LES -PRACTICE MEDICINE MANAGEMENT

Contract Mechanism and Specification 2012-2013

Introduction

1.All Practices are expected to make available to all their patients the essential and those additional services they are contracted to provide. This local enhanced service provides for a review of repeat prescribing system processes. This activity is not covered by the GMS Contract QOF or existing Enhanced Services. The objective is quality improvement and reduced costs through improving medicine management processes which greatly impact on General Practice. No part of the specification by commission, omission or implication defines or redefines essential or additional services.

Background

2.The current financial climate, an increasing elderly population and an annual growth in prescription volume meansthere is anongoingneed to improve medicine management of repeat prescribing within Practices.

This service builds upon and continues the medicines management work undertaken by Practice staff throughout NHSGGC from October 2010 to March 2012. Evaluation of work undertaken to date has shown that non clinical staff members can positively impact onthe safety and efficiency of repeat prescribing processes. Practiceswill benefit from improvedstreamlining of repeat prescribing systems by continuing this LES.

Practices will be provided with training and support. This LES will benefit Practices in relation to supporting theQuality and Outcomes Framework of GMS contract and completion of RPI and GMS targets.

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Service Aim

3.To improve medicine management of repeat prescribing within Practices with the objectives:

To minimise waste of medicines

To support review of repeat prescribing processes

To optimise communication at primary and acute care interface

To support communication between CommunityPharmacy and GPPractices

To support implementation of NHSGGC agreed prescribing indicators

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Service Outline

4.This enhanced service,to improve medicine management andrepeat prescribing within Practices and reduce overall cost,will fund the following from 7thMay 2012 to 31st March 2013:

Practices to:

  1. Identify an appropriate member of Practicestaff to undertake theMedicine Management role.Practices to release designated staff for local training.
  2. A separate payment will be made to Practices for the release of appropriate staff to attend training of half to one day. The payment rates are outlined in Section 6
  3. In the event of further training events with additional time away from the Practice, additional paymentswill be made at the same rate
  4. Training at the Practice will be considered on an individual basis where there are constraints on releasing staff to attend local training
  1. Individual Practices tobe paid an achievement payment as outlined in section 6 where there is delivery of prescribing budget to expenditure balance or completion of actions as listed in sections 4a, 4d to 4i and 4k at 31.03.2013.
  1. An additional achievement payment will be made to individual designated Localities which generate further savings through achievement of a final prescribing expenditure less than budget. The agreed additional achievement payment will be based on the prescribing cost compared to expected cost using the NRAC formula (Appendix 1).This payment is in recognition of the additional work undertaken by Practices within the Locality. These additional payments areto be reinvested within the Locality to improve patient care as agreed with the CH(C)P.

Practicesare expected to undertake the actions listed below to achieve the LES payment:

  1. Productive General Practice Prescription module

This moduleaims to support Practices in improving the efficiency of the repeat prescribing process, while maintaining quality of care and releasing time to spend on more value added activities.

  1. Practice Manager and a nominated GP to attend Productive General Practice ‘Prescriptions’ 0.5 day training session
  2. Practice to complete Productive General Practice Prescription module
  3. Practice to provide evidence of at least one repeat prescribing process change which has taken place as part of the review and reflect on the change using the pro-forma provided (Appendix 2)
  1. Formulary compliance

Compliance with the NHSGGC Formulary(especially the preferred list) supports cost effective prescribing. The preferred list states the initial and second choice of drug in each BNF category.

  1. Practices to install current NHSGGC Formulary(including synonyms and contraindications files where appropriate) containing the preferred list and update as Formulary updates are published; usually every three months
  2. ≥ 78.5% of all prescribing to be within the NHSGGC preferred list of Formulary drugs at31.03.2013 or an actual increase of 1% towards target
  3. Practices to complete a Non-Formulary Request form(Appendix 3) to report patients initiated drugs listed in Appendices 3A and 3B. Forms to be submitted to the local or central prescribing team at the end of each month.
  4. Practice to review prescribing of drugs in Appendices3A and 3B(lists updated quarterly) throughout the MM LES durationand change those in Appendix 3A and those indicated in Appendix 3B to a preferred list equivalent where the prescriber deems clinically appropriate
  1. Patients on a monitored dosage system
  2. Review and update the Practiceregisterof patients on a monitored dosage system (MDS) on an ongoingthree monthly basis starting 07.05.2012:

Practices to:

