Medicines optimisation

How NICE resources can support local priorities

“This resource will be a fantastic tool to inform a sustainability and transformation partnership about how NICE supports the medicine optimisation agenda.

It’s a really useful resource for delivering good quality integrated care at local and neighbourhood levels for anyone involved in delivering medicines optimisation in practice to improve patient outcomes in all care sectors.”

Karen O’Brien, Controlled Drug Accountable Officer
leading on Greater Manchester Implementation Strategy,
Greater Manchester Health & Social Care Partnership.

A number of medicines of all shapes and size laid out on a table.

The case for medicines optimisation

Getting the most from medicines for both patients and the NHS is becoming increasingly important as the aging population mean more people have complex multimorbidities. We spend £17.4 billion a year on medicines but up to half of medicines prescribed for long-term conditions are not taken as intended, and around 5 to 8% of hospital admissions are medicines-related. Many of these are preventable. 

Medicines optimisation is about ensuring the right patients get the right choice of medicine, at the right time. It is a person-centred approach that improves safety, adherence to treatment and reduces waste.  

Medicines optimisation is part of the NHS Long Term Plan as well as the NHS 10 Point Efficiency Plan in the NHS Next Steps on the Five Year Forward View and Lord Carter’s review on productivity in NHS acute hospitals.

For the system, medicines optimisation ensures that prescribing is high quality, safe and good value. It needs greater patient engagement and collaboration by practitioners across health and social care settings.

Dr Bruce Warner, Deputy Chief Pharmaceutical Officer at NHS England, explains the importance of medicines optimisation. He talks about using our resources to improve care through local partnerships.

Supporting health and wellbeing

Our guidance and quality standards on medicines optimisation can support several strands of work to improve people’s health and wellbeing.

Shared decision-making

We're committed to helping patients and clinicians have more meaningful conversations about their treatment options – see our information on shared decision-making. Our guideline on medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence has recommendations to help clinicians have more meaningful conversations with people about their treatment options. We also produce brief summaries of our guidance for the public, for example in our guideline on medicines optimisation. And we also produce decisions aids which support discussions between health professionals and patients about complex decisions.

To identify ways to improve quality of care around shared decision-making on medicines, you could use our quality standard on patient experience in adult NHS services. This covers the need for patients to:

  • have opportunities to discuss their health beliefs, concerns and preferences (statement 4)
  • be supported by healthcare professionals to understand the benefits, risks and potential consequences of their treatment options (statement 5)
  • be actively involved in shared decision-making and supported by healthcare professionals to make fully informed choices that reflect what is important to them (statement 6).

Multimorbidity

Our guideline on multimorbidity: clinical assessment and management has recommendations relevant to medicines optimisation for people with multiple conditions.

You can use the baseline assessment tool to check whether practice in your area is in line with the recommendations in the guideline, and plan activity to meet the recommendations.

You could use our quality standard on multimorbidity when considering priorities for improvement. It includes quality statements:

  • identifying adults with multimorbidity (statement 1)
  • giving people with an individualised management plan a chance to discuss their values, priorities and goals (statement 2)
  • making sure they know who is responsible for coordinating their care (statement 3).

The key therapeutic topic on multimorbidity and polypharmacy summarises the evidence base to support medicines optimisation. It has advice on polypharmacy and reducing the burden of medication and waste in the system. It also signposts to other key resources.

New models of care

We have guidance and quality standards covering medicines management for people in care homes or their own homes, and when moving between settings.

The NICE Pathway on medicines optimisation brings together recommendations about service organisation. This includes cross-sector working, communication and medicines review and reconciliation. The following video explains how to use NICE Pathways.

For recommendations covering medicines optimisation during transfer of care, see our guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs. It includes recommendations on supporting high-risk patients, information sharing and training and development.

In particular, the guideline recommends that all relevant staff are trained in the hospital discharge process as soon as possible after they start work, and with regular updates (recommendation 1.7.1).

Shared learning case studies are examples of how organisations have put our guidance and quality standards into practice to improve local services. The following examples involve new care models:

  • NHS Wigan Borough CCG employed a team of pharmacists to work with GP practices and care homes on medication reviews, in line with our guidance. This led to a reduction in the number of pills people take, and in inappropriate polypharmacy.
  • Western Health and Social Care Trust focused on older people in intermediate care, using a case management model led by a consultant pharmacist. 
  • In the IMPACT project at Leeds Teaching Hospital a medicines care plan was added to discharge summaries for older people at risk of having problems with their medicines. This improved teamwork between secondary and primary care. It may also have reduced readmission rates.

