S T E P SDr MIKE SCOTTChief PharmacistUnited Hospitals TrustAntrim HospitalNorthern IrelandProcurement Distribution Interest Group (PDIG)

8 June 2006

safe

therapeutic

economic

pharmaceutical

selection

STEPS(Modified SOJA)

Medicines Management

“Encompassing the entire way that medicines are selected, procured, delivered, prescribed, administered and reviewed, to optimise the contributions that medicines make to producing informed and desired outcomes of patient care.”

Audit Commission 2001

Integrated Medicines Management

Decreased length of stayDecreased readmission rateReduced wastage of patients’ own drugsMore accurate drug historyImproved appropriateness of medicine use

Improved patient safetyImproved use of medical and nursing staff timeFaster discharge processImproved discharge prescription accuracyImproved medicine use – counsellingImproved communication across the interface

Tasks Undertaken

Communication with primary care on admissionAccurate medical historyManagement of patients’ own drugsInpatient management including counsellingPharmacist discharge and counsellingCommunication with primary care on discharge

More Accurate Drug History

Mean number of queries on the initial inpatient kardex was reduced by 4.2 per patient, reflecting improved medicines

management and impacting on length of stay.

Improved Medicine Use

There was a significant improvement in the medication appropriateness index.

AdmissionDischargeControl 13.16 9.97Intervention 17.48 5.69

Health Service Journal Award 2003

Lack of Integrated Product Use

This was identified as a significant deficient element in the current medicines management system.

- different choice of agents in a therapeutic class

- different generics and parallel imports being used in primary care

- confusion for patients, particularly the elderly

CostSECONDARY CARE PROCUREMENT

Contract based - 3 yearsAll trusts contributeTender by generic nameBids assessed by a pharmacist advisory panelRecommendations made to the Executive Panel for approvalExecutive Committee of Trust Chief Executives

SuccessThis contract process has worked well and achieved significant savings for the secondary sector.

In the 2004-2007 contract savings in excess of £2 million per annum were achieved representing a 7.6% reduction.

87.2% being subject to good procurement practice as defined by the Audit Commission.

Problems

Lack of primary care element

Loss leading to gain primary care business (80% of spend is in the community)

Product name constraint therefore there is no mechanism to consider therapeutically equivalent usage

Procurement Primary Care

Independent contractors both GP and pharmacist

GP prescribes ideally generically

Pharmacist supplies cheapest product by procurement

Prices set by CSA on tariff

Hello! Hello!

Northern Health and Social Services Board (NHSSB)

Population of 440,000

Three stage process -Stage one – branded genericsStage two – therapeutic classesStage three – generic generics

NORTHERN AREA PRESCRIBING FORUM

Professional Secretary - Dr M ScottConsultantsGeneral PractitionersCommunity PharmacistsHospital PharmacistsBoard Director of Pharmacy

(Chairman)Area Medical AdvisorPrescribing Advisors (Boards)Prescribing Advisors (PCGs)NursesMedicines Information Pharmacist

Local Medical Committee

Locality Groups for Community Pharmacists

Drug and Therapeutics Committee

IMPLEMENTATIONPhase OnePrimary Care

Prescribing advisors and prescribing support assistants actually promoted and implemented the changes with GPs

Secondary CareConsultants agreed to the product switches automatically carried out by pharmacistsUnited gave notice to companies tendering for Regional Contract that NHS price would be a determination in their adjudication – hence different products used

THREE YEAR PERIOD

Calcichew Adcal

ImdurElantan

Isotard XL

Adalat LA Coracten

Gaviscon Peptac

Nitrate Patches Nitrodur

Proctosedyl Preps

Uniroid Preps

Diltiazem brands

Slozem (once daily)

PRIMARY CARE PERCENTAGES FOR NITRATES

Elantan LA 25 -10.4%

Elantan LA 50 -17.6%

Imdur SR -27.2%

Modisal MR -23.5%

Monomax SR -31.9%

Ismo Retard -58.3

Isotard XL +223.9%

STAGE IITherapeutic Tendering

Competitive tendering for pharmacologically similar products

Current processes use generic name for bidding purposes

By default excludes similar chemical entities with the same pharmacological actions and range of potential therapeutic issues

Tendering therapeutically will create competition and therefore ensure product standardisation at best value

Eeeny MeenyMiny Mo

safe

STEPS

therapeutic

economic

pharmaceutical

selection

STEPSQuality first, then safety, then cost- effectivenessFull product integration between primary and secondary care Full ownership by both general practitioners and hospital consultants Standardisation of generics (plus branded)Therapeutic tendering

STEPSSelection - agreed criteria (weighted)1st Step - Clinical Evaluation2nd Step – Safety Evaluation3rd Step – Budgetary Impact AssessmentSelected medicines for 70% prescribingNo restrictionsTransparent and Defensible

STEPS

Improve quality of prescribing information across primary / secondary careFramework updated regularly with emerging evidenceThree year formulary (for 70% prescribing will be class specific)No discount into the secondary care sector International Links

