Background. Prescribing Incentive Scheme for GP Practices Summary

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Jemimah Francis
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1 Summary This specification outlines a new Prescribing Incentive Scheme (PIS) as part of the Primary Care Offer for This scheme is offered to all of the NHS Wiltshire CCG GP practices to improve the quality, safety and cost effectiveness of prescribing. Successful implementation of this scheme will deliver benefits in and beyond. As part of the Primary Care Offer, payments of up to 1 per raw list size per year will be made available to individual practices as the Gateway payment according to the specific criteria set out in this document. This is funded from the SLA payment to practices currently allocated to prescribing. If the Gateway criteria are met, a further 2 per raw list size per year will be made available after the end of the financial year. The level of payment is split into bands, dependent on the individual practice s achievement against their prescribing budget for that financial year, according to the specific criteria set out in this document. Up to 1.50 per patient based on outturn, and an additional 0.50 available for any practices that achieve and maintain a consecutive underspend. This scheme will be funded from the prescribing budget. In achieving payments as part of the PIS, all practices are expected to prescribe in line with local formularies and work with the Medicines Management Team at NHS Wiltshire CCG. Background NHS Wiltshire CCG recognises that there is significant variation in prescribing between practices due to many different influencing factors. However, the CCG has had a steadily increasing spend on prescribing over the last 3 years after changes made to QoF as well as the transition from a PCT to a CCG. The current position as at December 2015 data (NHSBSA) is that NHS Wiltshire CCG is predicted to be approximately 3.5m overspent on primary care prescribing alone. It is vital that there is financial stability within the CCG and its constituent practices, by maintaining control of prescribing costs. Introducing a prescribing incentive scheme is in line with the wider Primary Care Offer and Wiltshire CCG s five year plan aiming for any funds released to practices or localities to invest in primary care services across a locality or the wider CCG to encourage patient care closer to home. NHS Wiltshire CCG will continue to provide prescribing and medicines management support to all practices, with the aim of reducing waste, improve patient concordance and the quality and safety of prescribing, and also to identify areas of variance. It remains, however, the responsibility of individual practices to ensure their prescribing is clinically up to date, in line with local formularies and cost effective, as well as in line with GMC Good practice in prescribing and managing medicines and devices 2013 ( ). Prescribing incentive schemes can allow CCGs to encourage and reward GP practices to improve prescribing to further enhance its quality, safety and cost effectiveness. The PIS does not simply reward low cost prescribing, but also includes criteria for the Gateway payment that relates to the quality of prescribing. NHS Wiltshire CCG also recognises that where practices are already achieving the targets specified in the scheme, they should be rewarded in the same way as those practice meeting the targets for the first time. Prescribing Incentive Scheme as part of Primary Care Offer V2 23/03/16 1

2 Finance Details Budget Setting Budgets will be set using the existing framework on an ASTRO PU basis, with an additional allowance for care home patients (i.e. using the same methodology applied in ). This methodology will remain static throughout the period of the primary care offer. A change for onwards is that specific areas will be excluded from the primary care GP FP10 budget to ensure that the target is achievable and within the GP's control. The actual amount excluded will be recalculated on an annual basis. Appliances Whilst GP practices will still be required to prescribe dressings, continence care, stoma and nutritional supplements, this proportion of the budget will be held centrally by the CCG. Practices will be set a budget based on the specific practice use of these areas during (i.e. if 10% of the practice s spend in was on these areas, a 10% reduction will be applied to the practice budget for ). Horizon Scanning It will also be necessary to hold a central reserve for 'horizon scanning' to include new drugs and those likely to transfer from secondary care to primary care. All spend on prescribing for the specified drugs identified in the horizon scanning process as being likely to impact on primary care will be excluded from the GP FP10 spend. The list will be reviewed on an annual basis as further information is released from the DoH. Current drugs (and indications) to be excluded for are: Drug Eluxadoline Evolocumab Alirocumab Sacubitril Valsartan Vorapaxar HDM-AIT Capsaicin Patch Indication (if specified) IBS Hypercholesterolaemia Hypercholesterolaemia Heart Failure Artherothrombotic events in patients with history of MI House dust mite allergen immunotherapy Peripheral neuropathic pain in adults with diabetes Agreement Period This agreement is to cover the three years from 1 st April 2016, with each financial year being treated as a separate entity. This means the full PIS is available each and every financial year for the three years of the primary care offer. Any funds will be paid on a PRACTICE basis but funds can be pooled as a locality for investment in services. Method of Payment Part 1 Gateway payment monthly as per specification below Part 2 Incentive Scheme payment based on financial outturn There is not expected to be any application process for incentive scheme payments, and all payments will be made by 30 th June following each financial year (i.e. once the end of year financial e-pact data is available from the NHSBSA). As per the DoH guidelines above, practices will need to ensure that any payments made to practices or localities are used for the benefit of patients and all expenditure must be fully auditable. Prescribing Incentive Scheme as part of Primary Care Offer V2 23/03/16 2

