Quality use of medicines: who owns it now?

[Music] Welcome to the Australian Prescriber Podcast. An independent, no-nonsense podcast for busy health professionals.

I'm Dhineli Perera, your host for this episode, and it's a pleasure to be speaking to both Jonathan Dartnell and Darlene Cox today about the recent changes to the quality use of medicines landscape in Australia. Jonathan is the Managing Director of QUM Connect, with years of experience dedicated to improving and implementing QUM research and evidence. Darlene is the Executive Director at Health Care Consumers’ [Association] and has been an eminent advocate for health consumers being part of the movement since the late 1990s.

Jonathan and Darlene, together with their co-authors, Paresh Dawda and Catherine Hill, have discussed the need to maximise the opportunities and mitigate the risks to improve QUM in the context of the new distributed stewardship function in Australia. So a warm welcome to you both on this really interesting topic today.

Now, Jonathan, I might get you to start us off by refreshing us on what NPS MedicineWise was and explain what quality use of medicines is.

JD: Thanks for that, Dhineli. So, NPS MedicineWise began in 1998. It was first called the National Prescribing Service. It was set up by government to be outside of government as an independent not-for-profit organisation for the quality use of medicines. And in that role, it was supporting the National Medicines Policy alongside the pharmaceutical industry, alongside Therapeutic Goods Administration, and alongside the Pharmaceutical Benefits Scheme.

So quality use of medicines were sitting in the centre, in effect, bringing all of that together. And NPS MedicineWise was the steward for Quality Use of Medicines [QUM] supporting that. And the job it had was to put QUM in the minds and actions of consumers and health professionals whenever and wherever medicines were being used. But practically speaking, it provided a coordinated and national approach to improving how we use medicines.

First of all, it provided a wide range of resources, complementing some other national information resources such as Therapeutic Guidelines and Australian Medicines Handbook. In addition to those resources, data was at the heart of what NPS was doing to understand the problems, to provide feedback to prescribers, and to evaluate the impact of all these activities.

Another important facet was around conducting national quality use of medicine education programmes to target specific problems for GPs, pharmacists and nurses. One last thing was around the evaluation of the work of NPS, looking at how resources were used, their impacts on knowledge of both health professionals and consumers, and how prescribing and test use and sometimes health outcomes were changed through the different activities that were implemented.

Prior to NPS MedicineWise wrapping up, Jonathan, there was a redesign of the Australia Government-funded Quality Use of Diagnostics, Therapeutics and Pathology programme. What changes did this redesign result in?

JD: The redesign resulted in some really major changes and, in the context of those changes, NPS MedicineWise was wound up as an organisation. So I guess there are 3 main areas of change. Many of the assets were transferred to the Australian Commission for Safety and Quality and Healthcare. That included the [NPS] website, the MedicineInsight data programme, PBS Practice Reviews, RADAR Publication*, MedicineWise app, Choosing Wisely, and some other things.

And then some things were put out for competitive tender. That included Australian Prescriber (the journal), the National Prescribing Curriculum, and Medicines Line. And then the last tranche in terms of change was around the national quality use of medicine education programmes. Some of the funding that had gone to NPS to run those national programmes became available as competitive grants, either to support consumer health literacy or for health professional education.

Right. So it was like a redistribution, if you like, to a few different paths, but trying to keep some of these programmes in function and all under review.

JD: Yes.

So Darlene, from a consumer's perspective, could you walk us through what opportunities have opened up as a result of these changes, and your experience in this area?

DC: Yeah, thanks for that. I think one of the things that NPS was able to achieve was to be a trusted source of information for consumers as well as pharmacists and other health professionals. In terms of consumers, one of the clear areas in the contestable grant rounds is for consumer health literacy. And it was an opportunity for Health Care Consumers’ [Association] to partner with a number of other great organisations to develop a Quality Use of Medicines Alliance and to apply for that funding. So the consumer health literacy grants are allocating a number of millions of dollars over a couple of years to focus on meeting consumer needs.

