Oxfordshire CCG Prescribing Incentive Scheme 2017/18

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Winfred Green
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1 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 and reward to improve the quality, safety and cost effectiveness of prescribing. This is one of many elements to further enhance the quality and cost effectiveness of prescribing within the area and successful implementation will deliver benefits in 2017/18 and subsequent years. This scheme for 2017/18 aims to offer all practices a financial incentive to reduce prescribing costs. It is not solely based upon budgets and recognises that much work to improve the cost effectiveness of prescribing has already been carried out in many practices. Practices are asked to review prescribing in a chosen therapeutic or process area where the cost effectiveness of prescribing could potentially be successfully improved, without impacting on the quality of patient care. Practices are targeted to achieve a minimum saving equivalent to 2 per patient. The GP practice is required to submit a Medicines Optimisation Benefit Share Plan that is agreed by the OCCG Medicines Optimisation Programme Board, and deliver 25% of the minimum savings target. The practice will then receive a payment equivalent to 0.25 per patient. If the practice delivers 100% of their target, they will receive a payment equivalent to 1 per patient. For any further savings achieved in excess of this, the practice will be entitled to 50%. The Incentive Scheme is aimed to deliver initial target savings of 1,454,000, based upon 2 per registered patient however there is also opportunity for additional savings through agreement of individual practice plans. Practices will have to submit, and have approved, a Medicines Optimisation Benefit Share Plan, the CCG will have an oversight of the forecasted savings and spend, and fully mitigate the CCG from any risk of rewarding practices without corresponding savings to the total prescribing budget. Additionally, benefit from the Scheme is dependent on practice and locality achievement against budgets. This will mean that OCCG will be likely to achieve an overall saving on the prescribing budget. The CCG is keen that practices perform against the PIS throughout the year to ensure GP practices are undertaking cost-effective prescribing decisions on an ongoing basis. It is hoped that such activity will produce ongoing savings throughout this and future years, and secure the performance against efficiency targets. GP practices will be required to record actual savings obtained through the 1

2 implementation of their Medicines Optimisation Benefit Share Plan. In addition, the CCG will evaluate the performance of the scheme at Medicines Optimisation Programme Board, and consider an annual extension of the scheme on a rolling basis. Outline of Proposed Benefit Share Scheme GP practices will be invited to agree a practice based Medicine Optimisation Benefit Share Plan. This should focus on those areas identified which offer the greatest potential to deliver benefits at a practice level. Practices will be set a target of reducing expenditure by 2 per patient. Practices will receive a payment equivalent to 0.25 per patient for submitting a Medicine Optimisation Benefit Share Plan, which must be approved in June 2017, and delivering 25% of the target savings within it. Practices will receive a further payment of 0.25 per patient when 50% of target savings have been achieved. When the target savings of 2 per patient is met then the practice will receive 50% of any further savings made. Table 1 Summary of the payment criteria for the scheme Savings Target of 2 per Patient Savings Criteria (% of target) Total Payment to Practice % per Patient % of Savings Total per Patient Tier 1 25% 50p 12.50% 25p Tier 2 50% 1 25% 50p Tier 3 100% 2 50% 1 Table 2 Example of potential benefit for a typical 10,000 patient practice, target of 20,000 Example Practice of 10,000 Patients: Savings Target 20,000 Savings Criteria (% of target) Total Payment to Practice % Actual Savings % of Savings Total Payment < 25% < 5,000 nil nil Tier 1 25% 5, % 2,500 Tier 2 50% 10,000 25% 5,000 Tier 3 100% 20,000 50% 10,000 A key aspect of agreeing a practice based Medicines Optimisation Benefit Share Plan will be that practices identify sufficient resources to deliver the plan. These resources should be provided by the GP practices and funded utilising the anticipated savings that will be delivered. The CCG will not be liable for any costs incurred by GP practices to deliver their plan. 2

