10th National Conference for

1
10th National Conference for Primary Care
Prescribing Advisers 18th 19th June 2009 Keele
Conference Centre
The Constitution and Beyond What next for
prescribing support?
Clive Jackson Chief Executive
2
Evolution?
One objection to evolution is that it is too
slow for the current age Anon.
Charles Darwin
3
Evolution prescribing support
Prescribing Support for primary care, has
however, come a long way since it emerged at the
start of the 1990s.
4
Evolution - numbers

• Spring 1991
• 2.5wte pharmaceutical advisers across the whole
  of the NW Region (14 FHSAs)
• Spring 1996
• c220 pharmaceutical advisers across England (100
  HAs)
• Spring 2005
• c1500 pharmaceutical advisers across England
  (gt300 PCTs and also Practice-based)

5
Evolution - roles

• Spring 1991
• PACT analysis (paper), supporting Medical
  Advisers, GP Practice visits
• Spring 2009
• Virtually anything related to medicines /
  pharmacy emerging in the organisation, including
  Flu!

6
Evolution - objectives

• Spring 1991
• Saving money on medicines
• Spring 1996
• Cost effectiveness of medicines use
• Spring 2003
• Quality and cost effectiveness with medicines use
• Spring 2008
• Quality, cost effectiveness, choice and
  concordance with medicines - integrated with
  wider healthcare / service commissioning and
  public health

7
Evolution drug budgets

• Spring 1991
• Whats a drug budget?
• Spring 1996
• Indicative Fundholding - separate drug
  budgets
• Spring 2005
• Part of cash limited, health economy allocations
  - with reasonable annual growth
• Spring 2012 - ???
• What budget?

8
The National Prescribing Centre (NHS)

9
National Support from the NPC

• Formed in 1996 national NHS body, funded and
  managed through the Department of Health
• Remit / work programme - has grown significantly
  over last 10 years
• Now evolving further to support
• Advisers / other key audiences across the NHS
• NICE (around information e.g. MeReC / NHS
  Evidence
• DH in policy implementation

10
National Prescribing Centre (2009)

New Vision

• To be a leading national organisation in the
  field of medicines use, facilitating developments
  in policy and providing relevant and valid
  support on prescribing and medicines management

Mission Statement
To support individuals and the NHS to deliver
rational, evidence-based, safe and cost-effective
use of medicines for the benefit of patients and
the public
11
NPC - Core Activities (2009 -)

• Will still cover 3 main areas
• Information on Medicines
• MeReC and New Medicine Scheme
• Education and Development
• NPC Associates, NPCi
• Therapeutics / medicines management
• Dissemination of Good Practice
• e.g. Controlled drugs, repeat prescribing

12
NPC - Core Activities (2009 -)

• Important new strands of support for NHS, linked
  to implementing DH policies
• Non-medical Prescribing
• CDs Accountable Officer roles
• Next Stage Review / NHS Constitution
• Local Decision Making on medicines

13
NPC - Core Activities (2009 -)

The Next Stage Review and the NHS Constitution

• Local Decision making about Medicines
• Why, what and when?

14

• The NHS Constitution
• January 2009
• A combination of
• Rights
• Pledges and
• Responsibilities

15
Resources for PCTs and NHS Trusts
Baseline survey to measure current PCT local
decision making processes (completed November 08
and published March 09)
High-level Guiding Principles to inform decision
making processes around medicines (published with
the NHS Constitution January 09)
Handbook of good practice to support rational
local decision making about medicines (including
individual funding requests) (published March
09)
Ongoing programme of support (recently
commissioned)
16
NPC Outputs

• The PCT Baseline Survey

17
A Comprehensive Survey of PCTs to Evaluate Local
Decision-Making Processes for Funding New
Medicines (Undertaken during August / September
2008)
Survey Report February 2009
ADELPHI RESEARCH UK
18
Sample Structure by Strategic Health Authority

• Strategic Health Authorities
• No. PCTs No.
  PCTs
• Surveyed
• East Midlands 9 9
• East of England 14 13
• London 31 23
• North East 12 6
• North West 24 23
• South Central 9 7
• South East Coast 8 7
• South West 14 14
• West Midlands 17 15
• Yorkshire Humber 14 13
• Total 152 130

North East 50
Yorkshire The Humber 93
North West 96
East Midlands 100
West Midlands 88
East of England 93
South Central 78
London 74
South East Coast 88
South West 100
Total PCT Coverage 86
19
Consistency of Decision Making Across PCTs
Mean Rating
5.0
Base 130 PCTs Source Q68
20
Information Sharing Across PCTs
Mean Rating
6.8
8.1
Base 130 PCTs Source Q66 Q67
21
ECP Workload by PCT
Q Approx how many cases have been considered by
the ECP in the last financial year?
Base 100 PCTs, All Excluding Dont Know/ Not
Sure Source Q51
22
APCs (or equivalents) - Information Sources
Supporting Decision-Making Processes
Q Which, if any, of the following information
sources are used by the APC?
Local Sources
Regional Sources
National Sources
Base 130 PCTs Source Q17
23
Awareness of, and planning for, Clinical Trials
by SHA
Q How proactive is it in managing drug supplies
following termination of pharmaceutical company
sponsored clinical trials? (n81)
Base 81 PCTs All those whose committees are
aware of clinical trials Source D3 Q28
24
Awareness and Understanding of Decisions
Q Which of the following groups are aware of the
decisions made by the ECP APC?
Q On a scale of 1-10 how well do the following
groups of individuals understand decisions made
by the ECP APC?
(mean score higher being a better understanding
)
(6.3)
(6.1)
(4.5)
(4.2)
Base 97, 109, 62, 74 PCTs respectively All PCTs
making groups aware of decisions made, yes at
Q59 Source Q60
Base 130 PCTs Source Q59
25
PCT Perceptions of Post Code Lottery
Mean Rating
6.0
Base 130 PCTs Source Q69
26
NPC Outputs

