How Medicines Optimisation Will Work in the Changing NHS

Vishal Mashru Discusses the Role of Clinical Pharmacists in a Restructured NHS, with Reference to Successes within Cross Counties Healthcare PCN

In 2015, NHS England introduced sustainability and transformation plans, which set out a 5-year vision for all aspects of NHS funding within 44 geographical footprints covering the whole of England.¹ The aim was to develop long-term, place-based plans based on local priorities and challenges to improve the quality, efficiency, and integration of health and care services—and, in turn, the health and wellbeing of the patient population—in each geographical area.¹

Building on these plans, NHS England published the NHS long term plan in 2019,² a transformational programme of improvements to structures and ways of operating designed to ensure that the NHS is‘fit for the future, and to get the most value for patients out of every pound of taxpayers’ investment’.³ The three key building blocks on which the plan is based are:³

• making sure everyone gets the best start in life
• delivering world-class care for major health problems
• supporting people to age well.

Box 1 shows how the NHS intends to achieve this ambitious 10-year plan.

The key areas I will focus on in this article are what these changes mean for current structures within the NHS, and how these structures are likely to change in the future.

Medicines Optimisation: Past and Present

The new GP contract, Investment and evolution: a five-year framework for GP contract reform to implement the NHS Long Term Plan, was issued by NHS England in early 2019.⁴ This was one of the most significant reforms of the GP contract in years, and is fundamental to the direction of healthcare in England. The new contract translates the following objectives of the NHS long term plan into core components of the GP services contract:⁴

• addressing workload issues resulting from workforce shortfall
• bringing a permanent solution to indemnity costs and coverage
• improving the Quality and Outcomes Framework
• introducing automatic entitlement to a new Primary Care Network (PCN) Contract
• joining up urgent care services
• enabling practices and patients to benefit from digital technologies
• commitments in the NHS long term plan
• giving practices clarity and certainty on 5-year funding
• testing future contract changes before introduction.

These changes at primary care level were accompanied by changes at the level of commissioning and strategy. Plans for all parts of England to be served by an integrated care system (ICS)—a partnership between the organisations that meet health and care needs across an area—from April 2021⁵ generated some uncertainty about the future of CCGs. Although many areas had already been working collaboratively in the preceding 5 years, this formal change was intended to integrate them into single strategic organisations. What this would mean for functions currently carried out at commissioner level, and which of these would be affected, were just some of the questions being asked, particularly in the field of medicines optimisation.

In 2016, regional medicines optimisation committees (RMOCs) were developed with the aim of optimising ‘the use of medicines for the benefit of patients and the NHS’.^6,7 RMOCs were put in place to support, but not replace, area prescribing committees (local formulary committees). There was to be no change at the level of area prescribing committees,⁸ and this structure is to remain in place for the foreseeable future—but will work in more strategic ways to improve the use of medicines. This was reinforced by the RMOC Operating Model, which was revised for 2021.⁷

The role of medicines optimisation teams (also termed medicines management teams) has varied over the years since the need for pharmaceutical advisers was first recognised by health authorities in the 1990s.⁸ Some have supported the strategic function of the role, whereas others have focused on the provider function. Since the introduction of clinical pharmacists through the NHS England Clinical Pharmacists in General Practice programme, which has led to more than 1000 full-time-equivalent clinical pharmacists working across England since the scheme began in 2015,⁹ many CCG medicines optimisation teams have focused on the strategic function of the role.

The Place of Medicines Optimisation in Primary Care Networks

In April 2019, GP practices began to establish PCNs—collaborations with other practices and organisations providing integrated care to local populations.¹⁰ The development of the PCN Directed Enhanced Service (DES) Contract outlined the core requirements of PCNs,¹¹ which are summarised in Box 2. The Network Contract DES formed part of the larger package of contract reform to implement the goals of the NHS long term plan set out in Investment and evolution.^4,11

The Network Contract DES committed to an investment of £2.4 billion by 2023–2024 for the development of approximately 1250 newly formed PCNs (or £1.47 million per typical PCN).^11,12 This funding was intended to assist PCNs to:

• deliver eight new service specifications over 5 years^4,10
• recruit additional healthcare professionals to support the provision of care⁴
• tackle inequalities and improve care across multiple domains through the Investment and Impact Fund (IIF).¹³

The introduction of PCNs is key to the future of medicines optimisation within the NHS. Although the introduction of some PCN service specifications has been delayed by the COVID-19 pandemic, medicines optimisation was among those introduced in 2020 as part of the new GP contract. These are:^4,10

• enhanced health in care homes
• structured medication review and medicines optimisation
• extended hours access
• early cancer diagnosis.