3 Key Points Practices must express an interest (by to Medicines Optimisation Team at ) to participate in the scheme. The deadline for expressions of interest is 30 th. Practices must work with the Medicine Optimisation Team to agree a detailed practice based Medicine Optimisation Benefit Share Plan submitted by 15 th May 2017 using the template Benefit Share Plan at the end of this document. This will identify priority areas for service improvement and the proposed investment that the GP practice will make in the Plan to deliver it. GP practices are required to demonstrate how they plan to implement the plan The CCG have compiled a menu of practice-level prescribing savings opportunities to support practices to develop their plan. However practices are invited to present alternative options where they feel that savings can be achieved. Performance, and thus payments under the scheme, will be measured solely upon delivery against the detailed practice based Medicine Optimisation Benefit Share Plan NOT the practice outturn against the prescribing budget. The scheme requires practices to submit a detailed practice based Medicine Optimisation Benefit Share Plan to achieve prescribing savings of at least 2 per registered patient list. The CCG would encourage practices to submit more stretching detailed practice based Medicine Optimisation Benefit Share Plans, beyond the 2 per patient target. Savings achieved but not identified in the detailed practice based Medicine Optimisation Benefit Share Plan will not be considered under the scheme i.e. payments will be made only against savings identified in the detailed Practice Based Medicine Optimisation Benefit Share Plan Practices who have submitted a detailed Practice Based Medicine Optimisation Benefit Share Plan which achieves savings exceeding their targeted 2 per registered patient list will be rewarded at a rate of 50% of any savings made. Practices must evidence achievement of the plan to demonstrate the actual savings achieved. Actual savings achieved will be the measure used to determine payment under the scheme, and will be subject to post-payment verification by the CCG A suggested template for practices to submit their detailed practice based Medicine Optimisation Benefit Share Plan, and also to submit their achievements is attached. The Medicines Optimisation Team will be available to practices to support the scheme, but will not be in a position to perform the actions required to deliver the scheme for practices. The scheme requires that practices must use their own resource to implement the plan. 3

4 All savings identified and achieved in the detailed practice based Medicine Optimisation Benefit Share Plan must be recorded as full year* figures It is OCCG s intention to review the PIS for future years, following a detailed review of performance, dependent upon the success of the scheme. Payment Gateways Participating practices must underspend their total prescribing budget by at least the amount of saving achieved through the delivery of their Medicine Optimisation Benefit Share Plan. In circumstances where this is not achieved an appeal process through submission of details to the Medicines Optimisation Programme Board will make recommendation to the CCG Executive for approval. Underspend of locality budget allocation is a gateway to achieve savings payments to practices. If the locality does not underspend its budget by the total of the member practice Plans achieved savings, the payment to all practices will be reduced to reflect the locality achievement versus target savings. However it is anticipated that it is unlikely that a locality will be overspent unless a significant proportion of practices do not engage in attempts to prescribe cost effectively. Expressions of Interest Practices will be required to provide the following information to the CCG as part of the practice Expression of Interest Key Practice Details Name of Practice Prescribing Lead Demographic Brief explanation of key demographic characteristics and implication for Characteristics Medicine Optimisation Proposed Priorities for 2017/18 Brief explanation of proposed priorities for 2017/18 Brief description Brief explanation of rationale and objectives, and how Benefit Share Plan will be delivered in 2017/18 Anticipated level of saving to be achieved in each priority area and rationale for target 4

5 If preferred, practices could submit their Benefit Share Plan using the attached template as their Expression of Interest. Following receipt and review of the Expression of Interest a link Medicine Optimisation team member will be available to provide some support to the practice to develop the plan. However the attached template plan is for practices to use or adapt as wished.. Practices will be required to produce a detailed plan including actions to be undertaken to improve quality of prescribing in each priority area Following submission, plans will be reviewed by the Medicine Optimisation Programme Board. Initial feedback and recommendations about the plan will be provided and practices will be given an opportunity to revise the Plan ahead of final consideration The Medicines Optimisation Programme Board will be responsible for reviewing and signing off the final version of the Medicine Optimisation Benefit Share Plan. There will be a quarterly review of progress in delivering practice Medicine Optimisation Benefit Share Plan. At the end of each quarter the Medicine Optimisation Team will provide an analysis of practice performance against the key targets set, where possible. Where it would be beneficial a review meeting will be arranged between a member of the Medicines Optimisation Team and the prescribing lead GP for the Medicine Optimisation Benefit Share Plan. Any agreed changes to Medicine Optimisation Benefit Share Plan targets or to the proposed delivery plan will be considered for agreement by the Medicines Optimisation Programme Board. End of Year Assessment At the end of the Financial Year, on March epact data availability, the Medicine Optimisation Team will conduct an assessment of performance against the agreed Medicine Optimisation Benefit Share Plan and will provide a recommendation, setting out the level of benefit achieved. Following the presentation of the draft conclusions to the practice, this will be considered by the Medicines Optimisation Programme Board. 5

