Date published: 31 July, 2023
Date last updated: 19 October, 2023
Integrated care, Medicine

National medicines optimisation opportunities 2023/24

This guidance describes the 16 national medicines optimisation opportunities for the NHS in 2023/24, and signposts to resources to help with their implementation. We recommend integrated care boards (ICBs) choose at least five medicines optimisation opportunities to focus and deliver on alongside their local medicines optimisation priorities. Progress against chosen opportunities will be reviewed using available data.

Introduction

The NHS England Medicines Optimisation Executive Group (MOEG) has identified and agreed 16 national medicines optimisation opportunities for the NHS in 2023/24 to deliver on integrated care boards (ICBs) four key objectives:

  • Improve outcomes in population health and healthcare.
  • Tackle inequalities in outcomes, experience and access.
  • Enhance productivity and value for money.
  • Help the NHS support broader social and economic development.

Listed alphabetically and not in any priority order, these 16 national medicines optimisation opportunities are:

Appropriate use, access and uptake

  1. Addressing problematic polypharmacy
  2. Addressing low priority prescribing
  3. Improving uptake of the most clinically and cost-effective medicines
  4. Obtaining secondary care medicines in line with NHS England commercial medicines framework agreements
  5. Standardising product formulations of aseptically compounded medicines
  6. Using best value biologic medicines in line with NHS England commissioning recommendations.

Specific clinical areas

  1. Addressing inappropriate antidepressant prescribing
  2. Appropriate prescribing and supply of blood glucose and ketone meters, and testing strips
  3. Identifying patients with atrial fibrillation and using best value direct-acting oral anticoagulants
  4. Identifying patients with hypertension and starting antihypertensives where appropriate
  5. Improving respiratory outcomes while reducing the carbon emissions from inhalers
  6. Improving valproate safety
  7. Optimising lipid management for cardiovascular disease prevention
  8. Reducing course length of antimicrobial prescribing
  9. Reducing opioid use in chronic non-cancer pain
  10. Switching intravenous antibiotics to oral.

These opportunities were selected based on alignment to the following integrated care board (ICB) priorities:

  • improving medicines-related patient safety
  • delivering value to the system
  • improving patient outcomes
  • supporting equity of access
  • supporting NHS recovery through increasing capacity
  • reducing health inequalities
  • improving sustainability.

More detail on these including definitions is in Appendix 1.

We recommend ICBs choose at least five national medicines optimisation opportunities to deliver on, alongside their identified local medicines optimisation priorities.

NHS England (national and regional teams) will review data for the chosen national opportunities to identify improvements and share best practice across the health and care system. This is in line with the Hewitt review, which places emphasis on the availability and use of data across the health and care system for transparency and improvement.

This guidance provides information and links to resources that support the implementation of each of the national opportunities.

Accountability

ICBs have responsibility and accountability for overseeing NHS delivery of their medicines optimisation strategies and plans aligned to the NHS Long Term Plan.  

Regional teams will support ICB leaders to select the national medicines optimisation opportunities that best align with their local priorities and will deliver most benefit for their system. NHS England will use available data to review progress against the chosen opportunities.

Implementation

When implementing the opportunities locally, systems should ensure their clinicians take a shared decision-making (SDM) approach when discussing medicines options (starting, substituting, tapering and stopping medicines) with their patients.

Systems should also consider national policy guidance and commissioning arrangements when implementing the opportunities, to ensure they have no unintended consequences for other parts of the system; for example, decisions about prescribing and the potential impact this could have on national community pharmacy contracts. Systems may also use their local incentive schemes as financial levers to drive the medicines optimisation opportunities.

The NHS has a responsibility to deliver financial balance within the resources allocated by government and Parliament, and within that to deliver the maximum benefit for patients from each pound spent. Medicines optimisation efficiency savings present a significant opportunity for integrated care systems (ICSs) to deliver balanced financial plans. The national medicines optimisation opportunities along with regional arrangements for medicines optimisation guidance, supports systems to deliver on these efficiencies.

Systems should work together across medicines optimisation teams, pharmacy leaders, medical directors, commissioning and finance to understand current spend across commissioning budgets, taking into account that ICBs are funded for all locally commissioned services including medicines (both primary care and hospital prescribed medicines).

ICBs must carry out suitable Equality Analysis when making decisions and give due regard to the findings.  ICBs should follow their own governance process for Equality and Health Inequality decision making. 

Measuring success and progress

Responsibilities and accountabilities for delivery of the opportunities are set out in the regional arrangements for medicines optimisation. These include, for each of the opportunities, use of metrics and other data sources to monitor progress; however, ICBs will have responsibility and accountability for demonstrating progress against their chosen opportunities.

For some opportunities, metrics are in development to enable systems to access and view their own data and to track progress against the opportunity. Headline metrics for the opportunities will be collated into a dashboard with a single overview function. This will support local decision making by allowing each organisational level to view their position relative to other areas and identify greatest opportunities for delivery. While the dashboard is in development, we have shared links to existing, relevant data sources that could support implementation.

Appropriate use, access and uptake of medicines

1. Addressing problematic polypharmacy

Overprescribing is the use of a medicine where there is a better non-medicine alternative, or where the use is inappropriate for that patient’s circumstances or is inconsistent with their wishes, and can lead to problematic polypharmacy (a person’s concurrent use of multiple medicines). Polypharmacy may be appropriate for a person with complex or multiple conditions if their medicines are optimised and prescribed according to best evidence. However, it can be problematic when the benefit of the individual medicines is not realised.

The focus of this opportunity is on:

  • identifying and reviewing patients with problematic polypharmacy
  • supporting cultural and behavioural changes.

