Digitisation is crucial to driving productivity in medicines management – and the ‘system view’ provided by integrated care systems is having a positive impact. But big challenges remain, reports Andrea Downey

It’s a problem faced across the NHS: overstretched budgets are hindering productivity and innovation. The situation is no different with digital medicines management. While there has been progress towards a more joined up system, a lack of capital investment is slowing transformation.

Nevertheless, the embedding of integrated care systems in the health service one year ago has resulted in a more systematic approach to medicines optimisation, shifting away from the traditional organisational level, according to NHS Confederation’s report Taking Stock

“There is a very varied picture for medicines optimisation, from time-consuming manual workarounds to innovative approaches to using digital technology and linking data and records,” the report states.

“Overcoming these challenges requires prioritisation as well as financial and workforce capacity and capability, currently under enormous strain.”

The right foundations

Edward Jones, senior policy advisor at the Confederation who works as part of its ICS Network, is confident there are exciting opportunities ahead if the right foundations are put in place.

“The first year of statutory ICSs has been one of establishment and set up. Relationships are bedding in, system pharmacy leads have been recruited and local medicines optimisation governance set up,” he says.

“The short-term impact has been new system pharmacy leads and medicines optimisation committees and relationships developing. You can’t improve care for patients and reduce errors without these enabled, but the impact isn’t felt immediately.”

The commissioning of community pharmacy services has been delegated from NHS England to all 42 integrated care boards across the country. But a directive from the centre for ICBs to cut their running costs by 30% will impact their capacity to make radical change in medicines optimisation.

“Managing delegation of community pharmacy commissioning and planning reductions to running costs has also taken capacity away from transformation, but as these settle systems can turn to the opportunity,” Jones adds.

He says digitisation is “crucial” to driving productivity in medicines management but, as always in the NHS, capital is “key” but lacking.

“ICBs are uniquely placed to work with system partners to build a system view of how medicines are prescribed and used and their impact on patient outcomes,” he says.

“Yet there are big challenges around sharing data, digital interoperability and unfit IT systems which are not unique to medicines optimisation. This is a long-standing challenge for organisations that will be increasingly exposed as ICSs develop and increase collaboration across different parts of a system. These challenges could serve as significant barriers to progress.

“Critically, national capital investment is key to driving digitisation. However, historically low capital investment across the NHS over many decades is still holding back change.”

Drive from the centre

There is however a drive from the centre towards medicines interoperability to improve quality of care and reduce medication errors. That drive accelerated during the covid-19 pandemic as health systems looked to new ways of working to support patient care remotely.

“It is evident there is a significant drive from NHS England to develop digital services including medicines management across the country, and with that comes change, both positive and negative, challenges and complications,” says Mike Williams, head of prescribing at Civica.

“One of these challenges is creating a framework for a digital solution, such as electronic prescribing service (EPS), that is flexible enough to cater for multiple different scenarios and workflows to accommodate the huge variety of healthcare professionals that would utilise it.”

This will require improved data sharing, digital interoperability between systems, sharing of best practice and fit-for-purpose technology in the health service, barriers Jones explains must be overcome to see the full benefits of medicines optimisation. It will also require digital upskilling of all staff expected to use the digital system.

The digital acceleration seen during the pandemic has not been maintained. However, while progress may have slowed, it has not stalled.

“New methods of working continue to be improved as both staff and patients become accustomed to changes and the systems embed,” says Williams.

“The benefits and limitations of digital health technology have been so widely visible to both staff and patients, this now continues to feed creativity and innovation within healthcare to further drive improvement. So watch this space,” he adds.

As ICSs take the lead on digital medicines management the picture of prescribing across multiple organisations is becoming clearer. FDB managing director Darren Nichols says the sharing of best practice is on the increase.

“As they become established, we are seeing ICSs showing an appetite to address population-specific challenges at scale from a medicines point of view. To achieve this, organisations need timely data and the right tools,” he explains.

“We are currently collaborating with some pioneering ICSs to help them make progress, pinpointing significant cost savings opportunities which are crucial given the current pressure on NHS budgets, without compromising medicines safety.”

Cost benefits and patient safety

While implementing system-wide change and governance requires capital, the delivery of medicines optimisation has the potential to deliver significant cost benefits and improvements to patient safety. There are more than 237 million medication errors each year in England, costing the NHS more than £98 million. More than half of medication errors are made at administration level; one in five are made during prescribing.

Embedding EPS and Electronic Prescribing and Medicines Administration (ePMA) in an organisation can reduce the risk of medication errors, and eventually reduce costs.

At the end of 2022 North Cumbria Integrated Care NHS Foundation Trust, part of NHS North East and North Cumbria ICB, introduced an ePMA to support effective use of medicines from a patient’s hospital admission through to discharge. It is now in place in all adult inpatient wards at West Cumberland Hospital and the community hospitals run by the trust. Rollout to the Cumberland Infirmary is planned in 2024.

Paul Fieldhouse, chief pharmacist at the trust, says the benefits to the system include “improved compliance with many key indicators in the prescribing audit”. He adds that drug charts are less likely to be lost and there are fewer transcription errors due to charts not needing to be re-written every 14 days. All professional groups have improved access to the drug charts.

“At point of discharge the record for the full admission is available so all changes, and the reason [for the changes] can be captured on the discharge to be communicated back to the GP with much less effort, compared to going back through notes or old drug charts when using a paper prescribing system.”

For those organisations looking to implement their own ePMA or digital medicines management system digital maturity can be a challenge, Fieldhouse says.

“There have also been many obstacles relating to existing trust processes and accepted practices that have needed to be changed in order to implement the ePMA but could not have been anticipated at the planning stages,” he adds.

“These have often been unique to an individual clinical area, so working closely with teams to implement key business changes in their area before roll-out has been imperative to the success of the project.”

Promising developments

Industry and NHS leaders are optimistic about what lies ahead, although there are some concerns that with 2024 an election year, the focus will be drawn away from its long-term goals.

“If ICBs are able to build a system view of prescribing, how medicines are used, and their impact on patient outcomes, this could contribute significantly to understanding population health and other clinical programmes, including where inequalities exist in terms of use and access,” Jones says.

“As changes related to the running cost allowance set in, relationships mature and systems grow in confidence, ICSs should be able to go further and faster with medicines optimisation transformation. But these things still take time to make the biggest impact.”

He adds: “The risk is, as we enter an election year, a national focus on the short-term and quick fixes will undermine the more fundamental, but slower impact, transformation.”

There are, however, promising developments that will continue to evolve.

“One of the significant trends we are seeing is the continuation of a move towards a patient-first, rather than drug-first, approach to care,” Nichols says.

“Medicines management systems are now capable of being highly tuned to the individual patient, and we anticipate further enhancements, such as reducing the number of alerts generated, and improving the specificity and usefulness of those already in place.”

The long-awaited EPS for secondary care has begun roll-out, which Williams says will have major benefits for patients and staff in both inpatient and outpatient services and will “transform current practices as we know it”.

“Future developments could see more trusts targeting paper processes that complement medicines management such as electronic file management systems and controlled drug registers, as well as more focus towards closed loop administration.”

Overall, it has been a year of embedding systems to better support transformation in medicines management. Benefits are already being reaped as ICSs oversee community pharmacy, providing further opportunities to integrate services and gain a clearer picture of a patient’s medication journey.

However, transformation takes time and without additional investment and improved data sharing capabilities the full power of digital medicines management will not be harnessed.