Case study: University Hospital Southampton

Medicines management and gain share with commissioners

  • - £446k saved per year by patients stopping unnecessary therapy

  • £303k saved per year by reducing biologic therapy dose

The implementation of a dedicated biologics review clinic at University Hospital Southampton has saved £750k through improved medicines management of high cost biologics. The savings are shared between the hospital and commissioners through an innovative gain-share agreement.

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The challenge

The University Hospital Southampton has a low number of rheumatology consultants per head of population and was therefore unable to meet NICE guidelines for reviewing biologics patients every six months. The service wanted to monitor biologic patients better to eliminate inappropriate use of high cost biologics and reduce biologic spending.

The solution

  • - A biologics review service for inflammatory arthritis patients was established, to regularly review biologics patients and ensure that only responders continue to receive these high cost therapies (see the service care pathway)
  • - An electronic database and prescription system captures patient details at each visit. Reports on patient outcomes and drug spending can be produced to feed back to commissioners
  • - The service also revised its homecare delivery programme to reduce the stock available to patients (from 16 weeks to four weeks) in an attempt to cut wastage and costs
  • - The design of the service was based on the NICE guidelines on the use of biologics in RA patients1 and the EULAR 2010 recommendations regarding dose reduction of biologics

Service performance and outcomes

  • - The new biologics review pathway was implemented from January 2012, and between then and January 2013, 319 rheumatoid arthritis patients entered the service
  • - The mean time between appointments was reduced substantially to 4.6 months, which is in accordance with NICE recommendations
  • - The regular appointments led to frequent changes in therapy
  • - Cost savings were made through patients stopping high cost biologic therapy and through patients reducing the dose of therapy when they attained clinical remission
  • - Patient care was improved by switching patients to alternative therapy if they had a poor response, or allowing them to enrol in clinical trials if they had failed all approved therapies

Patient focus and satisfaction

  • - As this service is led by one consultant, patients receive excellent continuity of care. Care coordination has also been implemented through a specialist nurse and direct access telephone hotline for patients and GPs
  • - In a recent patient satisfaction survey, 100% of patients were satisfied with the care they received in the clinic

Financial performance and outcomes

  • - The biologics review service realised annual cost savings of £446,000 due to patients switching therapy or reducing dose and £303,000 was saved due to patients stopping therapy or entering a clinical trial
  • - To incentivise the hospital to make the initial investment, an innovative gain-share scheme was employed to share cost savings equally between the trust and commissioners

Commissioning priorities

  • - The Southampton medicines management and gain share service is an example of commissioning best practice in rheumatology and meets a number of the priorities for commissioners as outlined by the King’s Fund in 2013:3
  • - Medicines management (co-produced with a pharmacist) – through treat-to-target to international standards, use of IT and changes to homecare delivery, the service reduced wastage of high cost biologic therapies, while improving patient outcomes
  • - Managing ambulatory conditions – regular reviews ensure that patients’ conditions are closely managed to avoid extra hospital visits
  • - Active support for self-management - patients are educated during meetings with consultants and have access to a telephone hotline to manage issues between appointments
  • - Care co-ordination - through the specialist nurse and direct access for patients and GPs to the integrated care team
  • - Furthermore, the use of gain-share between commissioners and hospitals is also recognised by the Department of Health as best practice for commissioning. This service is therefore a best practice model for all services where high cost products are routinely used and need close monitoring and adjustment

Sponsorship statement

This best practice case study project has been sponsored by UCB and supported by a medical education grant from Pfizer.
UCB and Pfizer have not had any influence over content: editorial control remained with the British Society of Rheumatology.

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We gratefully acknowledge the generous support of our sponsors, which enabled the case study project to take place.