3 The two sections of the PIS will be as follows: Section Payment Criteria Payment Schedule Eligibility Total potential CCG Expenditure Part 1 1 per raw list size Payment to be All practices must Gateway for each financial made to practices on meet all criteria 483,705 PIS year of PCO* a monthly basis in specified in this payment 12ths document for part Part 2 PIS payment Up to 2 per raw list size for each financial year of PCO*. Payments to be made as a one off payment according to achievement after the end of the financial year after prescribing data is made available via e-pact (NHSBSA) 1 Only practices who have met the Part 1 Gateway criteria will be eligible for the PIS payments ,410 (according to list size for NHS Wiltshire CCG December 2015) *The list sizes of all practices will be reviewed each year, and payments will be allocated using the raw list size as at 31 st December of the previous financial year. **Total possible payment based on raw list size for NHS Wiltshire CCG December Windfall Savings Windfall savings will be taken into account when calculating the end of year outturn against budget.. Each windfall saving (i.e. each drug) will be discussed and agreed at CCG level as and when they arise as it is not possible to predict the financial impact in advance. Windfall Savings are defined as any savings made purely as a result of a change in Drug Tariff reimbursement without any change in prescribing behaviour by the practice, or if prescribing of certain drugs move out of primary care such as shared care drugs moving to specialist commissioning. This does not included fluctuations in costs due to Category M. Governance The DoH 2010 document Strategies to achieve cost-effective prescribing discussed prescribing incentive schemes and identifies the need to: inform board members (governing body) in advance and to publish details of the scheme s arrangements on the CCG website ensure payments to practices go into practice funds (and not individuals) for the benefit of patients and practices should have auditable written records of expenditure ensure incentives do not conflict with or duplicate other funding rules (e.g. QOF) and must not reward for blanket prescribing of particular named medicines without consideration of the individual circumstances of the patients. The budget setting methodology and prescribing incentive scheme will be agreed by the finance committee of NHS Wiltshire CCG which subsequently is accountable to the Governing Body. All payments will be approved by the Finance Committee according to the criteria set out in this document. NHS Wiltshire CCG may withhold PIS payments where a prescribing underspend has been achieved by lack of implementation of NICE Technology Appraisals contrary to the NHS Constitution. All complaints and disputes should be addressed in the first instance to the Medicines Management Team, and if this is not resolved, it can be escalated to the Director of Primary Care. Any unresolved disputes will be taken to the Finance Committee, and if early resolution cannot be reached, it will be escalated further to the Governing Body. Prescribing Incentive Scheme as part of Primary Care Offer V2 23/03/16 3

