Standardisation of medicine doses enhances safety

Optimisation of medicines management is a new category in this year’s HSJ Awards and is about helping patients derive the most benefit from their medication to improve their experience, safety and outcomes, and to achieve the most value from medicines for the health service.

Medicines are crucial to maintaining health, preventing illness, managing chronic conditions and curing disease. With an ageing population and restrained budgets ensuring patients get the best out of medicines is crucial, which is why Spirit Healthcare wanted to sponsor the award, says the company’s CEO Chris Barker.

Previously chemotherapy doses were always made up specifically for individual patients by hospital pharmacists, according to the patient’s weight or surface area. These dosages were calculated down to finite numbers of milligrams or millilitres of liquid

“There are significant opportunities for reducing expenditure while maintaining or improving clinical outcomes,” he says. “Medicines optimisation teams are doing amazing work in this area. With ever tightening budgets and an aging population, maximising the opportunities to share best practice and learn what works elsewhere is more important than ever.”

Although this is the first time a medicines optimisation category has appeared in the HSJ Awards, initiatives in deriving the most from medicines and pharmacy have previously been recognised in the HSJ Value Awards. In 2017 the award went to NHS England specialised commissioning (medicines optimisation clinical reference group) for its work standardising chemotherapy drug doses across England through the implementation of a standardised approach to dose banding.

The National Dose Standardisation for Chemotherapy project is improving value at a national scale by reducing drug wastage, enabling the bulk purchasing and preparation of chemotherapy drugs, and freeing up pharmacist time for more patient facing activity and research work.

Previously chemotherapy doses were always made up specifically for individual patients by hospital pharmacists, according to the patient’s weight or surface area. These dosages were calculated down to finite numbers of milligrams or millilitres of liquid.

“Given that somebody’s weight can change by plus or minus 5 per cent over a relatively short period of time, and in the course of treatment everybody’s liver function, renal function and how they metabolise drugs will also change and vary quite significantly, for us to try and get the dosage so tight is just illogical,” explains Rob Duncombe, director of pharmacy, at The Christie Foundation Trust in Manchester, who has had a key role in the project.

Bands for chemotherapy

Dose standardisation into bands for chemotherapy means that chemotherapy can be prepared in bulk, days in advance of patients attending, which means that it is cheaper to prepare, patients are highly unlikely to turn up and find that their dose is not ready and if a last minute dosage adjustment is required it is usually available almost “off the shelf”, which means the patient experience is better, he says.

The project has already developed and agreed standardised dosing tables for 19 different chemotherapy drugs and agreed implementation of this through a national Commissioning for Quality and Innovation scheme which has been agreed with 88 hospital trusts.

As most chemotherapy drugs are stable for at least 30 days, bulk preparing them in dosage bands rather than for individual patients means that there should be far less drug wastage

The next phase of the project is now expanding this approach to a much broader range of chemotherapy, with the aim of standardisation of >90 per cent of all chemotherapy doses in England. A CQUIN has been agreed for 2017-19 to support delivery of this.

Previous attempts to try and standardise chemotherapy doses have failed, perhaps because of a lack of enthusiasm or national uptake, and because no consistent methodology had been agreed for dose standardisation across the country, says Mr Duncombe. “There are a number of ways that you could dose band chemotherapy and if everybody was doing it their own way then there would be no consistency across the country and you wouldn’t get the resultant savings.”

Chemotherapy is the biggest single service area within the Specialised Commissioning portfolio commissioned directly by NHS England. The annual spend on chemotherapy in England is approximately £1.5 billion across England and it is increasing to be at least 8 per cent per year.

The project has already identified a potential £27 million saving, that will be achieved through waste reduction and reduced pharmacist time preparing doses, which it aims to deliver by 2019.

As most chemotherapy drugs are stable for at least 30 days, bulk preparing them in dosage bands rather than for individual patients means that there should be far less drug wastage, Mr Duncombe says.

While many of the base drugs cost only a few pounds, their manipulation to the correct dosage can cost 10 times that in pharmacists’ time, so preparing doses in larger quantities will allow pharmacists to be able to devote more time, energy and effort into more patient focused activity and involvement in other projects, including research.

The Carter report and others have highlighted that increasing levels of consistency improves safety. Standardisation of doses also supports safety through consistency of working practices, Mr Duncombe says, as from a pharmacist, nurse or other clinician’s point of view, wherever they work in the country, chemotherapy is prepared and administered in exactly the same way.

The HSJ Awards 2018 are now open for entries. Click here for more information or contact Chris Edwards, awards director, HSJ.