Structured medication reviews (SMRs) can be used to review patients identified as having problematic polypharmacy. They provide a comprehensive and clinical review of a patient’s medicines and detailed aspects of their health, and are facilitated by shared decision-making conversations with patients around whether medicines are safe, effective and personalised to their needs and current situation. Appropriate advice and support around medicines issues will be offered to patients, including information on when and how to seek further help. Any decision to withdraw a medicine is based on the patient’s individual clinical conditions, the medicines they are taking, and their values and preferences.

Benefits of the intervention and impact

SMRs are the best tested intervention for reducing problematic polypharmacy; estimates for the percentage reduction in the number of medicines a patient is taking range between 2.7% (Baqir et el, 2017) and 9.9% (Appendix D: Health Economics Analysis of Polypharmacy Reviews). In care homes, SMRs can reduce the number of medicines a person takes by around 19.5% (Baqir et el, 2017), although this population is not representative of the general population experiencing polypharmacy.

Problematic polypharmacy increases the risk of drug interactions and adverse drug reactions (ADR), impairing medication adherence and impacting on a patient’s quality of life, with this risk increasing with the number of prescribed medicines and for specific therapeutic combinations.

Observational studies have found that ADRs – also referred to as adverse drug events – are a major driver of avoidable hospital admissions and have caused or contributed to patient deaths. There is a clear relationship between the increased likelihood of an ADR and a higher number of medicines being taken by a patient, with significant costs to health systems arising from hospital admissions, extended length of stay, as well as the direct costs of overprescribing.

For this opportunity, most benefit will be realised by identifying patients who are taking many medicines concurrently and are therefore most likely to benefit from an SMR. These include those in the following patient groups:

  • care home residents
  • with complex and problematic polypharmacy, specifically those on 10 or more medications (with increased focus on those over 75 years)
  • on medicines commonly associated with medication errors
  • with severe frailty, who are particularly isolated or housebound or who have had recent hospital admissions and/or falls
  • using one or more prescribed medicines from the following groups that can cause dependence or withdrawal: opioids, gabapentinoids, benzodiazepines and z-drugs.

Metrics to support implementation and monitoring

Case studies and examples of good practice

Resources to support implementation

What success looks like

  • Improved patient experience and quality of care through being involved in the decision-making process and having a better understanding of the medicines they take.
  • Less risk of harm from medicines (eg adverse drug events, side effects, hospitalisation or symptoms of dependence and withdrawal).
  • Better value for local health systems.

2. Addressing low priority prescribing

Policy guidance on includes medicines:

  • for which there are significant safety concerns
  • for which there is a lack of robust evidence of clinical effectiveness
  • that are clinically effective but not the most cost-effective intervention available
  • that are clinically effective but deemed a low priority for NHS funding.

Prescribers are advised that no new patients should be started on these items, that they should be deprescribed for current patients and that, where possible, suitable alternatives should be identified for patients.

However, the guidance does identify some circumstances where it may be appropriate to prescribe some of the items on the low priority prescribing guidance list.

Since the guidance was first published in 2017, total prescribing volumes for the medicines covered have fallen by 58%, with the largest reductions for some of the most unsafe and ineffective medicines:

  • co-proxamol (unsafe); 87%
  • homeopathy (ineffective); 92%
  • glucosamine and chondroitin (ineffective); 88%.

Good progress has also been made on ensuring patients are on the most cost-effective medicines. Prescriptions for trimipramine are down 70% since 2017, with patients switched to often cheaper alternatives, saving the NHS around £13 million in 2022/23 compared to the spend in 2016/17. And overall, in 2022/23, the NHS spent £78 million less on these medicines than it did in the year before the guidance was published, and over the lifetime of the guidance, £294 million less on these medicines.

Benefits of the intervention and impact

As prescribers are advised to consider suitable alternatives, patients are now being prescribed medicines that are safer and more clinically effective, and cheaper.

Maintaining these improvements, or going further for some items, is an opportunity for ICBs, other commissioners and prescribing healthcare professionals to continue to improve patient outcomes and deliver value for money.

The efficiencies delivered could be used for other higher priority areas that have a greater impact on patients, support improvements in services and/or deliver NHS transformation.

Metrics to support implementation and monitoring

Case studies and examples of good practice

Examples are being collated and will be added to the National Prescribing and Medicines Optimisation – FutureNHS Collaboration Platform. Please email england.medicines@nhs.net if you have an example you would like to share with colleagues.

Resources to support implementation

What success looks like

  • Current reductions in prescribing maintained for all items that are not routinely recommended for prescribing, with no new prescribing.
  • Further reductions on items identified as opportunities for ICBs.
  • Improved patient outcomes through prescribing of safe and effective medicines.

3. Improving uptake of the most clinically and cost-effective medicines

In 2022/23 NHS England’s Innovation, Research and Life Sciences team ran the Medicines Pathway Evaluation Programme to identify key system barriers and opportunities to increase uptake of the most clinically and cost-effective medicines.

The 2019 voluntary scheme for branded medicines pricing and access (VPAS) committed the NHS to promoting uptake of the most clinically and cost-effective medicines. Since it was signed, NHS England has worked to get new innovations to patients faster and set up appropriate delivery mechanisms at a local level – for example, by incentivising primary care in areas such as atrial fibrillation treatment.

Benefits of the intervention

Improved uptake of the most clinically and cost-effective medicines means more patients can benefit from access to medicines and health inequalities tackled.

Metrics to support implementation and monitoring

The Innovation Scorecard provides the most comprehensive data on the use of NICE approved medicines. The scorecard now tracks regional variation in prescribing for certain groups of medicines, and from April 2023 it shows data at ICB level. NHS England will continue to use and evolve it to measure uptake of new clinically and cost-effective medicines.