4 Specification Part 1 Gateway payment 1 per practice list size Principles NHS Wiltshire CCG recognises that practices may have different methods of reviewing prescribing, and different levels of engagement with the Medicines Management Team. The criteria specified in this section (Part 1) are intended to provide a secure framework for practices to ensure prescribing remains high on the practice agenda, and practices demonstrate evidence of driving prescribing change within the practice. Practices will be paid 1 per patient list size as at 31 st December the previous financial year, on a monthly basis in 12 ths. This is to provide adequate resources to allow the prescriptions lead (GP, Practice Pharmacist or Prescription clerk) protected time to focus on prescribing. If it is clear at the end of the year that not all of the criteria specified below have been met, NHS Wiltshire CCG withholds the right to claw back funding paid to practices. Any practices that have funding withdrawn will NOT be eligible for the PIS part 2 payments. Practices will need to achieve ALL of the elements in part 1 to be eligible for any PIS part 2 payment. Criteria Description Payment Mechanism 1.1 MMT Each practice must meet with a member of the Part of the Meeting Primary Care Medicines Management team before 'gateway' 30th June of each year payment. No To review current performance from a clinical payments will and financial perspective be made To establish the key potential areas of focus for unless this the next financial year criteria has This meeting can be at a locality or practice level, been met however it is expected that the nominated prescriptions lead (and their clinical lead if applicable) is present However, the most benefit will be gained if all clinical staff are able to attend 1.2 Nominate Prescriptions Lead Each practice should nominate a prescriptions lead Can be a practice manager, GP, practice pharmacist or senior prescription clerk / dispenser This person will be responsible for ensuring any recommendations are acted upon within the practice (with all clinical decisions being agreed by the overarching prescribing lead GP). Recommendations may be made by the MMT, via the newsletter, or the practice may be reviewing current procedures and protocols with the practice. ONL if the nominated person is not a clinician (e.g. prescription clerk) the practice will also need an overarching nominated clinical lead (e.g. Prescribing Lead GP). A qualified dispenser (including ACT) would also require a clinical lead. Part of the 'gateway' payment. No payments will be made unless this criteria has been met. Documents to be returned Proforma (Appendix 1) to be completed by the relevant medicines management pharmacist and agreed with the practice before submission Proforma (Appendix 2) returned to CCG by 1st May of each year. If any changes are made during the year, an amended form should be submitted. Prescribing Incentive Scheme as part of Primary Care Offer V2 23/03/16 4

5 1.3 Driving prescribing change within the practice see details below The nominated prescriptions lead should drive best practice both in prescribing behaviour and in repeat prescription processing. For further details see specific requirements section below. Practices may also review prescribing according to local formulary guidance using the clinical systems where appropriate as a tool (e.g. TPP searches, Optimise Rx, or advice from the Medicines Management Team) Practices must ensure all staff are familiar with the medicines management website It is likely that this element will be reviewed and requirements agreed on an annual basis as it is difficult to predict current issues 3 years in advance. (e.g. will it be necessary to attend a workshop each year or just in year 1) Part of the 'gateway' payment. No payments will be made unless this criteria has been met. Proforma Appendix 3 by 31st march (end of year) each year. See year 1, 2 and 3 detailed specification below. Specific requirements for 1.3 Driving prescribing change within the practice ear Expectation for element A) Practices to facilitate a regular prescribing slot in the practice meeting and provide evidence that actions have been taken (minimum 4 times per year). This may include actions taken as a result of the Medicines Management Newsletter, or a specific review conducted as a result of identified variance in the practice's prescribing B) Nominated Prescriptions lead to attend a workshop provided by MMT to review current protocols for managing repeat prescriptions within the practice. This workshop will facilitate development of these protocols and templates will be provided. Dates and venues to be arranged with at least 2 months notice. NOTE : The aim is to have an adequate and agreed set of protocols by the end of year 1 so that ALL staff are following them in year As per year 1 (regular prescribing slot at practice meetings). Practices will also need to provide evidence that protocols are agreed and all staff working with prescriptions are working to the protocols. This will be reviewed on at least an annual basis as required As per year 1 (regular prescribing slot at practice meetings). Practices will also need to provide evidence that protocols are agreed and all staff working with prescriptions are working to the protocols. This will be reviewed on at least an annual basis as required. Prescribing Incentive Scheme as part of Primary Care Offer V2 23/03/16 5

