The use of medicines is the most common therapeutic intervention in the NHS, and medicines continue to constitute a significant element of total NHS spend.1 Total UK NHS spending on medicines (GP and hospital):
- grew 3.5% (compound annual growth rate) between 2007 and 2011
- was £13.6bn (list prices) in 2011.
Most patients derive benefit from medicines, but the harm prescribed drugs can cause, and drug wastage to the NHS, are probably under-recognised. To address these issues, in 2000 the Department of Health (DH) published Pharmacy in the future,2 setting targets for the implementation of medicines management schemes in all primary care organisations. A similar scheme was proposed for hospital services in ?A spoonful of sugar: medicines management in NHS hospitals, in 2001.3 The overall aim of these schemes was to:
- improve health outcomes
- reduce NHS waste
- help patients to get the best from medicines.
The current approach to medicines management grew out of this early work of trusted prescribing advisers to health authorities, primary care groups, and primary care trusts, and continues in the new NHS landscape.
Recent NHS changes focus on outcomes-based commissioning and the needs of patients. These recent changes are all about creating a stronger voice for patients and are underpinned by the new NHS architecture, which now includes:
- NHS Employers
- clinical commissioning groups (CCGs)
- Public Health England
- Healthwatch England
- local Healthwatch organisations.
The Care Quality Commission and Monitor ensure appropriate quality among providers. The commissioning aspiration for 2013/14 is clearly outlined in Everyone counts: planning for patients 2013/14, which sets out the incentives and levers to be used for service improvement (from April 2013), with improvement driven by clinical commissioners.4 Overall, there is a renewed focus on patient outcomes rather than processes, extension of choice and competition, and increased autonomy for NHS foundation trusts regulated through the creation of a licence issued by Monitor. Medicines optimisation reflects this change of focus and spans and supports all five domains of the NHS Outcomes Framework?(see Box 1, below).5
Box 1: NHS Outcomes Framework ‘five domains’5
- Domain 1 - preventing people from dying prematurely
- Domain 2 - enhancing quality of life for people with long-term conditions
- Domain 3 - helping people to recover from episodes of ill health, or following injury
- Domain 4 - ensuring that people have a positive experience of care
- Domain 5 - treating and caring for people in a safe environment; and protecting them from avoidable harm.
Medicines management versus optimisation - what is the difference?
Terms such as 'medicines management' and 'medicines optimisation' do not have a commonly accepted meaning. Medicines management and prescribing, as enabling services, have been around for some time but mean different things to different people. In the past, medicines management has been seen by some mainly as a process to control budgets and expenditure.
For example, in a recent survey carried out by MGP, publishers of Guidelines in Practice,6 18% of respondents stated that they did not know the difference between medicines management and medicines optimisation. Of the 75% of respondents who gave a description, comments ranged from 'it is unclear', to 'I use it to mean the same thing', and 'there is no difference' (see Figure 1, below). Since the majority of respondents to the survey were clinicians (45% GPs, 10% hospital doctors, 25% pharmacists, 13% nurses), this lack of clarity indicates that there is some work to be done.
Encouragingly, other feedback from the MGP survey identified an apparently clear distinction between how the two terms are perceived: medicines management is seen to be more about cost and process, medicines optimisation about quality and outcomes.6 The former view has, in part, been driven by the nature of reporting about medicines and the NHS, which tends to focus on the cost of medicines. Over time, this has fuelled a view that medicines are a cost that needs to be controlled. Little thought was given to why a medicine was given in the first place, and what the ideal outcome should be for the patient. Instead, systems and processes focused on budgets, cost pressures, formularies, and performance management (aimed at controlling growth, for the most part), and prescribing advisers were tasked with delivering results.
