Medicines optimisation: How should value be measured?

In his role as director of medicines optimisation and chief pharmacist for Frimley Integrated Care System, Yousaf Ahmad has had many conversations with colleagues on how to secure the best value from medicines. Often, he says, they are discussions grounded in consideration of budgets and finance. And while he understands why, he is also keen to encourage a wider view of value.

“Many people in the ICS world will have had a very difficult last few months looking at how their drug budgets are going, especially with significant increases in price concessions [the process through which the Department of Health and Social Care agrees a new fixed price for a drug when it is said to be unavailable at the rate in the Drug Tariff]. I know with my CFO we’ve had lots of conversations on how we could get better control of our prescribing medicines budgets.

“But we need to look at value beyond the drug acquisition cost and actually beyond the outcomes – we need to look at the impact on the patient’s life, and the impact of the medicine on that.”

To adopt this sort of multifaceted understanding of value in medicines is to encounter a challenge: how best to measure it. After all, costs lend themselves to a quick and easily understandable spreadsheet. Securing an understanding of outcomes and their impact on patients, and using that as part of the basis to calculate medicine value, is a much more complicated proposition.

Confronting it was the mission of a recent HSJ webinar. Run in association with Spirit Health, it brought together a small panel to consider just how the full value of medicines should be measured.

For Mr Ahmad at Frimley ICS, answering that question is involving working with colleagues in a dedicated population health insights team. “The team has developed a number of tools to support us to better understand the needs of our population but also track changes based on interventions,” he explained.

“So I can get data looking at postcodes, looking at the number of people in and out of work, data such as socioeconomic data, which all adds to the picture of quality of life, and of true patient care.

“For me, there’s an evolution of understanding population health demographics through tools and mechanisms that allow us to understand how our patients are doing beyond the scope of healthcare. It’s then using those to help map out your interventions and medicines.”

Panellists suggested the now-statutory basis of ICSs provided new opportunities for this sort of work. Kalveer Flora is the lead rheumatology specialist pharmacist at London North West University Healthcare Trust, where she project manages the rheumatology biologics service – these are high-cost drugs but can be transformative for patients. She explained that those in the specialty are already seeking to collect data which supports a broader understanding of value, with the hope that ICSs may further help here.

A key theme to emerge during the debate was the need for the medicine value conversation – including discussion on how to assess value – to involve a broad range of professionals

“Value is more than just drug acquisition costs,” she emphasised. “It’s ensuring patients are able to work, it’s ensuring their quality of life is not affected, and it’s their long-term prognosis – keeping them well and not needing joint replacements. It’s looking past just the price of medicine.

“So the British Society for Rheumatology has an annual early inflammatory arthritis audit and as part of that, we look at if people stay in work and we look at the impact their condition has on their general lifestyle.”

The next step, she says, will be to data by local population. “We don’t have that yet, but it’s definitely something we can look at now that we have our integrated health systems.”

A need for teamwork

A key theme to emerge during the debate was the need for the medicine value conversation – including discussion on how to assess value – to involve a broad range of professionals. Certainly, any changes in practice resulting from those conversations will need to be communicated widely.

Selma Abed is head of medicines optimisation at Spirit Health, where she designs and implements medicines optimisation programmes for ICSs. She says such programmes must involve “looking at the entire patient journey”.

“It’s looking at patient experience, and connecting the dots between secondary care down to primary care through to community pharmacy. And with any protocols we design, we give the right people the chance to have their say.”

Another key group whose voices need to be heard: patients themselves. “Part of improving access for patients and the health of the patient is actually listening to the patient and how they feel about their condition,” Ms Abed said.

“That can involve looking at lifestyle changes as well – non-medicine prescribing can come into it. So what we try to do in our programmes is measure these things as we go through, so at the end, we can say: ‘Actually, beyond cost saving, how clinically effective have we been with our patients?’ And clinical effectiveness comes into de-prescribing and optimising dosages, and having the correct monitoring a patient needs.”

Ultimately, the event was an optimistic one. Panellists felt that a broadened understanding of the value in medicines – one that looks beyond simply the price tag – is not only possible but that there is increasingly the data and means to assess it.

“I think the ICS landscape automatically presents an opportunity for pharmacy professionals to engage in a different type of conversation [about value],” concluded Mr Ahmad. “There’s something about grabbing that opportunity and using it to have better conversations.”

An on-demand version of this webinar is available.

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