We were first introduced to the term Medicines Optimisation some five years ago, shortly after the 2010 general election. Finally, after years of 'medicines management' focus, there was acknowledgement that cost containment should be scaled back and shared decision making and patient-centricity should become the new philosophy.
The Chief Pharmaceutical Officer for England gathered together experts in medicines and pharmacy to scope out requirements to address overwhelming evidence of poor adherence to medicines; repeated hospital admissions due to avoidable events; an estimated £300 million of wasted medicines; and avoidable clinical exacerbations from poor use of medicines.
With great enthusiasm and commitment, NHS England, the Royal Pharmaceutical Society and many others set about reframing the way medicines should be used to realise full value for patients and the NHS. Medicines Optimisation patient centric principles[i] were developed and socialised across the NHS and industry to give patients access to the most appropriate, evidence-based medicines. A new partnership was developed between NHS England and ABPI to collaborate under a mandate from the Ministerial Industry Strategy Group and embedded into the 2014-18 PPRS. All the necessary elements seemed to be in place for stakeholders to pool resources to embed Medicines Optimisation into the hearts and minds of the NHS and improve patient outcomes.
Two years later, has the way in which medicines are used and prescribed in the NHS really been optimised? It would seem possibly not. Changing mindsets and processes is no easy task, and the challenges of a complex system and NHS financial challenges have delayed the embedding of new thinking that could provide significant benefits for patients and demonstrate the true value of medicines. What we've seen to date is the effort of a small dedicated few leading the way but struggling to make a difference. It would seem that the wolf of medicines management remains close by, thinly disguised in the sheep's clothing of Medicines Optimisation.
It is hard to contain disappointment at the lack of inclusion of Medicines Optimisation goals in the recently published NHS Planning Guidance 2016-17. Recent discussions on the Hospital Medicines Optimisation Programme (HoPMOp) element of the Carter Review, in addition to continued cost containment activities by some organisations across the country, suggest that the term Medicines Optimisation is often simply being used as a euphemism for old medicines management practices. Cost containment is still very much alive and kicking, and the concepts of understanding an individual patient's needs and prescribing the right choice of medicine seems a long way from being delivered. Instead, industry stakeholders see their substantial PPRS repayments falling into the central NHS 'black hole', while on the ground innovative medicines continue to be seen as a cost pressure and a budget line to be cut.
Of course, there are some positive developments. All eyes from industry are now on England's fifteen Academic Health Science Networks (AHSNs), which are leading efforts to demonstrate that Medicines Optimisation does make a difference. A myriad of imaginative, patient-centric programmes are being implemented, such as the West of England 'Don't Wait to Anticoagulate' initiative giving a clear rationale to prescribers for appropriate use of NOACs; Inhaler Technique and COPD support programmes in Newcastle and Sunderland; and numerous structured medication review programmes adopting agreed START and STOPP[ii] criteria for patients on multiple medicines such as the example adopted in Greater Huddersfield & North Kirklees CCGs .
However, if industry is to keep the faith regarding Medicines Optimisation, the excellent work of the AHSNs needs far greater reach and influence beyond their networks and the world of pharmacy. NHS England's commitment - to embed Medicines Optimisation into mainstream NHS thinking and planning - needs to happen as originally agreed back in 2013. It's encouraging to see the narrative adopted by NHS England in the recent letter to Medical Directors announcing the establishment of Regional Medicines Optimisation Committees to be supported by AHSNs. The committees have been created to: "help eliminate unnecessary duplication of effort in the evaluation of medicines and instead refocus scarce resources towards implementation activities, and in particular, achieving best value and patient outcomes from all medicines (i.e. including well established medicines) through implementation of medicines optimisation".
Positive news indeed. However, it remains to be seen if the medical directors and members of these new groups are truly committed to medicines optimisation. Adoption of core principles into their terms of reference and the next phase of NHS planning, Best Possible Value Initiative, led by Paul Baumann, NHS England Chief Financial Officer and the NHS Right Care Programme needs to happen quickly and at scale to avoid losing the momentum the AHSNs are gathering. In the face of constant reminders from all angles of the need for efficiency savings, there is a risk that we will see a return of cost containment and an unravelling of the hard work and effort to improve outcomes for patients.
NHS England, together with continued industry commitment, must not let the wolf of medicines management re-emerge and remove all vestige of hope that patients will be listened to, understood and supported to gain the best possible outcomes from the right choice of medicine.
[i] RPS Medicines Optimisation Principles
[ii] STOPP: Screening Tool of Older People's potentially inappropriate Prescriptions ||START: Screening Tool to Alert doctors to Right i.e. appropriate, indicated Treatments.
Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): Consensus Validation. Int J Clin Pharmacol Ther 2008; 46(2): 72 – 83. PMID 18218287