Case studies and examples of good practice

NHS England has learnt lessons about what works well; for example, where innovation means a new way of administering an existing product – to cut treatment time from hours to minutes in the case of the breast cancer combination Phesgo®. Examples are also being collated and will be added to the National Prescribing and Medicines Optimisation – FutureNHS Collaboration Platform. Please email england.medicines@nhs.net if you have an example you would like to share with colleagues.

Resources to support implementation

What success looks like

  • Greater national visibility of uptake of all newly NICE approved medicines in terms patient numbers, for individual indications, at an ICS level, demonstrated against estimated eligible population.
  • Greater ability for trusts / systems to benchmark their uptake against neighbours or other comparable systems.
  • Enhanced ability to monitor variation and investigate whether it is warranted (due to local population needs) or unwarranted.

4. Obtaining secondary care medicines in line with NHS England commercial medicines framework agreements

Medicines Value and Access directorate in NHS England and the Specialist Pharmacy Service (SPS) work together to ensure that systems are ready to deliver efficiency opportunities from new biologic and generic medicines becoming available. Horizon scanning processes are identifying medicines coming into the medicines supply pipeline early on to assess and plan opportunities for early uptake.

NHS England’s Commercial Medicines Unit (CMU) is responsible for buying and securing the supply of medicines prescribed in NHS hospitals in England. The CMU does so using medicines framework agreements for:

  • generic medicines including those newly available for use in hospitals
  • branded medicines, biosimilar medicines and IV fluids
  • blood products and dose banded chemotherapy and flu vaccines for hospitals
  • some homecare medicines.

Benefits of the intervention and impact

Accelerating the uptake and adherence to the medicines covered by the frameworks will deliver savings for the NHS as the frameworks deliver the same quality of medicine at a more affordable price, specifically when a medicine’s patent expires and other manufacturers start making the medicine.

Metrics to support implementation and monitoring

The Model Health System Top 10 Medicines Dashboard allows NHS acute trusts and specialists to review their potential savings opportunities for this initial group of 10 medicines, which includes biosimilar medicines, where usage is calculated. Metrics focus on the ‘potential framework savings versus annual plan’ and ‘supply chain issues versus total number of products live’ in a financial year. Reports are created by CMU to support action-led engagement with relevant stakeholders.

Case studies and examples of good practice

The commissioning framework for biological medicines (including biosimilar medicines) includes examples that systems can use, adapt and adopt for their local populations:

  • Assessing the opportunity in Mid Yorkshire Hospitals NHS Trust – switching programmes for infliximab and etanercept.
  • Patient engagement in North Bristol NHS Trust – approaches to engaging patients when starting or switching to biosimilars.

Resources to support implementation

The CMU framework page links to resources that can support implementation:

  • all pharmaceutical groups within SPS portfolio
  • CMU systems
  • RX-info
  • trust procurement colleagues
  • specialised commissioning finance.

What success looks like

  • Accelerated uptake of the CMU frameworks to make savings and reduce or minimise the duration of supply chain issues.

5. Standardising product formulations of aseptically compounded medicines

The NHS spends £3.8 billion a year on aseptically produced injectable medicines is in England. Lord Carter of Coles’ report Transforming NHS pharmacy aseptic services in England highlights that transformation can deliver better clinical outcomes, an improved patient experience, considerable savings in product costs, release clinical staff time and reduce inpatient bed days, with the added benefit of enhancing our international status as an innovator in new medicines. Transformation is essential to ensure resilient product supply and meet growth in demand.

Traditionally aseptic medicines primarily comprise systemic anticancer therapies and parenteral nutrition. However, the COVID-19 pandemic highlighted that having aseptically compounded standard presentations of critical care medicines improves supply resilience and releases nursing time, and having injectable medicines in ready-to-administer (RtA) form enables more care out of hospital.

Individual prescribers, clinical teams and hospital pharmacies have tended to develop their own preferred formulations for aseptic medicines, leading to an inefficient small-scale local production model and a lack of consistency of the types of product and service offered across the country. Standardisation is an essential first step to improving productivity, capacity and supply resilience. Widespread implementation of chemotherapy dose banding has improved the situation, but there is more to be done.

The national Infusions and Special Medicines Programme aims to increase the national capacity for aseptic production of RtA injectable medicines 10-fold with a network of regional aseptic compounding hubs producing standard products at scale using the latest in technology for optimal safety and productivity. This expansion could release 4,000 whole time equivalent nursing staff and over 1 million hospital bed days, and will support the introduction of innovative and complex medicines, through increased capacity to supply clinical trials and growth of specialist expertise.

Systems should:

  • Prioritise purchase of licensed RtA products where available, maximise their use of nationally standardised aseptic products, increase batch production and ordering, and reduce patient-specific production and ordering.
  • Collaborate to develop a strategy and business case(s) for the development of MHRA authorised regional aseptic hubs to produce aseptically compounded RtA injectable medicines, and for local hospital pharmacy aseptic units to maintain high quality services for ultra-short shelf-life products, clinical trials and complex innovative and bespoke treatments. Associated workforce plans will be required.

Benefits of the intervention and impact

Product standardisation will enable larger scale batch production of a smaller range of products. This is significantly more efficient than small-scale production of individual doses and allows suppliers to make and hold stock of products, making supply quicker and increasing capacity for other products.

With standardisation some RtA products can be licensed, with purchase of licensed products releasing aseptic compounding capacity to meet demand for other products.

Standardisation of product formulation, naming and labelling also enables the dm+d coding of these products, supporting inclusion and transfer of information within and between digital systems to improve patient safety and procurement processes.

Metrics to support implementation and monitoring

Metrics for this opportunity are in development.