The first real attempt to a more outcomes-based approach was in the Primary Care Clinical Effectiveness (PRICCE) scheme in East Kent,7 as described by the National Primary Care Research Centre in 2000. The PRICCE scheme demonstrated that outcomes-based approaches could result in changes in physician behaviour and improve the management of chronic conditions.7 The Quality and Outcomes Framework (see www.hscic.gov.uk/qof) introduced a dynamic that drove up the more appropriate, evidence-based use of specific medicines and began a culture shift towards an outcomes-based approach, particularly in primary care.
This approach recognised that the way medicines are used cuts across every aspect of the NHS and can have a significant impact on improving patients’ conditions throughout their lives. Optimising care means:
- increasing use of evidence-based medicines in preventing disease
- implementing better systems for managing patients
- bringing better care and improved outcomes for patients.
Benefits of medicines optimisation
The medicines optimisation process will help healthcare service commissioners and providers to:
- focus on improving outcomes for patients by promoting high-quality, cost-effective use of medicines
- continuously improve the appropriate, safe, and effective use of medicines by doctors and other healthcare professionals
- promote close collaboration between professionals working in different healthcare and social care settings, putting patients at the centre
- help provide seamless, consistent, high-quality services resulting in health gain and improvement for patients.
On its website, the Royal Pharmaceutical Society encapsulates the concept of optimising patient benefit and outcomes through rational use of medicines as part of patient care:8
'Medicines management is a part of the wider medicines optimisation agenda.It focuses on the prescribing of medicines, the impact on the prescribing and drugs budget, the access to high-risk and high-cost medicines and elements of safety.’
In an interview published in October 2012, Keith Ridge, Chief Pharmaceutical Officer for England, is reported as saying that medicines optimisation:9
'... is about improving quality, outcomes and value for patients from their use of medicines. It is also about a higher level of engagement with patients and the public as well as breaking down the barriers between profession... . It incorporates concordance and adherence, and is more sophisticated than medicines management.'
Increasingly, all healthcare professionals will need to engage with the medicines optimisation process, regardless of setting. This aspiration was reflected by the 48% of respondents in the MGP survey who indicated that groups other than just commissioners or providers were likely to be involved in medicines optimisation.6
Why is medicines optimisation so important?
There is increasing evidence that current use of medicines across the patient pathway in the UK is suboptimal in a number of ways. The cost of avoidable medicines wastage in primary care is thought to be £150 million per year.10 It is estimated that 30%–50% of medicines prescribed forpatients with long-term conditions are not taken as recommended, and that:11
- ambulatory care-sensitive conditions (i.e. actively managed conditions that do not normally require hospitalisation) account for 1 in 6 emergency admissions, at a cost of £1.42bn each year
- adverse drug reactions account for 6.5% of hospital admissions, and over 70% of these reactions are avoidable.
These factors are recognised in the MGP online survey results, which cite the top three priorities for the 12 months to May 2014 as being: 6
- containing costs
- managing the prescribing budget
- improving quality.
Optimising use of medicines has become increasingly important against the current backdrop of flat NHS funding for the foreseeable future, and growing demand from chronic disease morbidity brought about by the demographic shift. There has been a long-standing view that more rational (not cheaper) prescribing in primary care would result in better quality care for patients, as well as bringing benefits to major economies in drug expenditure.12,13 In some cases, rational prescribing could even increase the drugs bill, but might improve outcomes for patients by reducing early deaths and hospital admissions, bringing an overall cost efficiency to the NHS.14 This sort of approach is very much in line with the current concept of medicines optimisation.
The impact of prescribing advisers and medicines management teams in driving up the quality of prescribing in the NHS is well recognised,15–17 and this impact is likely to continue, with 72% of respondents to the MGP survey expecting to see no change in the numbers of personnel providing these services over the next year.6 Secondary care exerts significant influence on the prescribing of GPs; with the advent of ‘payment by results’ and pressure to free up beds, a co-ordinated approach is essential in optimising medicines use across all services.
Guidance and resources for medicines optimisation
Although the term ‘medicines optimisation' is relatively new, there are a number of supporting resources available (see Box 2, below).