6 Specification Part 2 Prescribing Incentive Scheme payment up to 2 per practice list size Criteria Description Payment Mechanism PLEASE NOTE CHANGES IN TABLE BELOW 2.1 MMT Payments will be tiered as per the Meeting tablet below ONL PRACTICES WHO HAVE MET ALL THE CRITERIA SPECIFICIED IN PART 1 GATEWA WILL BE ELIGIBLE FOR PART 2 Payment will be made on achievement the end of each financial year (March) data is available from e PACT (expected June). The total available to any practice in any year is 2.00 per patient. Paid on PRACTICE basis but funds can be pooled as a locality for investment in services Documents No requirement (monitored using e PACT data from NHSBSA) Practices will be provided with monthly updates Practices will be paid the highest level that can be applied Incentive Payment (additive) End of year position Change in year Tier 1 50p per patient <10% over budget >5% reduction Tier 2 50p per patient <5% over budget >7.5% reduction Tier 3 50p per patient On or below budget >10% reduction Tier 4 (bonus) 50p per patient Maintain or reduce current underspend (NOTE: only practices which were underspent in the previous year will be eligible for this payment in the following year) Example calculation: Practice A Baseline (assuming (year 1) (year 2) (year 3) no change) Predicted overspend 17% over 11% over 8% over 4% Tier achieved Tier 1 Tier 1 Tier 2 Reason for achievement >5% reduction within <10% over budget <5% over budget year Payment Due 50p per patient 50p per patient 1 per patient Practice B Baseline (assuming (year 1) (year 2) (year 3) no change) Predicted overspend 7% over 4% over 1% under 2% under Tier achieved Tier 2 Tier 3 Tier 4 Reason for achievement <5% over budget On or below budget Maintain or reduce current underspend Payment Due 1 per patient 1.50 per patient 2 per patient Prescribing Incentive Scheme as part of Primary Care Offer V2 23/03/16 6

7 Responsibilities GP Practice Responsibilities To liaise with the medicines management team on a regular basis regarding any current prescribing issues (e.g. medicines management newsletter articles, current news headlines, new guidelines, variance prescribing information) To ensure their prescribing and medicines management arrangements are clinically and cost effective and in accordance with local formularies To participate in the scheme as specified in this document Medicines Management Team (Wiltshire CCG) responsibilities To attend a meeting at each practice (or locality level where each practice is represented) to review current performance from a clinical and financial perspective, and to establish the key potential areas of focus for the next financial year To provide support via the Medicines Management website, newsletter, and telephone and to respond in a reasonable timeframe to any queries raised To maintain an accurate profile on FDB Optimise Rx to reflect the local formularies To provide shared searches on GP Clinical Systems (TPP SystmOne) for use within the practice to identify patients To facilitate a workshop to discuss and develop practice protocols for the management of repeat prescriptions within the practice To provide ongoing support to agree the protocols developed Training/Service Development A training workshop will be provided in year 1 for all nominated prescription leads This service will be developed according to need in years 2 and 3 but the intention is to develop an active forum across Wiltshire to encourage sharing of best practice with regards to repeat prescription management and any other relevant issues Objectives and Outcomes NHS Wiltshire CCG Strategic Objectives A B C D E F G Description To drive towards a clinically led model which delivers integrated high quality patient services within the community based upon neighbourhood teams to provide 'wrap around' care at or close to home Commission appropriate services to meet the needs of the local population and national priorities, delivered in the right place (ideally in a primary care setting but acute where necessary) and accessible at the right times identifying and addressing health inequalities Engage effectively with the local population to enable patients and practices to influence the services that we commission Achieve a sustainable health economy optimising appropriate use of resources for the delivery of efficient and effective healthcare Develop an effective and responsive clinically led commissioning organisation, working collaboratively with partner organisations Enhance quality and safety of services by ensuring effective mechanisms are in place to set quality standards, assess performance, address concerns and drive continuous improvement Encourage and support the Wiltshire population in managing and improving their health and wellbeing, wherever possible increasing the ability of people to manage their own care and to make their own choices Relevant Prescribing Incentive Scheme as part of Primary Care Offer V2 23/03/16 7

