NHS England’s medicines optimisation guidance: What are the opportunities to improve uptake of medicines at ICS level?

The NHS has been plagued by difficulty when it comes to variation in the uptake of NICE approved medicines. With the establishment of ICSs, there has been an attempt to position medicines as strategic enablers of improved patient outcomes and NHS productivity and efficiencies ─ rather than just a clinical intervention for patients. The publication of NHS England’s medicines optimisation guidance 2023/24 last week signals a shift to create a national framework around this ambition, which NHS England (NHSE) has linked to integrated care board (ICB) priorities. Reading the guidance, the financial imperative is clear ─ the broader goals of medicines optimisation e.g., reduced wastage, improved outcomes, and improved safety, are consistently correlated to helping systems ‘deliver financial balance’. 

However, with financial constraints placed on ICBs and the ongoing operational pressures facing staff, the root perception that medicines optimisation equates to doing more with less must be tackled first.  

NHS England’s new guidance sets out 16 national medicines optimisation opportunities for 2023/24, and signposts to best practice resources to support implementation. NHS England recommends that ICBs choose at least five medicines optimisation opportunities.  

What does Industry need to know and do following publication of this guidance?  

Here are a few of our thoughts: 

• Start with thorough analysis of the issue: Before rushing to fix the problem of variation in uptake of NICE approved medicines between and within ICSs, we must understand the differing barriers to low uptake in local systems, and map the opportunities, including accounting for why previous initiatives may have fallen short of ambitions.  

• Demonstrate value across the whole patient pathway: Demonstrating value to the entire system has never been more important, as the savings should be better realised at ICS level, and therefore secondary impacts may hold greater weight. Where specialised services will be delegated to ICSs, it is important this optimisation guidance is implemented with regard to these forthcoming changes ─ a detailed review and re-design of patient pathways is anticipated after the transition in commissioning responsibilities.  

• Empowering patients and clinicians, and incentivising primary and secondary care structures to support implementation: NHSE highlights shared decision-making and the use of local financial incentives as levers to support successful implementation but includes limited further detail. Understanding a patient’s preferences for different treatments and empowering patients from all backgrounds to have open dialogue with their clinicians can help to improve timeliness for starting, substituting, tapering, and stopping medicines. A consultation on the future of the quality and outcomes framework (QOF), which targets GP practices, is due this summer and must consider tackling variation in access to medicines as a central objective – speculation of continued reduction in the number QOF indicators may mean fewer financial levers to support implementation.  

• NHS regional teams are decision makers: Regional NHSE teams will support ICB leaders to select national medicines optimisation opportunities. Whilst ICBs will be accountable, prioritising engagement with both ICBs and NHS regional teams is key to having influence.

• Sharing best practice can influence annual prioritisation of the 16 opportunities: NHSE encourages several routes to sharing examples or case studies with NHS regions to improve uptake of the most clinically and cost-effective medicines and inform the 16 opportunities. Priorities will be updated as required on an annual basis. From a health inequalities perspective, this is crucial to preventing a counter-intuitive postcode lottery.

• The Innovation scorecard is set to become more detailed: As of April 2023, the scorecard now tracks regional variation in prescribing for certain groups of medicines at ICB level. NHSE will be ‘evolving it’ to measure uptake against the estimated eligible population at ICS level. More detail is required on how this will be used to drive accountability and course-correction.

As we look to implementation, many questions remain. Will we see ICSs prioritise the same five ‘opportunities’ and what does it mean for progress in the opportunities that are not selected? How should system partners tailor their approach to targeted interventions in each ICS, each with differing local barriers? Finally, what additional strategies can help ensure that healthcare inequalities are not exacerbated? The ambition is high and must be matched by collaborative action at national, regional and local levels.