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Part of: Pharmacies

Related to: Patient Experience, Infectious Diseases and Pandemics, Heart Failure, Coronary Heart DiseaseChronic Kidney Disease, Ill Health and Disability, Mental Health and Illness 

Key Facts:

  • Bath and North East Somerset has one of the lowest prescribing cost per weighted prescribing unit in England (top 5% of the 211 CCGs).
  • The NHS in Bath and North East Somerset has one of the lowest level of prescribing of antibiotics in the South of England (lowest 10% of the 50 CCGs) but B&NES prescribers choose a higher proportion (9.4% vrs. 5.9% in England) of antibiotics which are viewed as less good to prescribe from a perspective of reducing C dif in the community).
  • NHS B&NES CCG has comparatively low or average levels of prescribing of medicines associated with risk e.g. prescribing for hypnotic insomnia, antidepressants, and NSAIDs.
  • NHS B&NES CCG however continues to show good outcomes on all the appropriate use of medicines  in the management of long term conditions in all the Quality and Outcomes Framework Clinical indiators:  Chronic Heart Disease, Hypertension, Diabetes, Heart Failure, Artrial Fibrulation, Peripheral arterial disease, Stroke and TIA, Chronic Kidney Disease, Epilepsy, Osteoporosis  (from QoF data).
  • 49% of respondents to the 2015 Voicebox Resident Survey said they had 1-10 boxes of unused over the counter medicines in their household.
  • 29% of respondents to the 2015 Voicebox Resident Survey said they had 1-10 boxes of unused prescribed medicines in their household.

Background and Definitions 1

Medicines management has been used to describe all aspects of care where medicines are involved in all settings of health and social care:

  • Primary Care Prescribing (prescribed by GPs)
  • Secondary Care Prescribing (prescribed in hospital)
  • Community Services (prescribed in community clinics and community hospitals)
  • Community Pharmacy Services (national NHS contract with three service elements: Essential, Advanced and Local Enhanced)

There are different ways of benchmarking the use of medicines in these settings, it can based on spend in total, spend per weighted populations, rolling growth and various quality indicators. However Medicines Management should not be looked at in isolation from other data sets because they impact on admissions data, outcome data from data sets like the GP Quality Outcome Framework (QoF).

Medicines Optimisation - encompasses a wide range of functions to ensure the NHS is achieving maximum health gain from all medicines.  It involves maximising the use of medicines in preventing disease or the progression of disease and in improving patient outcomes from medicine taking.

The NHS Reforms 2013 - There are some key changes in who has lead responsibility for managing activity in the Medicines Management and Medicines Optimisation work programme as a consequence of the NHS Reforms:

  • Community Pharmacy Commissioning is led by the NHS England Area Team.
  • High Cost Drugs which had historically had an impact on the local health community will now mostly (70-80%) be commissioned by NHS England Specialised Commissioning Teams. The remaining 20-30% will be commissioned by the local Clinical Commissioning Groups (CCGs).

Prescribing Unit (PU)- are used to weight prescribing information to allow information users to compare practice level information. The weighting is applied based on the patient, with patients under the age of 65 and temporary residents being counted as a single PU, and patients aged 65 or over being counted as three PUs. 2

What does the data say?

Cost of prescribing 3 4

The current size of the prescribing budgets for Bath & North East Somerset’s population at various healthcare settings are as follows (estimated):

  • Primary Care - £23 million
  • Secondary Care - £8 million
  • Community Services - £0.5million 

Prescribing accounts for approximately 10% of health spending.

Nationally the growth in primary care spending on prescribing peaked at about 4.3% in September 2010. However, it is currently at about -1.25% in the South West. The growth in secondary care spending is over 13%.

Medicines Management- cost of perscription units scatter graph

Figure 1: Percentage cost growth by new PCT (Rolling 12 month Average)

 

Figure 2: Cost per weighted prescribing units of B&NES CCG Primary Care prescribers (Red bar) compared to the 211 NHS communities in England. The dark blue bars depict the other CCGs in our Local Area Team (Left to Right: Wiltshire, Gloucester and Swindon) (Jul 2014 - Sep 2014).

The graph shows B&NES has one of the lowest prescribing cost per weighted prescribing unit in England, approximately 20% less than NHS England, 13% less than NHS South of England.

Generic (non-branded) Prescribing 5 6

Prescribing generically (non-branded products) is a key indicator of low cost but quality prescribing. The following graph shows how B&NES CCG is doing compared to the rest of England. This graph shows B&NES CCG is in the top third for generic prescribing.

 Medinces Management - Percentage of prescribing that is non-branded products - bar graph

Figure 3: Percentage Generic Items - B&NES NHS prescribing vrs the rest of the South West and England (Jul 2012 - Sep 2012 and Jul 2014 - Sep 2014).

Antibiotic Prescribing 7 8

Antibiotic resistance occurs when the antibiotics normally used to cure specific infections stop working. This poses significant threat to public health. Emerging resistance against antimicrobials that are currently used and an increase in a number of types of infections, some of which had previously been well-controlled, are two factors that contribute to this threat. Of particular concern is methicillin-resistant Staphylococcus aureus (MRSA) which remains a serious threat, especially to hospital inpatients.

Addressing healthcare-associated Clostridium difficile infection also remains a key issue on which NHS organisations have been mandated to implement national guidance. This guidance includes restriction of broad spectrum antibiotics, and in particular second and third-generation cephalosporins and clindamycin. The guidance states that broad spectrum antibiotics such as quinolones and cephalosporins need to be reserved to treat resistant disease and should generally be used only when standard and less expensive antibiotics are ineffective.

Figure 4 shows B&NES CCG volume of antibiotic prescribing compared to other CCGs in England. The graph shows that B&NES CCG has the 19th lowest level of prescribing of antibiotics in the 211 CCGs in England.

Medicines Management - Antibiotics prescribing - bar graph

Figure 4: Antibiotics (Antibacterial) prescribing in the NHS in B&NES vs rest of South West and England (Jul 2012 – Sep 2012 and Jul 2014 - Sep 2014).

Figure 5 shows that the CCG in Bath and North East Somerset has one of the highest rates of prescribing quinolones and cephalosporins (broad spectrum antibiotics) in England, while being one of the lowest overall prescribers of antibiotics in England.

Medicines Management - A and Q Antibiotics prescribing - bar graph

Figure 5: Quinolones and Cephalosporins prescribing in NHS B&NES vs rest of South West (Jul 2012 – Sep 2012)

Hypnotic Prescribing (for insomnia) 9 10

Risks associated with long term use of hypnotic drugs have been well recognised for many years. Nevertheless, overall prescribing of hypnotics is not decreasing.

As long ago as 1988, the Committee on Safety of Medicines advised that benzodiazepine hypnotics should be used only if insomnia is severe, disabling or causing the patient extreme distress. It also stated that the lowest dose that controls the symptoms should be used, for a maximum of four weeks, and intermittently if possible. NICE guidance also recommends that when, after due consideration of the use of non-pharmacological measures, hypnotic drug therapy is considered appropriate for the management of severe insomnia interfering with normal daily life, hypnotics should be prescribed for short periods of time only, in strict accordance with their licensed indications.

NICE also confirms that there is no compelling evidence of a clinically useful difference between zaleplon, zolpidem and zopiclone (the so called ‘Z drugs’) and shorter-acting benzodiazepine hypnotics from the point of view of their effectiveness, adverse effects, or potential for dependence or abuse. There is no evidence to suggest that if patients do not respond to one of these hypnotic drugs, they are likely to respond to another.

The data shows that B&NES CCG has average rates of prescribing of hypnotics compaired to other CCG in England and the use of these medicines continues decreasing in line with the national decline.

Medicines Management - Hypnotics prescribing - bar graph  

Figure 6: Hypnotics (anti-insomnia) prescribing in NHS B&NES vs rest of South West and England (Jul 2012 – Sep 2012 and Jul 2014 - Sep 2014)

Statin Prescribing 11 12

Statin therapy should usually be considered for all adults who have established cardiovascular (CV) disease or who have a high of developing it.

Figure 7 shows that B&NES CCG is below the England average for use of this class of medicine. However figure 8 shows that B&NES has a lower  than expected prevalance of cardiovascular disease compaired to CCGs with similar demograhics.

Medicines Management - Statin prescribing - bar graph  

Figure 7: Statin (for heart disease) prescribing in NHS B&NES vs rest of South West  and England (Jul 2012 – Sep 2012 and Jul 2014 - Sep 2014)

Figure 8: Heart disease in B&NES CCG compared to similar CCGs – Prevalence, risk factors death and spend 13

NSAID (Non-steroidal anti-inflammatory drugs) prescribing (type of painkiller) 14 15

There are long standing and well recognised safety concerns with all NSAIDs regarding gastrointestinal (digestive) and renal (kidney) adverse effects, and increased thromboembolic (a blood clot in a deep vein) risks with many NSAIDs, including coxibs and some traditional NSAIDs.

