Items which should not be routinely prescribed in primary care - - PowerPoint PPT Presentation

www.nhscc.org

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 not be routinely prescribed in primary care Julie Wood 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

From April to Sept 2018 prescribing data was reviewed for the 18 items included in wave 1 CCG guidance

Wave 1 – evaluation (18 items)

• 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 20.2%.

Percentage change in spend April to September 2018 compared to April to September 2017

www.nhscc.org

• 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.

Evaluation continued…

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

• 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.

Wave 3 - how we arrived at the list of new items

www.nhscc.org

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.

How we arrived at the list

• f new items

www.nhscc.org

• 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:

How we developed the proposals

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

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}.

Recommendation

• ptions

www.nhscc.org

• 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.

Proposals for updated CCG guidance

Rubefacients

A cream or gel believed to relieve pain in various musculoskeletal conditions

www.nhscc.org

8 new items - uses

Blood glucose testing strips Type 2 Diabetes Needles for Pre-Filled and Reusable Insulin Pens Type 1 & 2 Minocycline Acne Dermatology Silk Garments Eczema or dermatitis Bath and shower preparations Dry and pruritic skin conditions Amiodarone Arrhythmias Cardiology Dronedarone Some types of atrial fibrillation Aliskiren Essential hypertension Items Typical use

www.nhscc.org

8 new items - categories

Cost-effectiveness Aliskiren Blood glucose testing strips for type 2 diabetes Needles for Pre-Filled and Reusable Insulin Pens Low evidence of effectiveness

• r safety issues

Amiodarone Dronedarone Bath and shower preparations for dry and pruritic skin conditions Minocycline for acne Silk Garments Cardiology Dermatology Diabetes

www.nhscc.org

Proposals for new CCG guidance

Cardiology Recommendations Amiodarone Dronedarone

• Advise CCGs that prescribers should not initiate in primary care

for any new patient.

• 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

• ther healthcare professional.

Aliskiren

• Advise CCGs that prescribers in primary care should not initiate

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

Proposals for new CCG guidance

Dermatology Recommendations Bath and shower preparations for dry and pruritic skin conditions

• Advise CCGs that prescribers in primary care should not initiate

bath and shower preparations for any new patient.

• Advise CCGs to support prescribers in deprescribing bath and

shower preparations in this category and substitute with "leave-on" emollients and, where appropriate, to ensure the availability of relevant services to facilitate this change.

Minocycline for acne

• Advise CCGs that prescribers in primary care should not initiate

for any new patient.

• Advise CCGs to support prescribers in deprescribing in all

patients and, where appropriate, ensure the availability of relevant services to facilitate this change.

Silk Garments

www.nhscc.org

CCG variation

www.nhscc.org

Proposals for new CCG guidance

Diabetes Recommendations Blood glucose testing strips for type 2 diabetes

• Advise CCGs that prescribers in primary care should not initiate blood

glucose testing strips that cost >£10 for 50 strips for any new patient

• Advise CCGs to support prescribers in deprescribing blood glucose

testing strips that cost >£10 for 50 strips and where appropriate, ensure the availability of relevant services to facilitate this change.

Needles for Pre-Filled and Reusable Insulin Pens

• Advise CCGs that prescribers in primary care should not initiate insulin

pen needles that cost >£5 per 100 needles for any new diabetes patient

• Advise CCGs to support prescribers in deprescribing insulin pen needles

that cost>£5 per 100 needles and, where appropriate ensure the availability of relevant services to facilitate this change.

There is a wide selection of effective testing strips and needles available that are less than £10 and prescribers and patients will be supported to use these in line with best practice on when and how often to test.

www.nhscc.org

CCG variation

www.nhscc.org

• 3 month national public consultation will run from 28 Nov 2018 to

28 Feb 2019*

• Opportunity to provide views on the proposals.
• Online consultation survey

https://www.engage.england.nhs.uk/consultation/items-routinely- prescribed-update/

• Range of other face to face and online events.
• Reponses can also be send to england.medicines@nhs.net
• Written responses or further questions can be sent to:

NHS England, PO Box 16738, Redditch, B97 9PT * We are unable to accept responses after this date

Consultation

www.nhscc.org

During the national consultation CCGs are encouraged to provide a response to based local consultation and engagement activities which could include:

• the CCG’s own perspective on the guidance;
• the outcome of any relevant local consultations; and/or
• local engagement with patient participation groups, local community

groups representing people with protected characteristics, Healthwatch and/or discussion with the local overview and scrutiny committee of the Local Authority

Local engagement

www.nhscc.org

• Feedback from todays meeting will be added to other

responses.

• Taking into account the consultation responses CCG

commissioning guidance will be further developed.

• Guidance aims to support CCGs with appropriate use of

prescribing resources.

• CCGs would be expected to take this into account in formulating

local polices, and for prescribers to reflect local policies in their prescribing practice.

Next steps

www.nhscc.org

• 1. How do you feel about the proposed recommendations

for the 9 items, to be included in the Clinical Commissioning Group (CCG) guidance?

• 2. Do you feel that these proposals would impact on any

particular groups of the population?

• What do you think this impact would be?

Questions

www.nhscc.org

Questions not answered today can be sent to

england.medicines@nhs.net

Thank you