  • Readcode patient records(unless previously coded)
  • Achieve 90% of patients on MDSto receive seven or 28 days supply of their regular repeat medicines, excluding ‘when required’ medicines
  • Undertake Level 1 medication review annually in 90% of patients
  1. Practice to develop and implement a protocol to communicate MDS medication changes to the patient’s designatedCommunityPharmacy and keep a record of these communications using the pro-forma provided (Appendix 4) on a quarterly basis.
  1. Review and update the Practice patient register of patients resident in a care home on an ongoingthree monthly basis starting 07.05.2012:
  2. Practices to:
  3. Readcode patient records (unless previously coded)
  4. 90% of patients in a care home to receive seven or 28 days supply of their regular repeat medicines, excluding ‘when required’ medicines
  5. Undertake Level 1 medication review annually in 90% of patients
  1. Level 1 medication review
  2. Practices to readcode patient records when undertaking a Level 1 medication review
  3. Perform a Level 1 medication review in40% of all regular repeat prescribing recordsbetween 07.05.2012 and 31.03.2013 as defined within Appendix5
  1. Where compliance issue(s) are identified in patients with four or more medicines (as part of the Level 1 medication review) the Practice will:
  2. Take action to reduce under-compliance (where patients order less than expected) in0.5% of the weighted Practice population (approximately one patient every two weeks in an average sized Practice) by 31.03.2013
  3. Take action to reduce over-compliance (where patients order more than expected) in 0.5% of the weighted Practice populationby 31.03.2013
  4. Practiceto provide evidence using pro-forma provided (Appendix 6) on a quarterly basis
  1. Chronic Medication Service (CMS)

CMS is rolling out across all CH(C)Ps in NHSGGC in next financial year.Appendix 7 provides details of the practice activities related to the service.

  1. Monitoring Tool
  2. Practicesmust complete and return areporting tool(Appendix 8) on a rolling three monthly basisto
  3. Completed reporting tool to be sent electronically within five working days at the end of each quarter

(December 31st, March 31st, June 30th, September 30th)

  1. In the event that a Practice does not complete the agreed contracted work set out in the LES, Practice payment recovery mechanisms for the LES will be instigated

Enhanced Service Time line

5.The LES will follow a12month time line detailed below

  1. Practicesasked to opt inby07.05.2012; LES to start07.05.2012
  2. Practices to receive a one offengagement payment in May2012if opted into LES and undertake service outline sections relating to
  1. staff nomination and training (4a)
  2. Formulary compliance (4e (i))
  1. Quarterly reports generated by Practices on work completed. Electronic reports to be submitted within five working days at end of each quarter

Payment

6.Engagement Fee

  1. Payment will be made on the basis of a one off engagement fee of £150per Practice in May 2012.

Training Payment

  1. Payment to Practices for essential training
  1. £75 per half day – Practice Manager
  2. £40 per half day – AfC Band 4 member of staff
  3. £130 per two hour session – Medical Practitioner
  4. £210 per four hour session – Medical Practitioner

Achievement Payments

  1. Payment is based on achievement of prescribing financial balance (i.e. expenditure has not exceeded budget):
  1. £1per registered patient as at 07.05.2012 for payment period May2012 to March 2013
  1. In the event that the Practice does not achieve prescribing financial balance, the Practice can provide evidence of the work undertaken (see 4k) for:
  1. May2012 to March 2013; a 60% payment of the sum available to the Practice(60p per patient)

LES Payment Schedule

  1. Payments for financial year 2012-13:
  1. 50% of the achievement payment will be paid in advanceto Practiceson 31.03.2013.The remainder will be paid (or advance payment recovered) on 31.07.2013 once March 2013prescribing information is available and achievement assessed
  2. If prescribing figures indicate non achievement of financial balance but the Practice can provide evidence of the work undertaken (see 4k), the Practice will receive 60% of the achievement payment; 50% paid on 31.03.2013 then the final 10% of the remaining fee paid on 31.07.2013
  3. If prescribing figures indicate both non achievement and no evidence of work (see 4k) undertaken, the 50% paid on 31.03.2013 will be recovered
  1. Readjustment of the NHSGGC prescribing budget may be necessary in year where clear movements in prescribing costs through national prescribing adjustments are evident. Any practice budget alterations require agreement by the CH(C)P Directors.
  2. Where there is evidence of nonallocation or misallocation of prescribing by Practitioner Services Division of NHS Service Scotland, adjustments to expenditure and/or budget figures plus the related achievement fees will be made on 31.07.2013.

