Building PBC capacity through pharmacy event

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Building PBC capacity through pharmacy event

• Thursday 28th June 2007
• Leeds United Football Club

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Welcome Introductions

• Giano Celino, Director, Webstar Health
• Michelle Webster, Assistant Director, Improvement
  Foundation
• Dr James Kingsland, NAPC

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Building PBC capacity through pharmacy event

• Thursday 28th June 2007
• Leeds United Football Club

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Practice Based Commissioning (PBC)
Michelle Webster Assistant Director
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Who is IF

• Established 1st April 2006
• Incorporates National Primary Care Development
  Team (NPDT - established 2000)
• Core business is supporting public services in
  improvement work.
• NHS
• Other public services
• International improvement work
• Co-ordinator of all national PBC activity for
  Department of Health

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The Structure of the Programme

• Preparatory Phase
• - Baseline assessment framework
• - PBC training event 1
• - PBC training event 2
• Assessment Point
• Workshop Phase
• - Learning Workshop 1
• - Learning Workshop 2
• - Learning Workshop 3

Action Periods
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Whos Involved

• Nationally
• 120 PCTs
• Over 20 million patients covered

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IF PBC programme

• PCT PBC days
• Commissioning Course
• Website- resources and service improvement
  examples
• Web casts
• Learning Exchanges

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Community Pharmacy and PBC

• Three Building PBC capacity through pharmacy
  workshops
• Pharmacy and PBC bulletin
• Pharmaceutical Assessment Toolkit
• IF Leadership Programme
• Quality Improvement Skills Programme (QuISP)- for
  small teams

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Challenges in Implementation of PBC

• Ensuring Patient Focus
• PCT Finances
• 18 Week Target
• Clinical Engagement Inclusivity
• Continued Development / Partnership with all
  Stakeholders

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Lessons learnt

• Need to break from Provider Led NHS Commissioning
  Culture
• Advent of PbR
• Importance of Effective Commissioning as a
  separate function within a cycle
• Commissioning / Contracting / Procurement
• Who is best placed to commission for services?

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Lessons Learnt cont..

• Engagement of GPs / Clinicians and Practice Teams
• PCT Support for All Parts of the Health Economy /
  Development of Primary Care
• Clear / Inclusive Planning (Context of the Whole
  Systems Needs e.g.18 week target)
• High Quality Information / Information Systems
  (not just data)

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PBC - The Key Elements

• Fair / Transparent Budget
• Efficiency gains / Freed-up resources, (FURs)
• Effective service redesign process
• Involvement of Service Users
• Effective Communication Systems

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The Successes

• Improved Working Relationships
• Shared Understanding and Vision between Practices
  and PCTs
• Shared Responsibility
• Good Systems in place to Collect Data and Monitor
  Budgets and Outcomes
• Practices have Welcomed the Opportunity to Lead
  Change

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Case Study

• Control practice
• Reduction of 14
• Increase of 2
• 12 rise

• Pilot practice
• 58 reduction in overall number of nights
  patients stay in hospital
• 97 reduction in excess bed days, (over trim
  point and therefore costing lots)
• 97 reduction in cost due to reduced bed days

Saving of over 0.25m for practice .. and
increasing Potential of 3 million for cluster
and more!!
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Contact Details

• Improvement Foundation PBC Team
• Tel [phone]
• Email eloise.glew_at_improve.nhs.uk
• Website www.improvementfoundation.org

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Building PBC capacity through pharmacy event

• Thursday 28th June 2007
• Leeds United Football Club

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PBC and pharmacy

• Gianpiero Celino, Webstar Health Dr James
  Kingsland, NAPC

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• Did someone say PBC?
• Gianpiero Celino

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PBC Current picture
The current picture Practices forming groups /
consortia Submitting plans (linked to PbC
payment) Developing terms of reference and
operational infrastructure
Factors affecting progress Motivation Appetite
for role Prescribing performance Funding for
infrastructure Availability and confidence in
data Willingness to provide
Groups moving at different speeds Leaders Follow
ers Sceptics
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The issues for pharmacy

• National message is PBC is important we should
  be doing something but not sure what!
• Very little (local) information reaching pharmacy
  - what there is, is focused on secondary care
  (not our forte?)
• Fear risk to (existing) local commissioning by
  PCTs
• GPs holding all the cards (and money!)
• Is PBC a better fit with the role of practice
  pharmacists?