Case studies and examples of good practice

Examples are being collated and will be added to the National Prescribing and Medicines Optimisation – FutureNHS Collaboration Platform. Please email england.medicines@nhs.net if you have an example you would like to share with colleagues.

Resources to support implementation

What success looks like

  • Clinical teams and hospital pharmacies maximising the use and procurement of standardised products.
  • Hospital pharmacies purchasing products from CMU and regional procurement frameworks wherever available, leading to increased proportion of outsourced products ordered in batches versus individual doses.
  • Hospital pharmacies purchasing RtA injectable medicines (such as irinotecan, gemcitabine and pemetrexed) from MHRA authorised commercial or NHS suppliers where available, and not compounding them in local aseptic units increasing uptake.
  • Hospital pharmacies purchasing standard aseptically compounded products from suppliers in batches, using local data to forecast demand.
  • Improved supplier resilience and responsiveness through predictable customer ordering and increased capacity to batch manufacture and hold stock.
  • Reduced workload pressure on local hospital pharmacy aseptic units releasing more capacity for supplying clinical trials and managing complex bespoke medicines.

6. Using best value biologic medicines in line with NHS England commissioning recommendations

NHS England is driving a step change in ICB uptake of best value biologic medicines when commissioning hospital trusts to provide such treatment, to ensure specialists can offer their patients the choice of switching to a new product.

The NHS can make significant savings by adopting best value new products.

The Medicines Value and Access directorate in NHS England ensures that systems are ready to deliver efficiency opportunities from new biologic and generic medicines when they become available. Horizon scanning processes are identifying medicines coming into the medicines supply pipeline early on to assess and plan opportunities for early uptake.

Ophthalmology is an example of a service that may particularly benefit from the opportunity to use biologics. Medical retinal vascular conditions currently account for some of the highest cost and volume treatments in secondary care, and with an ageing population the NHS expects that demand for medical retinal vascular treatments will continue to increase.

Benefits of the intervention and impact

Best value treatment choices, if followed, will generate financial savings and make best use of NHS resources, reduce unwarranted variation whilst maintaining clinical choice.

Metrics to support implementation and monitoring

Uptake of best value biologic medicines can be monitored on the Model Health System Top 10 Medicines Dashboard, allowing NHS acute trusts to review the potential savings opportunities.

Case studies and examples of good practice

Examples are being collated and will be added to the National Prescribing and Medicines Optimisation – FutureNHS Collaboration Platform. Please email england.medicines@nhs.net if you have an example you would like to share with colleagues.

Resources to support implementation

What success looks like

  • Adoption of best value biologics in 90% of new patients within 3 months of biologic launch.
  • Adoption of best value biologics in 80% of existing patients within 12 months of a biologic launch.

Specific clinical areas

7. Addressing inappropriate antidepressant prescribing

Depression is a common disabling condition, second only to cardiovascular disease. For many people it is a chronic, relapsing condition that can lead to considerable personal disability, lost quality of life for individuals, their family and carers, multiple morbidity, suicide, greater service use and many associated economic costs.

In 2007, the total cost of depression in England was £7.5 billion (Policy paper: The economic case for improving efficiency and quality in mental health), made up of £1.7 billion in health service costs and £5.8 billion in lost earnings. When the cost of informal care, lower productivity and other public sector costs are factored in, the estimated cost rises to £20.2–23.8 billion a year.

In 2011, the UK government published No health without mental health, a cross-government mental health outcomes strategy for people of all ages. Following this, the NHS Long Term Plan Mental Health Implementation Plan 2019/20 – 2023/24 highlights the need to increase mental health spending (by at least £2.3 billion a year), including to help 380,000 more people a year get therapy for depression and anxiety by 2023/24.

In 2020/21, almost 80 million prescriptions for antidepressants were issued to around 7.8 million patients. Annual statistics for ‘Medicines used in Mental health – England’ show that the number of antidepressant items issued and the number of patients receiving antidepressants continue to increase; in 2020/21 for the fifth consecutive year.

Antidepressant prescribing rates reflect health inequalities; they are noticeably higher in areas in the most deprived Index of Multiple Deprivation decile (NHS England (2023).

Antidepressants have an important role in the therapeutic management of depression when used appropriately and in line with the NICE guideline [NG222] Depression in adults: treatment and management. When a patient and clinician decide withdrawal from an antidepressant is appropriate, in many cases this can be done through gradual discontinuation without major difficulty. However, around half may experience long-lasting and severe symptoms of withdrawal which may subsequently lead to inappropriate long-term use (Horowitz et al, 2023).

NHS England’s Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for integrated care boards (ICBs) and primary care sets out actions for systems to consider in supporting patients to address antidepressant prescribing, including establishing locally commissioned specialist services. To help clinicians and patients to withdraw antidepressants, the Royal College of Psychiatrists has produced information on stopping antidepressants.

Benefits of the intervention and impact

  • Reduced inappropriate long-term prescribing, and avoidance of harmful and distressing symptoms associated with potentially harmful methods of discontinuation.
  • Reduced inappropriate spend on antidepressants.

Metrics to support implementation and monitoring

Case studies and examples of good practice

Resources to support implementation

What success looks like

  • Use of antidepressants in line with NICE guidance on treatment and management of depression.
  • ICB commissioned services in place to support people suffering from protracted and severe problems associated with antidepressant withdrawal.

8. Appropriate prescribing and supply of blood glucose and ketone meters, and testing strips

This opportunity’s aim is to promote uptake of the best value (high quality, low cost) blood glucose and ketone meters, and testing strips. Prescribing and spend on these items in primary care falls under Part IX of the Drug Tariff.