To help you focus on areas for quality improvement, the quality standard on medicines optimisation has 2 quality statements on medicines reconciliation when people move between settings. Statement 4 covers admission to hospital, and statement 5 covers GP records after a discharge from a care setting.

Our guideline on medicines optimisation has recommendations on medicines management relevant to integrated care, covering medicines related communications systems when patients move between settings (section 1.2), and models for organisational and cross-sector working (section 1.8).

For new models of care to support people in their own homes, the following sections of the guideline on managing medicines for adults receiving social care in the community are particularly relevant:

  • governance for managing medicines safely and effectively (section 1.1)
  • joint working between health and social care (section 1.3)
  • sharing information about a person's medicines (section 1.4)
  • ensuring that records are accurate and up to date (section 1.5) .

Discussing and planning medicines support is a quick and user-friendly guide to the guideline for home care managers. It covers the main points of the guideline on managing medicines for adults receiving social care in the community.

For new models of care covering care homes, our guideline on managing medicines in care homes is highly relevant. It covers policies for medicines use, supporting people to make informed decisions and look after their own medicines, sharing information, medicines-related problems, prescribing and reviewing medicines, and giving over-the-counter medicines.

A key recommendation is that health and social care practitioners should work together to make sure that everyone involved in a resident's care knows when medicines have been started, stopped or changed (recommendation 1.9.3).

The tools and resources tab for this guideline includes a 2-part e-learning resource that we've endorsed as supporting the guideline.

The quality standard on medicines management in care homes has 2 quality statements that could support quality improvement. They cover making a list of medicines on the day a person moves into a care home (statement 1), and sending a discharge summary with details of current medicines with a person who moves into or from a care home (statement 2).

Care and safety

Medicines safety

Our guideline on medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes includes recommendations on medicines reconciliation and medicines review. It recommends that:

  • medicines reconciliation is carried out by a trained and competent health professional ( section 1.3)
  • organisations should identify the most appropriate health professional to carry out a structured medication review, based on their knowledge and skills ( section 1.4).

The quality standard on medicines optimisation includes quality statements on medicines reconciliation in acute settings ( statement 4) and structured medication review ( statement 6). These support quality improvement work in this area.

We have published key therapeutic topics advice in areas where there are opportunities for improving safe use of medicines, including:

We've key therapeutics topics on what clinicians need to know about high-risk drugs, including:

  • Safer insulin prescribing – clinicians and people taking insulin need to understand 'sick-day' rules.
  • Hypnotics – to reduce risks such as falls, and dependences, hypnotics should be used only if insomnia is severe, using the lowest dose that controls symptoms for short periods of time.
  • Non-steroidal anti-inflammatory drugs (NSAIDs) – review the appropriateness of NSAIDs routinely, especially for people who are at higher risk of gastrointestinal, renal and cardiovascular side-effects (for example, older people).
  • Anticoagulants, including non-vitamin K antagonist oral anticoagulants (NOACs) – ensure staff are trained, review procedures and protocols, audit services annually using the British Society of Haematology (BSH)/National Patient Safety Agency (NPSA) safety indicators and ensure patients receive information.
  • Medicines optimisation in long-term pain (safe use of opioids) – the risk of harm increases substantially at doses above an oral morphine equivalent of 120 mg/day, but there's no increased benefit. Opioids should be stopped if the person is still in pain despite using opioids, even if no other treatment is available.

Medicines-related incidents

Our guideline on medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes recommends that organisations should:

  • encourage reporting and learning from medicines‑related patient safety incidents
  • make sure patients and their carers know how to identify and report incidents
  • take action to reduce further risk after an incident.

These sections are particularly relevant:

  • systems for identifying, reporting and learning from medicines related patient safety incidents ( section 1.1)
  • clinical decision support ( section 1.7).

The guideline on managing medicines in care homes has recommendations on:

  • developing and reviewing policies for safe and effective use of medicines ( section 1.1)
  • identifying, reporting and reviewing medicines-related problems (section 1.5).

To support quality improvement, you could use the quality standard on medicines optimisation. In particular, statement 2 on involving patients in reporting medicines-related patient safety incidents, and statement 3 on learning from incidents.

Controlled drugs

The NICE pathway on controlled drugs: safe use and managementbrings together everything we’ve published on the subject in interactive flowcharts. This includes recommendations on governance arrangements, standard operating procedures, policies and processes and risk assessments.

