Systems Leadership: Integrating NHS pharmacy and medicines optimisation into Sustainability and Transformation Partnerships and Integrated Care Systems Pilot
OHSEL Board Briefing9th November 2018
What is the NHS Pharmacy and Medicines Optimisation into STPs/ICSs pilot programme?
In August 2018 NHS England and NHS Improvement announced the launch of a pilot programme, supported by the Pharmacy Iintegration Fund, to develop and test a core set of principles to Integrate NHS Pharmacy and Medicines Optimisation (IPMO) into Sustainability & Transformation Partnerships (STPs) or Integrated Care Systems (ICSs).
The programme was developed to help STPs/ICSs explore how to integrate medicine optimisation and pharmacy activities into every aspect of their work so that medicine and pharmacy functions are integral to all care settings and medicine optimisation is part of every patient-caring role as well as being the responsibility of pharmacy professionals.
STPs have been set-up to run services in a more coordinated way, to agree system-wide priorities and to plan collectively how to improve the health of local populations.
Strategic coordination of medicines and pharmacy by each STP will ensure that local knowledge of the population, processes and relationships and ability to work beyond organisational boundaries are encompassed into local strategies and work programmes. It is therefore essential that leadership comes from senior NHS pharmacists to set the direction for local systems to ensure there is collaboration among and support for all health and care professionals to deliver.
See more on NHS England Integrating NHS Pharmacy & Medicines Optimisation Programmehttps://www.england.nhs.uk/wp-content/uploads/2018/08/ipmo-programme-briefing.pdf
Why a Pilot in South East London?
The STP in South East London is called, Our Healthier South East London (OHSEL) and is one of seven STPs/ICSs in England selected to run a pilot. South East London was selected due to the progressalready made towards the integration of pharmacy and medicines optimisation and the maturityof its STP leadership. The OHSEL leadership welcomed and accepted this recognition of work to date and the opportunity to build on from this.
South East London spends circa £0.5bn on medicines . Medication safety continues to be a serious issue with around 6% of hospital admissions related to medicines and up to 50% of patients don’t take their medicines as intended. Use of multiple medicines is increasing with over one million people taking 8 or more medicines a day.
This programme aims to achieve measurable improvement in patient outcomes while maintaining an affordable medicines bill. We need to make sure patients get the right choice of medicine and that we improve the quality (safety, effectiveness, patient experience) of prescribing and medicines use.
Improving quality and productivity of pharmacy and medicines optimisation services depends on having a shared goal that unites the interests of all stakeholders; Patients, Service Users, Health & Care staff as well as Pharmacy staff in hospital & in the community.
What is expected from Systems Leadership pilot programme?
Phase 1: Sep-Dec 2018NHSE/NHSI believe the fundamental principles for achieving the vision is to establish a pharmacy and medicines leadership function and determine appropriate governance and accountability arrangements. In South East London we will review existing and emerging structures to identify effective and scalable models of accountability. The NHSE/NHSI programme requires two Plans on a Page; Medicine Optimisation & Workforce. We will establish two short-life working groups (SLWGs), each will co-produce a Plan on a Page and iterate through testing and refining over the three workshops in October and November.
Phase 2: Jan-Dec 2019From January 2019 OHSEL will be expected to be delivering an integrated model of pharmacy and medicine optimisation. This second phase will provide an opportunity to assess current models of optimisation and their potential for scale as well as run projects articulated in the Plan on a page. This will be an iterative process, involving service users, patients and carers in a meaningful way totest the effectiveness of the leadership structure and the plans developed in Phase 1, in a “test bed” approach.
Patient Benefits
Shared decision-making with patients and citizens:Evidence tells us that supporting patients to be actively involved in their own care, treatment and support can improve outcomes and experience for patients1. Evidence-Based Medicine remains at the core of best practice and guidance, but to optimise the use of medicines, the health and care system must use available evidence, clinical judgement and patient preferences together.
Putting the person receiving care at the centre of decisions about their medicines creates a personalised approach. Integrating pharmacy and medicine optimisation relies on integration with patients’ personal values and preferences to get the most out of medicine use. Putting patients at the centre also encourages health and care workers to find out what matters most to patients about their medicines, so that the care of their condition best fits their needs and situation.