8 Local defined outcomes A number of outcomes are expected to be achieved, in full or in part, as a result of successfully implementing this scheme. These include: Continued improvement in effectiveness and value for money of prescribing activity Improved compliance to local formularies Continued development of relationships between the prescriptions lead and the Medicines Management Team Improved accountability and responsibility for the prescribing budget by GP practices and localities Improved consistency and structure for staff working with prescriptions in practices across Wiltshire Reporting As described in specification above, using appropriate proforma see appendices Prescribing Incentive Scheme as part of Primary Care Offer V2 23/03/16 8

9 Appendix 1: Prescribing Incentive Scheme Gateway Medicines Management Meeting Notes This template will be completed by a medicines management pharmacist and agreed by the practice manager as a true reflection of the meeting. The meeting will be completed by 30 th June of each year, and this form will be completed by 31 st July of each year. Financial ear (delete as appropriate) Meeting Type Practice / Locality Practice Name Meeting venue Date MMT pharmacist Nominated Prescriptions Lead Clinical lead (where appropriate) Other Attendees Points Discussed 1. Data (information sheet) Gateway Criteria (MUST BE COMPLETED TO BE ELIGIBLE FOR PIS) Action Points Any other issues? Practice Packs Quarterly and Information monthly /18/19 Practice plans to address prescribing issues Communication / website access Prescribing Incentive Scheme as part of Primary Care Offer V2 23/03/16 9

10 Appendix 2: Prescribing Incentive Scheme Gateway Nominated Prescriptions Lead Practices are required to submit a copy of this form electronically to the CCG (prescribingwiltshire@nhs.net) by 1 st May of the current financial year Financial ear (delete as appropriate) Date form completed Practice Name Name of nominated prescriptions lead address of nominated prescriptions lead Job Role of nominated prescriptions lead IF REQUIRED Name of overarching clinical prescribing lead GP IF REQUIRED address of overarching clinical prescribing lead GP (e.g. Prescription Clerk, Practice Pharmacist) Only complete if the nominated prescriptions lead is non clinical Only complete if the nominated prescriptions lead is non clinical By completing and submitting this proforma, you agree to release the nominated prescriptions lead to attend a workshop facilitated by the medicines management team as set out in the specification of the Prescribing Incentive Scheme If any there are any changes to staff during any financial year, you agree to send a revised form to prescribingwiltshire@nhs.net within 1 month of any change. Prescribing Incentive Scheme as part of Primary Care Offer V2 23/03/16 10

11 Appendix 3: Prescribing Incentive Scheme Gateway Driving prescribing change within the practice Practices are required to submit a copy of this form electronically to the CCG (prescribingwiltshire@nhs.net) by 31 st March (end of each financial year). Financial ear (delete as appropriate) Date form completed Practice Name Name of nominated prescriptions lead Date of workshop attended Progress on development of repeat prescription protocols (year 1) only Do you have repeat prescription protocols in place (agreed by MMT) If yes, are all staff working to these protocols Confirm yes/no Attach signature sheet Evidence of prescribing issues being discussed at practice meetings (at least 4 per year) Meeting 1 Date: Item(s) discussed: Action as a result: Meeting 2 Date: Item(s) discussed: Action as a result: Meeting 3 Date: Item(s) discussed: Action as a result: Meeting 4 Date: Item(s) discussed: Action as a result: Add as required It is likely that this form will be adapted for each year depending on the development of this particular indicator Prescribing Incentive Scheme as part of Primary Care Offer V2 23/03/16 11

Oxfordshire CCG Prescribing Incentive Scheme 2017/18

Oxfordshire CCG Prescribing Incentive Scheme 2017/18 Oxfordshire Clinical Commissioning Group The Oxfordshire Prescribing Incentive Scheme is offered to all of its member GP practices as encouragement