• The High-level Guiding Principles

27
DH Guiding Principles

• Published at the same time as the Constitution
• Inform development local decision making about
  medicines
• Scoping statement
• Scope of what the principles cover
• Context in which decisions should be made
• Nine high level principles
• Heading with a broad statement
• Supporting context

28
Scoping Statement

• SCOPE
• Medicines (not or not yet covered by NICE)
• Annual commissioning round, in-year service
  developments and IFRs
• Across primary and secondary care
• Directed at PCTs and any collaborative
  arrangements
• CONTEXT
• National policies (inc WCC)
• Local priorities, prioritisation processes and
  governance frameworks
• Consider clinical and cost effectiveness relative
  to other interventions
• Consider available budget

29
Guiding Principles

• There are NINE guiding principles covering
• GOVERNANCE AND ACCOUNTABILITY
• PROCEDURES
• CRITERIA FOR DECISION MAKING
• DOCUMENTATION
• TIMELINESS
• APPEALS PROCESS
• ENGAGEMENT
• COMMUNICATION
• IMPLEMENTATION AND PROCESS IMPROVEMENT

30
NPC Outputs

• The Handbook of Good Practice Guidance

31
The Handbook

• Six key steps in local decision making
• Frameworks and checklists to support review and
  development of processes
• Quick diagnostic, other web resources

32
Key steps in local decision making
33
What next? - evolving NPC support

• DH have now commissioned NPC to provide an
  ongoing support programme for PCTs on local
  decision making
• Plans currently being finalised 2 phases of
  delivery.
• Phase 1 to this August
• Phase 2 Autumn onwards

34
What next? - evolving NPC support

• NPCs evolving support programme for PCTs
• Phase 1 already commenced.
• All PCTs to be contacted by an NPC Facilitator
• Identify actions to date
• Issues emerging as a result
• Areas where further support might be required
• NPCs APC Guide (2007) being updated
• Feedback on new Handbook being reviewed

35
What next? - evolving NPC support

• NPCs evolving support programme for PCTs
• Phase 2 commencing from autumn 2009.
• Four main areas for support / facilitation
• Clinical horizon scanning / new medicines
• Technical Information Mastery / understanding
  clinical trials / using data effectively
• Legal / ethical guide
• Applied generic skills (e.g. chairmanship /
  making decisions / communication etc.)

36
What next? - evolving NPC support

• NPCs evolving support programme for PCTs
• Phase 2 commencing from autumn 2009.
• Augmented with up to 5 NPC regional
  facilitators
• Facilitating networking and sharing of good
  practice
• Awareness raising of NPC developments / materials
• Helping plan and run a series of regional
  events
• Collating feedback and helping inform ongoing NPC
  work programmes
• A national conference on local decision-making
• Updating of the new Handbook, as required

37
What next? - evolving NPC support

• NPCs evolving support programme for PCTs
• Linked together, all these additional
  developments mean that the NPC requires more
  capacity to deliver
• The NPC will, therefore be
• Commissioning more work from experts in the field
• Extending / refining the scope of some existing
  outputs
• Recruiting some additional team members
• Moving to alternative offices as a result of the
  restrictions placed on us by the existing
  accommodation

38
What next? - evolving NPC support

• NPCs evolving support programme for PCTs
• More information on all these NPC developments
  available over the next few months
• Will allow provision of a more comprehensive /
  coordinated programme of support to you and other
  key NHS audiences
• Provide greater flexibility to meet emerging
  support requirements as the NHS evolves to meet
  the issues and potential difficulties of the next
  few years

39
Evolution What next for prescribing support?

• Key issues that will impact over coming period
• General Election by May 2010
• change in administration / policies?
• Credit crunch and squeeze on public spending
• from 2011(?) onwards
• New technologies
• relative costs / speed of adoption
• Professional regulation
• CPD, re-certification, re-validation

40
Evolution What next for prescribing support?

• Key issues to consider over coming period
• Delivering Value for Money will be critical
• both in medicines use but also on professional
  resources
• Better Care, Better Value indictors
• Repeat medication management / therapeutic
  optimisation
• Future investments will be to save money whilst
  maintaining quality

41
Evolution What next for prescribing support?

• Key issues to consider over coming period
• Supporting commissioning will underpin work
• Prescribing Advice
• a strong track record in delivering quality and
  VfM
• being able to demonstrate this will be critical
• CPD will need to be targeted, relevant and
  efficient

42
Evolution What next for prescribing support?

• The future is potentially a real opportunity
• Strategy will need to be ongoing evolution, but
  linked to capacity for speedy adaptation to the
  changing environment
• The NPC will be here to help you develop and
  deliver