The vision of the PCN in which I am currently Head of Medicines and Research is to develop a strong, collaborative approach to enable the delivery of high-quality care to the patient population. To facilitate delivery of this vision, the PCN board supported the development of a management team, consisting of a Clinical Director, Head of Operations, and Head of Medicines and Research. Together, our role was to develop the strategic plan, and implement delivery of the expectations of the Network Contract DES by the PCN.

The Role of Clinical Pharmacists

The Additional Roles Reimbursement Scheme (ARRS)—a scheme to support the recruitment of up to 20,000 additional staff to work in primary care teams implemented as part of the Network Contract DES^9,11 —was critical to the delivery of the PCN service specifications, in particular through the appointment of clinical pharmacists. The PCN board agreed to invest a significant proportion of our ARRS funding to increase clinical capacity through the recruitment of clinical pharmacists during 2020–2021; some would argue that this was ambitious. This investment in pharmacists for our PCN has since increased by a further 30% in 2021–2022. The investment has facilitated an increase in clinical capacity, and allowed us to enhance our focus on how medicines are managed at PCN level. Medicines management at PCN level includes:

• budgetary achievement
• managing safety alerts (for both the Medicines and Healthcare products Regulatory Agency and the Central Alerting System)
• determining the most cost-effective medicines in line with local policy
• safe management of medicines through policies and processes.

Over the past 5 years, the role of the clinical pharmacist has become more clearly defined. The attributes of these practitioners were first defined in Annex B of the Network Contract DES, and are detailed in Box 3.¹¹

Since the publication of the PCN DES, pharmacists within general practice have begun to support clinical capacity by completing a variety of activities, including:

• medication reviews (including structured medication reviews)
• medication-related queries (for example, to suggest alternative medication)
• audit and review of prescribing
• medicines safety
• drug monitoring and shared care.

The benefits of the clinical pharmacists working at Cross Counties Healthcare PCN have been remarkable, and they are now a core part of the PCN and practice offering. Tables 1 and 2 show the tasks undertaken by the clinical pharmacists during 2020–2021 and continuing into 2021–2022, and demonstrate the invaluable support they have provided to the PCN, its practices, and the members of the primary care team.

Table 1: Clinical Pharmacists’ Activities at Cross Counties Healthcare PCN, 1 April 2020–31 March 2021^A

Table 2: Clinical Pharmacists’ Activities at Cross Counties Healthcare PCN, 1 April 2021–31 August 2021^A

In addition, PCNs were set the goal of improving medicines safety as part of the IIF incentive scheme.¹⁴ The medicine safety domain of the IIF aims to:¹⁴

• support local reviews of prescribing, alongside other risk factors for potential harm
• minimise the use of medicines that are unnecessary and when harm may outweigh benefits
• identify when the risk of harm can be reduced or mitigated, including through prescribing of alternative medicines or medicines that mitigate risk
• reduce the number of hospital admissions that may be associated with medicines.

The specific indicators that PCNs were tasked with improving are shown in Table 3.¹⁴

Table 3: Achievement Across All Three Indicators of Medicines Safety at Cross Counties Healthcare PCN in March 2021^14,A

Clinical pharmacist-led activities at our PCN ensured that patients included in the IIF indicators were reviewed, the resulting reviews supported achievement across all three indicators in the medicines safety domain, earning the PCN £4612.92 for reinvestment into PCN services (internal data from Cross Counties Healthcare PCN).

Planning for the Future

The vision for medicines optimisation services at our PCN is to continue to develop the team through a 12-month internal education programme covering long-term conditions that will run alongside the Centre for Pharmacy Postgraduate Education’s primary care pharmacy education pathway.¹⁵ In addition to this, we aim to expand the PCN clinical research arm, and further expand the team to provide a complete pharmacy service across the PCN. In the meantime, the team will continue to support workload capacity and implementation of the PCN DES across primary care for the remainder of 2021–2022.

This vision is shared by many PCNs across England. As the PCN DES specifications are updated and the domains covered by the IIF increase in number, there will inevitably be more onus on the clinical pharmacy team at PCN level to lead the medicines agenda. This may be the new future for how medicines are managed across the ICS.

Summary

Those of you who have been transitioning and implementing the changes to the NHS over the past 2 years will know that this has been a challenging period. The light at the end of the tunnel is the development of additional roles to support you in developing new ways of working—particularly pharmacists, who have positively demonstrated the impact that can be made at practice and PCN level.

Vishal Mashru

Head of PCN Medicines & Research, Cross Counties Healthcare PCN and North Blaby PCN