Coloplast S6E4 Intro - Welcome to Stoma and Continence Conversations from Coloplast Professional. I'm Hannah, Ostomy Care Associate Education Manager at Coloplast. Working in specialist care, I know that stoma, bowel and bladder issues impact the lives of those you care for. This podcast is here to support your educational needs and help you in supporting your patients. You'll hear from fellow healthcare professionals and experts by experience, discuss the latest hot topics in the world of stoma, continence care and specialist practice. Hannah: Hello and welcome back to the podcast. This time we're bringing you a chat that Paul had with Scott Mackenzie back in June as part of our Webinar Wednesday series. The topic is whether formularies and cost-cutting measures actually save money. To start us off, Paul asks Scott where the formularies work for patients and what the number one mistake is that the NHS makes with them… Scott: Oh, two questions in one! The reason I always smile when you bring up the formulary question is, fundamentally what everybody's gonna have is a different view of the relevance of the formulary and the impact it has on their workload. Number one is we shouldn't be frightened of it. It's there as a guide, it's not law, it's not hard and fast, and it cannot be used as a big stick with which to beat us. But often it's sold as that. It's sold as you must do, and that just isn’t the case, but I'm sure we'll explore that in a bit more depth as we go today. Key thing for me is when I'm working with the NHS, and we start at any point to get mixed up with or look at the formulary. I find it works best for patients, and for clinicians in reality when it's really well-defined. And what I mean by that is that the next step is really clear. To further expand that, what you've got to keep in mind is that when a healthcare professional prescribes or refers, they're seeking an outcome for the patient, prescribe A to reach B. In my mind it's, if that doesn't happen, what's the next step? What's C to get me to D, and so on. That doesn't happen. What's E to get to F and at what point is the patient then going to be referred for a second opinion or a different opinion? So within my work, I spend a lot of time trying to work to define what a high quality standardised approach without any unwarranted variation would look like as the standardised care makes everyone in that team then interchangeable, which can often help in care delivery. Particularly when we're short-staffed, I can potentially borrow somebody from somewhere else who's working in exactly the same way, following exactly the same pathway, exactly the same formulary. Whereas if you work in varied ways, that's not possible, we can't really interchange them. Additionally, when you work in that way, what you then end up with is you can define everything. The kit and equipment, the drugs, the pathways, the patient education, the referral process, step up, step down care, even the patient discharge, everything can be defined. And that then frees you to focus on seeing the right patient in the right place at the right time, using the right healthcare professional, who's got the skills and resources to deliver the care required. So for me, the formulary is woven through that because it should define the next steps. So we've tried this, it's not worked, here's the next step. We've tried this, that doesn't work, this is the next step, and so on. And often that doesn't happen because the supplementary part to your question, what's the biggest mistake? We get fixated on the cost of the drug, the device, the appliance, the technology. And we forget the true cost of the care, which is actually driven by the contact and the number of contacts the patient has with the NHS. Because they don't get better, they don't get the outcome they're seeking, so they keep coming back. And in effect, the thing to keep in mind is the most expensive product is the one that's defined as cheap because its acquisition cost is cheap, inexpensive, but drives appointments, it drives referrals, and it drives admissions because the patient remains unwell. In other words, they don't get the outcome. And I have so many examples of that happening across 18 years of working with the NHS, and unfortunately, it's still happening today, even with the advent of integrated care systems and an integrated budget where I'm hoping we will see an end to that. I am unfortunately still seeing the price conversation over the conversation in my work right now. Good example. £20,000 per non-elective admission with a length of stay of 40 days. This is true, this is in mental health in patients with severe mental illness and schizophrenia. So that £20,000 goes up by 50% if the patient is put into an out-of-area bed. So they're sent out of their own area to a completely different hospital, and that is being driven by tablet medicine that costs around £20 per month per patient, versus an injectable treatment at £220 per patient. Now you look at that in staff and you just look at the cost, you're gonna go, oh no, we can't afford the £220. Reality is, £20,000 per non-elective admission, £30,000 if they're out-of-area. And for every four that we treat with the injection, we avoid a hospital admission. So I can leave everybody to work out which is the more cost-effective treatment. And I can tell you, that isn't what happens! We end up with the, you will