Good prescribing

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					Good prescribing
Professional duties and incentives




     CATCH PBC Forum Histon 23rd June 2011
          Allocation of funding
• We have an allocation of £30 million
• MMTdistributes this money to practices through allocation
  formulae
• We have overspent it by £1 million
• Some have overspent more than others.
• Yeah, Yeah Yeah! Same old excuses….
• We have a professional duty to prescribe
  what our patients need
• We have a professional duty to spend wisely
• We must not allow a conflict of interest to distort our judgement


                   CATCH PBC Forum Histon 23rd June 2011
Budgetary allocations are a quirk of history and
                demographic
  • The precise amount you are allocated
    doesn’t really matter in itself
  • You are neither rewarded nor
    penalised for your bottom line
    performance
  • So don’t get hung up about it
  • Just get on and do the work on quality
    – there is plenty to do – don’t waste
    energy


                       CATCH PBC Forum Histon 23rd June 2011
        What really matters is…
• Is our prescribing
   •   Rational
   •   Fair
   •   Evidence based
   •   Affordable
   •   In line with the imperative
       of distributive justice?
                                                           Who’s job is it to look
                                                            after this problem?




                   CATCH PBC Forum Histon 23rd June 2011
        Not just a local perspective
• Nationally
   • Quality and outcome framework
      • Medicine 6 and 10
      • PQ 1-5
                                                                Drowning, not waving
          • 28 points
• But we are so good that we need a local programme
  too, to make a dent in our overspend
   • Prescribing quality programme
      • Standards Audits and Indicators
          • 56 points each worth half a QOF point


                        CATCH PBC Forum Histon 23rd June 2011
   QOF Medicines management 6 and 10
• Medicines 6
   • The practice meets the PCT prescribing
     adviser at least annually and agrees 3
     actions related to prescribing
   • 4 points
• Medicines 10
   • The practice meets the PCT and provides
     evidence of change in the three chosen
     areas (or very good excuses)
   • 4 points                                Low achieving practice
                                                               manager preparing to
                                                                   meet PCT
                       CATCH PBC Forum Histon 23rd June 2011
  QOF Medicines management 6 and 10
• Medicines 6 and 10
• We recommend you choose:
   • methotrexate prescribing systems
   • practice repeat prescribing audits
   • systems dealing with prescription
      changes that may arise after hospital in-
      patient or out-patient visits
                                                                   High achieving
• Why? Because you have already done                            practice manager with
  most of the work and because repeat                              nothing to hide

  prescribing and monitoring of prescription
  changes initiated in hospital underpin much
  of the rest of the programme.

                        CATCH PBC Forum Histon 23rd June 2011
 QOF Quality and Productivity targets (QP)
• QP 1-5
  • QP1
     • Choose 3 areas for improvement of clinical
       appropriateness and cost effectiveness and
       notify PCT by 30th June of your draft plan for
       action (6 points)
  • QP2
     • Agree your areas in your locality group and
       with PCT by 30th September (7 points)
  • QP 3,4,5
     • Do the work on the three areas and measure
       the change in the last quarter of the year (3 x
       5 points)        CATCH PBC Forum Histon 23rd June 2011
                                       QP 1-5
•   You will need to demonstrate the percentage of
    prescriptions complying with the improvement
    plan for each of the areas, out of all the
    prescriptions written in that area during the last
    quarter.
•   Payment stages will be determined by the PCT in
    discussion with CATCH. The payment stages will
    reflect performance in a 20 percent band up to the
    75th centile for national achievement in the
    chosen area.
•   We have chosen these areas because most
                                                                         Relax
    practices already achieve the upper payments
    and plans will need to focus on maintaining
    current quality standards rather than making big
    improvements.

                                 CATCH PBC Forum Histon 23rd June 2011
                                       QP 1-5
We recommend the usual suspects.
• ACEi items: 73.86% (upper threshold); 53.86%
   (lower threshold)
• Low cost lipid modifying drugs: 75.96% (upper
   threshold);55.96% (lower threshold)
• Low cost PPIs: 96.44% (upper threshold); 76.44%
   (lower threshold)

    Why?
       • There is a good evidence base
       • Solid national data are available to establish
         the targets
       • Most practices already achieve the upper
         levels of performance and will need only to
                                                                         It could have been
         maintain current behaviour                                           easier….
                                 CATCH PBC Forum Histon 23rd June 2011
               For example
• Low cost PPIs
• The best PCT in England achieves 98.81%
  compliance
• Nationally, the 75th centile for achievement is 96.44%
• Locally we reach 95.96%
• You will get maximum points if you achieve 96.44%
• You will get no points if you achieve under 76.44%




                CATCH PBC Forum Histon 23rd June 2011
Prescribing Quality Programme
     • Standards, Audits and Indicators

     • Standards
        • Inhaled corticosteroids: monitoring and step
          down for high dose users
        • Proton pump inhibitors: minimum
          maintenance doses to reduce risks of ADR
          (fractures, C dif, low Mg)
        • NSAID: management of risks of ADR (GI
          and cardiov)
        • Antibacterials: compliance with local advice
           CATCH PBC Forum Histon 23rd June 2011
  Prescribing Quality Programme
• Standards, Audits and Indicators
Audits
   • Atorvastatin 80mg
       • Patients should not remain on high dose statin for
         longer than 12m (if stable)
   • Platelet agents
       • Follow evidence base and don’t use red listed agents
   • Fentanyl
       • Prescribe to minimise risk of ADR and overdose
   • Antipsychotics
       • Prescribe to reduce ADR in elderly

                  CATCH PBC Forum Histon 23rd June 2011
Prescribing Quality Programme
     • Standards, Audits and Indicators
     Indicators
          • Antihistamines: comply with formulary
          • ACE and AIIRA: Ace first and ARA only if specifically
             indicated or ARA not tolerated
          • Antidepressants: use sparingly, comply with formulary
          • Diabetes blood glucose test strips: follow evidence
             based use and prescribe most cost effective strips
          • Statins: formulary statins only
          • Ezetimibe: minimise use as efficacy remains uncertain
          • Calcium channel blockers: comply with formulary




            CATCH PBC Forum Histon 23rd June 2011
    Who is carrying the baton?
• Work out a timetable, and use these meetings to
  comply with the requirements.
• Follow the locality group decision to minimise
  workload
• Set clear practice targets
• Be realistic about what you
  have time to do
• Get started now



               CATCH PBC Forum Histon 23rd June 2011
     Just a reminder from the LMC
• You can't charge. You can't charge your own patients for seeing them, or for advising,
    prescribing to them, or treating them. (except for the very limited list of exclusions to the ban e.g. some
    travel vaccines and some certificates.).

• You can prescribe anything to anybody if it is in
  their interests. Normally that would be on the NHS for your NHS patients, though you can
    prescribe privately even if the patient is eligible on the NHS if they prefer (e.g. if the cost to the patient is less
    than the prescription charge) – but remember the first rule. You can prescribe privately if the NHS won't fund
    something, but remember the first rule. You can offer to prescribe privately if the patient wants a
    particular drug / brand / formulation if the cheaper drug / brand / formulation you offer on the NHS is
    not acceptable to the patient, but their needs are met by the one you choose (but remember the first
    rule).

• You must not direct patients to a service you own;
    you must be transparent and give patients choice. If you offer a private prescription (under rule 2) whilst not
    charging (rule 1) your patient must have the choice of taking it to you to dispense (and then you can charge
    for dispensing it) or to a local pharmacy (who will also charge).




                                 CATCH PBC Forum Histon 23rd June 2011

				
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