Shared learning database

Northumberland Tyne and Wear NHS Foundation Trust
Published date:
September 2009

Project to identify and overcome the barriers to implementing shared care guidelines for dementia medicines.

This example was originally submitted to demonstrate implementation of recommendations in NICE Technology Appraisal (TA) 111. The TA has been replaced and updated by TA217. The example remains consistent with the guidance. The review and re-appraisal of donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer?s disease has resulted in a change in the guidance. Specifically:
- donepezil, galantamine and rivastigmine are now recommended as options for managing mild as well as moderate Alzheimer?s disease, and
- memantine is now recommended as an option for managing moderate Alzheimer?s disease for people who cannot take AChE inhibitors, and as an option for managing severe Alzheimer?s disease.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

NICE originally issued guidance in 2001 recommending use of acetylcholinesterase inhibitors (AChEIs)for Alzheimer's-type dementia for initiation by a specialist and for continuation by a GP under a shared care prescribing arrangement. Although local specialists were early adopters of NICE recommendation to offer these treatments, local GPs would not agree to implement shared care prescribing arrangements because of clinical and financial concerns. This project set out to identify and overcome the barriers to implementing shared care guidelines for these medicines. * Develop a shared care prescribing guideline for acetylcholinesterases * Agree commissioning arrangements to enable implementation of this guideline * Assess impact of implementation

Reasons for implementing your project

Specialists were obliged to provide regular long-term prescriptions for these medicines, which consumed significant resources on behalf of otherwise stable patients. This system also involved large amounts of dispensed medication being posted to around 500 patients/carers/community pharmacists from the hospital pharmacy service at significant clinical risk to patients and financial risk to provider trusts. It resulted in many problems, for example: some patients became harmed by unintended interruption of treatment following admission to acute medical units or when medication was lost; unsafe working practices evolved and there were significant levels of drug wastage.

How did you implement the project

Between October 2006 and April 2008: 1. A shared care protocol was developed A business case was developed in partnership with a neighbouring provider trust 2. Commissioning arrangements were agreed with local PCTs 3. A database was developed in collaboration with the trust IT department; incorporated into the electronic patient record system; capturing treatment-related clinical data (e.g. MMSE scores) it enables assurance reporting to stakeholders Communications forms were developed to improve the flow of clinical information to GPs 4. Stakeholders were kept informed of developments via local representative committees and bulletins 5. Systems and protocols were put in place to safely manage the transition to shared care

Key findings

We monitored outcomes via: 1. Analysis of primary and secondary care prescribing data 2. Review of hospital dispensary workloads 3. Review of the trust clinical incident database 381 patients were transferred to shared care during 2008/9; 96% of requests to GPs for shared care arrangements were accepted. Corresponding hospital prescribing and dispensing rates fell dramatically, freeing up resources for the management of new referrals; primary care prescribing rates rose in line with transfer of patient to shared care arrangements. Patients benefited from closer relationships with their GPs, enhancing GP involvement in their dementia care; GPs benefited from more timely and comprehensive out-patient communications. In line with the projected financial gains, health economy-wide growth in CHEI drug spend fell from 21% in 2006/7 to 5% in 2008/9 following the implementation of the new scheme, releasing NHS resources for the care of more patients No plans to publish at present

Key learning points

That, with careful forward planning, the implementation of shared care prescribing arrangements for large numbers of patients can be managed safely and effectively, ensuring that the projected clinical and financial benefits are realised

Contact details

Mr Tim Donaldson
Trust Chief Pharmacist/Associate Director of Medicines Management
Northumberland Tyne and Wear NHS Foundation Trust

Secondary care
Is the example industry-sponsored in any way?