bankrupt the system. And I'm like, no, we've already done that, that's why we've got all these non-elective admissions costing us £20,000. But that conversation is still going on in this day and age Paul: And it's almost, not being too melodramatic, it's an upsetting thing to hear when you do hear that. You know, and again, I wouldn't say I'm a fan cause I know that formularies are Marmite. But you know, there's, you know, I don't think there's any, there's no, I can take 'em. I don't mind them. It is a Marmite situation when it comes formularies. Some people say, brilliant, they really do support me. Some people say they're not worth the paper that they're written on! And I've taken on board what you've said. You know, it's formularies. You can't look, from what you've said, you can't look at formularies in isolation, formularies are a formula, in better words, a gear in a bigger machine, to drive improvement, to drive things forward, to drive a better cost outcome and better outcomes for the patients. But I'm in a very privileged position as Coloplast Professional, where I get to speak to a lot of clinical nurse specialists. As, you know, my area of specialty is stoma care, but I do get approached by clinical nurse specialists from all different areas. So I, you know, whether it's continenence, whether it's diabetes, whether it's wound care. You know, it is, you know, as a wider community of clinical nurse specialists. And I get to hear both of these Marmite arguments, you know, I get to hear the pros, the cons, the positives, the negatives. But it kind of always leaves me with a similar kind of quandary, which is, or almost a statement more than that is, formulas don't drive clinical product choice, they just make products available to use. So how is almost that a true statement? Scott: Errr, it is! I often find myself highlighting there can be no restrictions placed on what any healthcare professional chooses to do or prescribe. The reality is there can be no blacklists in terms of, you can't prescribe this, and you can't prescribe that in restricted formularies, because the clinician always has the choice to prescribe whatever they want. They may then end up having to defend that decision, ultimately, if there's a problem with the patient or something goes wrong, clearly they're gonna have to end up defending whatever decision they make. But, reality is they've always got the choice. And even more so if there's a NICE technology appraisal, or a NICE tag as they're often called. And if there's anybody sat there thinking, oh, I wonder if that's right, there is a court case from, it's a few years ago now, but a simple search engine of Rose R v Thanet CCG, which went to court and is now not open to challenge, reminded the NHS that when there's a NICE technology appraisal in place, you cannot have any form of restriction on what can or cannot happen. It should be made available to the patients. Now I'm gonna add to that and quantify it by saying there is a but, because of course there's always a but! I always believe it's much better and it remains much better to secure engagement in a new product, because we can demonstrate the problem we'll solve and the outcomes that we're going to deliver by offering access to a new product. So that, again, could be around things we've talked about before around improved patient outcome. Clearly, that's the big one. Then as a result of that improved outcome, do we reduce unnecessary appointments, referrals, and admissions? You know, are we closing the inequalities gap? Are we redesigning the pathway? Are we delivering on some aspect of the primary care network? Any of those things are much better to engage around. Funnily enough, my last big formulary interaction was with Dry Eye Disease of all things, where formulary adherence was 80%, meaning the product really needed to be on formulary to have any chance locally of being used. So how did we do it? It was done by getting a GP lead fully engaged. They then engaged the hospital, and jointly they approached the formulary team with a really well-structured case for change, which highlighted the cheapest chips as they described it. It cost us 2.5 prescriptions a month per patient versus one of what we're proposing. The 2.5 prescriptions a month was costing them about £12.50. If we used the newer product, it was gonna cost £8, and that was how the case for change was won, and the product was added to formulary. Equally with the same project in a different part of the country, formulary adherence was less than 30%, so they just cracked on there, there was no point in even starting to have the formulary conversation. So that goes back to your point about… it depends on, is the reality on where you're working and what the adherence is like. Paul: It's really interesting that you say that. You know, so taking that on board, you know, you've got some areas where a company, the country, will adhere 80% adherence to a formulary. You've got other places which have got a 20-30% adherence. And we've already said that formularies, if they're a standalone, they don't really work. But as a gear in a larger system, they do work. But obviously, and again, we've said it in the last two webinars that we've done, if something isn't working, if the end result isn't given us a satisfactory outcome, if that outcome isn't satisfactory, why are we still doing it? So kind of that leads me