Developments in in how patients with Type 1 diabetes monitor their blood glucose (for example, using continuous glucose monitoring) has meant some patients no longer need testing strips. However, sometimes these are not removed from prescriptions and people continue to order them.

Blood glucose and ketone testing strips and continuous glucose monitors are prescribed and dispensed in primary care but secondary care has a significant influence on which brand is prescribed. As suppliers provide the meters free of charge at the place of diagnosis, this means the patient receives a meter directly from a clinician in secondary care and will then receive the same brand’s testing strips in the community, regardless of whether these reflect best value.

Benefits of the intervention and impact

Higher proportion of total use of best value blood glucose and ketone meters, and testing strips.

Implementing this opportunity and NHS England’s commissioning recommendations will ensure that people living with diabetes have access to clinically effective meters and test strips, underlining the NHS’s commitment to providing the best quality treatment and care at the lowest possible cost to the taxpayer.

Metrics to support implementation and monitoring

Case studies and examples of good practice

Examples are being collated and will be added to the National Prescribing and Medicines Optimisation – FutureNHS Collaboration Platform. Please email england.medicines@nhs.net if you have an example you would like to share with colleagues.

Resources to support implementation

What success looks like

  • Based on a patient’s individual needs and requirements, prescribing of best value meters and test strips that have met the value and quality thresholds.

9. Identifying patients with atrial fibrillation and using best value direct-acting oral anticoagulants

Cardiovascular disease (CVD) affects over 6 million people in England and is responsible for 1 in 4 deaths in the UK. People with CVD risk factors need to be identified and offered treatment, to avoid large numbers of CVD events (Dale et al, 2023). Improving healthcare and outcomes for people with CVD is likely to have the greatest population mortality benefit over the next decade. Better diagnosis and treatment for people with heart disease and stroke are NHS Long Term Plan priorities.

An estimated 1.5 million people in England have atrial fibrillation (AF), and those affected tend to be older or living with long-term (chronic) conditions such as heart disease, high blood pressure or obesity. An estimated further 400,000–600,000 people will have AF but have yet to be identified. AF contributes to around 1 in 5 strokes. If a patient with AF is at high risk of stroke, anticoagulant medication may reduce the risk by preventing a blood clot.

NHS England’s Commissioning recommendations for the national procurement of direct acting oral anticoagulants (DOACs) outline the best value treatment choices to maximise affordability and support treatment for the greatest number of patients. With increased diagnosis of AF, the recommendations aim to:

  • improve availability of direct-acting anticoagulants (DOACs)
  • support uptake of DOAC medicines.

Four DOACs are licensed to treat AF in the UK and all of these are recommended in NICE guideline [NG196] Atrial fibrillation: diagnosis and management.

Benefits of the intervention and impact

The detect, protect and perfect (DPP) objectives of the national initiative to expand the use of DOACs for the treatment of AF are:

  1. Detect – reduce incidence of stroke by diagnosing more patients with AF.
  2. Protect – ensure patients diagnosed with AF are offered anticoagulation, where appropriate.
  3. Perfect – ensure patients with AF are on the correct dose of the best value DOAC (edoxaban), where clinically appropriate. If edoxaban is not clinically appropriate, consider rivaroxaban, and then apixaban or dabigatran.

Their implementation could reduce the number of people experiencing AF-related deaths and strokes by around 5,400 and 21,700, respectively, over the next 3 years.

In 2023/24 ICBs are receiving rebate payments linked to best value DOAC primary care prescribing practice, and are recommended to reinvest these in CVD prevention. Primary care networks (PCNs) previously received support for the programme via the 2022/23 Investment and Impact Fund (IIF) incentive scheme.

Although the GP Contract in 2023/24 encourages more patients with AF to be treated with DOACs (CVD-05) and, where clinically appropriate, more of those treated with DOACs to be prescribed edoxaban (CVD-06), the IIF indicators were removed. Therefore, ICBs are encouraged to consider local schemes to increase the number of patients with AF who are identified and initiated on treatment, where clinically appropriate.

The Quality and Outcomes Framework (QOF) guidance for 2023/24 includes an indicator that supports anticoagulant prescribing for patients with AF: “AF008: Percentage of patients on the QOF Atrial Fibrillation register and with a CHA2DS2-VASc score of 2 or more, who were prescribed a DOAC or, where a DOAC was declined or clinically unsuitable, a vitamin K antagonist (12 points, LT 70%, UT 95%)”.

Industry-funded DPP’ investment schemes available in 2022/3 enabled local health systems to implement initiatives, including locally designed and bespoke projects, to increase the detection, treatment and monitoring of patients with AF. From January 2023, investment from industry to support these local initiatives has increased.

Metrics to support implementation and monitoring

Case studies and examples of good practice

Examples of local DPP projects are available on the Daiichi Sankyo website (joint working summaries).

Resources to support implementation

What success looks like

  • Significantly more people identified, diagnosed with and treated for AF.
  • Starting anticoagulation in patients who are diagnosed with AF in line with NICE guidelines.
  • Using best value DOACs where clinically appropriate.

10. Identifying patients with hypertension and starting antihypertensives when appropriate

Cardiovascular disease (CVD) affects over 6 million people in England and is responsible for 1 in 4 deaths in the UK. People with CVD risk factors need to be identified and offered treatment, to avoid large numbers of CVD events (Dale et al, 2023). High blood pressure significantly increases the risk of having a heart attack or stroke, and one of the aims of putting tackling health inequalities and prevention at the heart of the NHS Long Term Plan was the prevention of 150,000 strokes and heart attacks as a result of CVD within a decade.

