NHS Ayrshire and Arran: Pharmacist Led Review of Patients Prescribed Last-Line Antimicrobials
Resistance to antimicrobials is increasing, and with no new drugs on the horizon and a lead time for development of seven to 10 years, antimicrobial resistance will soon become a major public health problem.
There are a number of antimicrobials remaining to which resistance is currently rare and the use of these agents is restricted in Ayrshire, however the use of several of these restricted agents is still the highest per head of population in Scotland. The vast majority of prescribing episodes are initiated by infection specialists.
To reduce the use of these restricted agents, reviewing all prescribing episodes at Ayr and Crosshouse Hospitals.
An antimicrobial pharmacist was employed for one year at Crosshouse Hospital to review all patients prescribed restricted antimicrobials, along with the Ayr Hospital antimicrobial pharmacist. All episodes were fed back to the consultant microbiology team daily, along with three multi-disciplinary ward rounds a week and a weekly case conference. The lead antimicrobial pharmacist attended the case conferences along with some of the ward rounds to encourage open dialogue around prescribing practice to minimise the development of resistance.
The use of linezolid, a powerful drug against MRSA, was reduced by 82 per cent; bringing Ayrshire back in line with the rest of Scotland. There was a corresponding increase in the use of the first line agents vancomycin and teicoplanin. There was also a reduction in the use of the broad spectrum agent meropenem (which is used to treat Gram negative sepsis in hospital) and the antifungals voriconazole and caspofungin. The resistance to these agents is thankfully very low so it was not possible to measure a reduction in resistance. There was no associated increase in infection rates. The benefits are increased specialist clinical input into patient care and preserving the use of these restricted agents to those patients most at need. By minimising the development of resistance, it is hoped that these agents will be effective for years to come.
Efficiency Savings and Productive Gains
In 12 months, the cost saving was £514,000 from a drug budget of £1.61 million, representing a 32 per cent efficiency saving. This was delivered against a background of increased clinical service, with more individual patient reviews and closer monitoring of outcomes, so there was an increase in both efficiency and productivity.
On the basis of the above results, the one year pharmacist post was made permanent and a further two sessions of consultant microbiologist time were secured to support this service long term.
This work was only possible through funding provided on a 'spend to save' basis, together with effective clinical joint working and a shared ambition to reduce antimicrobial resistance and deliver the best clinical care for our patients. This also would not have happened without a lead who was prepared to champion the cause. A good business case is also important, as is regular feedback to the funding body of the results and next steps.
NHS Forth Valley: GP Prescribing Incentive Scheme
In the context of rising costs for GP prescribing, a local prescribing efficiencies group was established. The group has a Board-wide prescribing strategy and one of the key strands of this is the GP prescribing incentive scheme.
The problem identified related to the rising costs in GP prescribing resulting in a significant budget overspend of £3.4 million in financial year 2009-10. Additionally NHS Forth Valley was consistently reported as having the highest cost per patient in Scotland.
The aim was to achieve a sustainable reduction in GP prescribing expenditure across NHS Forth Valley whilst protecting patient care.
The GP Prescribing Incentive Scheme involves General Practices engaging in a range of cost-effective prescribing activities with the outcome measure of reducing their cost per patient towards the comparable Scottish average figure.
80 per cent of the savings generated by the scheme are retained by NHS Forth Valley to manage the overall primary care prescribing budget. The remaining 20 per cent is used to finance achievement payments to General Practices and to sustain a CHP development fund to take forward priorities identified by the CHP.
Monthly finance reports are provided to General Practices to allow them to assess their progress against target.
Chart 16 shows the downward trend in cost per patient for NHS Forth Valley and the other NHS Boards in Scotland.
Efficiency Savings and Productive Gains
The scheme generated the following savings, whilst maintaining the quality and safety of patient care in primary care:
Phase 1: £1.5 million
Phase 2: £2.3 million
Phase 3: In progress with a target of £1.2 million
The CHP development fund has provided General Practices with back scanning of medical records, freeing up space within premises, improving patient flow/consulting space. The fund has also provided ambulatory blood pressure monitors to improve hypertensive patient care.
The contract for each phase of the incentive scheme requires that General Practices maintain their reduced cost per patient for at least one year after the scheme ends or incentive payments will be clawed back.
Phase 3 of the scheme is nearing completion and NHS Forth Valley is considering future developments of the scheme.
Chart 16: Health Boards GIC per patient
- Improved finance reporting to General Practices has proved a useful tool to initiate change.
- Close working between pharmacy and finance colleagues, together with buy in and ownership from senior management and GPs is key to the success of the scheme.
