The development of primary care networks (PCNs) - a global policy initiative reported across more than 15 OECD countries, including the UK, Australia, France, Switzerland and the United States – is essential to supporting neighbourhood-level population health management within wider integrated care systems.¹ In the UK, as with other areas, PCNs have a key focus on supporting personalised care, including through the delivery of outcome-focused, structured medication reviews, and supporting the safe and effective use of medicines, amongst other areas.²

Prescribing – most of which is carried out in primary care settings – is one of the top healthcare interventions in the UK and accounts for around £20 billion, or c.15% of the total National Health Service (NHS) budget. It has a significant influence on health outcomes and inequalities, care experience and per capita costs of care.^3,4 Improving medicines management and safety is not just a healthcare problem – there are significant public health implications from the practice of prescribing. For example, antimicrobial resistance is a global health threat, prescribing for the primary prevention of cardiovascular disease (CVD) is one of the fastest ways to reduce health inequalities from cardiovascular disease, and there are concerning increasing trends in opioid prescribing and opioid-related deaths in England and globally, where drugs that cause dependency have an impact on family, work, health and wider life outcomes.^5,6 On the environmental agenda, the ambition to achieve a ‘net zero’ health service, where the NHS contributes around 4-5% of the total UK carbon footprint, will also require a focus on tackling medicines waste, which accounts for around 20% of NHS carbon emissions.⁷

Between 30%-50% of medicines prescribed for those with long-term conditions are wasted (not taken as intended) and there is a clear need to use data-driven medicines optimisation solutions to understand medicines use and variation, support quality improvement, ‘do no harm’ from prescribing and support positive behaviour change for professionals and those prescribed medicines in order to improve outcomes relating to medicines use.^8-16 There is strong evidence emerging that data-driven and electronic audit and feedback of prescribing data has a positive, cost-effective quality improvement effect on prescribing practice.^8-16 A Cochrane review of 140 randomised trials found that audit and feedback produced a median 4.3% absolute improvement (interquartile range 0.5% to 16%) in health and care professionals’ compliance with desired practice, such as recommended prescribing.^8-16 These improvement gains from audit and feedback may appear modest, but incremental gains through repeated improvement cycles can support system-level improvement at scale, for example, across an integrated care system (ICS). ^8-16 ICSs could start by focusing on two or three prioritised medicines-related areas across their PCN teams, identifying and addressing unwarranted variation through learning what works and what doesn’t across networks to support quality improvement, and scale from there.

Prescribing data from a single data source only (e.g. in-hours general practice data) is likely to under-report prescribing activity and outcomes compared with joined-up data from multiple sources in venues where prescribing occurs. These can be community pharmacies, community services and wider secondary/tertiary services, and where biopsychosocial outcomes from prescribing may be documented. Scalable and programmable population health platforms that securely connect data from multiple sources in near-real time from a range of settings are required to give a joined-up, standardised and system-level view of medicines and prescribing activity – not just for professionals, but increasingly for citizens. This joined-up view of an individual’s medication in the context of the care they receive, their care record and documentation will be critical in supporting safe and effective medicines use, personalised care and integrated digital medicines management, as well as assisting applications that help understand and optimise individual health outcomes that may be influenced by medicines use, both positively or negatively. In future, these advantages will extend to personalised prescribing, research, development and interventions tailored to individual biopsychosocial factors in the real-world setting – not just for medicines, but wider ‘prescriptions’ related to the social and wider determinants of health.

How Cerner can help

Cerner’s UK health network team provide data-driven transformation services leveraging the Cerner suite of population health and healthcare technology solutions to support improved medicines management and safety across ICSs and PCNs.

Our offer to clients:

• Identification of system-level prescribing use cases and mapped data sources
• Cerner-powered medicines management and safety improvement programmes including person-level case finding tools to support point of care management improved patient engagement
• Cerner-powered medicines use and variation analysis, including PCN educational outreach and service evaluation

References

_{1. OECD (2020), Realising the Potential of Primary Health Care, OECD Health Policy Studies, OECD Publishing, Paris.}

_{2. https://www.england.nhs.uk/primary-care/primary-care-networks/network-contract-des/}

_{3. https://digital.nhs.uk/data-and-information/publications/statistical/prescribing-costs-in-hospitals-and-the-community/2019-2020}

_{4. https://www.england.nhs.uk/medicines-2/medicines-optimisation/}

_{5. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance}

_{6. https://pubmed.ncbi.nlm.nih.gov/33318133/}

_{7. NHS (2020) Delivering a net zero national health service. London. NHS}

_{8. Audit and feedback effects on professional practice and patient outcomes (including some digital interventions): https://www.cochrane.org/CD000259/EPOC_audit-and-feedback-effects-on-professional-practice-and-patient-outcomes. A Cochrane review of 140 randomised trials found that audit and feedback produced a median 4.3% absolute improvement (interquartile range 0.5% to 16%) in health and care professionals’ compliance with desired practice, such as recommended investigations or prescribing.¹² These improvement gains from audit and feedback may appear modest, but “cumulative incremental gains through repeated audit cycles can deliver transformative change” across large health and care systems.} 

_{9. Cost-effectiveness of an electronic audit and feedback intervention to improve medication safety using electronic health records and quasi-experimental methods: https://www.valueinhealthjournal.com/article/S1098-3015(20)31050-0/abstract}

_{10. Insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205419}

_{11. A systematic review of electronic audit and feedback: intervention effectiveness and use of behaviour change theory: https://link.springer.com/content/pdf/10.1186/s13012-017-0590-z.pdf. Three of seven studies found a positive effect of the e-A&F intervention on the quality of care but heterogeneity of other studies made average effects unreliable.}

_{12. Effects of computer-aided clinical decision support systems in improving antibiotic prescribing by primary care providers: Two systematic reviews: https://pubmed.ncbi.nlm.nih.gov/25125688/ and https://www.sciencedirect.com/science/article/abs/pii/S0149291819300566}

_{13. Computerised interventions designed to reduce potentially inappropriate prescribing in hospitalised older adults: a systematic review and meta-analysis; https://academic.oup.com/ageing/article/47/5/670/5035018}

_{14. A pharmacist-led information technology intervention for medication errors (PINCER): a multi-centre, cluster randomised, controlled trial and cost-effectiveness analysis: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61817-5/fulltext}

_{15. Impact of integrating pharmacists into primary care teams on health systems indicators: a systematic review: https://bjgp.org/content/69/687/e665}

_{16. Clinical and budget impacts of changes in oral anticoagulation prescribing for atrial fibrillation: https://heart.bmj.com/content/early/2020/10/27/heartjnl-2020-317006}