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The opportunities

• Knowledge of patients and medicines not just
  what is prescribed but how it is used
• Premises and infrastructure modern, open longer
  hours, no appointment, more time
• New contract
• Repeat dispensing / Electronic prescription
  service
• Medicines Use Review
• Business background competition welcome to our
  world

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The challenges

• Mapping pharmacies to PBCs/GPs
• Overlapping and competing providers
• Being accepted by GP stakeholders sharing the
  risk/accountability
• Putting up a good argument for pharmacys
  involvement
• Making links between contribution and priorities
  for PBCers
• Should we work for or with GPs?

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So what can pharmacy do for PBC?
GC
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Where do the opportunities lie?
Commissioning New to pharmacy (and to most
GPs!) Pharmacy may have useful insight into
needs, esp. where data is poor First hand
knowledge of gaps in medicines support Helping
redesign care pathways

• Provision
• Pharmacy more familiar with the
  provision/procurement function
• Potential to use existing infrastructure and
  expertise
• Indirect support release GP capacity through
  other services
• Wont providers need pharmacy expertise? Service
  redesign

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Example PBC Priorities
Focus Appropriate referral Primary care
pathways Avoidable admissions Follow ups
Embedding the new contract Essential
services Advanced Services Local
commissioning Enhanced Services PBC
commissioning New Services
Diabetes
AE Attendance
What is the potential Contribution of CP?
Dermatology
Community Services
Rheumatology
Prescribing
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Models for engagement
Provider Model
Role for pharmacy
GP commissioner use new resources commission
others to provide
Third party provider bring to bear skills and
experience in primary care / business
GP provider use existing resources and
infrastructure provide new services in house
Reduce workload in general practice to provide
time to perform new roles
GP led providers mixed model of existing and
new resources
Enhance skills mix in general practice by
including pharmacy
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Asthma management service

• A focused medicines use review delivered by
  community pharmacists through a structured
  consultation with the patient, in the pharmacy
• The service aim to opportunistically identify
  patients who are experiencing difficulties with
  controlling their asthma. Evaluation of the
  service found that
• 63 of patient may not have been controlled
  during the past 4 weeks
• 52 of patients reviewed required further patient
  education
• 22 needed help with inhaler technique
• 25 had concordance issues
• 38 were identified as having poor control due to
  therapeutic inefficiency
• 26 were referred to their GP, of which
• 42 were prescribed add on therapy in line with
  BTS guidelines
• 14 had a change in therapy
• 14 had their inhaler type altered

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Care home management service

• A dedicated community pharmacist support service
  for care homes linked to the GP practice
• Aims to identify and address clerical and
  clinical recommendations to improve outcomes for
  patients and the use of resources. Evaluation of
  the service found
• The pharmacist made 4.5 recommendations (3
  clinical and 1.5 clerical) per patient
• One in every three clinical recommendations lead
  to discontinuation of medication and
• One in every 1.5 clerical recommendations led to
  removal of unwanted medicines from the patients
  records
• The service resulted in a 60 reduction (from
  4800 to 1800 per month) in prescribing cost in
  the pilot home.
• Subsequent roll out in three nursing homes with a
  combined population of 165 elderly patients,
  reduced prescribing costs from 120 to 82 per
  patient per month

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Community pharmacy moving forward with PBC
Past
Future
Traditionally a nationally commissioned service
Local commissioning a growing factor
Benefited from PCT advocates for the profession
Influence shifting from PCTs to PbCs unknown
territory
Historically engaged with GPs via a proxy
Direct engagement required
An important supporting service
May be seen as competitors by some GPs
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• Now that we have led the horse to the water how
  do we make it drink?

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Encouraging engagement
PCTs
PBCs
LPCs
Review local engagement between PBC and pharmacy,
develop enabling environment
Share priorities, plans and data with local
pharmacy stakeholders
Prepare and equip pharmacy champions to engage
with local PBCs. Work with PCT MM teams.
Develop clear communications channels
Review how essential and advanced pharmacy
services can support PBC
Understand how PCT/PBC processes will work and
communicate this to all contractors
Facilitate strong local engagement between PCT
medicines management teams, community pharmacists
and PBC and PCT commissioners
Engage with pharmacy leaders
Ensure that PBC information i.e. priorities,
plans, data, etc. can be accessed by all
contractors
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Encouraging engagement
Pharmacists
GPs
Organise into groups to mirror PBCs structures
Share priorities, plans and data with local
pharmacy stakeholders
Engage with local GPs, to discuss progress with
essential and advanced service
Review how essential and advanced pharmacy
services can support PBC
Use LPC websites and communications to understand
local progress and/or talk to LPC members
Engage with local pharmacists
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Love is.
PBC
Pharmacy
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Building PBC capacity through pharmacy event

• Thursday 28th June 2007
• Leeds United Football Club

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NHS REFORMandCOMMUNITY PHARMACY

