In their latest column, the All Wales Medicines Strategy Group reports on the progress they’ve made in supporting healthcare professionals to optimise their prescribing in Wales since 2015, and highlights the continuing challenges.

The principles of Prudent Healthcare were first articulated by the Bevan Commission in Wales in December 2013. (1) After consultation, they were finalised and adopted by NHS Wales in 2015 as a framework to guide the delivery of safe, effective, efficient and equitable healthcare in Wales. (2) During the consultation on the principles of Prudent Healthcare, it was recognised that ‘Prudent Prescribing’ could contribute to achieving Prudent Healthcare in Wales. (3) In this article the All Wales Medicines Strategy Group (AWMSG) discusses the relevant areas in relation to each of the four Prudent Healthcare principles.

1. Achieve Health and Wellbeing with the Public, Patients and Professionals as Equal Partners through Co-Production

Co-production is defined as a ‘way of working whereby citizens and decision-makers, or people who use services, family carers and service providers work together to create a decision or service which works for them all’. (4) Prescribing is considered as an active co-productive partnership agreement between the patient and those health professionals who are involved in prescribing, preparing, administering and monitoring the effects of the medicine(s); not simply a ‘procedure performed’ on a passive patient.

To ensure the primacy of the patient voice in making decisions and planning services around medicines, AWMSG established a Patient and Public Interest Group (2013) and Engagement Strategy (2014) to ensure input into consultations and documents.

Patient Interest Groups in Wales and other parts of the UK are invited to provide advice on the recommendation process for access to new medicines in Wales (through the Health Technology Appraisal process). In the cases of new medicines for rare diseases, an additional group known as the ‘Clinician and Patient Involvement Group’ provides further detailed input if one of these medicines receives a preliminary negative recommendation.

In 2016, AWMSG funded a ‘Citizens’ Jury’ of members of the public living in Wales who deliberated on the rising challenge of antimicrobial resistance. The jury made several recommendations, including proposing a new approach to engaging the public, moving away from ‘health education’ to a more sophisticated and co-ordinated attempt to engage the public, and change behaviour through ‘social marketing’. (4)

2. Care for those with the Greatest Health Need First, Making Most Effective Use of all Skills and Resources

In 1999, Wales decided to make the best use of its own skills and resources in therapeutics by accepting NICE’s judgements on availability of new medicines and subsequently asking AWMSG to advise as soon as feasible on medicines not on NICE’s work programme (and to develop therapeutic guidelines in those areas). This, together with the New Treatment Fund introduced in November 2017 to further speed up access to medicines, means that approved clinically- and cost-effective medicines are now available for patients in NHS Wales in an efficient and timely manner (reaching the health board formularies in an average of approximately 13 days). Some medicines (including those for off-label indications) are not amenable to appraisal by NICE or AWMSG but the One Wales Interim Commissioning Process has been working effectively since 2015 to address this gap.

Any funding from patient access schemes which have been agreed with manufacturers of new medicines is recouped to ensure that the best value for money is achieved from Wales’ spend on medicines. Work is also underway to promote reductions of certain medicines less suitable for prescribing so that resources can be freed up to deliver more efficient healthcare.

3. Do Only What is Needed – No More, No Less – and do No Harm

Since 2002, AWMSG has agreed and monitored the safety, quality and efficiency of prescribing indicators. These National Prescribing Indicators (NPIs) allow health boards, primary care clusters and individual GP practices to compare their prescribing against their colleagues across Wales (5) and the continuing improvements in these are very encouraging. Data for all the NPIs is already available to prescribers across Wales on the Server for Prescribing Information Reporting and Analysis (SPIRA).

It is impossible to completely avoid all side-effects from medicines, although some are potentially avoidable with appropriate prescribing and careful monitoring. A previous article in Welsh Pharmacy Review has highlighted how Wales is seeking to reduce severe avoidable harm from medicines. (7)

4. Reduce Inappropriate Variation Using Evidence-Based Practices Consistently and Transparently

Feedback on the changes in NPIs is given to prescribers and health boards across Wales. In addition to movements in the desired direction of change, reduction in variation between health boards can also be seen. One example involving prescribing of tramadol is shown in Figure 1.

The Future

Ceri Phillips, who was a Bevan Commissioner and one of the team who originally developed the Prudent Healthcare principles (1), has recently been appointed Chair of AWMSG.

He has already ensured that AWMSG members have had an early opportunity to discuss and plan the way forward to ensure that prudent prescribing principles can help healthcare professionals to deliver the best outcomes from medicines, reduce avoidable medicines-related harm and support the delivery of value-based healthcare for people in Wales.

References

1. Aylward M, Phillips C, Howson H. Simply Prudent Healthcare – achieving better care and value for money in Wales – discussion paper. 2013. http://www.bevancommission.org/en/prudent-healthcare

2. Bevan Commission. Prudent Healthcare.

http://www.bevancommission.org/en/prudent-healthcare

3. Routledge PA. Better healthcare outcomes and safer care through Prudent Prescribing (2014) http://www.prudenthealthcare.org.uk/prescribing/

4. Skills for Health. National Occupational Standards MH63.2013: Work with people and significant others to develop services to improve their mental health. https://tools.skillsforhealth.org.uk/competence/show/pdf/id/3833/

5. All Wales Therapeutics and Toxicology Centre. National Prescribing Indicators 2019–2020. Analysis of Prescribing Data to September 2019. http://www.awmsg.org/docs/awmsg/medman/National%20Prescribing%20Indicators%202019-2020%20Analysis%20of%20Prescribing%20Data%20to%20September%202019.pdf

6. All Wales Medicines Strategy Group Annual Report 2018–2019. http://www.awmsg.org/docs/awmsg/awmsgdocs/AWMSG%20Annual%20Report%202018%20-%202019.pdf

7. Welsh Pharmacy Review; Issue 42: 2019. http://waleshealthcare.com/welsh-pharmacy-review-latest-issue/