Additional Payments

  1. In addition to the above payments,Practices participating in this LESwithin an existing designated CH(C)P Locality will receive an agreed additional weighted patient based achievement payment. This is based on savings where Locality prescribing expenditure is less thanallocated budget. This is provided in recognition of the additional work undertaken byopted in Practicesin managing their prescribing costs.This payment is not available to Practices not participating in this LES.
  2. The agreed additional paymentwill be based on the prescribing cost compared to expected cost using the NRAC formula (Appendix 1) or pro rata up to 50% of the Localityunder spend
  3. Fee for specific actions (4a, 4d to 4i and 4k) if not completed within the specified time will be subject to the process for payment recovery
  4. In the event of a dispute the Practice will be required to provide evidence of work undertaken. The PMG PC will act as arbiter on the dispute using the evidence provided

Withdrawal

7.Both parties will provide a minimum of three months notice that they wish to withdraw from the contract.

Resources

All LES resources will be available on the NHSGGC website including training packs, audit tools, leaflets, Prescribing Indicator Scheme Implementation Guides and frequently asked questions.

Appendix 1NRAC additional achievement payment schedule

Appendix 2PGP Repeat Prescribing Process change evidence

Appendix 3 Non-Formulary Request Form

Appendix 3ANon-preferred drug list

Appendix 3B Non-SMC / new medicines in primary care list

Appendix 4Evidence of communication of changes to Monitored Dosage System patients

Appendix 5Level 1 medication review

Appendix 6Evidence of review of under and over ordering

Appendix 7Review of CMS patients

Appendix 8Practice Medicines Management LES Reporting Tool

Appendix 1

NRAC Additional Achievement Payment Schedule

Modelling of LES Additional Payments

It has been decided that Practicesparticipating in this LES in an existing designated CH(C)P Locality will receive an agreed additional achievement payment based on savings achieved by prescribing expenditure being less than allocated budget. This is in recognition of the additional work undertaken to produce the extra cost efficiencies within the budget set. The supplementary payment provided will not exceed 50% of the total extra cost efficiency within the existing designated CH(C)P Locality.

Actual spend versus Budget / Actual spend versus NRAC (expected spend) / Practice payment as percentage of budget saving / Where total additional payment would exceed 50% existing designated CH(C)P Locality budget saving
Payment adjustment (PA) (50% total existing designated CH(C)P Locality / Total existing designated CH(C)P LocalityPractice additional payment)
Less than budget / < 75% / 25% / 25% x under spend x PA
Less than budget / ≥75% and <90% / 20% / 20% x under spend x PA
Less than budget / ≥90% and <100% / 15% / 15% x under spend x PA
Less than budget / ≥100% / 10% / 10% x under spend x PA
Practice or Total existing designated CH(C)P Locality over allocated budget / n/a / n/a / n/a

Specific Parameters

  • Total additional payment to Practices up to 50% of total existing designated CH(C)PLocality saving on allocated budget
  • No additional payment to Practices if existing designated CH(C)P Locality prescribing budget is overspent
  • Final Practice budget adjusted for any national adjustments
  • Any known misallocation at Practice level adjusted for

Appendix 2

PGP Repeat Prescribing Process Change Evidence

Practice Number:Date:

1) List up to three issues identified with repeat prescribing processes as a result of PGP review:

2)Which issue(s) did the Practice decide to address? (Tick all that apply)

1 2 3

3)What change(s) did the Practice make?

4)Did the change(s) solve the issue(s)?

Yes No

5)What positive impact did the change(s) have on the Practice? (Note all)

e.g. data shows removal or lessening of the occurrences of the issues identified, data shows

a gain of three hours per week ‘free up’ of staff time as a result of change

6)Does the Practice feel that the PGP review was a useful exercise?

Yes No

7)Is the Practice planning to re-run the PGP prescribing programme?

Yes No

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CPT / RH 20120419

Practice Medicine Management LES 2012-13 Final 20120420_2

Appendix 3
NHS Greater Glasgow and Clyde Health Board
REQUEST FOR A NON-FORMULARY (NF) MEDICINE /

This form is to be completed by GPs either wishing to commence a non-Formulary or non-SMC accepted medicine for a patient, or for those GPs who have received a request from another clinician (e.g. local consultant) to initiate such a medicine. This form does not overrule the clinician’s independence to prescribe whatever he/she sees as being the most appropriate treatment for an individual patient.

