Thread by @GrahamStretch

💊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?)

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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

£££££++

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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

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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

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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

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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🎯

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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‼️

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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 💚

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