Moving forward with the greater manchester formulary

Moving forward with the Greater Manchester FormularyAndrew White, Head of Medicines Management | Greater Manchester Commissioning Support Unit

The GM Joint Formulary Moving forward

Andrew WhiteHead of Medicines Management

Greater Manchester CSU

Are we all that different?• …..researching and developing over two-thirds of the current

medicines pipeline, ensuring that the UK remains at the forefront of helping patients prevent and overcome diseases.

• …..to ensure that patients are able to benefit from the latest and most advanced medicines.

• ……the pharmaceutical industry ……. in improving the health, wellbeing and productivity of the UK population is often underestimated.

GM LandscapeBig and complex!

2.8 Million population• Biggest conurbation outside

LondonSignificant Deprivation

64% of people living in areas of economic and social deprivation

Significant morbidity• CVD, Respiratory, Diabetes,

Mental Health, Pain• Poor Mortality outcomesGM NHS spend - £5bn• 12 CCGs• 13 providers

6% of UK drug spend - £650M • 1o Care - £475M• 2o Care - £175M est.• £232 per registered patient

Better care Better value• now retired but amongst worse

in country

High cost per capita

Variation • Between and within

localities

But ……..

BIG variation in prescribing

FEW Local Health economy Formularies• Not consistent• 2o care well established, but majority independent

Persuade GM leadership to initiate project• 18 months!• CEOs, DoFs, DoCs, DPHs, Trusts

• QIPP• Reducing spend

– overall – not necessarily in drugs budget alone• Change in environment – IH&W

– Localism– Integration and partnership working– New healthcare providers

• Healthier Together– Reduce admissions by improving the health of the population– Change the shape of primary care delivery– Need for consistency, not irrational variation

Drivers for change

It can’t go on like this!

“Education is the most powerful weapon which you can use to change the world.” ― Nelson Mandela

Supporting medicines optimisation to reduce avoidable admissions

• EUR processes– Consistent – Respected decisions– Monitoring approval criteria

• High cost drugs– appropriate use and recharging– Develop audit standards for providers– Exit strategy – clinical pathways

• Homecare development– Improve take up - Best value– Shape patient pathways

Strategic MM serviceAll 12 CCGs

• GMMMG products– IPNTS– Formulary

• Redesign of clinical pathways – aligned KPIs– outcome monitoring– exit strategies

• Provider contract management• Procurement savings• Supporting regulatory

compliance eg CQC

Local Transformational support

CCG• Locality implementation support• CCG & Practice based

Local Authority• Public Health, PNA, Advice, PGDs, De/recommissioning of services,

independent advice to H&WBBs, emergency resilience / civil contingency

Others• Area Team - Medicines Governance (CDAO), PGDs, Specialised comm• AHSNs – NICE implementation• Other CCGs/ CSUs collaboration

– GMMMG like approaches – local, regional and national

Governance GMMMG

Interface Prescribing and New Therapies

SubgroupNew therapies

recommendationsRAG list, shared care

protocols

Formulary Sub groupProduce formulary

Do Not Prescribe listMaintain and manage

formulary

CCG members make decisions – Supported (lead) by CSU.

Why do we need a GM formulary?• Seamless care across the 1o – 2o care interface

– Consistent across all of GM– Lack of postcode lottery– Reduce need for switching

• Patient choice– Improved consistency of outcomes regardless of location of care

• Pharmaceutical Industry– 6% of UK drug spend– Good process essential – ABPI, EMIG

• “Do not prescribe” list. • Adherence strongly recommended by GMMMG

– Will supersede all local formularies

Consultation was hard!….But good!

Launched July 2011– Over 100 industry attendees– 3 months to reply– Consulting on content

• Many replied regarding process not content!

420 replies (after internal NHS consultation)– 50:50 - Industry : NHS– Very time consuming

• 6 months to review/refine/approve

Worthwhile– Improved quality, process improved,– Transparency, NICE compliance strengthened

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NHSIndustryPatient group

NICE & other challenges

Innovation Health and Wealth– NICE compliance regime – We do comply– In an 80% formulary?

