Over the last two days I’ve had Rick Astley going round and round in my head (you’re welcome), but also going round and round on my timeline has been a discussion on whether ‘medicines optimisation’ is ‘medicines management’ after a haircut, shave and with a nicer tie on.  140 characters hasn’t been enough to effectively explain why I don’t think that’s the case, so this blog is my attempt to say why I think medicines optimisation is not just a rebranding exercise.

I was struggling where to start this blog until this Thursday, when I had a practice visit by the currently PCT, but soon-to-be-CSU, pharmacist. I’ve got plenty of time for this pharmacist, certainly compared to their colleagues, and it’s always nice to have a chat and catch up.  Towards the end of our meeting they came to the last item on what turned out to be their ‘must discuss’ list from the boss, which was a copy of a recalled prescription from NHSBSA. The item was a ‘specials’ cream prescribed to Mr R: a mash-up of Betnovate, coal tar and salicylic acid, used in this case for psoriasis, a 200g pot of which was costing me a grand total of £447.

Now whether you live and breathe healthcare or not, you can’t have failed to notice that the NHS is a little stretched for resource, and let’s face it, a cream coming in at nearly 3.5 times the price of silver seems somewhat extravagant. But to me, it’s right here that the difference between medicines management and optimisation is clear, and through the power of alternate history I will try to explain all…

It is the time of Medicines Management: the pressure to cut costs from the drugs budget under the banner of QIPP is unrelenting even though as a CCG we’re already £400,000 under-spent despite two rounds of ‘efficiency savings’ being removed from the budget.  The PCT pharmacist asks what can be done about the cream: it’s clear that it’s not deemed acceptable and that suitable cheaper alternatives must be sought.  Betnovate on its own, with separate Cocois is suggested and the new GMC guideline on prescribing unlicensed medicines is wheeled out to drive the point home.  This is relayed to the prescriber who feels he has no option but to ‘trial’ the new regime with the patient. The PCT pharmacist returns to base safe in the knowledge that the special has been managed out of the system and the cost contained…

But consider also…

It is the time of Medicines Optimisation: the pressure to cut costs from the drugs budget under the banner of QIPP is unrelenting even though as a CCG we’re already £400,000 under-spent despite two rounds of ‘efficiency savings’ being removed from the budget.  The PCT pharmacist asks what can be done about the cream: it’s clear that it’s not deemed acceptable and that suitable cheaper alternatives must be sought.  We pull up Mr R’s medical record and look to see what’s going on.  The cream was initiated in 2011 by the dermatologist at the local acute after a series of attempts using other preparations, guided by NICE, failed to control the plaques on this 71 year old’s trunk and lower limbs. His next step will be oral methotrexate but in numerous clinic letters the consultant says the patient is adamant he’s not started this medication, and goes on to note that since initiation of the special cream his plaques have subsided to two small patches the size of a 50 pence piece so we can probably avoid the cytotoxics. Whilst Mr R uses an emollient each day, he has reduced his application of the specials cream so that 200g lasts about three months.  His personal circumstances are also reviewed, including his reducing mobility and dexterity.  Realising that for Mr R, what matters is keeping his plaques under control as easily as possible so that he isn’t forced onto methotrexate, the decision is taken that despite the high cost and unlicensed status, the specials cream is the right medicine for him and so far is proven to deliver the outcome we all want.  A note is added to his record that it will be prudent to discuss the risks associated with long term steroid application and consider a switch in the choice of emollient, and the PCT pharmacist agrees to relay back to the CSU that this patient’s therapy has been optimised to achieve an appropriate outcome.

What I didn’t speculate on in my alternate history is what would’ve happened to Mr R had the change in his therapy been forced under medicines management. Would he have adhered to the new medicine regime, would his plaques return and would he feel pressured into starting methotrexate?  I don’t know and that’s why I didn’t speculate, but it’s not hard to imagine that some of that would apply.

So is medicines optimisation the shiny new version of medicines management? No, I really don’t think so, though I admit that’s not always been the case.  It is different in my mind, but perhaps that’s the problem – every other bugger’s going to have a different opinion because although the term has been formally around since 2010 no-one official has come up with a decent, acceptable definition. How can anyone get behind something that’s taken two years to define? How can a profession coherently apply themselves to something that’s seemingly insubstantial?

For me that’s the prime issue in all of this – let’s stop going round and round on whether it’s different or not, but let’s, all of us, make sure it is different.

And for the record, one of those alternate histories is a true reflection of last Thursday. I’ll leave you to decide which you think it is…