Phil Routledge- Prudent Healthcare, medicines, and COVID-19 in Wales

Phil Routledge is a Bevan Commissioner and retired founding Clinical Director of the All Wales Therapeutics and Toxicology Centre. Below he explores whether the Prudent Healthcare principles remain relevant in the time of COVID-19

Prudent Healthcare has been described by our Bevan Commissioner Don Berwick, co-founder of the Institute for Health Improvement (IHI) in the USA, as a “remarkably efficient and compelling set of design principles that can guide the reconfiguration of care” (1).


I examine below, using examples involving medicines and medicines safety, whether the four Prudent Healthcare principles first articulated by the Bevan Commission in 2016 remain relevant in the time of the COVID-19 pandemic and whether they can also guide us in the future in Wales.

Principle 1- Achieve health and wellbeing with the public, patients, and professionals as equal partners through co-production.

Co-production has been described as “an approach to public services based on equal and reciprocal relationships between professionals, people using services, their families and their communities” (2) The prescribing of a medicine carries with it the requirement for healthcare professionals and patients to continue to monitor treatment together. It is an essential part of the goal of optimising benefits and minimising potential harms from medicines. It therefore requires timely and effective communication and ready access to required investigations. This is something which has been made more difficult because of lockdown and the pressure that COVID-19 has put on the delivery of health and care services. We know that that medication errors may occur during the treatment of chronic conditions. The COVID-19 pandemic has clearly illustrated that virtual clinics can contribute positively to monitoring care, and we have yet to fully explore the potential for increased use of other developments such as near-patient testing, telemedicine and other innovative approaches in delivering safe and effective care in a co-productive manner in the future.

The All Wales Medicines Strategy Group (AWMSG) was established in 2002 to advise Welsh Government on issues around medicines and access to them. AWMSG has set up a Patient and Public Interest Group (PAPIG) which has agreed to strengthen the patient and public voice in the matters related to medicines. The views of patients and patient interest groups are sought every time AWMSG considers whether a new medicine should be generally available in NHS Wales. A separate Clinician and Patient Interest Group (CAPIG) is also involved in the assessment of certain new medicines for rare diseases (“orphan” medicines) so that the experiences of patients and caregivers can fully inform decision-making in these circumstances (3). Although these processes were developed before the pandemic, we need to ensure we apply the same fundamental principles of co-production to future policies involving new medicines and access to them post-COVID-19 (2).

Principle 2- Care for those with the greatest need first, making the most effective use of all skills and resources.

At the beginning of lockdown, AWMSG’s professional support group, the All Wales Therapeutics and Toxicology Centre (AWTTC) began monitoring stocks of critical medicines in hospital pharmacies across Wales, working with Health Board chief pharmacists, Welsh Government, and the NHS Wales Informatics Service (NWIS). AWTTC staff monitor daily the top 20 critical medicines required to respond to the COVID-19 pandemic, so that national medicines procurement leads can have ready access to up-to-date information. This will ensure the most effective use of the medicines, and that the NHS in Wales can guarantee timely access to the appropriate medicines for those in greatest need when they urgently need them.

This new monitoring process was developed rapidly in response to Covid-19 as a digital solution to the challenge of medicines availability throughout the pandemic. It illustrates the value of a coordinated and collaborative approach across Wales using a combination of skills and resources. It also demonstrates just how quickly the NHS can respond in an emergency. These important lessons must not be forgotten in the future as we move towards even greater interconnectedness in health and care services.

Principle 3- Do only what is needed, no more and no less, and do no harm.

Medicines make an important and often essential contribution to positive health outcomes for many people. However, as with all other aspects of the NHS spend, there remains scope for the reduction of waste, inappropriate variation, as well as the prevention of avoidable harm.

Efficiencies will help us to ensure that the resources at our disposal are used effectively to achieve the best outcomes from medicines for all patients. In 2018-19, 80.1 million items with a net ingredient cost of £563.2 million were prescribed by GPs and dispensed in the community in Wales. This net ingredient cost was a decrease of £15.3 million (or 2.6%) on the previous year (2017-18), and £21.2 million (or 3.6%) less than in 2007-08 (4).

The ongoing Low Value for Prescribing initiative in Wales was first launched in 2017 and provides healthcare practitioners with information to help them to optimise the appropriate prescribing of certain medicines that offer a limited clinical benefit to patients and where more clinically- and cost-effective treatments may be available. The supporting documents are available at https://awmsg.nhs.wales/medicines-appraisals-and-guidance/medicines-optimisation/prescribing-guidance/items-identified-as-low-value-for-prescribing-in-nhs-wales/

Recent data shows reductions in the prescribing of some of the medicines included in the initiative (5,6).