• Dr James Kingsland
• Chairman
• National Association of Primary care
• General Practitioner
• Wallasey, Merseyside

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Getting the message right
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Drivers for Change

• CHOICE
• PLURALITY
• HEALTH INEQUALITIES

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Vehicles for Change

• PBC
• PbR
• PCC
• FTs

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Roadmap

• NHS Plan July 2000
• Our Health, Our Care, Our Say a new direction
  for community services

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Guidance sat nav

• PBC engaging Practices in Commissioning - Oct
  2004
• Commissioning a patient-led NHS July 2005
• PBC achieving universal coverage Jan 2006
• Health reform in England update and
  Commissioning framework July 2006
• PBC Practical Implementation 2 documents
  published 28 Nov 2006
• The NHS in England Operating Framework for
  2007/08 - Dec 2006
• Commissioning framework for Health and wellbeing
• - 6 Mar 2007
• (health and social care working in partnership)

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Future of Commissioning in the NHS

• Devolution of decisions about securing services
  to the front line
• Demand and Divi is over no more local
  monopolies
• Referrer defines service requirement through
  referral activity and deploys resources
• Traditional model is unsustainable
  uncontrolled/unchallenged activity must cease
• Release resource tied up in existing providers
• Engagement/collaboration is key

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PBC What it is

• A drive to improve efficiency in the deployment
  of NHS resources....by
• Shifting the focus to extending Primary Care
  delivery....by
• Extending the skills and mix of the PHCT....who
• Have the opportunity to redesign NHS care.by
• Commissioning services for their patients.with
• A devolved indicative budget

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PBC- How its done

• In Partnership.but
• Practices are free to choose if they work with
  other practices or not.and
• Its not a one-size-fits-all approach
• Other clinical groups can hold a budget.but
• Seek to obtain good value for money but most of
  all we need.
• Skilled leadership, cultural change and the tools
  to make it work

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OPPORTUNITYNOWHERE
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PROVIDER OPTIONS

• Extending GP contract provision
• Creating new clinics in General Practice
• Developing expanded community provision

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PROVIDER SERVICES

• Community Nursing
• Extended in hours practice opening times.
• Practice based clinics and OPD follow up
• Diagnostics and physiological tests
• Hospital at home services
• Specialist community clinics

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KEY MESSAGES

• The devolved budget and moving to fair shares
• Any willing provider reducing the need to
  tender
• No local Monopolies
• Incentives for new providers
• Patient choice expanding
• Clarifying like for like services
• Tariff unbundling
• Deployment of released resources

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Doing the same thing the same way and expecting a
different result

• INSANITY
• Albert Einstein

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And for pharmacists?

• The story so far -

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Creating new strategic partnerships

• Working together for patients with joint codes of
  conduct and governance
• Establish longer and more accountable
  associations
• Refocus away from any previous poor practice
• Networking in different ways

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From Partnership- to Integration

• Providing a service through APMS or sPMS
• New care pathway design supporting PBC. New
  health economic models
• Managing Rx reviews of LTCs in the community
• Providing NPT/diagnostics
• Supporting new community hospital development

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Building PBC capacity through pharmacy event

• Thursday 28th June 2007
• Leeds United Football Club

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Refreshments 11.00 11.20

• Interactive workshop sessions
• 11.20 12.30

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Workshop A

• Steve Morris Richard Seal, National Prescribing
  Centre

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The Dragons Apprentice
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The Scenario

• Cost effective management of dyspepsia- what can
  community pharmacy deliver?
• Read the instructions sheet
• 30 minutes to prepare proposal
• 3 minutes to make presentation
• Executives decision is final

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Lunch12.30 13.20
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Building PBC capacity through pharmacy event

• Thursday 28th June 2007
• Leeds United Football Club

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PBC and priorities in medicines management

• Richard Seal
• National Prescribing Centre

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Practice Based Commissioning

• Priorities in
• medicines management

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Poor Prescribing Medicines Management
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.leads to

• Harm not help
• Inappropriate interventions
• Failure of treatment
• Avoidable ill health
• drug interactions
• unwanted effects
• Unnecessary medicines - wastage
• Demands on scarce resources
• Time
• Money

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Poor medicines management So What?
Avoidable admissions

• Up to 50 of hospital admissions related to
  medicines(NPC MM collaborative)
• 200,000 fatalities from medical errors (JAMA
  1998)
• 40 of these are potentially avoidable(Leape et
  al. 1997)
• Medication errors cost the NHS up to 500 million
  in extra hospital days(Dept of Health 2003)
• Around 65 of consultations in family practice
  end in a prescription

Avoidable admissions Litigation
Patient complaints Clinical governance
Avoidable admissions Length of stay Litigation
Surgery staff time Costs
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Prescribing MM goal

• Right drug
• Right dose
• Right patient
• Right time
• Everytime !

