Name of team, and area
Imperial College Healthcare NHS Trust and Hillingdon Hospital NHS Trust
Brief description of the model
Due to a historic close working relationship, Hillingdon Hospital has for many years offered a DMD service (for a limited range of DMDs) as a 'spoke' of the neuroscience centre at Imperial College Healthcare NHS Trust (Charing Cross Hospital). At that time, the Hillingdon service had one MS specialist nurse and an MS consultant, who also worked at Imperial, but the service was not recognised by NHS England as a prescribing centre. As a result, certain prescriptions had to be issued by Imperial as the 'hub', and Imperial claimed reimbursement for the drug costs from NHS England.
This required the Hillingdon MS Service to refer people starting DMDs to the MS nurses at Imperial (and allocate them an Imperial hospital number) so that the DMDs could be prescribed from there.
Imperial retained responsibility for ongoing reporting (though Blueteq) and prescribing for Hillingdon patients, and the safe monitoring of their DMDs, whilst having no direct clinical responsibility for their ongoing care.
Disadvantages of this arrangement
- It was inefficient. The process involved Imperial MSSNs and pharmacy in an administrative process to set up patient records, generate prescriptions and check on monitoring without any clinical benefit to the person with MS. Any queries from people with MS involved time consuming liaison between the two teams.
- Clinical accountability was split. The prescribing Trust (Imperial) was not the same as the Trust delivering clinical input and monitoring for the person with MS (Hillingdon).
- The arrangements were potentially confusing to people with MS. For example, people with MS with queries about home care deliveries or other aspects of their DMD prescriptions would not know whether to contact the team at Hillingdon or the team at Imperial (with whom they had no relationship).
- Unnecessary increased workload for both Imperial and Hillingdon staff
How it works
Prior to implementing the change the MS nurse at Hillingdon engaged with key stakeholders at the NHS Trust. These included business managers, clinicians and pharmacy staff. Hillingdon staff needed to explore the impact of the proposed change on the existing services and how it would cope with the additional demand. The service also needed to ensure it was robust enough to continue to provide a service to all MS patients, not just those on DMDs.
The Hillingdon and Imperial teams then worked together to make the case that Hillingdon should be established as a DMD prescribing centre in its own right, and to set up the systems to make this happen.
How was it implemented?
The planning and implementation of the new service was led by the Clinical Commissioning Pharmacist at Imperial working jointly with the Hillingdon MS team. Clinical Commissioning Pharmacists are senior pharmacists, funded directly by NHS England to plan and manage the use of the highest cost drugs funded under Specialised Commissioning in larger NHS Trusts. Whilst these posts started in London, they are now spreading to other parts of England. Under the pharmacist's leadership, the team formulated a plan for DMDs at Hillingdon encompassing four components:
- Making the case for the change
The team described the vision for the service and explained why it would offer a better and more efficient service for people with MS in Hillingdon.
- Ensuring a funding stream for the DMDs
The team identified the number of people with MS on different DMDs who saw the Hillingdon MS service and the associated NHS England expenditure on each DMD, both over recent years and projecting forward. This was important to ensure that NHS England could plan the appropriate budget allocation for the Hillingdon service.
- Demonstrating appropriate governance at the new prescribing centre
The team described how people with MS who saw the Hillingdon MS service would have their DMDs prescribed and monitored, including local pathways and the fact that decisions about escalation and complex cases would be discussed within a formal cross-Trust multidisciplinary team meeting. Arrangements were made for Blueteq to be activated at Hillingdon and for a member of the team to be trained to enter the required data onto it.
- Ensuring capacity within the new prescribing centre
Discussions were held with the Hillingdon pharmacy department to ensure that they were aware of the workload implications of dispensing and billing NHS England for DMDs locally.
The MS service also needed to demonstrate that the changes could be incorporated into their service development plan. These elements were collated into a formal plan of action. This was shared and discussed with:
- The contracts (or 'Service Level Agreement') managers in each of the two Trusts, who would need to communicate. These are non-clinical teams who negotiate contracts with the commissioners.
- The supplier manager at the NHS England regional office (in this case both centres were within the same region, but if they had not been then the supplier managers within each region would have needed to be involved).
- The Programme of Care lead at the regional office of NHS England.
Following discussion and agreement with all of these parties, a date was agreed for the establishment of Hillingdon as a new DMD prescribing centre.
Who is the care aimed at?
People with MS on DMDs under the care of the Hillingdon MS nurse service
What are the benefits of working in this way?
The establishment of the new prescribing centre has streamlined the process of prescribing, monitoring and delivery of DMDs for people with MS in the area. This is in line with medicines optimisation goal of bringing services closer to patients' homes. It has ensured that clinical accountability is clearly defined and has reduced unnecessary communication between the teams.
Development of the service provided at Hillingdon has had a positive impact. It has allowed ownership and responsibility for the entire pathway, helping to future-proof the service. It has also allowed staff to develop their knowledge around available treatments and to gain support from a wider multidisciplinary team in decision making and managing more complex cases.
What needs to be in place for the model to work best?
- The new prescribing centre needed to ensure that it could describe clearly how it could manage DMDs safely and effectively. This includes formalised cross-Trust multidisciplinary decision making to ensure prescribing is in line with NHS England policy.
- The availability of an NHS England Clinical Commissioning Pharmacist or equivalent within the 'hub' Trust and a willingness by the contracts managers within both Trusts to define and agree the new arrangements.
- NHS Trusts without a Clinical Commissioning Pharmacist should engage with their local neurosciences pharmacist who can assist in identifying the most appropriate stakeholders to be involved.