The safe use of medicines is always a priority. It has been estimated that at any one time, 320 hospital beds in Wales can be filled by patients admitted because of adverse drug reactions (side-effects to medicines) (7). The Yellow Card system is an important contributor to monitoring medicines safety, allowing health care professionals, patients and carers to report suspected side-effects to the Medicines and Healthcare Products Regulatory Agency (MHRA). MHRA’s advice during the COVID-19 pandemic is to send their yellow card reports of suspected ADRs (side-effects) electronically rather than by mail. There is also new dedicated MHRA reporting website for reporting suspected side-effects to medicines, future vaccines or medical devices relating to COVID-19 treatment.The Medicines and Healthcare products Regulatory Agency (MHRA) has issued temporary advice for initiation of valproate in female patients and for annual review and pregnancy testing to support adherence to pregnancy prevention requirements during the pandemic when face-to-face appointments may not be possible.

Principle 4- Reduce inappropriate variation using evidence-based practices consistently and transparently

To ensure that all health care professionals in Wales have ready access to authoritative evidence-based information on the management of common medical conditions which might be impacted by the COVID-19 pandemic, AWTTC launched a Repository of relevant therapeutic guidance in March 2020. The resources are reviewed daily by pharmacists and clinical pharmacologists to ensure the latest information is always available. The Repository can be accessed on the AWTTC website at www.awttc.org/covid-19

Patients who have long-term medical conditions and are receiving medicines which require regular monitoring have faced challenges during the pandemic when face-to-face appointments can be difficult. The COVID-19 repository therefore signposts available information written for health care professionals by authoritative sources on the monitoring of several groups of medicines during the COVID-19 pandemic. There are also links to the on Wales interim commissioning guidance approved in April, which makes certain treatments accessible within NHS Wales for the treatment of high-risk locally advanced and metastatic, hormone-sensitive prostate cancer during the COVID-19 pandemic.


Summary

I believe that the examples I have discussed illustrate the robustness and continuing applicability of the principles of Prudent Healthcare to the current and future challenges in the use of medicines in Wales. This encourages me to believe that they can also act as Berwick stated, as a “compelling set of design principles that can guide the reconfiguration of care” much more broadly in other aspects of health as well as social care. The COVID-19 pandemic has resulted in the NHS rapidly delivering innovative approaches and solutions using all the skills and tools we have at our disposal. We need to build on the important lessons we have learned during the pandemic as we prepare for the future of health and social care in Wales. As Berwick also said, “All improvement is change, and Prudent Healthcare helps us to know what to change” (1).

References

1. Berwick DM. An international view of prudent healthcare. In “70 years on-What next? Personal reflections on the NHS in Wales from the Bevan Commissioners”. Eds. Tom Powell & Hannah Scarborough, Bevan Commission 2018

2. Dineen R. Co-production Wales (All in this Together), Accessed 17/07/2020 at http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Ruth%20Dineen.pdf

3. All Wales Medicines Strategy Group (2019). AWMSG appraisal process for a medicine for a rare disease. Accessed 17/07/2020 at https://awmsg.nhs.wales/files/appraisal-process/awmsg-appraisal-process-for-a-medicine-for-a-rare-disease-pdf-500kb

4. Welsh Government. Statistical First Release. Prescriptions in Wales 2018-19. Sep 2019. Accessed 17/07/2020 at https://gov.wales/sites/default/files/statistics-and-research/2019-09/prescriptions-wales-april-2018-march-2019-836.pdf

5. Deslandes P, Boldero R, Haines K, Routledge P. Medicines identified as low priority for funding: a Welsh perspective. Journal of the Royal Society of Medicine. 2019 Jul;112(7):268. doi: 10.1177/0141076819839396

6. All Wales Medicines Strategy Group. Items Identified as Low Value for Prescribing in NHS Wales – Paper 3 Accessed 17/07/2020 at https://awmsg.nhs.wales/files/guidelines-and-pils/items-identified-as-low-value-for-prescribing-in-nhs-wales-paper-3-pdf/

7. Auditor General for Wales. Managing medicines in primary and secondary care (2016) Welsh Audit office. Accessed 17/07/2020 at https://www.audit.wales/system/files/publications/Medicines-management-2016-english.pdf

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