6 A separate local dispute resolution process will be drawn up to identify areas for resolving disputes/appeals to the CCG. The process will also outline the steps the CCG will utilise in managing the delivery of the service and timely feedback Proposed Budget methodology A budget envelope will be allocated based on Outturn/Forecast Outturn average plus inflationary growth on a practice basis to set a notional practice based primary care prescribing budget allocation. Given the limitations of the various formulae used to calculate practice budget allocations, it has been proposed that for 2017/18 a simple methodology be used to allocate notional budget this coming year at practice level based upon average spend over the last 3 years - based upon outturn 14/15, outturn 15/16 and forecast outturn based upon M8 (latest data) for 2016/17. Review of this data at practice level for the last 3 years shows minimal fluctuation in expenditure for the majority of practices during this period. Locality budgets will also be set based upon their member practices forecast outturn. Practices that exceed their budget allocation (other than for the reasons in the paragraph below adjustment of incentive awards covering factors beyond a practice s control)) will have their budget allocation in reduced by the amount of any overspend in It is anticipated that there will be a similar Benefit Share Plan in if the current year s scheme is successful. Practices that have not managed to make savings in the current year will have the opportunity to do so in future years but will not be able to benefit from saving overspend in the current year. In addition, localities are requested to formally review their practices progress in the Prescribing Incentive Scheme through quarterly reviews at locality meetings attended by a member of the Medicines Optimisation Team with constructive discussion and to share learning or processes. A quarterly locality report should be prepared between Locality Clinical Director, Locality Coordinator and the Medicines Optimisation Team and circulated to member practices following this review. Adjustment of Incentive Awards It is recognised that there may be other factors such as national pricing or local commissioning decisions that could impact on practices prescribing costs. Therefore the CCG will determine whether there are any significant adjustment factors to take into account before calculating practice cost efficiency saving achievements. Typically, these significant adjustment factors may include: 6

7 the impact of any national pricing decision to increase or reduce Category M drug prices local CCG commissioning decisions that significantly impact on primary care prescribing costs or NICE guidelines that significantly impact on primary care prescribing costs significant population changes The CCG (through the Medicines Optimisation Programme Board) will therefore assess the impact of such items from practice prescribing costs before calculating practice savings. Governance The DoH 2010 document Strategies to achieve cost-effective prescribing discusses prescribing incentive schemes and identifies that: All payments under a scheme should go into practice funds and not to individuals. The scheme rules should specify that payments must be used for the benefit of patients, and, for audit purposes, practices should keep written records of expenditure; Incentives should not conflict with or duplicate other funding rules, e.g. QOF. Payments or any other inducements to good practice must not reward prescribers or their practices simply for blanket prescribing of particular named medicines (i.e. without consideration of the individual circumstances of patients). It is important that all practice prescribing decisions are compliant with National Guidance, NICE, Area Prescribing Committee Decision and Oxfordshire Formulary Recommendations and that any new quality initiatives are maintained and followed. Practices should not try to reduce their prescribing spend by the non-implementation of prescribing aspects of local and national policies such as NICE Guidance. 7

8 Menu of Possible Priorities this is not an exhaustive list but is aligned with OCCG Medicines Optimisation priorities and practices are also encouraged to identify and consider alternative initiatives. These are reproduced below in an example of a practice Medicines Optimisation benefit Share plan (see next page) which can be used/adapted/edited as preferred. Items may be deleted or substituted as preferred but forms submitted as in the example below are likely to be agreed without delay by the medicines Optimisation Team. 1 Reducing waste Conduct a review of the managed repeats process to reduce the inappropriate over-ordering of prescribed medicines. When Luton CCG reviewed their repeat prescribing systems, they were able to save 7% of their annual primary care prescribing budget) Reducing wastage through rationalising the use of needles, strips and lancets and aligning with prescribing of insulin and oral mediation Reviewing GP practices repeat prescribing policies and delivering education/training to repeat prescribing clerks 2 Oral Nutrition Review and reduce all prescribing or stop prescribing if appropriate of oral nutritional products (sip feeds, infant feeds and gluten-free products) inappropriately prescribed in primary care 3 PPIs Review and change prescribing (step down or discontinue) of Proton Pump Inhibitors to reduce risk of clostridium difficile infection 4 COPD T o optimise prescribing and outcomes for chronic obstructive pulmonary disease (COPD) patients through patient reviews Deliver targeted reviews to high risk patients Implement local prescribing guidelines for COPD Stepping down of high-dose inhaled corticosteroids (ICS)/long acting beta agonist (LABA) combination inhalers Implement the use of cost-effective inhalers in line with updated guidance and new formualry choices Implement inhaler technique training for all device types for appropriate healthcare professionals 5 Pregabalin Review pregabalin prescribing in line with local guidance & consider stopping or switch where appropriate. 6 OTC Medicines Review prescribing for self limiting conditions and for items recommended for OT C purchase inline with CCG policy 7 Care Homes Review medicines and prescribing in care homes to optimise medication. Use of deprescribing /rational prescribing tools e.g. STOPP START. 8 Scriptswitch All ScriptSwitch messaging is compliant with national and local guidance (NICE, Area Prescribing Committee decisions and Oxfordshire T raffic Light recommendations) and is maintained throughout the year by the Medicines Optimisation T eam. Individual practice data can be provided by the medicines optimisation team to identify opportunity savings as practice level.scriptswitch data shows that 720, savings has been achieved to date this financial year however there is opportunity for a further 5.2 million identified opportunity savings triggered in the ScriptSwitch system for Oxfordshire year to date. T he savings achieved represent 13.8% of the total available. It is acknowledged that it will never be possible to release 100% of these savings however there is significant opportunity in maximising our acceptance level and achieved savings released. 8

