Context

From April 2010 to March 2017 NHS Forth Valley contracted an enhanced service with GP practices called whole system working (WSW). In the financial periods of 2013–2014 and 2014–2015, WSW included an intervention that — alongside other activities to improve patient safety, to improve communication between practices, hospital consultants and out-of-hours services, and increase engagement with locality improvement activity — aimed to improve primary care prescribing safety by focusing on reducing the use of unsafe drug combinations. In each financial year, practices were paid £0.80 per registered patient (approximately £4000 for an average-sized practice of 5000 patients) for completing all work related to WSW.

Intervention specifics

Targeted high-risk prescribing (2013–2014) Patients aged ≥65 years prescribed the ‘triple whammy‘ combination (NSAID + ACEI/ARB + diuretic) Patients aged ≥65 years prescribed an NSAID without gastroprotection Current anticoagulant user prescribed an NSAID without gastroprotection

Targeted high-risk prescribing (2014–2015) Patients aged ≥75 years prescribed an oral antipsychotic

Educational workshop

A brief educational intervention focusing on NSAID risks (quarter two, 2013) and antipsychotic risks in older people (quarter two, 2014) lasting approximately 45 minutes was delivered each year in June, during a 2.5-hour long educational session on patient safety in primary care, which the majority of GPs attended. The 45-minute educational session included providing comparative data on practice rates for that year’s measures, and what was expected of practices.

Feedback and written educational material

During each year, around the same time as the educational workshop was held, each practice was given written educational material summarising the educational outreach workshop information. Accompanying this was a single round of feedback showing practice rates of targeted high-risk prescribing compared with the average for the health board and practices’ ranking within the health board. The same written material and feedback were given directly to all participants at the educational workshop.

Financial incentive

Within each year practices qualified for the WSW payment only when they provided evidence of completing all WSW elements. The evidence required for the high-risk prescribing component was simply to report to the health board the number of patients triggering the measures at baseline and 6 months later, rather than to provide evidence of change in high-risk prescribing rates.

Patient identification support

In both years, practices identified patients for review using search tools supplied by NHS Forth Valley to run in their own electronic medical record systems. Pharmacists employed by the health board reviewed the output of these searches to produce a clean list of patients for GPs to focus on (for example, by checking that the patient had actually received the targeted drug combinations). GPs were asked to review identified patients’ records, and then take whatever action they judged appropriate (for example, continuing, amending or stopping medication without further review, or contacting the patient to discuss). There was no WSW requirement to report to the health board the actual action taken.

ACEI = angiotensin converting enzyme inhibitor. ARB = angiotensin receptor blocker. NSAID = non-steroidal anti-inflammatory drug. WSW = whole system working.