Quality use of medicines really is about that amazing relationship between consumers and carers, prescribers and dispensers. And so what we're trying to do with the grants we have, with our Quality Use of Medicines Alliance, is really bringing together those different views to find out how can we make sure that people get access to the medicines they need, understand how to use them so that we can live the best lives we can. We've been able to identify a number of topics of importance to consumers and then develop the materials around that.

And so, Darlene, do you think that these changes have allowed for efforts to also shift to areas of greater need, such as aged care and Aboriginal and Torres Strait Islander health?

DC: So certainly in the work that we are undertaking, we have a focus on Aboriginal and Torres Strait Islander health and older people. I think more generally, there has been an increase in funding for the NACCHO [National Aboriginal Community Controlled Health Organisation] programme of Good Medicine Better Health, which is very, very good to see, and we want to see how that unfolds. But I can't yet see that there's been an equivalent focus on aged care. Certainly polypharmacy and deprescribing gets a very strong focus. But even in terms of the health literacy aspect, how are we supporting individuals as we get older or for those who are caring for older people? There's a whole lot of stuff around how we manage our medicines that we still need to be addressing for consumers, and this is compounded when we get older.

Definitely room to grow and improve in that sector as well. So, I guess with every new opportunity, which this redistribution of QUM responsibilities has opened, there is new risk. So Jonathan, could you describe some of these new risks for us with some tangible examples?

JD: I think the main challenge is that with more groups developing and delivering QUM-related work, there'll be greater fragmentation. With information and services for consumers and health professionals being more distributed across different organisations, across different places, it might be harder to find reliable sources. As Darlene was saying, NPS built its reputation up over 20 years, and you can't replace that role and trust instantly. And in the meantime, it's possible that other poorer-quality information resources may take up the slack.

There's a whole range of expertise needed to address quality use of medicines, different sorts of capability in implementation science, programme design, social marketing, and other areas. And I think we'll see a continuous development of that capability, but we've really got to nurture it. And I think there's one more risk that exists now, that as the work to support quality use of medicines is grant-based or tender-based, that there may be more discontinuity over time.

Coming back to the Australian Commission on Safety and Quality in Healthcare being the new custodians of the vast majority of programmes that NPS MedicineWise coordinated. Darlene, what do you think might be the best way for the Commission and the clinicians across the board, so prescribers, nurses, all allied health, how do we keep them connected with the health consumers? What would you think is the best way to keep that connection going?

DC: Well, I think this is actually one of the Commission's strengths, because they have the national healthcare standards, and in that there is a standard around Partnering with Consumers. It's a minimum set of standards where the expectation is that all publicly funded hospital and health services will be having processes, mechanisms in place to ensure that consumers feel empowered in their service, are more active in their care, treated as part of the team.

The Commission knows how to partner with consumers. They know how to do it well. So they can then guide other organisations who may not be as developed in the way in which they can work with consumers; they can provide that support for them. They are well-connected to a whole range of the state and territory peak bodies for consumer interests. Similarly, they've got good relationships with health professionals and a growing connection with colleges.

Coming back to a point you touched on, Jonathan, about some of the competitive tender processes where some of the functions of NPS went to a few other organisations outside of the Commission. Could you talk us through some of these distribution steps, and what has been involved in this process and where it's at?

JD: So the three main areas of tender work, Australian Prescriber was one. And ultimately, Therapeutic Guidelines won that tender and is now publishing Australian Prescriber, and I think we can all see the success of that transition. I wouldn't underestimate the challenge in actually making that transition happen seamlessly, which it has done. The other two tender outcomes related to the National Prescribing Curriculum, which went to the University of Tasmania, and similarly with the Medicines Line, that went to Australian Healthcare Associates and is known now as 1300 MEDICINE. I assume for both of those that that's worked out well. There's continuity and it's good to see that they've been supported adequately through those tender processes.

So I guess the rest of the functions may or may not stay with the Commission, but they're being reviewed and looking to be optimised in some shape or form. And so, Jonathan and Darlene, could you describe a few of the grants that have been awarded in August 2023, which aim to re-emerge as functions with targeted health professional education and consumer health literacy?

