Graham Stretch Profile picture
Aug 15, 2022 12 tweets 8 min read Read on X
💊PCN IIF vs DES SMR Priorities

🧐Some Unintended Consequences 🤔

(Sorry about the acronyms)


#SMR in #PCN should follow four high-level principles delivering:

▶️ Shared decision-making
▶️ Personalised Care
▶️ Safety
▶️ Effectiveness


🧵 Thread 1/12
#SMR should target 🎯 people with complex or problematic polypharmacy at greatest risk of med related harms, ergo those:

1️⃣ in care homes
2️⃣ with polypharmacy >=10 meds
3️⃣ on meds associated with errors
4️⃣ with severe frailty
5️⃣ on addictive pain meds

All agree so far?

🧵 2/12
Naturally the devil is as always in the detail

For example, only GPs & nurses or pharmacists with IP & advanced Hx taking & Exam techniques can deliver #SMR

For pharmacists means enrolled on or completed @CPPEPCPEP (acronyms++)

-OR-

CPPE Certified equivalence to PCPEP
🧵3/12
So, these rules mean some experienced pharmacists w/o CPPE are excluded from delivering #SMR, and #PCN pharmacy teams are not yet ‘mature’

SMR for a frail complex elder on 10 meds is a demanding, time consuming task requiring advanced person centred skills (all agree?)

🧵 4/12
As effective #SMR delivery is a complex skill, it is entirely reasonable to establish a baseline accredited skill set for pharmacists (most agree) [GPs & nurses too??]

The evidence based intervention that is SMR has attracted investment in ARRS funds & training

£££££++

🧵5/12
Welcome investment in primary care pharmacy teams has naturally come with targets & incentives….

Introducing the IIF !

An “incentive scheme focussed on supporting PCNs to deliver high quality care… & the delivery of the priority objectives”
including #SMR

🧵 6/12
So SMR-01A,B,C,D & SMR-02A,B,C,D & SMR-03

Pages 68 -81 of england.nhs.uk/wp-content/upl…

Essentially give a target threshold (44% (LT); 62% (UT) of target population for #SMR) for an incentive payment to your PCN

SMR-02&03 relate to specific high risk meds with ⬆️ targets

🧵 7/12
Now, keen eyed / well informed readers of the IIF documents will notice that (tweet 2)

2️⃣ with polypharmacy >=10 meds

The TEN OR MORE MEDS priority from the DES is missing from the IIF 😮

Although the other categories still stand in the IIF

So what❓-you may ask

🧵 8/12
So What❓

💡 Here is the paradoxical unintended consequence of the removal of the 10 or More meds priority from the IIF —

🎯The 44% IIF lower threashold for #SMR can probably be met with the ‘easier’ priorities without reviewing complex 10+ med patients🎯

🧵9/12
So, because, unfortunately, a reliable method of quantifying the 10+ ‘denominator’ was not available it was dropped from 22-23 IFF

🗒Result: A reverse incentive↩️

PCNs should be targeting #SMR in most complex polypharmacy++ instead ‘easier’ SMR are cherrypicked

🧵10/12
Whilst skill mix limitations and time pressures are all too real…

A PLEA

Those priorities from tweet 2 align with the evidence base for #SMR & the #deprescribing agenda…

‼️Let’s please target instead those patients at highest risk with complex 10+ polypharmacy‼️

🧵11/12
Also can we advocate for the targets in the IIF to be adjusted

➡️ to recognise overprescribing / polypharmacy priorities and specifically target those on 10 or more medicines for a #SMR

This will give SMR the highest possible impact on our patients QoL and health 💚

🧵12/12

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More from @GrahamStretch

Oct 3, 2019
I’ve long said a privilege of spending time with older people is hearing about their lives, these autobiographical stories can transform ones perception of an individual from frailty to one of admiration & awe -#BlackHistoryMonth has reminded me of such an encounter @nhs
Over a period of several years I got to know a couple who would visit my pharmacy, we would talk and chat about the usual pleasantries, until one day the husband let slip about his ‘thing on’ at the Victoria and Albert Museum. I was then presented with a copy of ‘their book’ #BHM
Modest by nature, I had to press hard for fascinating details of a whole lifetime of activism and campaigning now deposited in archives #BHM2019 cityoflondon.gov.uk/things-to-do/l…
Read 6 tweets

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