onto, you know, are there alternatives to developing a formulary? If you're thinking, hold on, look, formulary, you know, it's only 20% adherence to the formulary. So why are we spending all of this money, all of this time, all of these resources on creating the formulary that doesn't work? Is it part of education? Is it educating clinicians, et cetera? But is there another way we can, you know, standardise care, manage costs without formularies? Scott: Yeah, so again, that goes back to the point we made earlier about one of our drivers is to try and deliver that high-quality standardised approach without unwarranted variation. And without boring you, I've got examples of that at play in places like Newcastle Upon Tyne, Hartlepool and Stockton down in Leicester, Leicestershire and Rutland down in Coventry and Warwickshire, down at Bath, and I've got lots of examples of that absolutely being done, because we take a complete pathway of care. And that's pretty much what I described earlier. That's the alternative to just having a formula. And we actually look at the pathway, we work out the steps in the pathway, we work out then each step, what the treatments are, and of course what the next step is in terms of, you know, both the, the treatment and the referral. And if I use, again, I always like to do things on the basis of examples. If I look at one I've got right now, working with a hospital and they're working with piloting with one local primary care network. And the project is based on improving patient outcomes, where they identified that 80% of workload between the network and the hospital and the referral point was driven by suboptimal treatment, which they split into four categories. So this was kept for one month across three hospital consultants and the GP practices. And what we identified was four categories, correctly diagnosed but not on any treatment. Correctly diagnosed, but not on an appropriate treatment. Correctly diagnosed on the correct treatment, but not optimally dosed, so therefore not getting the outcome. And so sometimes they're neither assessed nor diagnosed, but are being treated. So we've found people in the system who were being treated for what appeared to be a particular condition, but there was no coding for it, so they’ve potentially never, ever really been formally diagnosed. So the project is very much focused on a complete pathway that addresses that, where patients are being, care plans are being, either developed or completely updated. The focus here is to significantly improve the patient outcome. Because that then has the knock-on effect of reducing unnecessary appointments, referrals, and admissions. And this project, which really surprised everybody involved, apart from the fact that nobody expected that 80% of the workload was being caused by suboptimal treatment, they now know and are working to correct that. And they now start every project by looking, is that what's actually driving our problem? Is that part of it is suboptimal treatment fueling our workload? So a complete pathway would be the alternative to just having a cold, hard formulary because the pathway then maps out the condition, all the steps that we're likely to see, the various options that we've got, and what you might consider using at that point. And it still leaves the healthcare professional with the freedom to choose what they want based on the patient that's sat opposite them. Paul: Brilliant. And I think, you know, it's really nice to actually hear that. Cause again, we hear, you know, again, there's lots of things about, things like the NHS, getting it right first time. You know, which I think is essential. It is growing, we know that it's growing legs, we know that it's developing. And personally, I am really, really excited about the future, hopefully when it comes to ‘Get it Right First Time’. Because again, I think it is this thing of, it's combining all the knowledge that we have. It's getting those experts and saying, do you know what this is what best practice looks like. Again, whether you are talking about, I know that it will start in orthopedics, but it's spreading out into… Scott: It’s a good point, it's really good. Yeah, it's a really good point because if the alternative is to not get it right first time, what does that mean? That means the patient's coming back, that that's gonna keep driving your workload. So the alternative isn't a good one. So if you go back to my, right patient, seen in the right place at the right time, buy the right healthcare professional, who's got the resources, the alternative is wrong. Patient seen in the wrong place at the wrong time, by the wrong healthcare professional who doesn't have the resources, but consumes resource doing something that actually, that isn't the right thing to do. So you don't want that. Nobody's going to advocate that, you know. So this is where getting it right first time is absolutely the route to go, patient's seen, dealt with. It's what the patient wants as well. You know, most people want to get seen, get a correct diagnosis, get early and correct treatment, get a quick recovery, and get on with life, and the quicker and easier we make that and we do that, the better it is for everybody involved. Then that's Paul: Then that’s it. And again, it comes down to that thing of like we've always been saying, it's almost a mantra for these webinars now, which is