Box 2: Guidance and resources for medicines optimisation
- Royal Pharmaceutical Society:
Medicines optimisation: helping patients to make the most of medicines
This provides a good overview. The supporting materials, including Medicines optimisation: the evidence in practice,10 are also useful and can be accessed at: www.rpharms.com/medicines-safety/medicines-optimisation.asp.
Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes19 (in process)
The scope of this guidance is quite extensive. Once complete, it will provide a useful repository of information and guidance to assist publically funded healthcare organisations to focus on this important area of their work.
- Keele University centre for medicines optimisation:
This website provides some useful resources and has an open access area from which materials can be downloaded. The resources include good practice examples and practical guidance and information, which, along with training, were the most highly rated types of support in the MGP online survey.6
Achieving medicines optimisation locally
Medicines optimisation focuses on the actions of all healthcare and social care practitioners and requires greater patient engagement and professional collaboration across all settings. An integrated approach to patient care, with appropriate use of medicines as a key part of an overall process, is needed.
Health practitioners need to look at the whole picture, use evidence to make interventions, and move money from one budget to another in order to facilitate change. It is essential that learning and effective tools from different disciplines inform the process. For example, formulary committees need to be able to consider not just the clinical and cost-effectiveness of individual treatments, but their place in a hierarchy of therapy, and more importantly how optimising medicines can be a catalyst for change. Below are some examples of successful local initiatives by CCGs.
Local CCG initiatives involving medicines optimisation
Tower Hamlets - addressing polypharmacy issues
In Tower Hamlets, patients with co-morbidities, complex medical needs (including dementia), who are receiving palliative care and/or multiple medications, have been selected for a medicines optimisation management approach. Patients in primary care are currently managed through multiple specifications with a disease focus. The new approach coordinates care around the patient. Planned roll-out is expected over the next few years (initially in Tower Hamlets, then hopefully extending out to the north east London CCG footprint). Local guidance (currently in draft) has been produced to help address the issue of polypharmacy in these specific patient groups. The guidance will be used throughout primary and secondary care, with training and support to help implement this change system-wide.
Newham - appropriate use of human insulin
Newham has among the highest prevalence of diabetes in England (6.9%),21 so its spending on treatments for diabetes is high. However, over 3 years ago, it was noted that Newham had been getting poor value for money for diabetes care compared with other CCGs, with high costs but poor outcomes.22 In particular, insulin-prescribing appeared expensive and inconsistent with NHS guidance on cost-effective treatment. Initiatives were taken on the appropriate prescribing of insulins: work in the first year involved multistakeholder engagement, and development of?joined-up local guidance and a structured education and training programme. This programme was implemented over the next 2 years, to help change behaviour and enhance skills. The performance of Newham CCG in diabetes has improved significantly over that time. Prescribing rates of human insulin have increased and use of long-acting analogue insulins has decreased, with no change in the number of diabetes outpatient appointments.23
City and Hackney - optimising therapy for asthma and COPD
In City and Hackney, significant work has been done to optimise care of patients with respiratory conditions. An independent prescriber from a specialist secondary care service has been providing outreach medication reviews at selected GP practices. This initiative has helped identify patients with asthma and COPD and who have poor maintenance inhaler adherence and technique. A significant number of these patients were receiving inappropriate therapy, impacting on their asthma control and quality of life. The number of steroid inhalers prescribed to the asthma group has since halved, and improved adherence to treatment, and understanding of how to self-manage the condition, has resulted in:
- improved peak expiratory flow rates
- better quality of life and asthma control scores
- fewer symptoms.24
Although the numbers involved in this work to date are small (about 84 patients), the process has delivered in-year medicines savings; more importantly, there has been a reduction in hospital admissions for respiratory conditions. The scheme is now being rolled out to more GP practices and in more CCGs.
