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We have been very busy since our last newsletter back in July and there are tonnes of exciting updates for you here!
Measure Update: Total Oral Morphine Equivalence
The Faculty of Pain Medicine has recently updated their recommendation on oral morphine equivalence (OME) which we use on our OpenPrescribing measure of OME. We have taken this opportunity to update and a new novel implementation of how we assess OME. Until this work is completed we have taken the decision to “suspend” the measure from dashboards however you can still view the old method using this link.
Victory! We have the hospital medicines data. Now: biologic medicines for severe Asthma
In July, Ben and Brian wrote a piece in the British Medical Journal arguing that hospital medicines data should be openly shared. Magnificently, the NHS has now made secondary care medicines data (SCMD) available. You can read the full technical specification of the data here but briefly: it is hospital pharmacy stock control data, which is collected and processed by Rx-Info, and is now published on the NHS Business Services Authority website in the NHS dm+d standard we know, love, and have documented well.
OpenPrescribing and DataLab Papers
It has been a busy month for paper publication at The DataLab. We have written a brief description of the most recent papers below. Please sharewith colleagues and [get in touch(mailto:[email protected])if you have any relevant observations! Remember you can read all our academic papers related to OpenPrescribing on our research page.
Just prior to the COVID-19 emergency we launched a new measure on OpenPrescribing, primary care prescribing of medicines defined by the NHS dictionary of medicines (dm+d) and devices as “hospital only”. In this blog we set out what exactly this means, describe some of our early investigations and interesting (but nerdy) details, and ask for your help in improving and maintaining this dm+d field.
A guest blog from Dr. Kevin Barrett (Twitter @DrKBarrett).
Last week the British Journal of General Practice published our paper on unsafe prescribing of methotrexate. As part of the publication Dr. Kevin Barrett talked to BJGP (see video below) about how he used OpenPrescribing to identify potentially unsafe prescribing in his practice and has also written a short blog below.
At OpenPrescribing we know that clinicians can be overwhelmed with guidance and data about many different aspects of care. We therefore have developed an innovative email alert service for every single practice, primary care network and clinical commissioning group in England that delivers bespoke custom emails to your inbox about your own organisations prescribing.
Methotrexate Prescribing Safety – New paper in BJGP
This week the British Journal of General Practice published our latest paper on unsafe prescribing of methotrexate. We found that the prevalence of unsafe methotrexate prescribing (10mg tablets) has reduced but remains common, with substantial variation between practices and CCGs. In the paper we also discuss recommendations for better strategies around implementation.
OpenSAFELY is a new secure analytics platform for electronic health records in the NHS, created to deliver urgent results during the global COVID-19 emergency. OpenSAFELY is a collaboration between the DataLab, the EHR group at London School of Hygiene and Tropical Medicine and TPP who produce SystmOne. OpenSAFELY is now successfully delivering analyses across more than 24 million patients’ full pseudonymised primary care NHS records. The first analysis from OpenSAFELY is Factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients with more answers to important questions expected shortly.
OpenPrescribing.net has been updated this week with the latest release of prescribing data covering March 2020. In-depth analysis will be needed over the coming months, but this release gives us the first glimpse into the impact that COVID-19 has had on prescribing. At the DataLab we have been quite busy with the new secure analytics platform OpenSAFELY but the following blog is a rapid analysis of the March prescribing data which others may find helpful to focus their own investigations. As always, all our analytical code is openly available on our GitHub for inspection and reuse by anyone.
The following is a rapid analysis of the “top 10” medicines in NHS England primary care in 2019. We prepared this analysis for a user who wanted to use the list in a teaching session with students to prepare them for the medicines they will most commonly see in general practice. We are sure others will find it useful – please get in touch and tell us how you use it via twitter @openprescribing or [email protected]. As always our analysis with complete analytical code is openly available on our GitHub page. You can also investigate the prescribing of any medicines you like using our tools like our Analyse page, chemical trends and our brand new browser for the NHS Dictionary of Medicines and Devices. Read on below where we describe the “top 10” medicines and class of medicines, in terms of volume and cost.
