Charlotte Gurr
When generic dapagliflozin became available, many of us saw the same message coming through loud and clear from NHS England. This was an opportunity to improve value. Like many medicines optimisation priorities, it brought a familiar tension. In NHS Sussex, we were faced with the familiar challenge of how to deliver large-scale prescribing change at pace without compromising patient safety or clinical credibility.
A time-limited incentive scheme was introduced to encourage general practices to switch eligible patients from other sodium-glucose co-transporter-2 (SGLT2) inhibitors to generic dapagliflozin. On paper, the objective was straightforward: to release efficiency savings while maintaining therapeutic equivalence. In reality, I was concerned that this cost-driven approach risked overlooking something fundamental: safe, consistent implementation at scale.
SGLT2 inhibitors are a good example of why switching programmes are rarely just about the medicine itself. Is there ever really ‘just a switch’? Every prescribing change creates an opportunity to review treatment, reinforce safety messages, engage patients in shared decision-making and improve consistency of care.
The medicine itself may change in seconds on a prescribing system but ensuring that change is understood, accepted and implemented safely is far more complex. SGLT2 inhibitors come with well-recognised benefits but also important safety considerations. In particular, the risk of euglycemic diabetic ketoacidosis, although rare, can be life-threatening. Prevention depends heavily on patient understanding, especially around sick day rules. From local audit and clinical experience, it was clear that this counselling was not being delivered consistently. That changed our approach.
Clinical leadership helped create trust in the programme, maintain professional credibility and ensure that the focus remained on improving patient care rather than simply reducing costs
As clinical lead for the programme, I was keen to ensure that any incentive-driven change was underpinned by robust clinical governance and delivered in a way that strengthened, rather than compromised, patient safety. We reframed it as a clinically driven programme rather than a transactional exercise.
Playing a central role in shaping and strengthening the work, I ensured it maintained a clear focus on patient safety and clinical credibility over cost efficiency. The programme was supported by an excellent medicines optimisation lead pharmacist, who coordinated delivery, and a wider multidisciplinary team, who enabled consistent implementation across Sussex. The aim was not simply to switch drugs but to standardise good practice across the system.
Achieving this required more than technical implementation. It depended on strong clinical leadership and shared ownership across the system. While I provided clinical oversight and helped shape the strategic direction of the programme, success relied on empowering colleagues to lead locally, translating a system-wide ambition into day-to-day practice. This combination of clear clinical governance, distributed leadership and local engagement was critical to achieving both pace and consistency.
We embedded mandatory safety requirements within the scheme, including documented verbal and written counselling, as well as a co-designed, patient-friendly leaflet. Practices were supported with searches, webinars and communication tools so that implementation was both rapid and consistent.
What stood out to me throughout was the importance of clinical leadership. Clinical leadership helped create trust in the programme, maintain professional credibility and ensure that the focus remained on improving patient care rather than simply reducing costs. So what did we see?
To date, over 10,000 patients have been identified as eligible across Sussex — around two-thirds switched with documented counselling. Overall switching rates have exceeded national and regional comparators, and a significant proportion of practices engaged early in the programme. Importantly, safety processes were implemented consistently.
Perhaps the most encouraging outcome has been the level of interest beyond Sussex
The financial impact has also been substantial, with over £2.5m in net annual savings achieved so far. Although, for me, what is more meaningful is that we have been able to use a national policy driver to improve the safety of prescribing, rather than simply its cost.
In addition, the programme aligns with national priorities to address inequalities in SGLT2 inhibitor prescribing. The National Institute for health and Care Excellence has highlighted lower uptake among older people, women and Black populations, and called for systems to monitor and address variation in access. While this scheme has focused on optimisation of existing prescribing and has not directly addressed these inequalities, the structured data collection has enabled monitoring of uptake by age, sex and ethnicity. This provides an important foundation for identifying and addressing local variation in access across the Sussex population.
There are, of course, limitations. Much of the data is drawn from routine sources and the programme is still ongoing, so we do not yet have long-term, patient-level outcomes. However, early feedback from practices has been positive. It suggests that when clinicians feel supported, and when safety is prioritised, large-scale change becomes both achievable and acceptable.
Perhaps the most encouraging outcome has been the level of interest beyond Sussex. Other systems have begun to adopt elements of our model, particularly the patient information resources and structured approach to safety.
For me, this work has reinforced a simple but important lesson: incentives can drive activity, but they do not guarantee quality. If we want to deliver meaningful medicines optimisation, we have to design programmes that integrate financial, clinical and behavioural drivers, rather than treating them as separate levers.
Done well, a switching programme becomes an opportunity to improve safety, strengthen clinical practice, develop leadership across teams and build capability across the system
Switching programmes will continue to be part of the NHS landscape, particularly as more medicines come off patent. Every change in treatment is also an opportunity to improve safety, reinforce good clinical practice and strengthen patient understanding.
Ultimately, the real success of any optimisation programme is not the saving it delivers but the confidence it gives clinicians and patients that change has been implemented safely, consistently and for clear reasons. Our experience in Sussex suggests that there is rarely such a thing as “just a switch”. Done well, a switching programme becomes an opportunity to improve safety, strengthen clinical practice, develop leadership across teams and build capability across the system. That, perhaps, is the real impact of medicines optimisation at scale.