Better, safer care for patients and citizens:The BMJ article ‘‘Doing prescribing’’: how might clinicians work differently for better, safer care2, underlined the following key messages;• There is extensive variation in the way patients take medicines, which
puts patients at risk and leads to significant harm in many cases.• Medicine taking is strongly influenced by patients’ beliefs and attitudes.• Concordance describes a process where patients and professionals
exchange perspectives and beliefs, and achieve agreement about the need (or not) for therapy.
• This process requires that patients are involved in decision making processes.
• Ensuring that patients use medicine effectively may require additional supportive interventions.
• Engaging patients in prescribing decisions so that they understand the risks and benefits of taking and not taking medicine will lead to better, safer care.
1 NHS England Patient Participation https://www.england.nhs.uk/ourwork/patient-participation/2G Elwyn, A Edwards, N Britten iQuality safety BMJ https://qualitysafety.bmj.com/content/qhc/12/suppl_1/i33.full.pdf
Patient and citizen engagement:Through-out Phase 2 of the Systems Leadership Pilot we will run a series of discussion groups and workshops with patients and citizens from South East London to engage, co-design and test new services and new ways of working.
We’re told to pop in to the Pharmacy now instead of going to see the GP, but I’m not so sure how it works. There are three pharmacies near to me, I don’t have a favourite, so I just went into the first one. I saw the Pharmacist and they said they could check all my medicines, in what they call an ‘MUR’ but I would need to collect my medicines from them for 3 months before they can review them.
I went into the local Pharmacy at the end of our road, I was looking to get a walking cane - just to help my confidence. I have a fine cane now and the pharmacist also told me about some local exercise classes that will also help. She checked my blood pressure, reviewed my medicines and reduced one of the medicines I take. After all that she updated my GP with everything she has done.
When I saw the COMMUNITY PHARMACIST
When I wanted my repeat prescription from my DOCTOR’S SURGERY
I was getting low on some of the tablets I take, goodness knows why I have to take quite so many; anyway I didn’t want to run out of medicines while I went on holiday. I called the Surgery and I was pleased to find out I don’t need to go into the surgery, my prescription will be sent directly to my local Pharmacy.
I called my GP Surgery to organise a repeat prescription and instead the receptionist made me an appointment to see a Pharmacist based at the Surgery. The receptionist saw I had not had my medicines reviewed in over a year. I got an appointment the same day to see the Pharmacist and they stopped two of the medicines I take and one of them I only need to take once a day from now on. I’m all set to enjoy my holiday!
When I took Mum to A&E they asked me if I had Mum’s medicines with me. I didn’t, so they asked if I could bring them in so they could see what medicines she was taking. That was OK but when she was discharged they gave her a bag of medicines and asked us to see our GP within 24hrs. I made Mum a doctor’s appointment, when we saw him, he didn’t know that Mum had been in hospital or what medicines she was now on. We had to make another appointment for a few days ahead when hopefully they would’ve received details from the hospital.
I took Mum to A&E. When the Consultant came to see her, we didn’t have to go into detail about Mum’s medical conditions, she had all the details from Mum’s GP and she even knew which medicines Mum was taking and which were running out - from details she received from our local Chemists. We didn’t have to worry about Mum’s medicines at all, when Mum got home a new prescription was waiting for us to collect from the Chemist and he told us about the new medicine, when and how to take it and how she might feel if she missed a dose.
When I took Mum to A&E
As it is now for patients… And how it could be…
My 5yr old son was complaining of a sore throat and was tired and listless. I called 111 to get some advice. After answering lots of questions the lady on the phone said I should make my son an appointment to see our GP.
My 5yr old son was complaining of a sore throat and was tired and listless. I called 111 and they put the call through to a local Pharmacist in my area. The Pharmacist told me to come into the Pharmacy where I would be able to get some over the counter medicines that would help and he would also check my son to make sure he did not need antibiotics.
When I called 111
When the time came for Dad to go into a CARE HOME
Dad’s dementia was getting worse, twice he was found wondering around the neighbourhood, lost and confused in the middle of the night. We realised Dad needed 24hr care and so we found a very nice Care Home for him. Dad had to see a new GP (who looks after all the residents in the Care Home) instead of his old GP. We were a bit unsure about the new medicines he had been prescribed and the staff at the Care Home didn’t seem to know much about his new prescription.