At The DataLab we like to work in the open and share our insights for the whole community, so we can fix a problem for us, then share the solution, and help fix it for everyone. We think this is efficient for us and the whole system. In this blog our magnificent coder Peter Inglesby sets out some analysis he has done of changes to the NHS prescribing data we use. It took us a few hours to investigate these problems for our own purposes, then document our findings and solutions internally; it took an extra 20 minutes to share in this blog post and now we give it to you so you don’t have to replicate our effort and can maybe find some insights we have missed!
Update September 2020: NHS England have announced a reduction in the number of planned measures including the majority of the measures on OpenPrescribing. We will remove the IIF dashboard in a future update.
Update: Due to COVID19 response NHS England has announced that the IIF will be postponed. We will continue to make this dashboard available as NHS England also states that they will continue to monitor the data to understand any impact.
At The DataLab we get many people contacting us every month asking us when OpenPrescribing will be available in their country. In this blog we are outlining OpenPrescribing.yourcountry where we give you the information that you can use locally to build a case for OpenPrescribing in your country and obtain funding to support development. We aren’t quite ready to build OpenPrescribing.yourcountry yet, but we will be soon and we wanted to share our plans so you can be ready when we are.
Most people share their end of year roundup during late December when everyone is too full of cake to read. Now you’re back in the saddle, here’s our roundup of everything the DataLab threw out into the world over the previous 12 months!
OpenPrescribing.net went from strength to strength, with over 135,000 unique users last year. We now have over 80 measures of prescribing safety, efficacy and cost-effectiveness and have been working on new types of measures and alerts to identify “outlier” prescribing, such as with zuclopenthixol. In 2019 we also: launched new dashboards and bespoke alerts for every single primary care network (PCN), sustainability and transformation partnership (STP), and NHS region; upgraded the Analyse page to support more organisations with bespoke medicines queries; and developed tools to help solve the problem of Ghost Branded Generics which cost the NHS an extra £11.6million per annum but has massively reduced during 2019.
Today on OpenPrescribing.net we have launched our National Institute for Health and Care Excellence – NICE Prescribing Dashboard. We have a NICE prescribing dashboard for every single general practice, primary care network (PCN), clinical commissioning group (CCG)https://openprescribing.net/ccg/, sustainability and transformation partnership (STP), NHS region and for the whole of England.This allows anyone to explore how NICE guidance has been implemented in their organisation, supporting effective, safer and more efficient prescribing. To access yours, simply go to your organisation’s measures page and select “NICE” from the drop-down. You can read more about our categories here or watch our short Youtube video.
PCN Dashboards Now Live!
We have now launched our long-awaited Primary Care Networks (PCNs) dashboard, made possible thanks to the the membership list being published by NHS England last week.
We have PCN prescribing dashboards for every single NHS PCN and their member general practices. (Don’t know your PCN’s name? You can find it on your practice dashboard). This allows anyone to explore NHS prescribing patterns in their PCN and how this compares to others across England – supporting safer, more efficient prescribing.
A guest blog from Calum Polwart (Twitter @ShinyBlackShoe)
At the DataLab we value openness and transparency as we believe open discussion of ideas and methods are the key ingredients for high quality data analysis. We think it is unhelpful that so much NHS data analysis is outsourced, or done behind closed doors, as this prevents coalface clinicians from engaging with data and sharing their expertise and insights. We build
Today on OpenPrescribing.net we have launched our Primary Care Networks (PCNs) dashboard. We have PCN prescribing dashboards available for every single NHS PCN and their member general practices. This allows anyone to explore NHS prescribing patterns in their PCN and see how this compares to other PCNs across England – supporting safer, more efficient prescribing.