- The scheme was deliberately non-prescriptive around how the reduction was achieved, leaving the decision to General Practices around which areas of prescribing to tackle. This allowed General Practices to target their efforts in areas of prescribing pertinent to their population.
- Prescribing support team input has proved invaluable to General Practices.
NHS Greater Glasgow and Clyde: ScriptSwitch Software Implementation across Inverclyde CHCP and East Dunbartonshire CHP
NHSScotland Efficiency and Productivity Programme: Progress Report - 2009-10 reported on NHS North Highland CHP and NHS Tayside pilots of the software. Both organisations reported positive outcomes from their pilot and continued to invest in the software. Given the potential to release savings the decision was made to initially implement the software in Inverclyde Community Health and Care Partnership (CHCP) and East Dunbartonshire CHP.
Increasing pressure on primary care services, increasingly tight prescribing budgets and a rising number treatments for long term conditions necessitate a multi-faceted approach to prescribing support. Existing prescribing teams have delivered excellent results in terms of reducing cost per patient and improving patient safety through bridging many interfaces. Prescribing teams review the constantly fluctuating drug market and offer advice to primary care prescribers on safe, cost-effective choices. Teams also assist in advising GPs on problems faced through the growing issue of drug shortages. This ever changing market presents significant risks in terms of drug expenditure and human resource. The ability to actively offer clinicians prescribing decision support during consultations was not addressed by existing strategies. The result was significant time spent retrospectively supporting General Practices in reversing less cost-effective prescribing decisions.
It was judged that ScriptSwitch software offered a tried and tested solution to the above problems while allowing existing teams to concentrate on valuable patient-centred work.
To implement ScriptSwitch software for six months in a CHP with a low level of deprivation within the population and a CHCP with a high level of deprivation to identify if this decision support tool improved cost-efficiency in both.
ScriptSwitch awareness sessions were run in the two CH(C)Ps. Community Pharmacy bulletins (post script Community Pharmacy) contained articles for awareness. A local database of messages was built and maintained by the central prescribing team. This database consisted of messages relating to patient safety, cost-efficiency and highlighting medicines shortages plus alternatives where possible.
ScriptSwitch software was installed in General Practices serving East Dunbartonshire CHP (practice population 101,436) and Inverclyde CHCP (practice population 86,699).
Two rounds of qualitative user satisfaction questionnaires were completed within the six months. Estimated savings were evaluated using ScriptSwitch analytics software.
After six months estimated savings are £125,610. The cost of procuring the software for 12 months was 78,000. The six month pilot therefore yielded a six month return on investment (ROI) of 3.1 to 1.
The efficiencies produced were similar across each CH(C)Ps despite the different levels of deprivation across the population.
This is largely in line with the ScriptSwitch reported national average of 3.3 to 1.
The ScriptSwitch user questionnaires indicated positive feedback with 89 per cent of users reporting that the software led to a change in prescribing habits and 89 per cent of users' opinion was that continued investment in the software was worthwhile.
Efficiency Savings and Productive Gains
It is estimated that the use of the software in these two CH(C)Ps released £125,610 in savings in six months. It was recognised that human resource was essential to support the software. Continual development and maintenance of the database is required with on-going funding covered by the efficiencies released by Board-wide implementation of the software.
Based on the six month outcomes, implementation of the software across 260 General Practices was started in March 2013. It is anticipated that this will produce estimated productivity savings for the population of NHS Greater Glasgow and Clyde (1,270,099 patients) in the region of £1.1 million net of an annual investment of £600,000.
ScriptSwitch customers in other areas, particularly in England, continue to invest in the software after many years and report a desirable ROI. The key elements for continued productivity are prescriber engagement and profile maintenance and development. NHS Greater Glasgow and Clyde has committed to a three year contract with ability to terminate this contract after one year if productivity is less than expected or more competitive comparable products come to market.
NHS Greater Glasgow and Clyde found that the building and maintenance of the profile of messages was a considerable piece of work that required dedicated staff that understood both the software and the needs of prescribers.
Involving NHS Board IT personnel was necessary for the smooth roll-out of the software and the on-going maintenance of the systems. Piloting the software on both clinical systems used in NHS Greater Glasgow and Clyde (EMIS PCS and InPS Vision) was highly beneficial from an intelligence perspective.
Good communication with all stakeholders was important and beneficial to ensure timely messages to prescribers and Community Pharmacy colleagues. Obtaining and acting on feedback from users of both systems was essential as fostered building of confidence and relevance in the system. Offering the General Practice the option of using ScriptSwitch use as a GMS indicator encouraged early opt in.
Email: Dayna Askew