We moved Dad into a Care Home when his Dementia got too difficult to manage. We were really surprised the Care Home had their own Pharmacist to help all the residents with their medicines. The Pharmacist at the Care Home talked to Dad, listened to our concerns and switched Dad onto a new type of medicine. The Care Home staff were really knowledgeable about Dad’s medicines and explained the side-effects they were looking out for and would notify the Pharmacist if they had any concerns.
After my Cancer diagnosis , the Hospital Consultant explained my treatment plan. I would receive my first dose of chemotherapy and would be sent home until my next appointment in 3 weeks time. After the treatment I had shocking side-effects and made a note to discuss them on my next visit. I travelled to the hospital Cancer Clinic to have a blood test and then went back to the clinic the next day for my chemotherapy dose. Under all the stress of the travel and diagnosis I forgot to ask more about the side-effects.
After my Cancer diagnosis , the consultant explained my treatment plan. I would not need to return to the Hospital until the end of the course of treatment. I would be looked after by my own GP, who would do a Toxicity Check at the end of each 3 week cycle and send the results to the hospital, before beginning the next dose of chemotherapy. The practice Pharmacist would work with me to minimise the side-effects. I had terrible nausea and sickness and the Pharmacist helped me to take the anti-sickness medicines differently, which has really helped.
When I visited the CANCER CLINIC
As it is now for patients… And how it could be…
What are the expected deliverables from Phase 1?
Phase 1: Governance & Accountability arrangements (Sep-Dec 2018)The following outputs are to be developed:
• A stakeholder engagement plan.
• A regional engagement event on 5th November 2018
• A “plan on a page” for delivery of national priorities related to pharmacy and medicines optimisation and contribution to STP/ICS priorities and work streams over the next two years
• A “plan on a page” for developing a flexible clinical pharmacy workforce over the next two years.
• A organogram describing the wider structure of the STP/ICS and how pharmacy interacts with each part of the system
• An organogram describing a pharmacy leadership structure, lines of accountability and job descriptions for new roles that enable this
OHSEL Leadership*
Integrating Pharmacy Medicines Optimisation (IPMO) Pilot Pharmacy Provider Productivity Board
Pharmacy & Medicines Optimisation Board
Pharmacy & Medicines Systems Leadership Group
Membership: PMO, STP Programme Director, CCG Chief Pharmacist, Hospital Chief Pharmacist, LPC CEO[Chair: SRO / SME]Role: Receives programme updates and performance and organises the response of the programme through governance and implementation groups.
Membership: PMO, CCGs, Hospital Trusts, LPC, HIN, RPS, APC Chair, KHP, NHSE/NHSI, OHSEL CBC [Chair TBC]Role: A larger group with representation from all stakeholders. Tasked with advising and decision making on work streams as they progress.
Medicine Optimisation
Short Life Working
Group
Workforce
Short Life Working
Group
Area Prescribing Committee
(APC)
Membership: All hospital Chief Pharmacists. [Chair: Roger Fernandes]Role: To receive updates on progress, steer and make decisions.
How will we meet the requirements?
This is a Phase 1 “Shadow” Programme Governance modelto get us underway. It aims to embed the IPMO pilot into the work of OHSEL and aspiring ICS programme, in addition to the pharmacy and medicines work within and across primary and secondary care.
We will shape this further as the pilot develops.
OHSEL Leadership
[SEE NEXT SLIDE ]Role: Receives programme updates and provides steer to ensure alignment with wider OHSEL strategy
Medicines Supply
Chain ProjectSRO: Roger Fernandes
Pharmacy Aseptics
ProjectSRO: Louise Dark
Role: The APC is a well established, multi-professional SEL committee. It makes medicines and high value pathway recommendations to SEL
Medicines Pathway Review
Group (MPRG)
Role: A current group that reviews and steers several medicines pathway developments .
Role: To develop a “plan on a page” with clear priorities to be delivered as part of Phase 2
Role: To develop a “plan on a page” with clear priorities to be delivered as part of Phase 2
We know there is already some good existing work and practice that happens across SEL, that is led through existing structures and groups. The APC through the MPRG have a clear focus on medicine pathway design. The NHSE/NHSI IPMO pilot provides an opportunity to bring some strategic coordination across the system and build on what works. Phase 1 will involve mapping and scoping the “as is”
[We expect this to be reviewed as part of Phase 1 and refreshed in Phase 2 as part of delivery]
10
SLaM is the key MH provider for Lambeth, Southwark and Lewisham
The system in South East London
The above demonstrates the current system in South East London . The OHSEL footprint has currently embarked on an 11 week aspirant ICS programme in partnership with NHSE/NHSI
How is OHSEL currently configured?.