Hypertension case-finding pilots across several PCNs, agreed as part of the 2019-2024 Community Pharmacy Contractual Framework, have informed the service specification for the NHS Community Pharmacy Blood Pressure Check Service. A community pharmacist now offers a free blood pressure check to anyone coming into the pharmacy who:

  • looks older than 40
  • confirms they have not previously been identified as having hypertension or a related condition; and
  • confirm they have not had their blood pressure measured by a health professional within the previous 6 months.

NICE guideline [NG136] hypertension in adults: diagnosis and management includes using ambulatory measurement to confirm a diagnosis of hypertension, and recommends that people aged over 40 should be considered for treatment of hypertension if ambulatory blood pressure monitoring confirms they have high blood pressure and certain risk factors are taken into account.

Benefits of the intervention and impact

By detecting hypertension early, the NHS Community Pharmacy Blood Pressure Check Service helps people live longer, healthier lives and supports risk identification and prevention of CVD. This service is accessible, convenient and sensitive to the needs of all service users, providing a joined-up approach to diagnosing hypertension and preventing serious health conditions.

The service:

  • identifies people over the age of 40 who have previously not been diagnosed with hypertension, and refers those with suspected hypertension for appropriate management
  • promotes healthy behaviours
  • refers people identified as likely to have high blood pressure to general practice, for ongoing care to manage their blood pressure.

General practices can also refer patients to a participating community pharmacy for a blood pressure reading or 24-hour ambulatory blood pressure monitoring. There are no specific requirements for referrals from general practice, to allow contractors and general practices to agree a local process that will work for both parties. Different practices may require different levels of support, so an open approach also allows contractors the flexibility to support each practice as needed at a local level.

Metrics to support implementation and monitoring

Case studies and examples of good practice

Resources to support implementation

What success looks like

  • Increasing the number of people who are diagnosed with and treated for hypertension (aligned to NHS priorities)
  • Diagnosing hypertension and starting antihypertensives when clinically appropriate in line with Hypertension in adults: diagnosis and management, (NICE).

11. Improving respiratory outcomes while reducing the carbon emissions from inhalers

Every year in the UK 61.1 million inhalers are prescribed for those being treated for asthma (5.4 million people) and many of those diagnosed with chronic obstructive pulmonary disease (COPD; a conservative estimate for which is 1 million people). The National Review of Asthma Deaths (NRAD): Confidential enquiry report 2014 (HQIP) found inhalers are not being used optimally and outcomes lag those in other European countries.

Medicines account for 25% of NHS emissions, with a few accounting for a large proportion. One such group – where emissions occur at the ‘point of use’ – is inhalers (3% of emissions). Most of the emissions come from the propellant in metered-dose inhalers (MDIs) used to deliver the medicine, rather than the medicine itself, and 85% of patients and carers think asthma patients should be encouraged to use more environmentally friendly inhalers (D’Ancona et al, 2021). Emissions are being lowered with, where appropriate: a move away from MDIs to dry powder inhalers (DPIs), return of inhalers to pharmacies for appropriate disposal, and the development  and adoption of lower carbon inhalers.

Benefits of the intervention and impact

By improving inhaler technique and choice we can improve patient outcomes, as well as lower emissions.

Supporting patients with lung conditions to use their inhalers as prescribed is of the upmost importance. By doing so, patients can reduce their symptoms, avoid an asthma attack or exacerbation of their lung condition symptoms, and stay well and out of hospital.

Metrics to support implementation and monitoring

Case studies and examples of good practice

Resources to support implementation

What success looks like

  • Offering patients a change from non-salbutamol MDIs to DPIs where appropriate and safe to do so, and via shared decision-making.
  • Prioritising lower carbon options (DPIs or lower carbon MDIs) for salbutamol inhalers.
  • Reducing short-acting beta-agonists (SABAs) over-reliance and over-prescribing.
  • Increasing the use of preventer inhalers.
  • Promoting appropriate inhaler disposal (returning used and expired inhalers to pharmacy for disposal).

12. Improving valproate safety

Valproate (as sodium valproate or valproic acid) has a marketing authorisation in the UK to treat epilepsy and bipolar disorder. As it is known to cause birth defects and neurodevelopmental disorders, valproate should only be prescribed to female children and women of child-bearing potential when other treatments are ineffective or not tolerated. It should also only be prescribed in the latter if the Pregnancy Prevention Programme is in place. This includes:

  • a requirement for patients to use highly effective contraception
  • informing patients of the risks in pregnancy
  • patients having an annual review by a specialist
  • patients having a signed ‘acknowledgement of risk form’ (ARF).

Despite these pregnancy prevention programme requirements, data shows ongoing exposure to valproate in pregnancy. In 2022, following review of safety data for valproate by the Commission of Human Medicines (CHM), the MHRA issued a valproate: drug safety alert reminding healthcare professionals of the Pregnancy Prevention Programme requirements and introducing further safety measures. The CHM advised that no patients under the age of 55 should be initiated on valproate and, where possible, patients currently on valproate should be switched to another treatment, unless two specialists independently consider and document that there is no other effective or tolerated treatment (or for the latter group the risks do not apply).

A clinically-led Valproate Safety Implementation Group (VSIG) co-ordinates work to reduce the use of valproate in female children and women of child-bearing potential by 50% by 2023, and to prevent unplanned pregnancies in this group.

Benefits of the intervention and impact

  • Ensuring people only take valproate in line with the Pregnancy Prevention Programme.
  • Reducing in utero exposure to valproate causing harm to babies.

Metrics to support implementation and monitoring

Case studies and examples of good practice

Resources to support implementation

What success looks like

  • Prescribing valproate only in line with the guidance issued by MHRA and CHM.
  • Reduction in babies born with birth defects and neurodevelopmental disorders.