9 Example of Plan topics and brief outline of detail requirements Example of Agreed steps for achievement Anticipated annual Actual savings Example of Proposed evidence/outcome monitoring data Practice identified savings by at year end to demonstrate change by based on data to Prescribing Action (data not available until June 2018) Reducing Waste Identify mechanisms to reduce the inappropriate over- 7% of annual Practice mechanisms undertaken to reduce ordering of repeat ordering of prescribed medicines. prescribing budget items not actually required Reducing wastage through rationalising the use of needles, Eg: strips and lancets and aligning with prescribing of insulin content/uploads/2015/06/pharmaceutical-waste-reduction.pdf and oral medication Adopt measures to reduce waste in care homes eg Reviewing repeat prescribing policies and delivering education/training to repeat prescribing clerks homes/send/102-care-homes-bulk-prescribing/3324-bulletin- 66i-bulk-prescribing-in-care-homes Practice policy on prescribing of testing scrips and other accessories, increased proportion of most cost-effective testing strips and reduction in overall spend epact data to evidence reduction in prescribing. Oral Nutrition Review and reduce all prescribing, or stop prescribing if % reduction of current Reduction in the number of prescriptions issued for these appropriate, of oral nutritional products (sip feeds, infant spend on ONS that products via epact. feeds and gluten-free products in line with OCCG policy) practice feels is inappropriately prescribed in primary care appropriate (new OCCG policy to restrict ONS except in exceptional circumstances about to be released)

10 Example of Plan topics and brief outline of detail requirements PPIs COPD Pregabalin OTC Medicines Care Homes and rational prescribing in those with fraility or multimorbidity over Review and change prescribing (step down or discontinue) of Proton Pump Inhibitors to reduce risk of clostridium difficile infection To optimise prescribing and outcomes for chronic obstructive pulmonary disease (COPD) patients through patient reviews Deliver targeted reviews to high risk patients. Implement local prescribing guidelines for COPD Stepping down of high-dose inhaled corticosteroids (ICS)/long acting beta agonist (LABA) combination inhalers Implement the use of cost-effective inhalers in line with updated guidance and new formulary choices Implement inhaler technique training for all device types for appropriate healthcare professionals Review pregabalin prescribing in line with local guidance & consider stopping or switch where appropriate. Review prescribing for self limiting conditions and for items recommended for OTC purchase in line with CCG policy Review medicines and prescribing in care homes and the frail elderly to optimise medication. Use of deprescribing /rational prescribing tools e.g. STOPP START. Potentially inappropriate prescribing rate using 30 STOPP indicators: % reduction of current Reduction in spend on PPI and number of patients spend on PPIs that discontinuing a PPI via epact. practice feels is appropriate % reduction of current Audit of 10% of patients on inhaled steroids showing actions of spend on high-dose review and medication changes. inhaled steroid and/or Increase in proportion of the most cost-effective inhalers the less cost-effective prescribed via epact. combination inhalers that the practice feels is appropriate % reduction of current Reduction in number of items prescribed for pregabalin. spend on pregabalin Number of those switched to generic version of pregabalin. that practice feels is epact data. appropriate 1 X practice population Reduction in items prescribed for a selected range of products that are available to purchase OTC and in line with OCCG updated policy on OTC medication 2017 via epact data. Practice prescribing Audit of 10% of care home residents and action at medication budget x % of practice review to rationalise prescribing. population over age of Use of STOPP/START tool 70

11 Example of Plan topics and brief outline of detail requirements the age of 70 years 36% Estimated 9% reduction in overall prescribing spend in those>70 years (Cahir C et al. Br J Clin Pharmacol 2010; 69: ) X 0.9 Scriptswitch Wound management Total of anticipated savings identified above Practice savings target of 2 per head Adopt Scriptswitch recommended changes where 50% of the potential appropriate Scriptswitch Oxon population 700,000 Potential Scriptswitch opportunities = opportunity per person (on average): 3.70 (Practice population x 3.70) Ensure maximum use of ONPOS and only prescribe % reduction of current dressings outside ONPOS/formulary where recommended spend on non-onpos by specialists if appropriate dressings that practice feels is appropriate Sum of the above As above Practice population x 2 Monitoring through Scriptswitch Monitor dressings on prescription via epact. Payment to practice if minimum 25% savings achieved (tier 1) Practice population x 0.25

12 Example of Plan topics and brief outline of detail requirements Payment to practice if achieve 50% of savings target (tier 1 and 2) Payment to practice if achieve 2 per head savings target (tier 1, 2 and 3) Practice population X 0.50 Practice population X 1.00 Additional payment to practice if maximum anticipated savings listed in this plan are exceeded 50% of the maximum savings in plan above the 2 per head payment

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