The NHS’ vision for medicines optimisation - the role for pharma in driving adherence

Clare Howard | Deputy Chief Pharmaceutical OfficerNHS Commissioning

Medicines OptimisationClare HowardDeputy Chief Pharmaceutical Officer

ABPI 19th June 2013

Medicines Optimisation

• Where are we now?/ the case for change

• Medicines optimisation

• Your role

NHS | Presentation to [XXXX Company] | [Type Date]3

The NHS, like health systems across the developed world, faces increasing pressures

Quarter more over 85s by 2015

Diseases of modern lifestyles Rising consumer expectations

The opportunity and challenges of new technologies

Medicines Utilisation in Practice

Medicines still most common therapeutic intervention and biggest cost after staff, but, for example:

• -30 to 50% not taken as intended

• - Patients have insufficient supporting information

• UK Literature suggests 5 to 8% of hospital admissions due to preventable adverse effects of medicines

• Medication errors across all sectors and age groups at unacceptable levels

• Medicines wastage in primary care: £300M pa with £150M pa avoidable

• NHS Atlas of Variation

• Relatively little effort towards understanding clinical effectiveness of medicines in real practice

• The threat of antimicrobial resistance

Annual Cost

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11

£ M

illio

n

Primary Care

Hospital

Items dispensed and dispensing fees received by community pharmaciesEngland, 1999-00 to 2010-11

450

500

550

600

650

700

750

800

850

900

1999-00 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11

Item

s d

isp

en

sed

/Fees r

eceiv

ed

Prescription items dispensed (millions)

Dispensing fees received (millions)

Source: NHS Prescription Services of the NHS Business Service

NHS | Presentation to [XXXX Company] | [Type Date]6

Adherence

Avoidable medicines wastage in primary care is estimated to be £150 million per year (this is a conservative estimate) (1)

Between 30 and 50% of medicines are not taken as recommended (2)

Ten days after starting a new medicine, 30% of patients are already non-adherent – of these 55% of patients don’t realise they are not taking their medicines correctly, whilst 45% do (2)

Ten days after starting a new medicine, 61% of patients feel they are lacking information (3)

50% of patients report a problem with their medication at 10 days and at four weeks, in 22% of cases , the problem is still there (3)

Just 16% of patients who are prescribed a new medicines are taking it as prescribed, experiencing no problems and receiving as much information as they need (3)

NHS | Presentation to [XXXX Company] | [Type Date]7

SafetyAmbulatory care-sensitive conditions (i.e. Actively managed conditions which don’t normally require hospitalisation) account for 1 in 6 emergency admissions at a cost of £42bn each year (4)

Adverse drug reactions account for 6.5% of hospital admissions and over 70% of these are avoidable (5)

A study of the Use of Medicines in Care Homes found that 70% of residents were exposed to one or more medication errors (6)

An estimated 180,000 people living with dementia are treated with antipsychotics each year of which it has been estimated that less than 36,000 may derive some benefit from them at a cost of 1,800 additional deaths and 1,620 cerebrovascular events (7)

The General Medical Council’s EQUIP study demonstrates a prescribing error rate of 8.9% in medication orders in 19 acute hospitals. The study found that errors are associated with all levels of doctors (8)

526,186 medication incidents were reported to the NPSA between 2005 and 2010. 16% involved actual patient harm. Delayed or omitted doses (16%) and wrong dose 915%) are the commonest categories (9)

An estimate of 1.7 million serious prescribing errors in general practice in England in 2010 (10)

NHS | Presentation to [XXXX Company] | [Type Date]8

Financial and organisational risksFinancial and organisational risks

Financial and organisational risks

Medicines are the most frequent healthcare intervention and the NHS spends £13.8 billion per year on medicines (11)

The number of prescribed items is growing at 5.3% annually (12)

In secondary care, about 60% of medicines expenditure is on high cost medicines excluded from the national Payment by results (PbR) tariff (13)

Care Quality Commission continues to highlight poor medicines management services as contributory in some cases to failing services (14)

In 2008/09 more than half a million bed days were attributed to adverse events caused by medicines, costing the NHS £235 million

At least 6% of emergency admissions are caused by medicines (15)

NRLS – Types of incidents

Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

National Reporting and Learning System (NRLS) in England and Wales medication incident reports 2005 - 10

Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

NRLS – who is reporting incidents?