13. Optimising lipid management for cardiovascular disease prevention

Cardiovascular disease (CVD) affects over 6 million people in England and is responsible for 1 in 4 deaths in the UK. People with CVD risk factors need to be identified and offered treatment, to avoid large numbers of CVD events (Dale et al, 2023). Lipid management for secondary prevention is a clinical priority for patients and the NHS; 43% of all adults have LDL-C levels above national guidelines. This priority is recognised by incentives in the Quality and Outcomes Framework guidance for 2023/24, which amount to 30 points and around £36 million. They include a non-HDL target of <2.5 mmol/L or, where non-HDL cholesterol is not recorded, an LDL-C target of <1.8 mmol/L, which for some patients may not be achievable with statins alone. Furthermore, many high-risk CVD patients could benefit from treatment optimisation and access to further combination therapies within the lipid management pathway.

Benefits of the intervention and impact

NHS England’s Cardiovascular disease high impact interventions show that improved lipid management in England can drive better CVD outcomes; after 1 year, every 1 mmol/L reduction in LDL-C reduces a person’s risk of a major vascular event by 25%. If 90% of people with CVD were prescribed a statin and 70% were put onto an optimal dose, this could prevent over 800 strokes and heart attacks in five years. This would save many lives, reduce admissions to hospital, and cut costs to the health and social care system.

Modelling has shown that in the secondary prevention population:

  • 1,062 cardiovascular events (death, myocardial infarction or stroke) could be prevented in 5 years by initiating a statin and adding second-line therapies if there is an inadequate fall in non-HDL-C
  • 648 cardiovascular events could be avoided over 5 years by changing those on a suboptimal statin to an optimised statin and adding second-line therapies if there is an inadequate fall in non-HDL-C,
  • 66 cardiovascular events could be avoided over 2–5 years in people not at target despite maximal statin if second-line therapies are added.

Metrics to support implementation and monitoring

The following two lipid management QOF indicators came into contract in April 2023, (publication pending September 2023):

Case studies and examples of good practice

Examples are being collated and will be added to the National Prescribing and Medicines Optimisation – FutureNHS Collaboration Platform. Please email england.medicines@nhs.net if you have an example you would like to share with colleagues.

Resources to support implementation

What success looks like

  • Reduced non-HDL or LDL-C (where non-HDL-C is not recorded) for secondary prevention patients.
  • Reduced CVD deaths, myocardial infarctions and strokes associated with CVD.

14. Reducing course length of antimicrobial prescribing

Antibiotics are the most widely prescribed antimicrobial agents, and the more we use antibiotics the less effective they become against their target organisms.

Research increasingly demonstrates that short courses of antibiotics are as effective as longer courses in treating patients with uncomplicated infection (Lee et al, 2023), (Garwan et al, 2023). Reflecting this evidence, NICE guidance for common infections routinely recommends the shortest effective course of treatment, to reduce selection pressure for antimicrobial resistance and inadvertent patient harm from antibiotic treatment. Five-day courses are recommended when antibiotics are indicated for sinusitis, sore throat, COPD infective exacerbation, cough (acute), pneumonia (community-acquired) and otitis media.

Primary care prescribing data suggests that the shortest effective courses of antibiotics are not consistently prescribed and across general practice there is considerable variation in the proportion of short and long course prescriptions. Within this there may be health inequality in patient exposure to the harms of antibiotics and the threat of antimicrobial resistance.

There is an important opportunity to safely reduce patient exposure to antibiotics and address antimicrobial resistance by supporting prescribing of the shortest effective antibiotic courses.

Benefits of the intervention and impact

  • Reduced risk of adverse drug reactions and toxicity.
  • Reduced selection pressure for antimicrobial resistance and with this of patients becoming infected with or carrying resistant bacteria.
  • Reduced disruption of commensal bacteria (normal flora or microbiota) and with this reduced risk of opportunistic infection with pathogens such as C. difficile.
  • Reduced risk of patients having ‘leftover’ antibiotics and inappropriately self-treating future infections with them or giving them to others.
  • Reduced risk of patients disposing of ‘leftover’ antibiotics in household waste or waste water, thereby reducing the risk of selection for antimicrobial resistance in bacteria in the environment.
  • Reduced waste in the manufacture, packaging, transportation and disposal of antibiotics with associated reduction in carbon footprint and costs.
  • Contribution towards the current UK AMR National Action Plan goal to reduce human exposure to antibiotics in primary care (expressed as days of antibiotic treatment per 1,000 population per day) by 25% between 2013 and 2023/24.

Metrics to support implementation and monitoring

The NHS England AMR programme Optimising Antimicrobial Use Dashboard (hosted by PrescQIPP) takes data from ePACT2 to report on novel course length metrics for amoxicillin 500 mg capsules and doxycycline 100mg capsules. For example, the dashboard presents dispensed amoxicillin 500mg capsules for 5-day courses – 15 capsule, and 7-day courses – 21 capsules as a proportion of all prescription items or absolute number. It displays individual month or 12-month rolling data, and data by age group, and allows comparison with peers at regional, ICB, locality, PCN and GP practice level. Data are also presented by age group. The dashboard will be expanded during 2023/24 to include other commonly prescribed antibiotics.

Case studies and examples of good practice

A medicines optimisation focus by health systems on prescribing the shortest effective course has seen a rapid and significant change in practice; for example, over 9 months the proportion of prescriptions for 5-day courses of amoxicillin capsules increased from 24% to 67%.

Case studies of interventions to promote prescribing of the shortest effective courses of antibiotics are on the FutureNHS AMR Programme Workspace.

Resources to support implementation

What success looks like

  • By March 2024, 75% or more of total amoxicillin prescriptions as 5-day courses.