What are the challenges
As statutory bodies responsible for commissioning healthcare, CCGs are required to achieve financial balance annually. Against a backdrop of flat growth, real terms cuts in funding, and possible changes to financial allocations, generating in-year cash-releasing savings has become increasingly important.
Historically, medicines management teams have performed well in promoting appropriate use of medicines and cost-effective treatments. This has raised expectations in organisations where, perhaps, system-wide change has been more difficult to deliver in-year.
To rely on medicines optimisation merely as a bank from which prescribing savings can be made is very limiting. The patient charter,25 ‘no decision about me without me’,26 NICE guidance, drug formularies, and evidenced-based prescribing all define good practice and will drive an increase in the use of medicines. This increase in prescribing needs to be viewed as an investment opportunity, with medicines optimisation as the new vehicle by which change can be delivered. There is a delicate balance to be found between making shorter-term financial savings through medicines management, and bringing longer-term benefits through medicines optimisation. This issue will continue to be problematic as long as annual planning rounds, with year-end financial balance, remain a key performance requirement for CCGs.
Data, information capture, and information technology are key enablers for medicines optimisation and system change. Timely access to high-quality data is needed, with useful interpretation and close collaboration with academic health science organisations. This will not only serve to demonstrate the value of medicines optimisation, but will also help disseminate good practice and its replication elsewhere. Indeed, over the long term, mental health, social care, and healthcare will need to work together so that holistic, joined-up approaches to health and wellbeing can improve patient care. New ways of thinking and working are needed, as well as effective mechanisms for measuring outcomes and moving money around the system. Patient-focused medicines optimisation projects will then be able to bring about system change.
One of the responses to the MGP online survey6 captured a useful summary of the opportunity provided by medicines optimisation:
'Medicines optimisation is an approach to the quality use of medicines that aims to produce the best possible outcomes. It differs from medicines management in a number of ways but [is] predominantly focused on outcomes rather than process, patients rather than systems, and is led rather than delivered ... .'
Medicines optimisation plays an important, multifaceted role in managing medicines effectively and in redesigning services around patients’ needs, and has the potential to become a catalyst for system change.
- Office of Health Economics. ABPI UK NHS medicines bill projection 2012–2015. Office of Health Economics, 25 June 2012. Available at: www.abpi.org.uk/our-work/library/industry/Documents/OHE%20ABPI%20Medicines%20Bill%20Forecast.pdf
- Department of Health. Pharmacy in the future: implementing the NHS plan. A programme for pharmacy in the National Health Service. DH, 2000. Available at: webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets
- Audit Commission. A spoonful of sugar: medicines management in NHS hospitals. London: Audit Commission, 2001. Available at: archive.audit-commission.gov.uk/auditcommission/sitecollectiondocuments/AuditCommissionReports/NationalStudies/nrspoonfulsugar.pdf
- NHS England website. Everyone counts: planning for patients 2013/14. www.england.nhs.uk/everyonecounts/ (accessed 13 January 2014).
- Department of Health. The NHS outcomes framework 2013/14. London: Stationery Office, 2012. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/213055/121109-NHS-Outcomes-Framework-2013-14.pdf
- MGP Ltd. Medicines optimisation survey. Online survey of eGuidelines.co.uk users, 8–21 May 2013. Data was based on the first 500 respondents (233 survey completions [46.6%]).
- Spooner A, Chapple A, Roland M. The PRICCE project (Primary Care Clinical Evaluation Project). Report from the National Primary Care Research and Development Centre, University of Manchester commissioned by East Kent Health Authority. 2000. Available at: www.population-health.manchester.ac.uk/primarycare/npcrdc-archive/archive/ProjectDetail.cfm/ID/69.htm
- Royal Pharmaceutical Society website. Medicines optimisation. www.rpharms.com/medicines-safety/medicines-optimisation.asp (accessed 2 January 2014).
