Collaboration between East Staffordshire CCG and Burton Hospitals NHS Foundation Provider Trust Pharmacy Team – Re-design of the management process to comply with NICE Technology Appraisals

The key aims of the project were to move a failing project into a success by:

• Ensuring compliance with commissioned NICE Technology Appraisals.
• Ensure medicines are available in a timely manner as per NICE Technology Appraisals guidance.
• Improve knowledge and expertise of the NICE Technology Appraisals across the health economy.
• Improving processes and governance by utilising the Blueteq technology more effectively.
• To improve working relationships with the local provider trust and to enhance collaborative working.
• To work in collaboration across the Staffordshire STP footprint for a uniformed approach.
• Improve the patient experience.
• To take a strategic view and create pathways for specialities.
• To drive the change to biosimilar options.

Historically the strategic overview and financial monitoring of non-Pbr High Cost Drugs for East Staffordshire CCG (ESCCG) was hosted by a partner CCG under a collaborative commissioning arrangement.

Due to changes in personnel and management structures this was no longer appropriate. Therefore in 2016 this function was returned to ESCCG and allocated to the Medicines Optimisation Team (MOT). This coincided with the introduction of Blueteq technology in the local provider trust, which was the subject of a CQUIN. There was a lack of expertise in both the provider trust and the commissioner organisations, which was resulting in poor engagement, lack of efficiency and delayed implementation.

Milestones were not being achieved. Improvements from the provider trust and commissioner were needed at pace. The commissioner was failing to consistently provide accurate Blueteq forms as per the NICE Technology Appraisals in a timely manner and in some cases this resulted in forms not being available to the provider trust within 90 days of NICE approval, causing conflict between the provider trust and the commissioner.

Clinicians were used to initiating treatments without a form, which sometimes meant patients were started on treatments for non-NICE approved indications, again leading to conflict.

To ensure full utilisation and to drive change, the East Staffordshire CCG MOT took a grass-roots approach, learning and listening to the issues from the provider pharmacy team. A face-to-face meeting between the two teams was arranged to discuss the practical issues and barriers to success. It was a little tense at first however barriers were broken down and addressed. This was followed up with the provider trust pharmacy team attending the CCG to walk in “each other’s shoes” to gain a better understanding and perspective of one another’s issues.

The CCG MOT were able to offer practical solutions:

• To provide dedicated resource and expertise by establishing a High Cost Drugs lead post in the MOT.
• Ensuring Blueteq forms were accurate as per recommendation from the NICE Technology Appraisals and practical. Previous forms had sometimes requested fields that the provider trust couldn’t supply. This was due to lack of expertise by the author and lack of consultation with the provider trust.
• Provider trust pharmacists and clinicians were given the chance to consult on the forms.
• A system was established to review historic patients that had been initiated on treatment outside of NICE criteria.
• On-going face-to-face monthly meetings and support.

The provider trust pharmacy team offered:

• Dedicated pharmacist resource to address backlog of historic patients not entered on Blueteq and ensure NICE compliance.
• Attendance at the monthly meetings.
• Positive, collaborative attitude.
• To respond to the MOT’s queries and challenges with regard to invoice and treatment challenges in a timely manner.
• To invite consultants to the monthly meeting to discuss treatment pathways.
• To challenge clinical decisions on behalf of the CCG if outside the scope of the NICE Technology Appraisals.

• When ESCCG took over implementation of Blueteq from the partner CCG there was a backlog of six months’ queries from the provider trust in relating to drugs which required prior approval e.g. non-NICE approved indications or patients not meeting NICE criteria. These have been resolved.
• There is a clear process of writing Blueteq templates involving the provider trust early and uploading with the 90 day timescale.
• There is improved performance management of high cost drugs, with systems in place to review treatment of non-NICE approved drugs, which were being initiated without any authorisation by the provider trust or the CCG. This has improved governance of safety and quality of prescribing, with non-NICE approved treatments now being referred to the Drug and Therapeutics Group at the provider trust and the CCG for prior approval.
• Dedicated resources at both ESCCG and the provider trust have allowed for the development of expertise and a timely response to queries.
• South Staffordshire High Cost Drugs Strategic Oversight Group was established to look at pathway design across the STP footprint. This work has evolved and now involves cross-border working with eight CCGs and four provider trust. The first pathway the group created was biologics and targeted therapies in rheumatoid arthritis. Gastroenterology and dermatology are next to be developed.
• With the establishment of the new High Cost Drugs post at ESCCG, invoice checking is now one of the main responsibilities of this post-holder with clear governance and accountability. The post-holder has the authority to challenge invoice submissions at the highest level. Challenges have been raised with significant potential cost-savings to the CCG e.g. duplicate invoices, drugs where the commissioner was not clear e.g. treatment of severe hidradenitis suppurtativa, Pbr included drugs inappropriately invoiced to the CCG e.g. insulin degludec, methotrexate.
• The enhanced engagement has resulted in the agreement of two gainshare initiatives for biosimilar switches. Negotiations had been on-going between the provider trust and the CCG for several years with no resolution. 50/50 gainshare have been agreed with the rheumatologists with potential savings of £257 k to be split between the CCG and the provider trust. This is due to be rolled out December 2017 and dermatology rolled out November 2017.

Prior to this project Blueteq technology had been purchased and levers for change e.g. CQUINS were in place, but the technology was not being properly implemented and the systems were failing.

This project demonstrates that technology and following processes will only succeed with dedicated human resources, training, mutual respect and collaboration and shared goals.