As of December 2022, nationally 5-day courses account for 44% of amoxicillin 500 mg capsule prescription items dispensed in primary care, which represents a steady improvement from 26% in 2018, when course length data first became available.

15. Reducing opioid use in chronic non-cancer pain

Pharmacological management of chronic non-cancer pain is associated with minimal benefits, and potential harm, when compared to effective biopsychosocial interventions. The evidence base for the use of opioids, and particularly strong opioids, in chronic pain is insufficient to justify their use for this indication, although it is acknowledged that because of dependency people can find it difficult to withdraw from these medicines.

For every 62 people with chronic pain prescribed opioids for longer than 90 days, one will die who would not have if the chronic pain had been managed with biopsychosocial interventions alone (Gomes et al, 2011), (Häuser et al, 2020). For people prescribed opioids for chronic pain, 1 in 10 suffer moderate harm.

Benefits of the intervention and impact

Patients who are supported to reduce or stop opioids that have been prescribed for chronic pain describe improved wellbeing, better quality of life, improved mobility and less pain (Live Well with Pain).

Metrics to support implementation and monitoring

Case studies and examples of good practice

Opioid Safety Improvement Programme: Medicines Safety Improvement Programme – FutureNHS Collaboration Platform.

Resources to support implementation

What success looks like

  • A year-on-year 10% reduction for the next 5 years in the number of people prescribed opioids for chronic pain for more than 3 months would save over 800 lives a year.
  • Fewer patients with a total oral morphine equivalent of 120mg or more per day in the most recent 28-day period.

16. Switching intravenous antibiotics to oral

When treating infections in NHS hospital inpatients are often treated with intravenous (IV) antibiotics. Intravenous antibiotics can sometimes be used for longer than necessary due to barriers to meeting, or being assessed to have met, the criteria for switching from IV to oral. Evidence to support the switch is provided in the English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report 2021 to 2022.

Benefits of the intervention and impact

Switching patients from IV to oral antibiotics when they have met the criteria for switching can:

  • reduce avoidable healthcare-associated bloodstream infections (estimated at between 860 and 2,570 a year)
  • increase hospital bed capacity by reducing length-of-stay; releasing up to 1.7 million bed days per year
  • reduce adverse events (from 16% to 4.5%)
  • reduce exposure to broad-spectrum antibiotics
  • increase nursing workforce capacity (reducing a typical course of IV treatment by one dose would release 1.7 million hours of nursing time per year spent preparing and administering IV antibiotics [equivalent to 870 full-time nurses])
  • reduce the carbon footprint of medicines; the carbon footprint for oral antibiotics is up to 70-fold lower than that for IV antibiotics
  • reduce the 60% potentially unwarranted variation in the proportion of antibiotic doses given intravenously
  • improve patient experience (75% of patients prefer the oral route)
  • reduce consumption of broad-spectrum antibiotics (World Health Organization watch and reserve) by up to 9%
  • deliver a £10 million to £35 million a year (£80,000–£250,000 per trust) saving in medicines expenditure.

Metrics to support implementation and monitoring

Standard metrics for monitoring improvement and for comparison between ICBs for IV to oral switching are available:

Case studies and examples of good practice

Trusts have had an IV to oral switching policy in place for many years. Examples of trusts that have made progress can be found on FutureNHS AMR – antimicrobial prescribing and medicines optimisation.

Resources to support implementation

What success looks like

  • All acute trusts meeting CQUIN03 for 2023/24: only 40% (or fewer) of patients still receiving IV antibiotics past the point at which they meet switch criteria.
  • Evidence of improvement in timely IVOS, monitored as a reduction in the number of IV doses dispensed (per 1,000 admissions) and the proportion of all antibiotic doses that are administered intravenously.
  • Reporting of performance against the IVOS indicator and striving for the above improvement goals by all providers commissioned to deliver the services to which the CQUIN indicators apply. If a trust elects not to adopt CQUIN03 as one of the five indicators in scope for their contract, they are still required to report.

Future medicines optimisation opportunity areas

Potential future opportunities can be flagged for consideration to regional chief pharmacists and by contacting the NHS England medicines policy and analysis unit england.medicines@nhs.net.These will be considered using the medicines optimisation governance framework, and the priorities updated as required on an annual basis.

Future priorities that may be considered for 2024/25 include:

  • addressing overprescribing by improving repeat prescribing processes in general practice
  • getting the best value from nutritional product prescribing
  • horizon scanning to identify and scope disruptor technologies (those that will require a significant change in the clinical pathway); for example, dementia care and managing obesity
  • implementation of Electronic Prescribing Systems (EPS) in secondary care
  • optimising the use of dressings, wound care products and stoma products
  • stopping over medication of people with a learning disability, autism or both (STOMP) and reducing antipsychotic prescribing.

Appendix 1: Definitions of ICB priority areas

  • Improving medicines-related patient safety – Addressing the most important, medicines-related, causes of severe harm and death from medication errors affecting the highest number of people at greatest risk.
  • Delivering value to the system – Deliver the highest quality health outcomes for patients at the lowest possible cost.
  • Improving patient outcomes – Improving the results from care and treatments patients have received in all care settings.
  • Supporting equity of access – Promoting equal access to health care for those in equal need of health care.
  • Supporting NHS recovery through increasing capacity – Driving the recovery of our NHS, not just to its pre-pandemic level but beyond by increasing capacity.
  • Reducing health inequalities – Reducing systematic, avoidable and unfair differences in health status between different groups of people.
  • Improving sustainability – To deliver the world’s first net zero health service and respond to climate change, improving health now and for future generations.

Appendix 2: Summary of opportunities against drivers for selection

Appendix 3 – Data and headline metrics

Publication reference: PRN00587

Date published: 31 July, 2023
Date last updated: 19 October, 2023