The role of NICE Medicines and Prescribing Associates (full article)
NICE Medicines and Prescribing Associates support and promote high quality, safe, cost-effective prescribing and medicines optimisation within their local area. Joy Ogden speaks to practising Associates to find out more about what they do and the rewards associated with the role.
Government policy and recent NICE guidance1 has shifted the focus from medicines management to medicines optimisation. This is a patient-centred approach, using the best available evidence to ensure patients can access treatment in the safest, most effective way to obtain optimum outcomes while recognising the patient’s beliefs, attitudes and wishes.
This progression to a wider remit brings new challenges to all concerned in health and social care and this is where the NICE Medicines and Prescribing Associates enter the picture: they play an important part in making sure that NICE’s guidance and the messages behind the news stories reach the ears of those who need to hear them in order to modify their practice and their interaction with patients where appropriate.
What do Associates do?
The job of Associates is to work in their own organisation and with a network of professionals in their local area to support high-quality, cost-effective prescribing and medicines optimisation. This includes helping clinicians to improve adherence, reduce medication and inappropriate polypharmacy and enhance their engagement with patients.
They identify key contacts – affiliates – including pharmacists, doctors, nurses, hospital clinicians and university lecturers, who work in different organisations locally, have an interest in prescribing and medicines optimisation and a role within a network of their own.
The Associates, supported nationally by four Regional Technical Advisers, tailor key information from NICE training days to the needs of their different affiliates and their organisations then pass the information to their affiliates. The affiliates then champion these messages in their organisations and cascade them to their networks.
Associates are not employed by NICE but have a memorandum of understanding with them. They work in their own organisation and local health economy and become part of a national multidisciplinary network with a direct link into NICE that gives them access to medicines education, expertise, support, materials, advice and an email forum that provides peer support.
How do you become an Associate?
Associates are recruited from professionals who are key influencers in prescribing and medicines optimisation in their organisation and their local area. These professionals are keen to commit to being actively involved in implementing best practice locally, reducing variations in prescribing and keeping up to date with the NICE recommendations.
Recruitment and selection programmes, so far held twice yearly, may in future be held annually. A two-day course in Manchester includes essential clinical epidemiology, information mastery, cognitive psychology and implementation science. A third day, around a month later in London, includes a written assessment of evidence-based medicine skills and an assessed presentation of an implementation project that the would-be Associate has completed, is working on, or plans to undertake.
NICE Associate Director Dr Louise Bate was a consultant neurologist before joining the National Prescribing Centre (NPC) in 2010, which became part of NICE in 2011. Dr Bate, who now leads the Associate programme, says: “I think the most important aspect of the programme is that it acts as a conduit between NICE and the service, and with patient-facing practitioners, so we are able to get key messages about medicines optimisation out to clinicians. We also get feedback from the services on their priorities and key implementation issues – so we can get broad messages out when new guidance is published – but also ask specific questions through Associates, who ask for clarification on issues.”
How did the Medicines and Prescribing Associates programme start and what could be done to improve it?
The programme evolved from the NPC, which had a network of local trainers and facilitators, who delivered local workshops to those involved in prescribing. NICE reviewed its existing programme to fit in with the needs of the changing NHS when the NPC joined them in April 2011. The new programme, developed and approved by the NICE Board in 2013, currently has 79 Associates in England, Wales and Northern Ireland, Guernsey and Jersey from a broad range of professions and organisations.
Dr Bate, who works with a team of five people to support the Associates programme, says: “We have good geographical coverage but we’d really love to have an Associate in every local health economy. We have a range of professions – mainly pharmacists but also a hospital physician, a GP, and people with nursing backgrounds and I’d like to keep broadening that.
“What’s lovely about the programme now is that we have a big range of expertise with people who work in social enterprises, prisons, armed forces, general practice, mental health units, primary and secondary care and in care homes.
“Improving the programme would mean improving its reach and depth – it’s about learning from each other. We’re working on it and we’re getting there.”
Associates’ main impact is on raising awareness on key issues but also in training prescribers in using tools provided by NICE, to help them make decisions about the implementation of guidance in practice. “Associates are absolutely brilliant and very generous at sharing good practice, which helps the spread of good work around the country,” adds Dr Bate.
What do Associates get from NICE?
NICE provides Associates with five face-to-face education workshops each year led by the medicines education team in the NICE Medicines and Prescribing Centre. These cover a wide range of topics, including teaching, facilitation and decision-making skills, clinical epidemiology, health economics and behavioural psychology that support ongoing development to Excellence and Mastery levels. They provide opportunities for networking across the country to develop and share good practice and ensure that organisations have the latest NICE outputs, as well as the chance to provide feedback and influence the work of the MPC and NICE as a whole.