STEPS ____________________

MATRIX CONSTRUCTION AND

CLINICAL EVALUATION

STEPSMatrix construction and Clinical Evaluation

Extensive literature review

Selection criteria identification

Expert panel – Consultants, GPs, Pharmacists

Relative weight assignments

Draft indicative scoring system

STEPSMatrix construction and Clinical Evaluation

Final scoring system for Matrix

Matrix sent to all relevant pharmaceutical companies

Validation questionnaire (Consultants)

Data analysis

Drug entities relative scores

ACE INHIBITORS MATRIXNumber of licensed indicationsNumber of formulationsTrough / peak ratio BP lowering

effectVariability in biovailabilityInteractionsClinical efficacySide-effectsDosage frequency

TOTAL 1000 pts

DRUG ENTITIES SELECTION

RISK ASSESSMENT

A - CRITICAL INFORMATION STEP

1. Labelling2. Packaging3. Storage conditions4. Blisters5. Patient information

leaflets

Accept

B - ADDED VALUES STEP (EXTRA POINTS)

1. Calendar packs2. EAN barcode3. Pack size4. Tab/cap colouring and

marking5. Label instructions space

BUDGET IMPACT ANALYSIS

DDD profilingDDD fractions refiningCost calculation both primary and secondary care pricesAffordability (selection / budget)

FINAL SELECTION OF PRODUCT LINES

Therapeutic Classes Completed

Statins July 06Proton Pump Inhibitors July 06ACE Is (now being regionalised) Oct 06

In progress –ARBs Oct 06SSRIs Oct 06

Key Requirements

COMMUNICATION80 meetings with key stakeholdersInteractive sessions

OWNERSHIP – LOCALConsultantsGPs

Key Messages

1) Patient care is enhanced

2) Efficiencya) Reduced cost to achieve the same

quality of patient careb) Reimbursement of the efficiency to –

i. Pay for new expensive treatment modalitiesii. Pay for primary care infrastructure, eg CPN

DEVELOPMENT

Development

1) Regional Steering Group

Regional Steering GroupChair - Consultant Clinical

PharmacologistConsultantsGPsHospital PharmacistsCommunity PharmacistsPrescribing AdvisorsABPI representation

Decide and oversee the work programme

Development

1) Regional Steering Group2) Regional Pharmaceutical

Procurement Unit

Regional Pharmaceutical Procurement Unit

Regional Procurement Pharmacist

2.5 wte Pharmacists

1 wte Clerical Officer

Requiring a Pharmacoeconomic Pharmacist

Linked to SGCE and PCEG

Contracting by RSS

Development

1) Regional Steering Group2) Regional Pharmaceutical Procurement

Unit3) Reorganisation of hospital contracts

Reorganisation of the Hospital Contracts

Coverage of all main therapeutic classes

Rolling 3-year contacts rather than one massive contract

Regional generic generics contract

Development

1) Regional Steering Group2) Regional Pharmaceutical Procurement Unit3) Reorganisation of hospital contracts4) Primary Care aspects

Primary Care Aspects

Linkage to quality and outcomes framework for new GMS contractLinkage to regional prescribing incentive schemeLinkage to new community pharmacy contract based on qualityLinkage to community pharmacy “Managing Your Medicines scheme” (IMM)

Development

1) Regional Steering Group2) Regional Pharmaceutical Procurement

Unit3) Reorganisation of hospital contracts4) Primary Care aspects5) Guidance

GuidanceAssessment relative to indication, egACEIs in hypertension

in heart failurein diabetic patients

Regional guidanceNICE? SMC

OTHER APPLICATIONS

DRESSINGS

Surgical dressings

Wound management products Aug 06

FOR BOTH PRIMARY AND SECONDARY CARE

BENEFITSOptimised patient careFully integrated product use in both sectorsSelection of product on safety and therapeutic efficiency as the prime determinantQuality at best value for the serviceRobust, transparent, defensible system of selectionWeb-based formulary – evidence basedDynamic with regular updatesCompliance with EU legislation

Matrices created for the different categories

HydrocolloidsSilver dressings

Logistics assessment

Pharmaceutical Clinical Technology

1) Medical and surgical disposables• Significant involvement of pharmacy

in their management• Improved management and cost

control

2) Point of Care Testing• Managed and controlled by pharmacy

via the regional contracting process

Pharmaceutical Clinical Technology

a) Medical and surgical disposableseg sutures Oct 06

endosurgery Jan 07endoscopy Jan 07

b) Point of Care Testing- urine testing Oct 06- blood glucose Dec 06- misc, eg troponin, BNP,

drugs of abuse screen Mar 07

Pharmaceutical Services Improvement Programme (PSIP)

Repeat dispensing

Minor ailments

28-day dispensing

Generic substitution

Medicines governance

Integrated medicines management

Therapeutic tendering

Pharmaceutical Clinical Technology