QIPP - Patient safety; quality; Patient experience; 2011-12 £13bn medicines spend in NHS; 66% in primary care; £4.5bn in hospitals of which 59% is HCD.IHWIncreased use of other HC providers such as third sector, private enterprise etc.Innovation – working with industry and academiaHealthier TogetherReview of health and care in GM to improve access, quality and sustainability of services for GM residentsLikely to change the face of primary care in GMLead to redesign of care pathwaysNeed to respond to changes and help support development of new care pathwaysNeed to ensure our expertise is heard and we are influencing the debate
Moving forward with the greater manchester formulary
Moving forward with the
Andrew White, Head of Medicines Management | Greater Manchester
Commissioning Support Unit
The GM Joint Formulary
Head 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
Big and complex!
2.8 Million population
• Biggest conurbation outside
64% of people living in areas
of economic and social
• CVD, Respiratory, Diabetes,
Mental Health, Pain
• Poor Mortality outcomes
GM 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
High cost per capita
• Between and within localities
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
• Reducing spend
– overall – not necessarily in drugs budget alone
• Change in environment – IH&W
– Integration and partnership working
– New healthcare providers
• Healthier Together
– Reduce admissions by improving the health of the
– 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
– 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 service
All 12 CCGs
• GMMMG products
• Redesign of clinical pathways
– aligned KPIs
– outcome monitoring
– exit strategies
• Provider contract management
• Procurement savings
• Supporting regulatory
compliance eg CQC
Local Transformational support
• Locality implementation support
• CCG & Practice based
• Public Health, PNA, Advice, PGDs, De/recommissioning of services,
independent advice to H&WBBs, emergency resilience / civil contingency
• Area Team - Medicines Governance (CDAO), PGDs, Specialised comm
• AHSNs – NICE implementation
• Other CCGs/ CSUs collaboration
– GMMMG like approaches – local, regional and national
Interface Prescribing and
New Therapies Subgroup
New therapies recommendations
RAG list, shared care protocols
Formulary Sub group
Do Not Prescribe list
Maintain 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!
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
– Improved quality, process improved,
– Transparency, NICE compliance strengthened
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
– ‘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
– 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
– 2o care - no new initiations
– 1o care - many stops
“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
• 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
• Developing their proposals into workable solutions
• Suggesting others for adoption
– 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
• CSU team will be leading the CCGs’ MM agenda
• Developing new business partners
• 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
• 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
• 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
• Does the group want / plan to engage as a group or as
– 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
– We need to gain a trusted relationshp!
• 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
George Bernard Shaw