FDB Insight into Tackling Low Priority Prescribing in Primary Care

On the primary care side, FDB OptimiseRx sits at point of care prescribing within clinical systems and has coverage in England and Wales of 38 million patients across NHS organisations.
  
Over the past year, we’ve been conducting analysis into prescribing behaviours with our primary care data to understand the value and impact of decision support, and gain better insight into what works for our customers.

This has included working with Kent Surrey and Sussex Academic Health Science network looking at best practice prescribing that can reduce adverse drug  events, one analysis discovered 26,000 falls may have been prevented due to GPs using our technology to change drugs for at risk patients. In addition, we’ve been looking at NHS England priorities, including low priority prescribing, which we include in OptimiseRx for our customers to use.

In 2018, NHS England worked with Clinical Commissioning Groups to identify items that would not be routinely prescribed in primary care as a way of reducing prescribing costs when appropriate. In total eighteen items were identified as part of the programme that were either low priority or had little evidence to support their usefulness in prescribing.

At that time our clinical content team researched and ensured that messages authored in OptimiseRx were aligned with these eighteen items, so that when they were prescribed in a practice with OptimiseRx enabled, a message would be presented to the prescriber. In addition to this, FDB developed reporting that could place a financial value on the costs avoided by not going on to prescribe this item.

Unsurprisingly with the roll-out of the NHS England guidance, we saw a high volume of these messages being triggered when prescribing, with high volumes this can lead to message alert fatigue – something we try to avoid through patient specific algorithms ensuring messages are displayed when appropriate to the prescribing event and patient.

As part of our analysis in the past year, we looked at our data around low priority prescribing and determined success as the customers achieving good acceptance rates.

Speaking with two of our customers who are consistently performing in the top decile for low priority prescribing areas we asked them for their advice on achieving good performance.

North East of England Commissioning Support Unit 

North of England Commissioning Support Unit (NECS) has been providing medicines optimisation support for several Clinical Commissioning Groups (CCGs) for many years who are OptimiseRx customers. 

Through well-established relationships with organisations across the region, NECS has built robust processes to ensure prescribers are aligned with local medicines optimisation plans designed to ensure cost effective and safer prescribing. Low priority prescribing is one area they targeted to improve prescribing costs for the region.

Susan Turner, Medicines Optimisation Pharmacist, NECS (Northumberland CCG) said: “Our drive behind successfully managing areas like low priority prescribing is setting teams up for success, this involves a lot of background work ensuring the Formulary lists are well managed and maintaining excellent communications with practice medicine managers and GP Prescribing leads. 

“This ensures engagement with the whole practice team, making them aware of initiatives and work plans comprehensively and with clear targets.

“We work towards the goal that the item isn’t prescribed in the first place – but with limited time in consultations, having OptimiseRx means that should it happen, it acts as a reminder to the workplans.” 

Building these relationships across primary care organisations has been key to their success. In addition, NECS investigates prescribing data to identify room for improvement. 

Neil Frankland, Medicines Optimisation Pharmacist, NECS (North Tyneside Clinical Commissioning Group) said: “We use and align data from OptimiseRx and ePACT to identify issues and anomalies. 

 “Marrying the data provides deep insight and means we can directly tackle problem areas and provide robust and achievable workplans that work for prescribers.” 

What are NECS’ top tips Top Tips for Managing Low Priority Prescribing? 

• Build prescriber confidence and a positive culture regarding medicines optimisation with a well-managed Formulary that is accurate and up to date.
• Work with organisations across the healthcare system to ensure that national priorities are understood and implemented by all. A well-functioning area prescribing committee has been key to enabling this in our area.
• Work with your practice medicine managers (or similar role) and GP prescribing leads, so they are informed and educated in what’s happening – this means they are empowered to tackle issues early on.
• Build teams for success by making things as simple and straight forward as possible as workplace pressures will always be present. 
• Make data driven decisions and plans; understanding the data is key to solving issues
• Provide clear quarterly targets and pro-actively measure, track and communicate performance.

Cheshire Clinical Commissioning Group 

In April 2020 Eastern Cheshire Clinical Commissioning Group, South Cheshire CCG and Vale Royal CCG merged with West Cheshire CCG to form NHS Cheshire CCG. Prior to April 2020 the Central and Eastern Medicines Management Team supported Eastern Cheshire CCG, South Cheshire CCG and Vale Royal CCG with medicines optimisation projects and prescribing support, which included the work into low priority prescribing to improve performance.

When looking at low priority prescribing and working to reduce the burden of these costs, Central and Eastern Cheshire enabled messages within OptimiseRx so they knew should a prescribing event happen, a message would be displayed to remind the prescriber of guidance. However, they knew this wouldn’t be enough to change behaviour alone, and it was important to educate prescribers and patients as to why this medication was now either not being prescribed or an alternative was recommended.

One area that became a priority for Central and Eastern Cheshire was bath emollients, which were on the list of medicines with low clinical value. Part of this prioritisation work involved review of the BATHE study into Bath Emollients and the prescribing recommendations from this study. Central and Eastern Cheshire’s   medicines management team then worked with practices and clinicians to identify patients who did not need the bath emollient or who would need to be switched to a leave-on emollient. The medical record could then be changed, and the team supported sending letters to patients to inform them of changes and why it was happening.

Laurelle Copnall, Prescribing Support Pharmacist, Cheshire Clinical Commissioning Group said: “Because we had evidence from the BATHE Study and supported the practice in identifying and communicating with patients, it meant it was a personalised approach and the end results meant that patients understood and accepted the change.

“In addition, should the prescribing event still happen, the clinician would see the OptimiseRx message and acceptance rates improved.”

This strategy has been an important part of Central and Eastern Cheshire’s tackling of low priority prescribing; informing practice clinicians why these medicines should not be prescribed in primary care and working to provide the optimal resolution for the patient. The medicines management team also worked with the Patient Advice and Liaison Service (PALS) teams to provide information should patients contact them regarding changes to prescriptions.

Ms. Copnall continued: “By doing the additional work to support the practice in prescribing change behaviour it has resulted in improved acceptance rates of OptimiseRx messages which ultimately has led to savings across the CCG."

“The practices feel empowered to deal with these changes through our team explaining what they can do instead, it simply didn’t help if it was a case of saying don’t do this.”

“In addition, we encourage and gather feedback from practices on messages and adjust accordingly, this means the clinicians are involved and we work together to optimise decision support.” 

What are Cheshire’s Top Tips for Managing Low Priority Prescribing?  

• Provide information and support to practices about prescribing changes so they are empowered to make informed decisions 
• Don’t simply say “don’t do this” to practice clinicians, provide the alternative based on guidance 
• Regularly review and enable the national messages authored and available in OptimiseRx 
• Review your messages to ensure Formulary statuses and workplans are mirrored 
• Support the practice in patient communications about medication changes and the ‘why is this changing’ 
• Encourage feedback from the practice on messages that are working and those that aren’t working

Our customers have provided insight into their approaches on tackling low priority prescribing and achieving targets and savings surrounding this NHS England priority. This is just one area that demonstrates the power of using OptimiseRx combined with local engagement activities to achieve maximum benefits with medicines optimisation programmes. We will be sharing these insights and more with all our OptimiseRx customers to support their programmes, and drive insight into prescribing behaviours and best practice.