low clinical effectiveness, where there is a lack of robust evidence of clinical effectiveness or there are significant safety concerns • Items which are clinically effective but where more cost-effective products are available, this includes products that have been subject to excessive price inflation. • Items which are clinically effective but due to the nature of the product, are deemed a low priority for NHS funding. www.nhscc.org
How we developed the proposals • Proposals have been developed by the joint clinical working group. Members include: NICE, DHSC, Royal Pharmaceutical Society, PrescQIPP, NHS BSA, CCGs, RCGP, MHRA and GMC. • Organisations represented on the joint working group have, taking into account previous feedback and evidence reviews, identified items in the categories which meet some or several of the criteria for inclusion. • The joint working group has then prioritised items based on the following criteria, whilst also considering equalities, health inequalities and unintended consequences: Safety issues Cost to the NHS Evidence of efficacy Strong clinician or patient feedback Degree of variation in prescribing Evidence of alternatives Existing NICE advice www.nhscc.org
Recommendation options The group assigned one or more of the following recommendations to items, advising CCGs: • that prescribers in primary care should not initiate {item} for any new patient; • that prescribers in primary care should not initiate {item} that cost {price} for any new patient. • to support prescribers in deprescribing {item} in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change; • to support prescribers in deprescribing {item} that cost {price} in all patients and where appropriate ensure the availability of relevant services to facilitate this. • if, in exceptional circumstances, there is a clinical need for {item} to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional; • that all prescribing should be carried out by a specialist; and/or • that {item} should not be routinely prescribed in primary care but may be prescribed in named circumstances such as {circumstance}. www.nhscc.org
Proposals for updated CCG guidance A cream or gel believed to relieve pain in various musculoskeletal Rubefacients conditions • The 18 items included in Items which should not be routinely prescribed in primary care: Guidance for CCGs were reviewed by the clinical working group, with one update proposed for rubefacients . • The update to rubefacients proposes exclusion of capsaicin cream from the current recommendations. This would mean the capsaicin cream could be prescribed in line with NICE guidance. • We are consulting on the proposal to exclude capsaicin cream only and not the inclusion of rubefacients as a whole . www.nhscc.org
8 new items - uses Items Typical use Amiodarone Arrhythmias Dronedarone Some types of atrial fibrillation Cardiology Aliskiren Essential hypertension Minocycline Acne Silk Garments Eczema or dermatitis Dermatology Bath and shower Dry and pruritic skin conditions preparations Blood glucose testing strips Type 2 Diabetes Needles for Pre-Filled and Type 1 & 2 Reusable Insulin Pens www.nhscc.org
8 new items - categories Low evidence of effectiveness Cost-effectiveness or safety issues Amiodarone Aliskiren Blood glucose testing strips for Dronedarone type 2 diabetes Bath and shower preparations for Needles for Pre-Filled and Reusable dry and pruritic skin conditions Insulin Pens Minocycline for acne Silk Garments Cardiology Dermatology Diabetes www.nhscc.org
Proposals for new CCG guidance Cardiology Recommendations • Advise CCGs that prescribers should not initiate in primary care Amiodarone for any new patient. Dronedarone • Advise CCGs that if, in exceptional circumstances, there is a clinical need to be prescribed, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional. • Advise CCGs that prescribers in primary care should not initiate Aliskiren aliskiren for any new patient. • Advise CCGs to support prescribers in deprescribing aliskiren in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change. www.nhscc.org
CCG variation www.nhscc.org
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