11 Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

NRLS – Critical medicines

Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

NRLS – Error category

Cousins D, Gerrett D, Warner B. Br J Clin Pharmacol. 2012

Body of evidence to show why we need to improve and how.

14

What about adherence?• Low adherence with prescribed treatments is common.

• In developed countries, adherence to long term therapies in the general population is around 50% (WHO, 2003)

• In England, less than 50% of patients eligible for treatment receive optimal therapy …..with low levels of adherence believed to be a contributory facts (DH, 2007)

• Between half and one third of all medicines prescribed for LTCs are not taken as intended(Horne et al 2005)

• LTCs with strong evidence of significant levels of non adherence include asthma, diabetes, HIV/AIDS and dyslipidaemia (WHO 2003)

NHS | Presentation to [XXXX Company] | [Type Date]15

Medication adherence rates for 7 chronic conditions during the first year of therapy (Briesacher et al, 2008)

Disease Percentage of patients achieving adherence ≥80%

Hypertension 72

Hyperthyroidism 68

Type 2 Diabetes 65

Seizure disorders 61

Hypercholesterolaemia 55

Osteoporosis 51

Gout 37

NHS | Presentation to [XXXX Company] | [Type Date]16

WHO - 5 interacting dimensions affecting adherence.

• Social/ economic factors (Age, gender, inability to pay)

• Health systems/ health care team factors (poor quality of instructions provided to the patient.

• Therapy –related factors (e.g. adverse effects for medicines, complexity of regime)

• Patient related factors (e.g. patient disagreement of necessity)

• Condition-related factors (e.g. dysphagia in Myasthenia Gravis)

NHS | Presentation to [XXXX Company] | [Type Date]17

18

•Put patients at the heart of everything the NHS does (“No Decision About Me Without Me”)

•Focus on continuously improving those things that really matter to patients - the outcome of their healthcare •Empower and liberate clinicians to innovate, with the freedom to focus on improving healthcare services

Specific extracts:

The community pharmacy contract, through payment for performance, will incentivise and support high quality and efficient services, including better value in the use of medicines through better informed and more involved patients.

Pharmacists working with doctors and other health professionals, have an important and expanding role in optimising the use of medicines and in supporting better health

Medicines optimisation –The Policy Context

Medicines Optimisation

• Will be a focus for NHS England and system

• Aims to deliver much improved quality, value and outcomes from

medicines use

• Could operate at system and patient level: from planning and

policy development to individualisation of care

• Will require a level of patient and public engagement not

previously seen

• Will require a level of inter and intra professional collaboration not

previously seen

• Will require an enhanced, transparent and vfm approach to

partnership working

• Will require an enhanced level of patient centred professionalism

A wonderful harmony arises from joining together the seemingly unconnected.

(Heraclitus)

IT is important to delivery

Jeremy Hunt said:“The NHS cannot be the last man standing as the rest of the economy embraces the technology revolution. “It is crazy that ambulance drivers cannot access a full medical history of someone they are picking up in an emergency – and that GPs and hospitals still struggle to share digital records. “Previous attempts to crack this became a top down project akin to building an aircraft carrier. We need to learn those lessons – and in particular avoid the pitfalls of a hugely complex, centrally specified approach. “Only with world class information systems will the NHS deliver world class care.”Published 16 January:

2013https://www.wp.dh.gov.uk/publications/files/2013/01/Review-of-use-of-Information-and-Technology.pdf

Medicines Optimisation Principles

A strategy might include…• Patient Engagement • Improving outcomes• Value for money • Partnership with Pharmaceutical Industry• Medicines pathway• Safety and assurance

22

Information and technology

The challenges and opportunities• Mobilising the profession

• DH and NHS England working together

• Infrastructure in NHS England

• Secondary care – Monitor, CQC

• NHS Improving Quality – the NHS Change Model

• Matrix working

• Executive sponsorship

The role of Pharmaceutical Industry• Recognition that adherence is a major problem

• Recognition of your role in the solutions

• Engage in Medicines Optimisation

• Support awareness raising with prescribers.

• Trials to address adherence

• Accept that the default position of non adherence is more realistic.

• Collaboration and calibration. Can we work together and measure?

NHS | Presentation to [XXXX Company] | [Type Date]24