NICE good practice guide– Formulary development– Compliant in all areas

• Minor tweaks only following gap analysis

Challenges?– ‘Drug X is a possible option in the treatment of condition Y’

• 3 drugs in same class with +ve ‘option’ TAs

• Can / should the NHS prioritise?

Do Not Prescribe List“I'm actually as proud of the things we haven't done as the

things I have done. Innovation is saying no to 1,000 things.”

A bit controversial!– 32 items – was 38 – Postcode lottery prevention– Evidenced based, rational disinvestment , covering wide area

Criteria– Products deemed not suitable for adults in 1o or 2o care within GM

• BNF “not NHS” or “DLCV” • Safety, efficacy and cost-effectiveness • IPNTS - Not recommended

Reviewed 6 monthly

Implemented differently– 2o care - no new initiations– 1o care - many stops

Why change?

“Change will not come if we wait for some other person, or if we wait for some other time. We are the ones we've been waiting for. We are the change that we seek.” ― Barack Obama

Developments

• Development moving to maintenance– CSU writing all chapters

• Consistency, format, research, cross checks• Links to service pathways

• Revised and improved web presence– To include interactivity

• Monitoring in primary care– see examples

Formulary Complianceby chapter/ practice

DNP variance

12 CCGs• Developing their proposals into workable solutions• Suggesting others for adoption

– Medicines – Clinical pathways– Redesign for efficiencies and to optimise pt outcomes– Innovation and partnership working

• Generate sufficient confidence in us to allow us to steer– Allow GPs to focus on clinical delivery

Building local business

Service development• CSU team will be leading the CCGs’ MM agenda• Developing new business partners

Service excellence• Customer satisfaction excellent• Responding to customer needs• Anticipating needs• We are indispensable to customers!

How will it look in 18 months?

• Building a brand and a reputation– Word of mouth excellent– New Media - Twitter - @GMMMG1

• Looking to gain new customers– North West – compete/ collaborate with other CSUs– Nationally

• Joint formulary toolkit– Set of processes and guiding principles that can be adopted by any

area– Support other localities to develop it to their own needs

Building the business

What you want to know..Based on questions received from ABPI North

• 3 themes– Priorities for the group– Engagement with industry– Joint working with industry

Priorities for the group?• Clinical leadership hardwired• Full engagement

– All NHS providers, commissioners– Bring in AQP and private providers

• Public and patient views– Recruiting currently

• Link up between Main group & subgroups– Much better understanding / alignment

Engagement• Ideas of areas the group are interested in engaging with

industry - Different views! – CSU – commercial partnerships welcome– CCG Boards – 2 approaches

• No free lunch• All we can get – we have no money!

– CCG Meds Man leads – no industry money – ‘no free lunch’ approach

• How does the group plan to engage? - How do they ensure they have worked with the right people?– Communicate, communicate, communicate!– New website - Interactive – Clearer processes for subgroups – WAS inconsistent

Engagement• Does the group want / plan to engage as a group or as

individual CCGs?– As a group ideally – BUT via GMCSU or NYRDTC as appropriate.– Guidance approved – will be on website shortly to clarify

• How should industry ensure we are included as an interested party– Communicate!– We need to gain a trusted relationshp!

Joint work• How does GMMMG plan to work with Industry?

– Ethical framework for rebates– 2-3 on the stocks currently

• CSU triaging for CCGs• Need to priortise due to capacity limitations

• What sort of offering/ solutions / support is the group / GM CSU looking for from industry?– In for the long term – for better for worse!

• Do they want a suite of flexible options or a blank sheet to do whatever is required?– Need to explore options on the table!– And push for more innovative ones!!

A thought for the future? (from the past)

“If you have an apple and I have an apple and if we exchange these apples then you and I will still each have one apple.

But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas.”

George Bernard Shaw