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, tamsin.fulton@nhs.net

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 instancerahul.singal@nhs.net