New Paper in BMJ
Our newest paper is now out in the BMJ! Here we show huge variation in adoption of warranted changes in prescribing behaviour, using some exciting new openly available change detection methods.
We now have over 80 measures!
This month we have launched a range of new measures. As always, measures are prioritised on your dashboard by potential for improvement so you can quickly and easily spot where your organisation is an outlier. You can also sort by potential savings or group measures by clinical condition.
This week we launched a new measure of seven day prescription for medicines used to treat long-term conditions. There is no current consensus on duration of prescription across the NHS and prescribers are advised that they should write a prescription for a duration that is clinically appropriate. For medicines that are for stable long-term conditions many areas have policies in place recommending one, two, or three month prescriptions.
At the DataLab we regularly collaborate on projects, both small and large, with users who get in touch. For development of this measure we would like to thank the NHS England Sustainable Unit and Centre for Sustainable Healthcare for their input on our work to support the NHS Long Term Plan. Another one of our collaborators on this work is Nicola Read, a respiratory doctor who is currently one of the National Medical Director’s Clinical Fellows. Below we set our new measure on inhalers and the environment and Nicola explains its importance for all inhaler prescribers.
Zuclopenthixol is an antipsychotic used for schizophrenia and other psychoses. In the UK, there are two injectable forms of zuclopenthixol:
This week we launched a new measure to support a new type of alert to identify any prescriptions of zuclopenthixol acetate for further investigation. It is not recommended to be prescribed in primary care, so prescriptions may have been prescribed in error.
New Feature! Measures linked to Analyse page
Following many requests from users, we have created links from our measures to the corresponding search on the Analyse page. This is particularly useful if you want to see multiple practices or CCGs on one chart, view the results on a map, or see exactly which products are included in the measure.
You will notice this is not yet available for all of our measures (which now number close to 100), due to the complex way some measures are constructed. This currently affects just 12 of our standard measures and 4 of the Low-Priority prescribing measures, and we hope to keep increasing the options in the coming months.
New Feature! DM+D browser
This week we have launched a new browser for the NHS Dictionary of Medicines and Devices, better known as dm+d. dm+d is the standard dictionary for the medicines and devices used across the NHS. At last count there were over 150,000 packs of medicines and devices described. You can read more about the dm+d in this detailed blog.
This week we have launched a new browser for the NHS Dictionary of Medicines and Devices, better known as dm+d. dm+d is the standard dictionary for the medicines and devices used across the NHS. It contains codes and descriptions for all these medicines and devices; at last count there were over 150,000 packs of medicines and devices described. You can read more about the dm+d in this detailed blog.
Over the past year we have been increasingly using NHS Dictionary of Medicines and Devices (dm+d). This blog post sets out to describe dm+d for the benefit of the wider prescribing analytics community and others.
What is the NHS Dictionary of Medicines and Devices (dm+d)?
dm+d is the standard dictionary for the medicines and devices used across the NHS. It contains standardised codes, descriptions, and metadata (such as price and pack size) for every entry. At last count it contained over 150,000 packs of medicines and devices.
New low-priority measures approved
Yesterday (27 June), NHS England completed its consultation on an additional proposed set of products being considered for a recommendation against regular use in primary care. Therefore, on the site we have now included these new items in the set of low-priority measures. The newly added products include bath and shower emollients, higher cost insulin pen needles and dronedarone. See how your practice or CCG is performing on these measures here, or navigate to the Low Priority measures from your favourite organisation’s dashboard.
Our technical team are busy improving how the engine room of OpenPrescribing. When they’ve finished we’ll get them to write a blog on exactly what they’ve done. In the meantime, as the work progresses we are able to add some additional exciting new features to the site.
One of the limitations of how our Analyse page worked was the ability to only search at one BNF level at a time. For example, you couldn’t search for products and presentations together. However, now you are able to add any combinations you want, making this tool much more powerful. For example, it’s helpful when looking at broad-spectrum antibiotics: previously you could only include either cephalosporins and quinolones (BNF paragraphs), OR co-amoxiclav (a BNF chemical). Now you can include all of them at the same time.