DC: We assembled a group of organisations to form a QUM Alliance, so Wiser Healthcare, which is a research collaborative, the [Royal Australian] College of General Practitioners, the PSA [Pharmaceutical Society of Australia], Medcast, a health professional education provider. And then a couple of issue-specific organisations, Eczema Support Australia and Arthritis Australia to join together with Health Care Consumers’ [Association] to really form that alliance. We decided to look at four areas. So we were looking at gout, anticoagulants, antidepressant use in older people, and use of topical steroids for eczema in particular. And the way we approached it was a consortia approach. We wanted that shared decision-making to frame our whole approach.

Health Care Consumers’ [Association] is leading the consumer health literacy grant. Medcast is leading the health professionals grant, but we work very closely together across both grants to inform them. So it's very complementary. We have an agreed set of principles around what health literacy means for all of our organisations, and also what co-design means for us. So we're using a tried-and-true robust methodology that was refined through colleagues who are working at the NPS and other colleagues, to come up with the research that we need to identify the issues and the gaps, and then develop interventions with consumers and carers to advance that. And so that's where we're up to.

So far, we've got our eczema resources online for health professionals and consumers, and we're just finalising the work around gout before leading onto the others. So it's been an amazing process of bringing together health professionals as well as consumers and carers to identify what's important and then come up with a design to deliver on interventions that meet the need.

Coming back to your article, Table 1 lists a lot of the functions that NPS MedicineWise had, and there seems to be many that are under review. Is there an expectation that these functions will continue, perhaps rebranded at some point in the future?

JD: MedicineInsight, as I understand, they're building up re-consenting general practices into MedicineInsight. It's not operational as yet, as I understand. Hopefully that will come to be, again, a really important general practice database to be used for many different purposes; for research, for understanding quality use of medicines issues, for providing feedback to general practice, for evaluating change.

Another good example is around the PBS practice reviews, which provided reports to individual prescribers about their prescribing practices or their use of tests in comparison with others, and is a really useful tool for QUM. Another example is the MedicineWise app, and we hope that continues to develop and be available as a really useful tool for consumers in managing their medicines.

DC: Another really important one for consumers is to know about the Adverse Medicine Events line, to know about the importance of reporting adverse events with medicines. And from a consumer advocacy perspective, we would love to know more about what is being reported. What are we picking up on? Are consumers in fact identifying trends in adverse events that we can do something about? Because there is a logical link to health literacy there.

This points to the issue of what we've lost with NPS, because we had one place for people to go to and there was brand recognition. We don't have that now. So the fragmentation means it is a bit harder for consumers to know where to go to for medicine information.

Do you see an overarching governance network being the answer to many of these linking and unanswered questions in the landscape? And if so, how do you foresee that it will be different to what NPS MedicineWise was in the first place?

DC: There is an obvious void that's been left by NPS MedicineWise finishing up. Ultimately though, in the current environment, no one single organisation or person owns QUM. All of us have to work collectively to address it, to understand what's important, and to make sure that we support people to make safe and wise decisions about medicine use.

Wonderful. Well, that's unfortunately all the time we've got for this episode. Thank you so much for joining us today, Jonathan and Darlene.

JD: Thank you very much, Dhineli.

DC: Yeah, thanks Dhineli. It's been a pleasure.

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Jonathan and Darlene's article, ‘Quality use of medicines: who owns it now?’ is available on the Australian Prescriber website. The views of the hosts and guests on the podcasts are their own and may not represent Australian Prescriber or Therapeutic Guidelines.

Jonathan Dartnell is Managing Director of QUM Connect, a member of QUM Alliance, who has won associated grants from the Australian Government Department of Health and Aged Care. Darlene Cox is the Executive Director of Health Care Consumers' Association (HCCA), which is also a member of QUM Alliance. HCCA is the lead agency for a Consumer Health Literacy grant, also distributed by the Australian Government Department of Health and Aged Care.

I'm Dhineli Perera, and thank you for joining us on the Australian Prescriber Podcast.