OHSEL BoardMonthlyMeets with Strategic Planning Group membership in private once a month, and every other month with a second part in public
STP Leadership Group / ICS Steering Group MonthlyMade up of Quartet + CPB, ABC, CBC and EPB leads. Receives STP Programme updates and performance and organises the response of the programme through governance and implementation groups
Mental Health
MaternityCYP
Cancer alliancePrevention
UEC
Elec. Orthopaedics
Pathology
TCP
Financial Strategy
Digital Workforce
Estates
Enabler Programme Board (EPB) Bi-MonthlyProviding oversight of Provider Productivity, Workforce, Digital and Estates programmes
Provider Productivity
Acute Based Care (ABC)Programme Board
MonthlyIncluding Specialised Commissioning
Clinical Programme Board (CPB) MonthlyActs as a clinical reference group to inform and recommend STP decision making and oversee implementation of plans. No longer carries out an assurance function.
CLG
s/
Pro
ject
s
Enab
lers
Provider Federation (Monthly)SEL Exec
Makes asks of… Makes asks of…
Accountable to
Accountable toAdvises/ recommend
Mai
n
Pro
gram
me
s
Reports to/ is assured by..
• Patient/ public groups• HWBB• GP Federation Board• Clinical Summits/
network events
Update and address
feedback from..
Provider/ Commissioner meetings to test/ inform STP work
Community Based Care (CBC) Programme Board
MonthlyIncluding Primary Care Transformation
Accountable to
ICS Working Group (supporting the Aspirant Programme)
Pharmacy & Medicines
Optimisation
Pharmacy and Medicine Optimisation is represented at the CPB through the Programme SME role
This structure represents the OHSEL leadership that is in place. It has engagement and representation of a wide range of stakeholders across organisations.
Pharmacy and Medicines Optimisation is recognised as a key area of the current programme.
Nov 19thNov 5thOct 19thSep 17thSep 5thEvents: Sep 29th
NHS Expo presentation
London Chief Pharmacists meeting
OHSEL Executive and CPB sign-off
Initial “kick-off” meeting
Share System Leadership Briefing
Agree scope for SLWGs
Leadership Group meet
Programme Board meet
Briefings for existing meetings and boards
Run 3 x 2 SLWGs
Co-Develop Plan On a Page x 2
Stakeholder Event
Review & refine
Phase 1 deliverables to NHSE and shared in SEL
Announce next steps for Phase 2
High Level Schedule of Events [Sept – Dec 2018]
Dec 7th Dec 20th
Phase 1 Road Map
Leadership Group
Focus:Scene-settingMust Have’sMust Dos
w/c 15TH Oct
Programme Board
Focus:Agree approach and scope for the Plans on a page (POP)
29th OctSLWG (1)Focus:Develop Plan on a page for Med. Op.
1st & 2nd Nov
w/c 12th Nov
Programme Board
Focus:Review -revisions and considerations for Plans on a page (POP)deliverables
w/c 10th Dec
Leadership Group
Focus:Sign-off & submission of deliverables to NHSE/I
SWLG (2)Focus:Develop Plan on a page for Workforce
SLWG (1)Focus:Final Iteration of Plan on a page for Med. Op.
26th & 27th Nov
SWLG (2)Focus:Final Iteration of Plan on a page forWorkforce
5th Nov
Stakeholder Event with NHSE/NHSI
SLWG (1)Focus:Finding flaws, & solutions –iterating POP Med. Op.
14th & 15th Nov
SWLG (2)Focus:Finding flaws, & solutions –iterating POPWorkforce
If you would like to participate in either of the Short Life Working Groups (SLWGs) or suggest a colleague to attend, please get in touch directly with Tamsin Fulton, [email protected]
Thank you for your interest, please share this briefing with colleagues and service users.
If you have any questions about the programme please e-mail ProgrammeLead, Rahul Singal in the first [email protected]