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Priorities for prescribing and medicines
management
Value-for- Money
Choice access
Effectiveness
Support for self care
Safety
Long Term Conditions
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Opportunities for Community Pharmacy

• Effective Prescribing
• Preventing Admissions
• Redesigning Care Pathways
• PBC- A practical guide for LPCs- June 2007
• PSNC

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Primary Care Drugs BillKey Facts

• NHS spends 8 billion a year on drugs in primary
  care
• 752 million prescriptions dispensed in primary
  care
• Further growth in drugs expenditure can be
  expected!

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NAO ReportPrescribing Costs in primary care

• Scope for more efficient and effective
  prescribing
• PCTs could save more than 200 million without
  affecting clinical outcomes through more
  efficient prescribing
• Statins
• Ace inhibitors / ARBs
• PPIs
• Clopidogrel

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NAO ReportDrugs Wastage

• Cautious estimate of value of waste -100
  million
• Some estimates of upto 10 of all drugs
  prescribed are wasted - 800 million?
• Reducing waste
• Limiting initial prescribing quantities
• Optimising repeat prescribing systems
• Raising public awareness

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Better Care, Better Value Indicators

• Identify areas for potential improvements in
  efficiency.
• Initial indicator set October 2006
• Low cost statin prescribing single Rx indicator
• Proposed Additional Indicators?
• PPIs
• Ace inhibitors
• Antiplatelet prescribing
• Potential generic savings

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Safety
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Is there a problem with medicines ?
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The LTC marketplace
Source Long term conditions Integrating
community pharmacy RPSGB (2007)
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PBR-Pricing Examples
B13
Cataract
(702)
Extraction
(702)
E28 Cardiac
(702)
(702)
Arrest (2114)
(2179)
R11 Spinal
Cord Surgery
(3087)
F35 Large
Intestine

Endoscopic
or
Intermediate
Procedures (476)
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Competitive advantages

• Acceptable to patients
• No waits
• Closer relationship to patient
• Well-located
• Disadvantaged communities
• Increased coverage
• Vulnerable hard-to-reach groups
• Out-of-hours
• Skilled and willing
• Cost-effective
• Huge potential
• Currently only 1 of community pharmacies are
  commissioned to provide disease specific
  medicines management services

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So what could community pharmacy contribute?
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Practical Example - Dyspepsia

• Referral ALARM symptoms
• Lifestyle advice
• OTC medicines support for self-care
• Medicines use reviews
• H. pylori screening eradication
• Long term disease management

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Further opportunities

• Essential services
• Dispensing/repeat dispensing
• Disposal of medicines
• Advanced services
• Medicines use review
• Prescription intervention
• Enhanced services
• Clinical medication review
• Medication monitoring
• Supplementary prescribing
• (Independent prescribing)
• Palliative care
• Out of hours provision
• Interface services

• Essential services
• Dispensing/repeat dispensing
• Disposal of medicines
• Advanced services
• Medicines use review
• Prescription intervention
• Enhanced services
• Minor ailment schemes
• Medication review
• Medication monitoring
• Supplementary prescribing
• (Independent prescribing)
• Palliative care
• Out of hours provision

• Essential services
• Repeat dispensing
• Advanced services
• Medicines use review
• Prescription intervention
• Enhanced Services
• Minor ailment schemes

• Essential services
• Disposal of medicines
• Promotion of healthy lifestyles
• Signposting healthcare services
• Advanced services
• Enhanced services
• Smoking cessation
• Minor ailment schemes

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Enabling environment

• Multidisciplinary involvement
• Quality assurance of services
• Acceptance by local healthcare staff
• Effective marketing to commissioners, doctors and
  patients
• Reimbursement

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Next steps

• Consider local needs very carefully
• Review existing services to assess development
  opportunities
• Identify synergy with GMS
• Identify local leaders
• Develop business case
• Independently
• Collaboration
• Make the case

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Building PBC capacity through pharmacy event

• Thursday 28th June 2007
• Leeds United Football Club

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Interactive table top sessions

• 14.00 15.20

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Building PBC capacity through pharmacy event

• Thursday 28th June 2007
• Leeds United Football Club

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Next steps

• Sean Fenelon
• Primary Care Contracting

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Building PBC capacity through pharmacy event

• Thursday 28th June 2007
• Leeds United Football Club

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Building PBC capacity through pharmacy event

• Thank you for attending