Medicines Optimisation Peer Review Programme - engaging GP practices to deliver medicines optimisation and implement NICE guidance

The aim of Medicines Optimisation Peer Reviews is to influence prescribers and their decision making processes to ensure evidence-based, safe, cost effective prescribing ensuring optimal clinical outcomes for Wigan patients
Objectives:
- Adoption of changes in practice to ensure implementation of evidence based prescribing in line with NICE guidance
- Improving patient safety and outcomes from the use of medication
- Improving quality indicators and reducing variation across the CCG. Achieving a reduction in the gap between the best performing and worst performing areas whilst at the same time raising the bar higher for everyone.
- Sharing the evidence base and updating prescribers knowledge of NICE guidance.
- Allowing peer challenge and debate leading to self-reflection, ultimately achieving a change in culture and outcomes.

In 2007 the National Audit Office issued Guidance for Medicines Management Teams (MMT) on how to communicate effectively with Prescribers which recommended a named MMT contact for all GP practices. They also recommended that teams targeted their efforts carefully and designed tailored practice action plans based on different levels of potential impact and ability and willingness to change.
The report highlighted the most effective, but also most expensive, method of communicating with prescribers was to visit them in person. It is therefore crucial to make the most of every MMT visit.
We developed the MMT by using pharmacy technicians allocated to GP practices, working on clinical areas selected by the practice. Using technicians allowed us to recruit a larger team allowing all practices to be visited regularly. Our MMT was very successful in some clinical areas but less so in others. Technicians sometimes lacked the clinical knowledge and confidence to discuss the evidence base with prescribers and found difficulty in changing prescribing behaviours in line with NICE guidance. We recognised that to achieve improved patient outcomes and implementation of NICE guidance across the CCG, MM Technicians would benefit from the support of the senior MMT to secure prescriber engagement.
There were several barriers we needed to overcome:
1. Engage prescribers to share our vision to encourage adoption of the change in practice. We knew it wasn't effective to tell GPs what to do, they needed to believe change was necessary and desirable.
2. Prescribers were not all aware of current evidence and NICE guidance. We needed to allow protected time for prescribers to discuss the evidence base behind the guidance, allowing concerns and questions to be raised and answered.
3. It is hard to change embedded habits. We needed to encourage those GPs not following the guidance to share the reasons for this and allow prescribers implementing the evidence to show how these barriers had been overcome in their practice.
We developed the Medicines Optimisation Peer Review which we believed would be an effective way to achieve large scale change in prescribing behaviour, reducing the gap between the best and worst performance and at the same time raising the bar higher for everyone.

Medicines Optimisation Peer Reviews are annual meetings run at locality level (groups of GP Practices that meet and work together). They are facilitated by the Senior MM Pharmacists and the GP Clinical Champion for the Locality. 5-6 Practices attend each meeting represented by the Practice Manager and a Prescriber. We encourage peer to peer debate to improve quality prescribing, reduce variation, implement NICE guidance and improve patient outcomes.
Chosen topics are based on NICE guidance, NICE key therapeutic topics (KTT), prescribing data and local priorities aiming for improved patient care with reduction in less cost-effective medicines and/or improvement in safe use of medicines. Key messages are agreed by the full Senior MM Team which includes GP Clinical Champions to maximise relevance to Prescribers.
Prior to the meetings we distribute benchmarked prescribing data at Locality level allowing comparison between practices within the locality and year on year. We discuss the topics and prescribing data with the practice based MM technicians. Feedback is obtained on likely barriers to implementation and examples of good practice. Full team involvement is essential to ensure a consistent message is shared with practices. The technicians are then able to discuss the peer reviews with practices providing early support to the practice manager.
At the peer review we discuss:
- Reason for topic selection
- NICE guidance and current evidence base
- Prescribing data
Prescribers are encouraged to share views and prescribing practices. Skilled facilitation by the Senior Pharmacists and GP Clinical Champion ensures decision making and prescribing behaviour is influenced allowing prescribers to learn from each other in a supportive environment.
Practices showing good prescribing practice share why they believe they have been successful. The Senior Pharmacists ensure that all key messages are delivered and attend all meetings allowing ideas from other Localities to be shared. Each practice must select 3 areas to work on in the next 12 months. The MM technicians then proactively work with practices to ensure implementation of agreed changes. This allows practices to select the approach best suited to their needs. The technicians provide further prescribing data, advice and support. This follow up work and support is a vital part of the process to ensure there are measurable achievements.

Antibiotic prescribing has been included in Peer Reviews due to high levels of prescribing across the CCG and the strong link between antibiotic usage and Clostridium difficile infection (CDI). We aimed to discourage the use of antibiotics for viral infections (CG 69 KTT9) and reduce use of antibiotics most commonly associated with CDI. The Peer Reviews enabled Practices to share how they manage patient expectations, secure full Practice engagement, use back-up antibiotics and the CCG antimicrobial guidelines.

We have achieved a reduction in overall antibiotic prescribing (9%) and use of antibiotics associated with a greater risk of CDI (7.5%). There has been a corresponding decrease in primary care CDI demonstrating improved patient care. This supports the NICE Antimicrobial Stewardship Guideline currently in development. We have identified and addressed prescriber knowledge gaps e.g. reviewing the effectiveness of newer diabetes medications to ensure cost-effective prescribing (CG87 KTT12). We have reduced prescribing of medications with little evidence base (Omacor - do not do from CG 172 and 181 KTT4 and Ezetimibe - CG 181 KTT3) meaning funding is available for drugs which do improve patient outcomes.

Practices discussed the importance of patient outcomes and positive patient responses as it was seen as one less medication to take. Hypnotic prescribing is a difficult issue to tackle in GP practices. The difficulties surrounding reduction of long-term hypnotics has been discussed at Peer Reviews. In some localities the success of one practice and the processes they have shared has inspired others to implement changes and we are seeing a reduction in prescribing for these Practices (TA77 KTT6). Prescribers have raised issues with managing nutritional supplements (CG32) at Peer Reviews. As a result of this feedback we have been able to recruit a Medicines Management Dietician. They provide advice on food fortification and different feeding options before the use of supplements. This has improved the quality of life of patients as socially it is best to eat and enjoy appropriate foods. Improving the quality of prescribing often leads to savings.

The Peer Review programme contributes to the QIPP savings achieved by the MMT (£1.8 million in 2013/14). This allows us to make the best use of resources and ensures we have money to invest in newer treatments and services and to implement new NICE guidance e.g. Atrial Fibrillation (CG180).

- Secure engagement of GPs to work with you at Locality level.
- Select topics that have agreement of your GP champions.
- Plan thoroughly, ensuring you understand the guidance, evidence base and limitations of any prescribing data.
- Involve the full team in discussions prior to the peer review meetings to ensure a consistent message is provided to all practices.
- Get intelligence from those in the team working directly with practices so that you can anticipate barriers and are aware of who is working on an area so you can prompt discussions if necessary. - Good facilitation skills are essential.
- Be prepared to listen to the practices and what they require to implement change and then endeavour to put support in place. This allows them to see we help them to deliver. feedback year on year - 'You said; we did; we are now in a different place'.
- Follow up the work to ensure change happens