Update November 2019: Our NHS PCN dashboards are now live at https://openprescribing.net/pcn/ and you can read more on our launch blog.
Update August 2019: Our amazing developers have written all the code necessary to display all prescribing measures and data for all PCNs in England on OpenPrescribing. Unfortunately there is no national list of PCNs and their membership available, as soon as this is published we will bring you our prescribing dashboards.
Varied implementation of UTI prescribing guidelines
One of our recent papers, published in the Journal of Antimicrobial Chemotherapy, highlighted variability in the speed at which different CCGs switched from prescribing trimethoprim to nitrofurantoin (as recommended by PHE for uncomplicated UTI).
It appears that the practices which changed the most were in CCGs that had taken some action to promote the new guidelines, such as a change in formulary. What are the implications? Read more on this in our blog and you can of course see any region’s performance on this measure on OpenPrescribing.
Just before Christmas we had a paper published in the Journal of Antimicrobial Chemotherapy. It looked at how GP practices responded to changes to the guidance for antibiotics for urinary tract infections (UTIs).
It’s an interesting story in itself, but we think that it prompts some wider questions about how GPs are helped to keep up-to-date on guidance on prescribing.
This week we have launched a new email alerting service that covers all of NHS England. Many users of OpenPrescribing already receive our monthly newsletter and our innovative email alert service for practice and CCG prescribing measures and for price concessions. We have now developed this service covering all of England based on user feedback. To sign up, just go to the All England page and enter your email address in the box beside the measures categories (see screenshot below).
At the DataLab we value openness and transparency as we believe open discussion of ideas and methods are the key ingredients for high quality data analysis. We think it is unhelpful that so much NHS data analysis is outsourced, or done behind closed doors. This blog sets out the steps we take with OpenPrescribing.net to ensure all our analysis and methodology is freely available for inspection, review, and importantly re-use, by anyone. We hope other teams will adopt these approaches so we can all collaborate to optimise analysis, generate insights and improve care for patients in the NHS.
On OpenPrescribing.net we provide data for individual practices and CCGs (and now STPs and regions!) making it easier for everyone to explore NHS prescribing patterns in England – supporting safer, more efficient prescribing. However, providing data for an individual location in isolation is rarely useful. We need to provide context, so that some sort of judgement can be made about whether the prescribing in question is especially high or low, and how extreme it is, in comparison with others. On OpenPrescribing we do this using deciles. We think providing transparency in our methods is really important, so in this blog I set out our rationale for doing so.
In the last year we estimate that price concessions have cost an additional £165 million in unplanned expenditure for Clinical Commissioning Groups (CCGs), and our OpenPrescribing.net price concession calculator was featured in a major BBC news story and in the Pharmaceutical Journal this week. However, interestingly, NHS price concessions do not just affect the NHS: they also represent unplanned expenditure for charities, local councils, and others. Here, we report our estimate of the impact on non-CCG organisations as an additional £5.6 million in 2018: a huge four-fold cost increase on top of expected prices for a sector that is already over-stretched.
Today we launched NHS regional and STP dashboards on
What is an NHS STP or Region?
New Price Concessions alerts
We have introduced a new email alert service, built upon our recently-launched NHS Price Concession calculator, which shows the cost impact of concessions for every single practice, CCG and for all of England combined.
At OpenPrescribing we have a range of prescribing measures that makes it easier for everyone to explore NHS prescribing patterns in England – supporting safer, more efficient prescribing. We now have 70 measures including our two latest on Freestyle Libre and herbal medicines, that we recently blogged about. The measures are available for for every single practice and CCG in England and cover a range of clinical areas such as medication safety and antimicrobial stewardship to support better prescribing.