starting at the patient and working backwards, work backwards from there. So I think with de-mystifying formularies, cause I think for a lot of people they hear the word formulary and it's almost a case of a formulary is an Excel spreadsheet with a list of products, a list of codes, a list of prices, and apparently you have to start at the top, which is the cheapest, and work your way down. You know, I think hopefully with de-mystifying that now and again, you know, so if we utilise formularies, if your formularies are utilised in an appropriate way in the correct setting, then hopefully it is gonna improve patient outcomes, it's gonna improve everything. So taking that on board, if a clinician out there again, any specialty says, well, I've got a formulary, but I don't know how it is you, I don't know how it is integral to a wider, a bigger machine. So how could that nurse interpret their local, that local formulary to drive optimum and excellent patient care if all they know is I've got a formulary? Scott: The thing to keep in mind is, is really, as you described, the formulary is and remains a list of products available for use. Whether it's adhered to is a completely different matter. And sometimes it, more often than not, it's where I'll start my work I do around the formulary, what does the compliance with it look like? Is it high or low? And then we go from there. But the thing that the healthcare professional needs to keep in mind is that they are free to choose, they try and give the patient the best possible outcome. From a patient perspective, it's, you know, get seen, get diagnosed, get treatment, get better, get back to life. Kind of five steps. And if we keep that in mind, the shortest and safest route is the one that we all want to find, healthcare professional and patient alike wants that. And actually that's likely to be the one that's the most cost-effective and the most value for money. And I often find it bewildering, again, I've got a business case just now where locally they spend £42 million a year on non-elective admissions to hospital, related to type two diabetes. And nobody wants to change anything. So my point being, so we have to be happy we're spending £42 million on that, and that's going to continue to go up and continue to rise. And the point I'm gently making and politely making is if we implement the NICE guidance that's been written over the last, certainly early stuff that was published last year, and then about 18 months before that, if we implement that in full, we would expect to take about 20% outta that. So you're, you're looking at taking about £8 million outta the non-elective admissions. What do we need to invest to do that? We need about a million. It's actually less than, it's probably about £700 thousand, between £750 thousand and a million. So either we, again, going back to what was said in previous webinars, we're 100% happy with where we are, or what are we going to change? So that's where I think the formulary is there. And clearly, if compliance is high, you're probably gonna have to get on formulary to get full use I would say with this. Not any use, but full use. And that's where it's worth time planning for. That it's worth time, you know, getting to know the medicines optimisation team and the key professionals that work around the formula. Key professionals in the area of interest, you know, so whether it's respiratory disease, it's cardiovascular disease, it's diabetes, it's whatever it is. Because even if compliance is low, I'd still want to work with the local optimisation team, I'd still want to get them engaged with my project, particularly when I'm really confident my product and my project approach is gonna help them do all the things that they want to do around improving the patient outcome. And at the same time, I often look to get the GP and the hospital consultant support for both product and project as part of any approach to make sure that we drive that optimum and excellent patient care and outcome. Because the alternative to that is that we don't have excellent patient care and we don't get a great outcome, in which case we get workload, because they'll continue to come until they get the outcome that they need. Paul: Yeah, I think that's, it's a brilliant point you kind of made there. Which again, kind of leads me down to something again that we've discussed in previous webinars, which is nurses… whether we call it fear, whether we call it worry, whether we call it concern. And you know, I, again, I'm in a privileged position because nurses do approach me and they say, Paul, what, you know, this is happening, what can I do? And I have had a rise in the number of nurses that come to me and say, you know, there's this formulary, I don't want a formulary in my area. I want to have the ability to do X, Y, and Z. And I think I know that hopefully now I'm gonna be able to give them that little bit more, if I say, look, don't think of formularies as a negative. Like I've said, you know, it's, they can be an incredible source of good. You know, again, depending on what the compliance is, and depending in my opinion, who is on that board of who's putting that formulary together, medicines optimisation, whether it's GPs, whether it's ICSs, et cetera, et cetera. So I would almost say, please put your head above the para pit. Because if you are not involved, if the formulary is being thrust