- Connelly D. Straight from the horse’s mouth—medicines optimisation explained. PJ Online website. PJ Publications, 2012. Available at: www.pjonline.com/news/straight_from_the_horse%E2%80%99s_mouth_%E2%80%94_medicines_optimisation_explained (accessed 2 January 2014).
- Royal Pharmaceutical Society. Medicines optimisation: the evidence in practice (presentation). Royal Pharmaceutical Society. Available at: www.rpharms.com/promoting-pharmacy-pdfs/mo---evidence-in-practice.pdf
- Barber N, Parsons J, Clifford S et al. Patients’ problems with new medication for chronic conditions. Qual Saf Health Care 2004; 13: 172–175. Available at: qualitysafety.bmj.com/content/13/3/172.full.html
- Audit Commission. A prescription for improvement. Towards more rational prescribing in general practice. London: HMSO, 1994. Available at: archive.audit-commission.gov.uk/auditcommission/subwebs/publications/studies/studyPDF/1089.pdf
- National Audit Office. Prescribing costs in primary care. Technical supplement. London: NAO, 2007. Available at: www.nao.org.uk/wp-content/uploads/2007/05/Technical_supplement_P1.pdf
- Gilley J. Towards rational prescribing. BMJ 1994; 308 (6931): 731–732. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2539645/pdf/bmj00432-0005.pdf
- National Audit Office. Influencing prescribing cost and quality in primary care. NAO, 2007. Available at: www.nao.org.uk/wp-content/uploads/2007/05/7484RC_Primary_Care.pdf
- Audit Commission. Review of national findings. Medicines management. London: Audit Commission, 2002. archive.audit-commission.gov.uk/auditcommission/SiteCollectionDocuments/AuditCommissionReports/NationalStudies/Acutemedmgt.pdf
- National Audit Office. Prescribing costs in primary care. London: HMSO, 2007. Available at: www.nao.org.uk/wp-content/uploads/2007/05/0607454.pdf
- Picton C, Wright H. Medicines optimisation: helping patients to make the most of medicines. London: Royal Pharmaceutical Society, 2013. Available at: www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf
- NICE. Medicines optimisation final scope. NICE, November 2013. Available at: www.nice.org.uk/nicemedia/live/14175/65802/65802.pdf
- Keele University website. Educational outreach: actions for commissioning teams. centreformedicinesoptimisation.co.uk/open-access-materials/actions-for-commissioning-teams (accessed 2 January 2014).
- Health and Social Care Information website. Quality and outcomes framework 2011–12, PCT level. www.hscic.gov.uk/article/2021/WebsiteSearch?productid=9592&q=QOF&sort=Relevance&size=10&page=1&area=both (accessed 17 January 2014).
- Public Health England website. Diabetes outcomes versus expenditure tool (DOVE). www.yhpho.org.uk/default.aspx?RID=88739 (accessed 17 January 2014).
- Khan S, Sotubo B. NICE guideline CG87 in practice: implementing recommendations on NPH insulin therapy in Newham CCG. Sponsored session (Lilly Diabetes) presented at: Pharmacy management national forum—medicines management to medicines optimisation. Tuesday 12 November 2013, London, UK. Meeting report available at: pharman.co.uk/cache/downloads/3pzbiuf724g00c4kwssoo0occ/D3_LILLY%20DIABETES%20satellite.pdf
- Khachi H, Karikari P. Impact of a pharmacist-led asthma and COPD reviews in general practice. Thorax 2013; 68 (Suppl 3): A110–111.
- Department of Health. Equity and excellence: liberating the NHS. London: The Stationery Office, 2010. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/213823/dh_117794.pdf
- Coulter A, Collins A. Making shared decision-making a reality. No decision about me, without me. London: King’s Fund, 2011. Available at: www.kingsfund.org.uk/sites/files/kf/Making-shared-decision-making-a-reality-paper-Angela-Coulter-Alf-Collins-July-2011_0.pdf G