Ghost Branded Generics are a relatively new category of cost-saving opportunities, caused by prescribers specifying a manufacturer for a generic product, often resulting in a higher reimbursement price compared to the true generic. We estimate the problem costs the NHS £11.6m a year. We have written about this extensively since our first blog on discovering the issue and developed a Ghost Branded Generics dashboard and measure for every practice and CCG in England.
Today we launched a new feature on OpenPrescribing: an NHS Price Concession email alerts service. This is in addition to our existing calculator that shows cost impact of price concessions, which can already be viewed on every practice, CCG and All England dashboard. You can read more about price concessions (aka NCSO) in our previous blogs.
…Identify CCG Cost Savings Opportunities using OpenPrescribing.net
Every year in the NHS local teams around the country put together “QIPP Plans”. QIPP stands for Quality, Innovation, Productivity and Prevention and is a large scale programme introduced across the NHS to ensure the NHS delivers more for the same funding. We make no comment on the programme itself but we think OpenPrescribing is a useful tool in helping develop “QIPP Plans” and to identify new areas for savings related to medicines spend.
Herbal medicines For techie reasons, we’re quite excited about the herbal medicines measure. We don’t like to write measures that require a manually managed list of preparations, as these require a lot of curation, and can quickly become inaccurate if a new drug is released. Therefore for most (if not all) of our measures we use the hierarchical BNF codes provided by the NHS Business Services Authority (you can read more on these here).
While investigating the data behind Ghost Branded Generics, we came across something that we didn’t expect. As part of our work in creating the Drug Tariff viewer (once we’d managed to obtain the data), we’ve got an archive of Drug Tariff (DT) prices going back to 2010. We used our DT archive to compare listed reimbursement prices with what was actually being paid for generics, we sometimes found that the price paid wasn’t the one listed in the tariff. Instead, sometimes the price was based on the drug tariff price…from the future. or to be more precise, one month into the future.
Before Christmas we wrote about Ghost Branded Generics, a very nerdy story about a problem we uncovered that costs the NHS………£11.6million a year. Since then we have launched a freely accessible Ghost Branded Generics dashboard on Openprescribing.net for every practice and CCG in the country; and a Ghost Branded Generics measure so practices and CCGs can track their prescribing of Ghost Branded Generics over time.
Before Christmas we wrote a nerdy story about Ghost Branded Generics, a problem that costs the NHS £11.6m a year due to prescribers selecting specific manufacturer’s products rather than true generics. This is largely avoidable. Today we launch our Ghost Branded Generics dashboard for every practice and CCG in the country. This can be accessed through every dashboard page (example below) and we think it will be useful to help people change prescriptions from Ghost Branded Generics to true generic prescriptions.
This a very nerdy story about a problem that costs the NHS £11.6m a year. It shows how one small design choice in the software GPs use can have huge ramifications for how we prescribe, and a huge cost impact on the NHS. More than that, it shows how problems like these can only be spotted, and addressed, by mixed teams like ours – doctors, pharmacists, researchers and software engineers – pooling our different skills to build tools and papers.
Each year, we estimate there are up to £5m of Out of Pocket Expenses (OOPE) expenses charged to the NHS, added by dispensing contractors to their invoices. Could some of these expenses be reduced? In 2014/15 NHS Islington CCG wrote to dispensing contractors highlighting such expenses, and from this single intervention achieved a 50% reduction; spread across the country this could amount to a saving of £2.5m.
In our third full year of existence we produced even more exciting outputs and continued to grow. We welcomed Lydia Berry, back from maternity leave; Dave Evans, Consultant Programmer, who joined the OpenPrescribing technical team; and Brian MacKenna, an Honorary Research Fellow Pharmacist and member of the NHS England Medicines and Diagnostics Policy Unit. We also welcomed Darren Smyth, a UK and European Patent Attorney – our work so far includes our pregabalin papers (here and here), and he has also contributed to our EUCTR work.
