Medicines management expert Jackie Lyon from NHS East Riding of Yorkshire explains how her team has knocked millions off its prescribing budget.
Our medicines management team works closely with 39 practices in NHS East Riding of Yorkshire. Our primary care organisation was probably one of the first in the country to start a team like ours. We have been going since 2001 – more or less a decade.
When we started, NHS East Riding of Yorkshire was very much outside the norms for prescribing spend. We were spending much more than other comparable PCTs, but now we've clawed it back.
We didn't really start recording our savings until the QIPP efficiency programme came in around 2009. We always knew we were achieving success because the cost-per-item was going down, but three years ago – when we actually began to work it out – we realised we had saved £2.5m in a single year.
It really was a ‘wow' moment when we looked at the numbers going in and were able to say to the GP practices: ‘It's working.'
The team's annual overheads are £335,000. This figure includes £216,000 for the GP practice team, 2.3 full-time- equivalent pharmacists and three full-time pharmacy technicians. We also hire in external support when needed and that takes up the remainder of our budget – £119,000.
For every pound invested in the medicines management team, we make five pounds in prescribing savings.
It's like a rolling stone, once you start, you see other things that need doing and then it just perpetuates itself.
How we did it
The first savings were relatively easy to achieve, but because we have been at it for so long we have had to take an increasingly detailed look at things, working more intensely with practices to keep cutting costs, year on year.
When we first began to look for savings with practices, we started with the easy pickings. We began by concentrating on the big five – statins, proton-pump inhibitors, ACE inhibitors, bisphosphonates and switching over from branded medicines to generics.
We tend not to do blanket switches unless it's non-clinical – for example, tablet to capsule – in which case the PCT pharmacist does these.
The change starts when the patient has their next repeat prescription. We are trying to get community pharmacists on board with the changes, so they know when a patient has their next prescription that it should be changed to x instead of y.
When changing patients over from one drug to another, we generally do a complete medication review. There's no point in changing someone to a new drug if they have tried it in the past and it was unsuccessful. We try to take a holistic approach to patients' medication.
Going granular
Having tackled a lot of the ‘low-hanging fruit', we are now looking at individual practice plans based on data from ePACT –
a service for pharmaceutical and prescribing advisors from the Prescriptions Pricing Authority that allows real-time, online analysis of the previous 60 months' prescribing data held on the NHS Prescription Services' Prescribing Database. It allows you to search, using BNF terms, the number of items for each therapeutic area and the cost.
This gives an overview of cardiovascular drug use, for example, or allows you to break it down into lipid-lowering drugs – or down further to, say, simvastatin. It allows us to have a close look at the statistics for a specific practice.
There's no right or wrong – it is just information.
What we find might reflect the demographics of that practice. Then we might liaise with colleagues in the PCT on its behalf and explain the practice's prescribing trends. Or we can say to the practice: ‘You appear high prescribers in this or that area – would you like us to have a look at it for you?'
Our approach
It is up to individual practices how they want to work with us. One already has its own pharmacist and prefers to work that way, so we don't interfere. We would never force a practice to get the medicines management team in. We work how the practices want us to work – because things get done much more efficiently that way.
But we do, tend to prioritise practices with the biggest potential savings.
When our team members go into a practice, they will log onto the practice computer system and work as part of the practice for the whole period that they are there. It is a time when the practice can ask questions and everyone can get to know each other.
It can be a single pharmacist who goes in or a team, depending on the size of the practice and what needs doing. Team members tend to become very integrated into the practice and can almost feel like practice staff members at times.
While they're there, they are part of the practice. The trust is there, the respect is there and that really helps in terms of getting things done. We are also available to all practices on the phone to answer their queries at any time – our work is not just about cost saving, although that is obviously a major part.
When we have finished working in a practice, we will leave it with the GPs to consider our recommendations and for them to decide what they do and don't wish to implement.
QOF
Practice engagement with the initiatives has been built around the indicators in the QOF. We had initial meetings with the East Riding and Hull LMC and now have an annual QOF visit to each practice to discuss how the medicines management team can help the practice in its objectives. Again, practices can choose not to engage if they have their own in-house expertise.
We have incorporated the new QOF prescribing indicators into the dashboard we send round to practices. We benchmark practices against the QOF indices using a traffic-light system of red, amber and green.
The majority of GPs have told us they like this system and can see the benefits. We are asking them to agree to a lot more work, but they tell us that it works.
We look at anything and everything now. We have a very focused team who are up to date on everything that is coming off patent and what is available generically, and can talk to the practices and ask them if they want to change to a new drug.
Keeping patients on board
We try very hard to keep patients on board with what we are doing. We work closely with the local media and get them to publicise what we are doing with, say, statins, to explain why changes are being made to medication.
We encourage practice patient forums to discuss the issues. We are led by the practices on how they wish us to inform patients. Some practices want to talk to their patients on the phone first, some are quite happy to do it by letter – and we don't hide from patients the fact that it is a cost-saving measure. We include a phone number so that patients can talk to the medicines management team directly or arrange a face-to-face meeting with the practice to discuss it.
We do get people ringing up for assurance. Some of those want to complain, but we encourage them to try it for a month or two and see how they get on. If they experience clinical side-effects we will change them back.
As a medicines management team, we also have a policy of active participation with the hospital drug and therapeutics committee and the area prescribing committee, liaising with providers around local guidelines.
The future
We think our services could be useful for the proposed new GP consortium arrangements. In our area we are working with the East Riding GP pathfinder consortium, which is co-terminous with the PCT. It is basically up to GPs to decide whether they want to continue to use us when they take over.
The National Prescribing Centre's competency framework for medicines management teams outlines the functions consortia will need to deliver. Hopefully we'll be asked to carry on.
Jackie Lyon is assistant director of medicines management at NHS East Riding of Yorkshire