upon you and it's part of a project, it's part of a wider thing. You almost, and it sounds quite harsh, you can't complain if you didn't put anything into it. If you didn't say, actually no, I need this. Whether it's a certain appliance, whether it's a certain catheter, certain drugs, anything formularies. If you don't put yourself forward and say, I'm actually talking for my patients here, I need to have this, I need to be involved in this selection process. If you are not, and it's just a case of well it’s gonna happen anyway. Please, please, please have the passion. We know as nurses, we are incredibly passionate. We've always got passion, cause otherwise we couldn't do what we do. You know, we, again, as clinical nurse specialists, a lot of the time we see patients at their lowest. We take 'em through a lot of the time we take 'em through hell and back. And we’re literally by their side all the time and sometimes I think we have to have that passion and take it, almost away from the patient and say, look, it's still gonna affect the patient. I need to take this passion forward, I need to move this forward. And that kind of then takes me onto, nurses a lot of the time have got their finger on the pulse. They know what is happening, what's coming through, what's, you know, I know this is gonna change my patients forever. This is gonna change the lives of my patients. Innovation, which is all well and good, but again, I'm gonna mention those five lovely letters, COVID, that hit, and there has been this incredibly robust and incredibly quick development when it comes to that. But, so there's lots of new innovations coming out. But how, if something, if you've got a really good formulary with a really high compliance formulary, how do we get new innovations into it? Especially if it's something that is a complete new category. You know, there's been loads of new categories put out, right? Always developments in it, you know, and again, I think of diabetes with the phone apps when it comes to diabetes and that sort of thing. You know, it turns into best practice. But if there isn't a category, what happens then with formularies? Scott: This is where you need, what I would describe as marketplace readiness. Where there's a lot of work will need to be done, kinda to create the right market conditions as well as customer and stakeholder readiness, and a willingness to even consider using the new products. So let's assume we've got all of that, that's been done. I also know of areas where, for example, a new item will only ever be considered for inclusion on the formulary after a formal written request comes from a consultant. So you've gotta keep that in mind as well. There might be various local routes that you need to consider, but this is where things like NICE technology appraisal or the Scottish Medicines Consortium, any sort of endorsement with one of those would be a key part as well as being able, you know, for you to demonstrate the obvious, the proven efficacy, the safety, the quality, and of course the cost is part of that as well. But when it comes to innovative new projects, this is where a small-scale pilot can often help you. Particularly if you're not getting traction with the medicines optimisation team. You know, or at system level or even at place level, this is where rein in your expectations. I'm trying for one department, one practice or department working with one practice. You know, so it, you know, whatever disease area you work with, the hospital potentially working with one practice out in primary care to start with, you know, gather all the outputs from day one and start to build a picture of how you're getting on in terms of the improved patient outcome, leading to reduced appointments, to reduced referral, reduced admissions. You know, if you're completely confident in the delivery, to me, piloting is the way to get your projects live and to actually create the interest. Because the natural reaction then of the GP and or the consultant involved is gonna be to get the medicines optimisation team involved. They're gonna want to get them on board and highlight, look, we're doing this at small scale. It's not gonna get outta hand. We're gonna have X number of patients over this amount of time. So it all becomes controllable to start to show, you know, the benefit that you deliver. But it goes all the way back to it covers right across all three webinars that we've done, that we are as an NHS, drowning in workload. There is now, not enough workforce to meet the demand. So new innovative products, whether it's, you know, tablet treatment, it's devices, it's appliances, it's apps, it's kit and equipment. They're now much more open to that than I would say they've ever been. I see customers that historically we'd never have worked with in industry, now partner with and actively working with industry for that very reason. So those are the kind of things I would be looking at if it was me taking a new product to market. Hannah: What a fantastic chat that was with Scott. We've put together a handout to go alongside this episode, and it's available in the show notes for you to download right now. Thanks for listening to Stoma and Continence Conversations. We'll be back with another episode next week. Outro - Stoma and Continence Conversations is brought to you by Coloplast Professional. To learn more, visit www.coloplastprofessional.co.uk