In October 2006, a review of the safety of selective and non-selective NSAIDs by the Commission on Human Medicines (CHM) identified that traditional NSAIDs, including diclofenac, may be associated with a small increased risk of thrombotic (a blood clot in a deep vein) events. This risk does not appear to be shared by ibuprofen at 1200mg per day or less, or naproxen 1000mg per day. Recently published data (see MeReC Rapid Reviews 1597 and 2451) supports these recommendations, particularly so for naproxen.

There are significant and widening differences between localities in the proportion of NSAIDs which are ibuprofen and naproxen, and in 2010, diclofenac still accounted for approximately 35% of all NSAID prescriptions in primary health care in England.

Figure 9 shows that B&NES CCG has a below average prescribing levels of NSAIDs in England. Medicines Management - NSAID prescribing - bar graph

Figure 9: NSAID prescribing in NHS B&NES vs rest of South West and England (Jul 2012 – Sep 2012 and Jul 2014 - Sep 2014)

Figure 10 shows that B&NES CCG has an above average performance on its choice of NSAID medicines.

 

Figure 10: NSAID (Ibuprofen & Naproxen) prescribing in NHS B&NES vrs rest of the South west and England (Jul 2012 – Sep 2012 and Jul 2014 - Sep 2014)

What does the community say?  16

Currently there has been limited input from the public on Medicines Strategy and work plan.

Voicebox Resident Survey - Questions about disposal of medicines 17

The large scale Voicebox Resident Survey aims to provide an insight into Bath and North East Somerset and its local communities and to capture resident’s views on their local area and council services.

In 2015 the questionnaires were posted to 3,650 addresses selected randomly in the local authority area, and a total of 1,067 residents completed it, a response rate of 29%.

The 2015 Voicebox Survey asked residents about:

  • Unused over the counter medicines in the household
  • Disposal of unused over the counter medicines
  • Unused prescribed medicines in the household
  • Disposal of unused prescribed medicines

Unused over the counter medicines in the household

When respondents were asked approximately how many boxes of unused (not been used for the over six months) over the counter medicines they had in their household, nearly half (49%) of said they had no boxes of unused over the counter medicines in their household.

The remaining 2% said they had more than 10 boxes.

Disposal of unused over the counter medicines

When the 751 respondents who responded to the question about the disposal of unused over the counter medicines were asked how they disposed of unused over the counter medicines...

Unused prescribed medicines in the household

When respondents were asked approximately how many boxes of unused (not been used for the over six months) prescribed medicines they had in their household, 70%  said they had no boxes of unused prescribed medicines in their household.

The remaining 1% said they had more than 10 boxes.

Disposal of unused prescribed medicines

When the 628 respondents who responded to the question about the disposal of unused prescribed medicines were asked how they disposed of unused prescribed medicines...

Are we meeting the needs? 18

The Medicines Optimisation Dashboard published in 2014 http://www.england.nhs.uk/ourwork/pe/mo-dash/ provides an overview utilising a range of indicators on how BaNES is doing optimising its use of Medicines.

key summary of the data shows:

  • BaNES CCG performs well against GP prescribing Quality Outcome Framework indicators

  • BGSW Area Team (includes BaNES) performs averagely on provision of New Medicines Reviews with patients

  • BGSW Area Team (includes BaNES) performs less well on the provision of Medicines Use  Reviews with patients
  • BaNES perform above national average in improving access to medicines through the provision of repeat dispensing
  • When the dashboard was published Electronic Prescription Service (EPS) had not been rolled out in BaNES. As of December 2014 EPS has been rolled out to many practicesin BaNES with plans for roll out across all practices to be complete by the end of March 2015.
  • There is an average ability of local Trusts in BGSW Area Team to be able to access medicines informationon attending patients through the Summary Care Record
  • BaNES CCG is slightly above the national average in prescribing the new Noval Oral Anticoagulation medicines
  • The RUH has a lower proposrtion of Medicines Incidents that cause harm than the national average
  • Data from the RUH on Medicines Reconcilliation rates is not available

What can we realistically change? 19

The current strategy of driving change to improve the provision of effective, safe and cost effective medicine to patients in a way which maximise the patient experience is through many different approaches of influencing prescribers these can be summarised as follows:

  • Regular contact with prescribers through series of prescribing visits and presentations at GP Forums
  • Good regular information being provided to practices through prescribing dashboards, newsletters, websites etc.
  • Imbedding practice pharmacists and care home medicines review patients into practices to work with practices to implement areas of agreed change
  • Use of IT prescribing tools to provide point of prescribing support to prescribers.  
  • Developing specific projects with identified resources to audit and implement change. 
  • 1. Prescription Services NHS Business Services (2011) Prescribing toolkit, B&NES PCT Medicines Management in-house analysis (downloaded 16/04/2012) http://www.nhsbsa.nhs.uk/PrescriptionServices/3232.aspx 
  • 2. NHS Business Services Authority (2013) Glossary of Terms http://www.ppa.org.uk/systems/glossary/glossary.html#  (viewed 23.09.2013)
  • 3. Prescription Services NHS Business Services (2011) Prescribing toolkit, B&NES PCT Medicines Management in-house analysis (downloaded 16/04/2012) http://www.nhsbsa.nhs.uk/PrescriptionServices/3232.aspx 
  • 4. Hirst J (Senior Commissioning Manager for Medicines Management & Primary Care) (2014) Email correspondence with Prince J (B&NES Council Senior Public Health Research & Intelligence Officer) – 19.12.2014, NHS Bath and North East Somerset Clinical Commissioning Group and Bath and North East Somerset Council
  • 5. Prescription Services NHS Business Services (2011) Prescribing toolkit, B&NES PCT Medicines Management in-house analysis (downloaded 16/04/2012) http://www.nhsbsa.nhs.uk/PrescriptionServices/3232.aspx 
  • 6. Hirst J (Senior Commissioning Manager for Medicines Management & Primary Care) (2014) Email correspondence with Prince J (B&NES Council Senior Public Health Research & Intelligence Officer) – 19.12.2014, NHS Bath and North East Somerset Clinical Commissioning Group and Bath and North East Somerset Council
  • 7. Prescription Services NHS Business Services (2011) Prescribing toolkit, B&NES PCT Medicines Management in-house analysis (downloaded 16/04/2012) http://www.nhsbsa.nhs.uk/PrescriptionServices/3232.aspx 
  • 8. Hirst J (Senior Commissioning Manager for Medicines Management & Primary Care) (2014) Email correspondence with Prince J (B&NES Council Senior Public Health Research & Intelligence Officer) – 19.12.2014, NHS Bath and North East Somerset Clinical Commissioning Group and Bath and North East Somerset Council
  • 9. Prescription Services NHS Business Services (2011) Prescribing toolkit, B&NES PCT Medicines Management in-house analysis (downloaded 16/04/2012) http://www.nhsbsa.nhs.uk/PrescriptionServices/3232.aspx 
  • 10. Hirst J (Senior Commissioning Manager for Medicines Management & Primary Care) (2014) Email correspondence with Prince J (B&NES Council Senior Public Health Research & Intelligence Officer) – 19.12.2014, NHS Bath and North East Somerset Clinical Commissioning Group and Bath and North East Somerset Council
  • 11. Prescription Services NHS Business Services (2011) Prescribing toolkit, B&NES PCT Medicines Management in-house analysis (downloaded 16/04/2012) http://www.nhsbsa.nhs.uk/PrescriptionServices/3232.aspx 
  • 12. Hirst J (Senior Commissioning Manager for Medicines Management & Primary Care) (2014) Email correspondence with Prince J (B&NES Council Senior Public Health Research & Intelligence Officer) – 19.12.2014, NHS Bath and North East Somerset Clinical Commissioning Group and Bath and North East Somerset Council
  • 13. Public Health England, (2014) Heart diease pathway NHS Bath and North East Somerset CCG
  • 14. Prescription Services NHS Business Services (2011) Prescribing toolkit, B&NES PCT Medicines Management in-house analysis (downloaded 16/04/2012) http://www.nhsbsa.nhs.uk/PrescriptionServices/3232.aspx 
  • 15. Hirst J (Senior Commissioning Manager for Medicines Management & Primary Care) (2014) Email correspondence with Prince J (B&NES Council Senior Public Health Research & Intelligence Officer) – 19.12.2014, NHS Bath and North East Somerset Clinical Commissioning Group and Bath and North East Somerset Council
  • 16. Hirst J (Senior Commissioning Manager for Medicines Management & Primary Care) (2014) Email correspondence with Prince J (B&NES Council Senior Public Health Research & Intelligence Officer) – 19.12.2014, NHS Bath and North East Somerset Clinical Commissioning Group and Bath and North East Somerset Council
  • 17. Marketing Means (2016) Voicebox 24, Section 4: Vaccinations and Disposal of Medicines Headline Draft Report, Bath and North East Somerset Council, November 2015 – January 2016
  • 18. NHS England (2014) Medicines Optimisation Dashboard, http://www.england.nhs.uk/ourwork/pe/mo-dash/ 
  • 19. Hirst J (Senior Commissioning Manager for Medicines Management & Primary Care) (2014) Email correspondence with Prince J (B&NES Council Senior Public Health Research & Intelligence Officer) – 19.12.2014, NHS Bath and North East Somerset Clinical Commissioning Group and Bath and North East Somerset Council