New “do not prescribe” measures on OpenPrescribing.net
At OpenPrescribing we pride ourselves on developing our tools in response to the needs of our users. Last week NHS England announced a new “Do Not Prescribe” list for consultation. Within an hour we made graphs showing every GP practice’s prescribing of these items. You can drill down to CCG level, and then practice level.
This week we launched a new feature on OpenPrescribing, an NHS Price Concession calculator. We show the cost impact of price concessions for the whole of England here and the calculator appears on every single practice and CCG dashboard so you can work out the impact locally.
Earlier this week NHS England announced a new “Do Not Prescribe” list for consultation.
Within an hour we made graphs showing every GP practice’s prescribing of these items. You can drill down to CCG level, and then practice level.
We hope that this data will be useful for clinicians and CCG pharmacists to identify where there is most room for improvement, or change. Or, to drive discussion about agreement on the guidance.
The data that drives OpenPrescribing is described briefly in our FAQ. It is supplied by NHSBSA and NHS Digital, and a few other sources.
Over the years we have come to understand the limitations of this data. We’re sharing them here, so researchers can take them into account when carrying out analyses.
When using Practice Level Prescribing Data, bear in mind:
All England Dashboard - A New Feature on OpenPrescribing.net
At OpenPrescribing we pride ourselves on developing our tools in response to the needs of our users. OpenPrescribing is being increasingly used at national organisations and we have had many requests for an All England dashboard. This month we launched the first version of the All England dashboard and blogged about it here.
Drug supply issues are an interesting use-case for OpenPrescribing. Here we will talk about a recent example.
What is the problem?
Last week the Department of Health and Social Care issued a “Supply Disruption Alert” for Epanutin (phenytoin) 30mg/5ml oral suspension: Pfizer, the manufacturer, will be out of stock of this product from the week commencing 29th October (today) until early December 2018. This means people currently taking Epanutin (phenytoin) 30mg/5ml oral suspension may need to be prescribed a different product.
This week we have launched a new page on OpenPrescribing.net, the All England dashboard, that allows anyone to see the quality of prescribing at a national level. For the first time we have aggregated all the savings from all our measures in one place. For the month of August these numbers are quite staggering:
Update: You can view a short Youtube video demonstrating this feature here.
You can select a category using the new dropdown menu above the measures…
At OpenPrescribing, we provide tools for analysing prescribing behaviour in primary care in the NHS in England. If you work with prescribing data, you may have noticed that practices which are “dormant” apparently continue to prescribe. This short article explains why, for the curious.
What is a Dormant practice?
Our prescribing data comes from the NHS Business Services Authority (NHSBSA), who are responsible for processing dispensing information supplied by pharmacies. Each line of the data includes a practice code which uniquely identifies the GP Practice that issued the prescription. To understand more about each practice (including its contact details, location, and CCG membership), we cross-reference this code with GP Practice data published by NHS Digital. That data contains a column, status, which sometimes contains the value D, for dormant.
Recently, we’ve been experimenting with integrating the Dictionary of medicines and devices (dm+d) into our prescribing data. dm+d is the standard dictionary for the medicines and devices used across the NHS, and it contains codes and descriptions for these medicines.
There are several benefits to using dm+d; the most useful side-effect is to allow us to show user-friendly names for drugs. The canonical names for drugs in the NHS prescribing data are sometimes very hard to read. They are taken from the NHS’ own version of the British National Formulary, which uses heavily truncated names, full of abbreviations, so they can fit within an arbitrary 15-character limit.
OpenPrescribing takes open datasets from NHS Digital and NHS Business Services Authority, and makes it easy for people to explore the prescribing dataset. We also use this dataset in our research, and offer bespoke data extracts from the prescribing dataset for researchers, clinicians and NHS staff (get in touch!). In this series of blog posts we’ll explain key concepts and share our knowledge of the prescribing dataset. In the first blog, we take a look at BNF codes.