Kirstie Ingram, Senior Medicines Management Advisor across two East Sussex Clinical Commissioning Groups (CCGs), was sounded out by a Regional Technical Adviser when she returned from maternity leave after a long working relationship with the NPC. Then, after “a fairly rigorous recruitment process”, she started as an Associate in May/June 2014.
She says the NICE commitments dovetail well with her current role at work, which is about ensuring good quality prescribing is in line with NICE guidance, and trying to reduce the variation in prescribing between individual clinicians. Much of her work involves developing information and tools to help GPs – implementation tools like audits or patient information leaflets – so the information from NICE and interaction with the Associates programme ensures she is consistent and accurate in putting the messages across.
Anurita Rohilla, Chief Pharmacist of West Essex CCG, was also formerly an NPC facilitator and has been a NICE Associate since the programme began in 2013. She, too, finds the NICE commitments complement her work role in the CCG of providing leadership, oversight and governance concerning policy and legislation relating to medicines. She also advises GP practices and leads the CCG medicines team to ensure the quality, safety and efficiency in the use of medicines in commissioned services.
Although, she says a “typical day” cannot be predicted, one recent day involved strategic meetings about pathways, dealing operationally with queries from GPs and liaising with the hospital about transfer of care, talking to patients’ groups and managing her team to make sure their objectives tally with the strategic objectives and everyone is on course to make medicines optimisation a reality.
Tips for new Associates
Ms Ingram believes that one valuable skill she has learnt to pass on to a new Associate is how to manage information. She says: “I think they call it information mastery: how do you know you’ve found good quality information? Where do you go looking for it? When do you stop looking for it?”
For Ms Rohilla, the way people arrive at conclusions is a key skill she has learnt and would pass on. She explains: “A bit like driving a car: the regular things you see you automatically make a decision about and that’s Type 1 thinking. If you see something odd you tend to go into Type 2 thinking, where you want to do a bit of research and get the best available evidence.”
What is the best thing about being an Associate?
Ms Ingram, like Ms Rohilla, also a pharmacist, says: “I think, for me, the best thing is the direct link to NICE and the additional information and support around understanding the guidance and help in terms of implementing it. Also being part of a community of practice experts means if you have questions and you’re saying, ‘I’m not sure of this… I’m thinking of doing a pilot, has anyone done this before?’ it’s a really good resource in helping you do your job better.”
For Ms Rohilla, the best thing about being an Associate is the networking and talking to colleagues, learning about what they are doing, how they are implementing the guidance, sharing and learning from each other.
… and the worst?
Says Ms Ingram: “I suppose it’s that you get really, really busy because once people know that you have these links you get earmarked as ‘the NICE person’ in the organisation and that generates an awful lot of, ‘Oh, you need to come to this meeting…’ because NICE impacts on just about everything a CCG does. It can be quite hard to manage your own immediate work priority in the wider interest that your role generates.”
Ms Rohilla comments: “I don’t think there is anything bad. We are always asked to give feedback and we’re always involved in the programme’s development. And they do listen, so I love being part of it. Time’s always an issue, of course, because you want to do so much and there is always more you could do.”
So what would you say to someone thinking about becoming an Associate?
“It’s a fantastic opportunity because it supports you in doing your job as well. If you enjoy networking, if you’re passionate about improving healthcare, it’s fantastic,” advises Ms Rohilla.
Ms Ingram says: “It’s definitely a good thing to do – the benefits we’ve seen in our organisation in having that additional information and support in bringing more quality on a day-to-day basis has been really good. Personally, the opportunities for continuing professional development and networking with people in pretty senior positions in medicines optimisation around the country opens up a wide range of personal and professional opportunities.”
What do employers get from supporting an Associate?
NICE Associates will act as a well-informed resource across the local health economy for all issues relating to prescribing and medicines optimisation, says NICE. They will help their employer’s organisation to reduce local variations in prescribing and in implementing NICE’s latest guidance. They will become more effective in their role and have direct access to regular updates, advice, key training and implementation tools from NICE, which could lead to cost savings and improved quality of care.
The role does not, however, mean attending lots of meetings or being required to do a lot more work. The Associates’ time commitment is a notional 7.5 hours (one day equivalent) per month, which includes the five national one-day training meetings each year and completion of a “very short” quarterly summary of activity. Other Associate activity, such as participating in the closed email discussion group, is integral to their everyday work and will help them to be even more effective in their current post, says NICE.
