The Medicines Optimisation Innovation Centre: a dedicated centre driving innovation in medicines optimisation-impact and sustainability

Background Sub-optimal medicines use is a challenge globally, contributing to poorer health outcomes, inefficiencies and waste. The Medicines Optimisation Innovation Centre (MOIC) was established in Northern Ireland by the Department of Health (DH) in 2015 to support implementation of the Medicines Optimisation Quality Framework. Aim To demonstrate how MOIC informs policy and provides support to commissioners to improve population health and wellbeing. Setting MOIC is a regional centre with multidisciplinary and multi-sector clinical expertise across Health and Social Care and patient representation. Development Core funded by DH, MOIC has a robust governance structure and oversight programme board. An annual business plan is agreed with DH. Rigorous processes have been developed for project adoption and working collaboratively with industry. Implementation MOIC has established partnerships with academia, industry, healthcare and representative organisations across Europe, participating in research and development projects and testing integrated technology solutions. A hosting programme has been established and evaluation and dissemination strategies have been developed. Evaluation MOIC has established numerous agreements, partnered in three large EU projects and strengthened networks globally with extensive publications and conference presentations. Informing pathway redesign, sustainability and COVID response, MOIC has also assisted in the development of clinical pharmacy services and antimicrobial stewardship in Europe and Africa. Northern Ireland has been recognised as a 4-star European Active and Healthy Ageing Reference Site and the Integrated Medicines Management model as an example of best practice in Central and Eastern Europe. Conclusion MOIC has demonstrated considerable success and sustainability and is applicable to health systems globally.


Background
Sub-optimal medicines use is a challenge globally, contributing to harm, poorer health outcomes, inefficiencies and waste [1,2].In healthcare, 1 in 20 patients experience preventable medication-related harm [3].Sub-optimal use of antimicrobials, contributing to antimicrobial resistance, is one of the top 10 global public health threats and the focus of the European One Health Action Plan [4].The ageing population and increasing numbers of people living with multiple long term conditions have escalated demand for medicines [5].Northern Ireland (NI) consumes more medicines, including antimicrobials and analgesics, than other parts of the United Kingdom (UK).The mean number of prescription items per person per year in NI is 23, costing £245, the highest in the UK [6].
The environmental impact of pharmaceuticals, including antimicrobial resistance and loss of biodiversity is a growing concern, requiring urgent action and the introduction of 'eco-directed and sustainable pharmaceutical prescribing' [7].Constrained resources, workforce pressures and the need to rebuild following the Covid-19 pandemic, further compound the unprecedented challenges faced by healthcare systems worldwide.Innovation in medicines optimisation, embracing pathway redesign, behavioural science, sustainability, pharmacogenomics, artificial intelligence and integrated technology solutions, including companion diagnostics, is needed to transform healthcare systems, supporting the delivery of high quality, safe, effective and sustainable person-centred care [8][9][10].
In 2016, the NI Department of Health (DH) published the NI Medicines Optimisation Quality Framework [11].The aim was to support better health outcomes for the population through gaining the best possible outcomes from medicines every time they are prescribed, dispensed or administered.The Framework focussed on the consistent delivery of best practice and supported the development and implementation of new, evidence based best practice delivered through an innovation and change programme involving multi-disciplinary professionals working together and with patients.
The Medicines Optimisation Innovation Centre (MOIC) was established by the DH in 2015 to support implementation of the Medicines Optimisation Quality Framework.

Aim
To demonstrate how MOIC informs policy and provides support to commissioners to improve population health and wellbeing.This provides an evidence base to influence change across the following four MOIC strategic themes: 1. Focus on the needs of patients and the NI population.2. Accelerate the adoption of innovation into practice to improve clinical outcomes and efficiency.3. Build a culture of partnership and collaboration.4. Make a meaningful contribution to the NI economy.

Development
MOIC was established as a regional centre of expertise in NI.It is a dedicated space to develop a systematic approach to finding, testing and scaling up service and technology solutions for the Health and Social Care (HSC) service.The HSC is the term used for the National Health Service (NHS) in NI.
MOIC is uniquely positioned.NI remains in the European Union (EU) single market for goods, in the EU Customs Territory and in full regulatory alignment with the EU.As a health service organisation, MOIC facilitates access to clinicians and patients across the HSC.

MOIC team
The Core Team is the Director, Deputy Director and Lead and a number of Senior Research and Innovation Programme Managers (educated to PhD level), Communications Manager and Secretary.The MOIC Team includes clinical pharmacy expertise, contributing to project design and delivery.This is complemented by multidisciplinary clinical expertise from across the HSC and patient representation.Two members of the MOIC Team are Health and Wellbeing Champions.

Funding
Funding is secured from three main sources:

Governance
Hosted in the Northern Health and Social Care Trust (NHSCT), a major HSC Trust in NI, MOIC has a robust governance structure and oversight Programme Board, responsible for overseeing the work and strategic direction.The Programme Board, chaired by the Trust's Accountable Officer, includes membership from across DH, healthcare, academia, industry and patient representation.Regular reports on activity and projects are provided to the Programme Board to monitor progress against the agreed business plan and to review projects undertaken via grant acquisition.For commercial projects, a bespoke project adoption process has been developed, incorporating project adoption documentation and a Project Adoption Committee.This process ensures that only projects which meet MOIC key themes are adopted.These measures ensure compliance with Regional Research and Information Governance requirements.

Communications and dissemination
Communications and dissemination strategies have been designed to ensure MOIC and its work, projects, outcomes and reports are promoted extensively across a variety of media.

Implementation
MOIC secures evidence to inform Departmental Policy and pathway redesign.

Collaborations and partnerships
MOIC establishes collaborations, partnerships and agreements with academia, industry, healthcare and representative organisations, locally, across Ireland, Europe and beyond.These are selected based on common objectives and synergies with MOIC themes.Working collaboratively, MOIC participates in projects and shares knowledge, supporting the scale and spread of innovative solutions and best practice.Having an international reach, MOIC is also well-positioned to advise on knowledge transfer and facilitate introductions to new markets.

Projects
In

Industry engagement
MOIC works commercially with companies, from Small and Medium-Sized Enterprises (SMEs) to multinationals.This includes the Pharmaceutical Industry and their representative association, the Association of the British Pharmaceutical Industry (ABPI).MOIC also manages the HSC Industry Partnership (HSCIP) on behalf of NI, which aims to ensure joint working between the Pharmaceutical Industry and the HSC to deliver 'Triple Win' benefits for patients, the Health Service and the economy.HSCIP is a portal for collaborative proposals to work together to achieve rapid and consistent patient access to innovation, more effective use of HSC resources, increased cross-sector research collaboration and a step change in the pace and consistency of adoption of evidence-based innovative medicines and technologies.

Hosting
A formal hosting programme has been established.Interested parties from across Europe and globally can visit MOIC, learning about its work, clinical pharmacy and related areas including antimicrobial stewardship.

Test bed
MOIC has developed a test bed within the HSC.This facility specialises in the handling of products at a late stage in their development and almost ready to market, and offers access to HSC clinicians and patients.Partnering with the commercial sector, academia and patient representatives, MOIC combines pharmaceutical and research and development skills with technology and business acumen to improve outcomes for patients.MOIC also assists with proof of concept and signposting to appropriate individuals/entities.

Evaluation
MOIC has demonstrated considerable success and sustainability.Through the Years): an Interreg VA project, focussed on ensuring the best and most sustainable use of medicines by training pharmacists and other healthcare professionals to deliver structured medicine reviews and embedding a shared approach to managing multiple medicines [36,37].• SIMPATHY: This Horizon 2020 funded project mapped polypharmacy management and identified best practices from across the EU, provided and promoted tools and resources for different local-regional contexts to change the management of polypharmacy to increase adherence in older adults [38].

Collaborations and partnerships
MOIC is partnering in a CwPAMS 2.0 project with colleagues from the UK and Tanzania supporting antimicrobial stewardship and clinical pharmacy.Further grant applications have been submitted across a number of areas including pharmacogenomics, multimorbidity, treatment persistency and antimicrobial stewardship.MOIC is also participating in the ENABLE COST Action focusing on technologies to support medicines adherence [39].
(ii) Health and social care MOIC has led the evaluation of an array of cross-sector projects.Post discharge telephone follow up by clinical pharmacists is now routine practice in NHSCT and Consultant Pharmacists for Older People input in Nursing Homes and Intermediate Care settings has been scaled and spread across NI [40][41][42][43][44][45].Others include a Medicines Optimisation Outpatient clinic, GP Practice-based Pharmacist case management, Pharmacy First Service in Community Pharmacy using rapid diagnostics in the management of sore throats, new models of prescribing by non-medical prescribers and the development of General Practice-based pharmacists and consultant pharmacists [46][47][48][49].In addition to supporting the work of the NI Genomics Partnership and antimicrobial resistance initiatives, MOIC also supports the implementation of the 'Transforming Medication Safety in Northern Ireland' Action Plan aligned to the WHO Global Patient Safety Challenge 'Medication Without Harm' and the Digital Innovation Steering Group [1,[50][51][52][53][54][55][56][57][58][59].

(iii) PhD
MOIC co-supervises and mentors PhD students across Europe, including Poland (University of Wroclaw; Medicines Optimisation pilot), Austria (University of Ulster; Antimicrobial Stewardship and Clinical Pharmacy), Norway (University of Oslo; Transitions in Care and Multiple Long Term Conditions) and Estonia (University of Tartu; Medicine Use Reviews) [13,14,16,17].
(iv) Quality improvement MOIC has co-developed a novel Change Package to support the WHO Global Patient Safety Challenge 'Medication Without Harm' [1].This work has been presented internationally and combines medicines optimisation approaches with quality improvement methodology.Discussions are progressing with the Institute for Healthcare Improvement and interested parties in Europe.

Industry engagement
MOIC has completed several projects with the pharmaceutical industry.Under the HSCIP, a project is underway in cardiovascular, focusing on priority pathways.The HSCIP has generated widespread interest and work to disseminate the model is underway.Under a revenue share agreement, MOIC worked with a healthcare company in Ireland to develop smart procedure packs for blood culture, lumbar puncture, peripheral lines and HIC/PICC lines.Evaluation of the blood culture packs demonstrated a reduction in false positives, significant benefits for patients and reduced healthcare resource utilisation.The packs are now commercially available [60].With a commercial company, MOIC co-developed and tested a solution to tag and track healthcare assets in real time in various settings.Working with a spin out company from Queen's University Belfast, MOIC trialled a novel adherence technology to support adherence in people with respiratory disease.

Hosting
MOIC has hosted numerous high level representatives and pharmacists from across Europe and globally.
Visitors such as Ministry of Health representatives or senior managers generally stay for a few days.Pharmacists may choose to stay for periods of up to 3 months, complete projects and take the learning back to change practice in their setting.Formal hosting arrangements are in place with organisations such as the Spanish Society of Hospital Pharmacists.MOIC is also a Statement Implementation Learning Collaborative Centre (SILCC) for the European Association of Hospital Pharmacy.This programme allows hospital pharmacists to visit SILCC hospitals to learn about pharmacy linked to the European Statements of Hospital Pharmacy.

Covid-19
MOIC was agile during the Covid-19 pandemic.Leading work on Personal Protective Equipment procurement and informing the modelling of critical care drugs, MOIC supported the NI Covid-19 response [61,62].The Team also participated in the COMET European research study to establish if certain medications affect clinical outcomes in those with Covid-19 [63][64][65].MOIC was commissioned by DH to support the coordination of evidence and drafting of reviews detailing the role of pharmacy in the Covid-19 response.

Income generation
MOIC has demonstrated financial stability and sustainability and has generated income from grant acquisition and the commercialisation of solutions, contributing to the wider NI economy.

Communication and dissemination
Disseminating extensively, including 64 journal publications, 21 reports, 121 oral and 72 poster presentations, and leveraging online, social media, electronic and print formats such as newsletters and brochures, MOIC has maximised reach.This has enabled extensive knowledge sharing and has facilitated further networks and collaborations.

Health and wellbeing
Health, wellbeing and inclusion have been prioritised and embedded in MOIC.An Action Plan has been developed and MOIC is currently undergoing a wellbeing workplace accreditation process.

Discussion
MOIC has achieved substantial success across all four MOIC themes and has demonstrated clear impact through driving innovation in medicines use.By optimising medicines use through practice and research to achieve person-centred and public health goals, MOIC supports innovation in Clinical Pharmacy [66].
MOIC is unique as an innovation centre focussed on medicines and associated technologies.The key facilitators for MOIC include the DH's strategic direction and support for its work and the link to informing policy to improve patient care [67].The person-centred approach and routine collaboration with stakeholders across academia, industry, healthcare, policy makers, patients and representative organisations are also key to MOIC's success.Importantly, the centre is instrumental in the scale and spread of good practice which is often lacking for many small scale pilot innovations in clinical pharmacy [21].The extensive international engagement, partnerships and reach, mean that MOIC is ideally positioned to scale and spread innovative solutions across Europe and beyond.MOIC's HSCIP is novel and sets out a mechanism to work collaboratively with Industry with appropriate governance.This model has substantively addressed previous concerns regarding working in partnership with industry.MOICs agility and expertise was key in supporting the NI Covid-19 response.
The UK exit from the EU and uncertainty about the UK association to Horizon Europe were barriers for MOIC.The UK has now associated and MOIC can continue to participate in European funding calls.The NI Protocol has ensured that MOIC is uniquely positioned as NI remains in the EU single market for goods, in the EU Customs Territory and in full regulatory alignment with the EU.MOIC has worked diligently to communicate this association and MOIC's unique position to colleagues across Europe.Another barrier has been the ongoing workforce and service pressures within healthcare, impacting on the availability of clinical staff to participate in projects and on hosting.To manage this, clinical expertise within MOIC is utilised and work is underway by the DH to develop the pharmacy workforce following publication of the Pharmacist Workforce Survey [68].The hosting programme is currently paused due to ongoing service pressures within HSC, however discussions are continuing to progress the reintroduction of this popular programme.
The income generated by MOIC and its financial stability have further supported the sustainability of the centre.Not only is MOIC important for the DH, interest has also been expressed by the Department for the Economy, particularly relating to European and International engagement and discussions are underway to develop this link.
Given the unprecedented challenges faced by healthcare systems and the need for novel approaches, MOIC has generated widespread interest across Europe and beyond.Building on key successes, MOIC will continue to extend and strengthen international collaborations and partner in funding opportunities, including exploring the potential to establish a network of MOICs.MOIC is committed to improving patient care going forward through harnessing capability and innovation in pharmacogenomics, artificial intelligence, rapid diagnostics, enabling technologies, AMS and the environmental impact of medicines and sustainability.

Conclusion
MOIC has demonstrated considerable success and sustainability, driving innovation and best practice in medicines use and associated technologies.Achieving extensive reach and recognition, MOIC is relevant and applicable to health systems and economies globally.

MOIC has established over 25
cross-sector agreements, Memoranda of Understanding and partnerships across Europe and Internationally (Fig.1).Examples include working with the Polish Society of Clinical Pharmacy to develop clinical pharmacy; Commonwealth Pharmacists' Association and Bugando Medical Centre, Tanzania, on antimicrobial stewardship and the development of clinical pharmacy; Cluster Saude de Galicia, Spain, on pharmacogenomics;Health Innovation Hub Ireland on clinical pharmacy and innovative technologies[12].MOIC has also established the UK and Ireland Antimicrobial Stewardship (AMS) Collaboration, an informal network of participants with an interest in AMS and co-hosted the first All-Ireland Conference on AMS with colleagues from the Collaborate Analyse Research Audit (CARA) network.Partnerships focusing on the Environment and Sustainability have been established across Europe, including Uppsala University, incorporating the Swedish Knowledge Centre on Pharmaceuticals in the Environment, and the One Health Breakthrough Partnership.Funding opportunities are being explored.Scale and spreadMOIC has informed and supported the scale and spread of best practice in clinical pharmacy and subsequent evaluation in Poland, Austria, Norway and Estonia, co-hosting its first conference in Europe focusing on clinical pharmacy in Poland in 2019 [12-17].The NI Integrated Medicines Management model has been highlighted as an example of best practice in Central and Eastern Europe [18-20].MOIC Co-chairs the Medicines Optimisation Thematic Working Group of the Reference Site Collaborative Network (RSCN) and NI has been recognised as a 4-star RSCN Active and Healthy Ageing Reference Site.The NI Chief Pharmaceutical Officer and MOIC have been invited to share work at the European Society of Clinical Pharmacy (ESCP) Symposium in Krakow, focusing on 'Implementing and scaling sustainable clinical pharmacy' [21].ESCP advances quality and innovation in clinical pharmacy, promoting, supporting, implementing and advancing education, practice and research in clinical pharmacy to optimise outcomes for patients and society [22-32].The work of MOIC closely aligns with ESCP aims.Projects (i) European funded projects MOIC has partnered in three large EU funded projects: • SHAPES (Smart and Healthy Ageing through People Engaging in Supportive Systems): a Horizon 2020 funded, 36 partner consortium which aimed to enable older people to live healthier lives at home and build, pilot and deploy a large-scale EU-standardised open platform [33-35].• iSIMPATHY (implementing Stimulating Innovation in the Management of Polypharmacy and Adherence

Fig. 1
Fig. 1 The Medicines Optimisation Innovation Centre (MOIC) European collaborations and partnerships UK exit from EU and uncertainty about UK association to Horizon Europe.The UK has now associated and MOIC can continue to participate in European funding calls.• Workforce and service pressures within healthcare, impacting on the availability of clinical staff for projects and hosting.Work is underway by the Department of Health to develop the pharmacy workforce.• Covid-19 pandemic as projects were paused.Health and Social Care has now reset and project work has recommenced. •