Antibiotic awareness

A key message of the NICE Pathway on antimicrobial stewardship is to discuss other options if prescribing an antimicrobial immediately is not the most appropriate option. The pathway includes recommendations from our guideline on antimicrobial stewardship: changing risk-related behaviours in the general population. The guideline aims to increase awareness of how to use antimicrobials correctly to minimise the risk of resistance, and how to control infections to reduce the need for antimicrobials.

Our contribution to the fight against antimicrobial resistance also includes:

The key therapeutic topic advice on antimicrobial stewardship: prescribing antibiotics covers the evidence and includes links to national guidance and initiatives.

A signpost in different shades of blue.
A series of three cogs connecting together.

Funding and efficiency

To support implementation of our guidance on medicines optimisation, we produce products designed to help improve efficiency and get the best value out of medicines. The costing statement on the tools and resources tab for the guideline on medicines optimisation shows that it could save costs by reducing variation, and the baseline assessment tool will help organisations in your local partnership check their practice against the guideline recommendations, and plan activity to meet the recommendations.

Some of our key therapeutic topics help with getting best value out of medicines, including biosimilar medicines and wound care products, and chemotherapy dose standardisation.

NHS England’s Innovation Scorecard shows how our technology appraisals are being taken up around England. It includes heat maps with data for individual CCGs, so you can benchmark performance in your local partnership.

Our outcome indicators can be particularly useful to local partnerships when:

  • creating local performance dashboards
  • benchmarking performance against national data
  • developing local quality improvement schemes
  • measuring progress that local health systems are making on outcomes.

Indicators that are particularly relevant to medicines optimisation include:

  • NM88: The percentage of patients with coronary heart disease with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken.
  • NM89: In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, the percentage of patients who are currently treated with an ACE-I or ARB.

Medicines management for populations

If you're leading and managing the wider development of medicines optimisation at a system level, our NICE Pathways are an easy way to find everything we've said on these topics:

  • Local formulary development covers systems and processes for developing and updating local formularies. 
  • Patient group directions covers good practice for developing, authorising, using and updating patient group directions. Patient group directions can be used to supply or administer medicines in certain care settings to patients with an identified clinical condition without a prescription or an instruction from a prescriber. The competency framework on the tools and resources tab of the guideline on this topic is a useful tool to assess staff competency in this area.

NHS England’s Innovation Scorecard shows how our technology appraisals are being taken up around England. It includes heat maps with data for individual CCGs, so you can benchmark performance in your local partnership.

Shared learning case studies

Medicines optimisation service improves care and saves money

GPs at a practice in NHS Wyre Forest CCG felt they were always rushed when reviewing medicines, and particularly when looking at discharge medicines. They employed a pharmacist to oversee management of medicines. This improved patient care and may have prevented hospital admissions.

As a result, a medicines optimisation service was commissioned for the CCG. Staff and patients were positive about the service. Analysis of 1 month’s work revealed 2,000 interventions. Of these, more than a third led to a medicine being started, stopped or changed. The annual saving was estimated at around £450,000. The CCG’s spend on prescriptions fell by 1.4%.

A male pharmacist wearing a white coat checks an inventory of medicines against a list on his clipboard.

Peer review improves medicines management

A medicines optimisation peer review programme set up by Wigan CCG has improved patient safety and overall prescribing performance in GP practices. Antibiotic usage has fallen in line with our guidance, and the work has also helped with meeting savings and productivity targets.

The programme consists of annual meetings in which 5 or 6 practices from a locality discuss prescribing issues, based on our guidance, prescribing data and local priorities.

Packets of coloured medicine capsules in pharmacy drawers.

Other support from NICE

We have a network of NICE Medicine and Prescribing Associates who can advise you. They're involved in medicines optimisation across the UK, and share information about our guidance across their professional networks. They can help identify key medicines issues in new guidance, share examples of good practice, and use the network to problem-solve specific issues. Some of them also sit on Regional Medicines Optimisation committees, which outline priorities for medicines optimisation. Your local medicines implementation consultant can put you in touch with an associate near you. Find out more on our medicines and prescribing page.

We produce daily, weekly and monthly medicines and prescribing summaries and alerts. Choose the level of support you need.

You can also subscribe to our monthly resource planner. This summarises the potential resource impact of new guidance and will help you to plan for implementing our guidance.

Our work is closely aligned with national programmes including RightCare and Getting it Right First Time (GIRFT).

"RightCare is all about looking at variation in healthcare and identifying unwarranted variation as part of this process. The evidence and support provided by NICE is necessary to enable some of those discussions to take place within local health economies."

Jas Khambh, National Pharmacy Adviser to NHS RightCare, NHS England.

A close-up of a pharmacist's hands holding a box of medication in each.