Kirstie Ingram explains: “I think, particularly with unpaid work, there’s always a slight scepticism at the outset about what is quite a big claim, that ‘it will help you do your job better’. They ask, ‘Can we justify you being out of the office for five days a year and doing the training?’ and that kind of thing. But within the first few meetings the information I was bringing back and using far outweighed the time going to the meetings.” In a geographically wide area, without close CCG neighbours, it has made them more outward looking and broadened their horizons, she said. And she had heard reports via her Regional Technical Adviser that her line manager was saying “how wonderful it’s been for our organisation”.
Anurita Rohilla says she did not encounter any scepticism, because of her previous role with the NPC. “I am known as the NICE Associate and they’re very proud, very supportive. They see it as an asset I think because they know I’m the Go-to. I can always go to the NICE team for clarification around something it has issued or ask the network if anyone else has come across the issue.”
How is success measured?
Associates agree their specific aims with their Regional Technical Adviser, which normally reflect identified programme-wide key priorities but also reflect local needs. They are required to complete a brief quarterly report to document their work to prove that they are meeting their aims and making a meaningful improvement in medicines optimisation in their local area.
What are NICE’s current concerns about prescribing practice?
Says Dr Bate: “I think one key issue for NICE is trying to focus on shared decision making, where we are helping in terms of providing tools like patient decision aids. Reducing inappropriate variation in prescribing is another. There are lots of reasons for variation in prescribing but we are trying to make people aware of the latest evidence and key messages and make sure that unsafe or ineffective medicines are not used.”
Dangers of polypharmacy
In the light of the 2015 NICE guidance,1 there has been a lot of work on training in the key messages on medicines optimisation and on reducing inappropriate polypharmacy, particularly in the light of multiple morbidities, says Dr Bate. NICE always highlights alerts from the Medicines and Healthcare products Regulatory Agency (MHRA), and after a training day Associates might have a plan to go back and do an audit on a certain drug and check that patients are prescribed this drug correctly.
Further guidance will be issued that covers multimorbidity in more depth, said Dr Bate. She adds: “I see it as a strand that we work on all the time in terms of shared decision making, reducing inappropriate variation in prescribing and making sure that people are aware of key safety messages.”
Ms Ingram highlights the problem of the lack of a proper evidence base for patients with multimorbidity because clinical trials are around people with single conditions. She explains: “You tend to have one guideline that says you should have this, for example, for your diabetes and another that says you should use this for your cardiovascular disease, and you can end up with reams and reams of medication. The skill – and the challenge for prescribers and clinicians – is in trying to tailor treatment as much as possible to the individual.”
Ms Rohilla echoes Ms Ingram’s views on the challenges presented by managing multiple co-morbidities with multiple medicines. There is research showing that about 50 per cent of patients do not take their medicines as prescribed, says Ms Rohilla. The doctor needs to know if that is the case, and doctor and patient must talk to each other so the patient can receive appropriate treatment.
She emphasises that individuals respond differently and it is vital that patients and their carers are actively involved and take control of their medicines. While acknowledging there is appropriate polypharmacy, she adds: “I would say, ‘Don’t be afraid to ask questions.’ I talk to patients’ groups, who say, ‘We don’t ask because doctor knows best’ and I say yes, but they need you to tell them what effects you feel the medicines are having on you.”
Ms Ingram says the Five Year Forward View2 talks about “patient engagement and activation” – which is nothing new – but putting it into practice is very challenging in terms of clinicians’ perceptions. She adds: “We need to accept that medics’ view of the best treatment might not be what patients actually want, or believe, or think is important. People won’t adhere to treatment if you don’t take into account what they want and that leads to very poor outcomes for patients and wasted medication.
“All NICE guidance now says ‘individualising the care to the person’. These are guidelines not tramlines and we don’t slavishly apply them without thinking how that impacts on the individual. It might be best practice according to two or three guidelines but when you consider the interaction between the drugs and patients’ quality of life, actually it’s better for them to be on only half of them. If they were three separate people, the evidence suggests you should be doing all those things.”
How does NICE ensure the Associates retain an independence of judgement?
Dr Bate concludes: “For me, there’s no problem with that. We are stricter than we probably have to be; we treat Associates like somebody who is a committee member so they have to complete a conflict of interest form every year. Before every training day, I ask for conflicts of interest on the topics we are talking about so it’s clear to everybody, and we have a framework of what to do. Nobody has ever had a conflict of interest that has led to them having to leave… but I have a matrix of what to do if they were to have a conflict. We are very clear and open and we haven’t encountered a problem but I’m not relaxed about it. We have to be – and be seen to be – independent and without conflict, and everyone is open to that.”
1. NICE. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NG5. March 2015.
2. NHS England. Five year forward view. October 2014. https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf