Verity Morton is a Senior Programme Development Lead who has worked for Health Innovation Manchester for the past 5 years, leading the delivery of health and social care innovation adoption and spread programmes. Prior to this she worked on system transformation programmes, service implementation and pathway re-design projects, as a health service commissioner, and in governance and quality lead roles for acute, community, and mental health trusts.

Over the past year, I have had the pleasure of leading the Health Innovation Manchester (HInM) Medicines Programmes. During 23/24 we collaborated with stakeholders from across the Greater Manchester (GM) health and care system and academic partners to design, develop, and deliver resources to GM health care professionals that support the reduction of problematic polypharmacy and long-term opioid use for chronic pain. Medication is by far the most usual form of intervention for many acute and chronic conditions. Medicines have saved and improved the lives of millions of people however the challenges of treating multiple medical conditions and a common misunderstanding of how to manage chronic pain can lead to unnecessary harm.

National Medicines Patient Safety Improvement Programme

GM has one of the highest opioid prescribing rates in England, with opioid use (as defined daily dose/1000 GP registrants/day) of 53.1 compared to 13.9 in London and 36.9 nationally.[1] In addition, opioid-related deaths and harms (such as dependency and addiction) have become increasingly prominent in the UK.[2] Optimising opioids has always been one of the priorities medication safety and optimisation agendas for local and national governments.[3]

The aim of the Medicines Safety Improvement Programme (MedSIP) is to implement the Whole Systems Approach to High-Risk Opioid Prescribing Framework. As part of phases 1-4 of the framework, the MedSIP team hosted discovery workshops with GM stakeholders, to identify where improvements were needed and what could be done to contribute to the programme’s national aim of reducing harm from opioids.

Our stakeholders told us that to successfully support people living with chronic pain, primary care health care professionals needed more education, training, tools, and resources. We then set up multi-disciplinary working groups to refine this aim and understand what the most effective outputs of the programme would be. The working groups agreed specific objectives:

The Greater Manchester Pain Management Resources Hub brings together all the medicine programmes’ assets in one place. This meets the four 23/24 MedSIP objectives outlined in figure 2 above.  The Hub launched on 17th January 2024 and is available on the GMMMG, GP Excellence, GM Training Hub, and HInM websites. The Hub was co-designed with healthcare professionals and people with lived experience of pain.

Available to healthcare professionals supporting people living with pain, the resources include a variety of useful resources including:

• Short, accessible guidance to support effective consultations developed by GM pain specialists,
• patient self-management information like our experience-based co-designed patient information leaflet,
• clinician aids and tools gathered, reviewed, and recommended by GM pain specialists,
• shared learning and education like the Pain Management Workshop recordings and our Primary Care Knowledge Boost podcast on Pain that has had 9.3k listens to date
• How-to guides to support use of data to understand the local population,
• Information to access related services across the conurbation including social prescribing

National Polypharmacy Programme

Running concurrently to the MedSIP, the National Polypharmacy Programme was entering its second year. Most medical research, guidelines and contractual agreements are focussed on single targets for single disease states, whereas, most people have multiple morbidities, requiring different treatments which create complex health care needs for some of the most vulnerable in society. As more and more people live longer with multiple long-term conditions, the number of medicines they take increases. The resulting polypharmacy (use of multiple medicines) can be appropriate or inappropriate.

The National Overprescribing Review’s (NOR) Good for you, good for us, good for everybody report was published in 2021 by the Department of Health and Social Care. It found that overprescribing is a serious problem in health systems internationally that has grown dramatically over the last 25 years.

In GM 13.3% (or 24k) of people aged 75 and over take 10 or more medicines compared to a national average of 9.87%.[7] The Health Innovation Network Polypharmacy Programme aims to support local systems and primary care to identify patients at potential risk of harm and support better conversations about medicines by promoting shared decision making.

The HInM Polypharmacy Programme team has supported NHSGM to reduce inappropriate polypharmacy and encourage effective shared decision making through three core principles (Pillars) of Polypharmacy: population health management, prescriber education and training, and evaluation of public behaviour change material, plus a community of practice.

We have been recognised by the national team for our contributions to all 3 programme pillars.

• In year one (2022/23), the team was asked to demonstrate the GM Tableau interactive maps that were developed by the Insights & Intelligence team using created with ePACT2 data and the Index of Multiple Deprivations (IMD) to identify and prioritise at risk patients
• By the end of 23/24 HInM was the highest referrer to the polypharmacy ALS training, with 78 GM prescribers completing the course
• Our successful public behaviour change pilot in 23/24 resulted in production of two case studies for the national programme and led to local adoption of the materials
• Our Primary Care Knowledge Boost podcast on Polypharmacy released at the end of January 24 has had 7.2k downloads to date and has been added to the national team’s website

Enablers for success

When reflecting on the challenges and achievements of HInM medicines programmes over the last year, key enablers to successful implementation were:

Collaborating for Success

Central to the success of both these programmes was engagement with our colleagues in the GM health care system and involvement of people with lived experience. It was evident that there were existing teams, individuals, and organisations with aims similar to our own. We did not need to raise awareness of the need for change, and we found partners and stakeholders who understood the problem and were motivated to support change.

The NHSGM Chief Pharmacist and the Integrated Pharmacy and Medicines Optimisation (IPMO) Group provided strategic direction to align with local medicine priorities. We also worked with place-based champions who were vital for gaining buy-in with frontline health care professionals and amplifying messages about events, training, and resources. Specialists led the development of local resources and their willingness to share their expertise and give their time to upskill their colleagues was inspiring. People with lived experience of chronic pain were supported by the project team to produce a patient information leaflet which focused on what they felt was important to share with others living with chronic pain. We also partnered with the University of Manchester using an experience-based co-design approach to review how we shared the pain management resources with the system and identify further improvements. Our use of discovery workshops, working groups, and experience-based co-design approaches meant that our outputs were optimised and met the needs of the intended audience.

Consolidated and Efficient Approach

We sought to capitalise on opportunities presented by the synergies between the two medicines programme. Both programmes involve an overlapping cohort of stakeholders and some of the outputs to address the problems identified apply to people with chronic pain and people experiencing problematic polypharmacy. The HInM team:

• worked with partners to cross-promote training courses and events
• developed deeper stakeholder relationships by working together on both programmes
• provided resources to support the shared aim of reducing medicines through effective structured medication reviews
• and established a GM Medicines Optimisation Community of Practice which focused on subject matter common to both workstreams

Adaptability and Continuous Learning

As we developed relationships with local stakeholders, we gained a greater understanding of their needs and how our interventions could be most effective. One of our early activities was to bring stakeholders together and discuss the problems within the patient pathway. These multidisciplinary workshops supported group discussion of problems, possible interventions, and desired outcomes. This ensured our programme outputs were right for the needs of our stakeholders. This was an approach we continued to employ throughout the programme. For example, attendee feedback from the first Pain Management Workshop was central to the design of the second. The focus of the event was adapted to meet the need expressed by health care professionals to hear from a wider range of services and alternatives to medicines.

Whilst our focus is on taking the most effective approach for our local health and care system, our methods are also informed through continued shared learning with our Health Innovation Network colleagues from across England. The national network acts as a learning and support system that enables programme teams to rapidly connect, learn from each other, share successes and valuable learning from challenges.

Integration and Sustainability

In addition to collaborating with stakeholders to develop interventions or support changes in practice, it is important to understand how any outputs can be maintained after the programme ends. Agreeing a plan for business-as-usual ownership from the beginning is key to longevity and informs how any outputs are developed including requirements for how to guides or standard operating procedures as part of any handover.

We worked closely with the GM medicines clinical governance structures to provide regular progress updates and agree outputs. We successfully obtained the support and endorsement of the Greater Manchester Medicines Management Group (GMMMG) and the Integrated Medicine and Pharmacy Optimisation Group.

Programme offers and assets require promotion to ensure adoption and use by the intended audience. Throughout the year, we identified communication channels and opportunities to promote events, training courses, and workshops. We used attendance at system or place-based meetings, newsletter articles, blogs, and podcasts to share information.

For the Greater Manchester Pain Management Resources Hub, we developed a communication plan with its own branding for engagement activity planned pre- and post- launch day. This included key messages that were amplified by HInM, our system partners, and stakeholders. We provided an overview of the available assets, details of the development process, supporting quotes from GM system clinical leaders, and the option to be notified when the Hub was launched.

What next?

The next steps from the polypharmacy programme are for primary care prescribers to share what they have learnt from the polypharmacy training, and to continue to introduce and embed the patient behaviour change materials in their structured medication reviews (the materials can be accessed via the Greater Manchester Pain Management Resources Hub).

The HInM team will continue to support and encourage health care professionals to access, review, and add to the Hub resources during 24/25.  We will work closely with our partners in the system to enable the application of the pain management and opioid reduction resources in practice. The HInM team will collaborate with key GM stakeholders to identify the focus of the MedSIP for 24/25, to ensure the programme has impact and contributes to the overall aim of reducing harm from opioids.

[1] Chen TC, Chen LC, Kerry M, Knaggs RD. Prescription opioids: Regional variation and socioeconomic status – evidence from primary care in England. Int J Drug Policy. 2019;64:87-94

[2] Gill S, Bailey J, Nafees S, Poole R. A qualitative interview study of GPs’ experiences of prescribing opioid medication for chronic pain. BJGP Open. 2022;6(4):BJGPO.2022.0085

[3] The Lancet Public Health. Opioid overdose crisis: time for a radical rethink. The Lancet Public Health. 2022;7(3):e195

[4] Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011 Apr;86(4):304-14. doi: 10.4065

[5] Payne RA, Abel GA, Avery AJ, Mercer SW, Roland MO. Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. Br J Clin Pharmacol. 2014 Jun;77(6):1073-82. doi: 10.1111

[6] Nivya K, Sri Sai Kiran V, Ragoo N, Jayaprakash B, Sonal Sekhar M. Systemic review on drug related hospital admissions – A pubmed based search. Saudi Pharm J. 2015 Jan;23(1):1-8. doi: 10.1016

[7] National ePACT2 data for Greater Manchester ICB as of December 2023