Best Value DOAC (BVD) switch project (2025)

Medicines Optimisation Team, NHS Cambridgeshire and Peterborough

Project summary

During early 2024 as a system NHS C&P had worked hard as a collective to ensure our market share of Edoxaban prescribing was as high as possible in line with the at the time national framework for direct-acting oral anticoagulants. Our system was acclaimed by national leaders due to the rapid rate of change achieved with the input of clinicians across secondary and primary care and the hands on support of several MOT clinical team and 10 external associate pharmacists.
Then the generic apixaban and rivaroxaban presentations became available in mid-2024 which was 2 years sooner than expected and the National commissioning recommendations for DOACs were updated. The at the time MOO dashboard rated NHS C&P as "1" - the system with the most opportunity to achieve by switching away from edoxaban to a BVD. The system had moved from the best to the worst position overnight.
With the switch to edoxaban in recent history and imminent GP group action looming it was a very hard sell to system clinicians to move to a BVD - despite the potential £5 million prescribing efficiencies available (based on a 90% conversion rate).
Honest and open discussions took place with system leads acknowledging their perceived "absurdity" of the situation. In line with standard governance procedures system formularies and guidance, GP clinical system prescribing support software were updated to support clinicians to prescribe a BVD in preference to edoxaban for new patients.
This strategy would not allow NHS C&P to take advantage of the nearly £5 million efficiencies hence system clinical leads were approached to endorse a switch programme. This involved challenging conversations however a switch programme was agreed.
GP teams were offered a payment per switch as part of a DOAC LES that ran for 2 months. This was not as successful as hoped due to the issue of capacity to deliver in general practice when challenged with other clinical priorities and around £1 million was released based on an investment £42k.

The next phase was to gain funding for 3 x prescribing pharmacists to deliver the programme on behalf of practice teams. This was granted by the finance team according to the presentation of a robust case. A switch guide (not SOP) was written to support the prescriber pharmacists.
Gaining GP engagement was initially challenging as the previous programme had required practice teams to deal with blood test requests, patient lists to authorise and deal with post switch patient enquiries.

Due to clinician education around DOACs at the time of the previous switch including for monitoring, and based on Eclipse data for the system we were assured nearly all of our patients were being monitored in line with national guidance (NICE/SPS). Hence the pharmacists could focus on discussing the switch with patients, gaining consent, safety netting and amending the patient record as needed. (Although alerting the patient if monitoring was overdue)