A FORM ONLY NEEDS COMPLETING AT INITIATION FOR THOSE MEDICINES INCLUDED ON THE HIGHLIGHTED NON-FORMULARY MEDICINES LIST

Section 1:GP PRACTICE and patient details

Please use practice stamp here / Patient details (insert CHI Number only):


Section 2:clinician requesting medicine

Medicine requested:
(Include indication if known)
Who is requesting the medicine?
(please tick) / I am requesting the medicine myself: / Another clinician has requested I initiate this treatment for this patient:
If another clinician has asked you to initiate this treatment, please provide details of them below
Clinicians Name:
(print clearly)
Specialty:
(e.g. consultant cardiologist)
Contact details:
(Hospital, address, contact number etc if known)

Section 3:other relevant information

Please provide any other information which may be useful in determining whether this treatment is appropriate or not in the space below (such as details of previous treatments tried for this condition)

Section 4:signature and date

Signature:
Person completing the form / Date: / / /

This form should be completed and sent to your local CH(C)P Office.

If you are unsure of the details, contact the Central Prescribing Team on (0141) 201 5157 for advice
Appendix 3A

Non-Preferred Drug List

Practices to complete a Non-Formulary Request form when patients initiated drugs from this list

Drug Name (Generic Name in Bold)
duloxetine (Cymbalta®)
escitalopram (Cipralex®)
esomeprazole (Nexium®)
ezetimibe (Ezetrol®)
compound alginic acid (Gaviscon®)
lercanidipine (Zanidip®)
omega-3-acid ethyl esters(Omacor®)
paracetamol 500mg with dihydrocodeine 20mg (Remedeine®)
paracetamol 500mg with dihydrocodeine 30mg (Remedeine Forte®)
tramadol MR (Larapam® SR, Mabron®, Marol®, Maxitram SR®, Tramquel® SR, Zamadol® SR, Zeridame® SR, Zydol SR®, Trandorec XL®, Zamadol® 24hr, Zydol XL®)
zolpidem (Stilnoct®)

MARCH 2012

Appendix 3B

Non-SMC Approved / New Medicines in GGC Drug List

Practices to complete a Non-Formulary Request form when patients initiated drugs from this list

Drug Name (Generic Name in Bold)
agomelatine (Valdoxan®)
aliskiren (Rasilez®)
buprenorphinepatches (Butrans® / Transtec®)
cannabinoid (Sativex® oromucosal spray)
cilostazol (Pletal®)
dabigatranetexilate (Pradaxa®)
denusomab (Prolia®)
dronedarone (Multaq®)
* drosperinonewithethinyloestradiol (Yasmin®)
* glucosaminehydrochloride (Alateris® / Glusartel®)
* glucosaminesulphate (Dolenio®)
glyceryl trinitrate ointment (Rectogesic®)
oxycodone with naloxone (Targinact®)
* paracetamol with tramadol (Tramacet®)
prucalopride (Resolor®)
ranolazineMR (Ranexa®)
tapentadol (Palexia®)
ticagrelor (Brilique® )

Drugs potentially suitable for GP switching

MARCH 2012

Appendix 4

Evidence of Communication of Changes to Community Pharmacy Regarding Monitored Dosage System Patients(copy of electronic excel version)

Practice Number: Month and Year:

Patient EMIS / Vision ID / Change Communicated (tick all that apply) / Date / Initials
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration
Medication:
Stop Start Alteration

Appendix 5

Level 1 Medication Review Guidance

Level 1 medication review to consist of:

  • Inactivation of duplicate repeat drugs – review of repeat prescribing and removal of identical duplicate repeat drugs. Non-identical duplicates i.e. same drug, strength, form but differing doses are referred to a clinician.
  • Inactivation of obsolete repeat drugs – review of repeat prescribing and removal of repeat medication which has not been ordered for a Practice specified time period e.g. one year. Clinicians to identify drugs which are not appropriate for removal without clinician review.
  • Alignment – review of repeat prescribing and aligning repeat medication quantities to a supply period on an individual patient basis e.g. ensuring all medication is 28 day supply for each monitored dosage system (MDS) / dosette patient. Clinicians to identify drugs where alignment is not necessary or not appropriate e.g. oral contraceptives remain as a three month supply.
  • Compliance check – review of repeat prescribing and check if medication is issued as expected e.g. one issue every two months for a patient receiving 56 days supply of medication. Part 4(i)of the MM LES contract asks the Practice to work to improve compliance where poor compliance is identified.
  • Identification / correction of drugs with missing or ambiguous directions – review of repeat prescribing and correction of drugs with missing or ambiguous directions e.g. ‘take as directed’. Clinicians to identify standard directions for selected drugs where appropriate or review directions on individual patient basis and correct.

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