TRUST BOARD OF DIRECTORS – May 2012

CNWL MEDICINES MANAGEMENT UPDATE

BOD55/2012

This report isfor publication

THE BOARD IS ASKED TO APPROVE THE REPORT AND NOTE FOR INFORMATION

EXECUTIVE SUMMARY

It is a requirement that the Trust Board receives regular updates on the use and risks associated with medicines. The Chief Pharmacist/Accountable Officer for Controlled Drugs will produce six monthly updates to the board. An annual report for 11/12 will be circulated to the Directors.

The report highlights the ongoing work programme for 2012. Key areas of note are:

a) A re-design of the patient information leaflets to compliment a resource pack of information to support patient, carers and healthcare professionals

b) The creation of ‘one stop shop’ clozapine clinics in Brent and Harrow

c) Supportthe trust’s research and development strategy with the creation of pharmacy clinical trials unit.

d) Completion of the business case for centralisation of pharmacy services

e) A medicines savings plan for 2012/13

f) Further integration of pharmacy and medicine processes across the trust

The trust’s current CQC QRP rating for Outcome 9 (Medicines Management) is low green. This is the best possible rating and has been this since mid 2011.

Mental health related medicines expenditure decreased by 6% in 11/12 from 10/11.

Areas of concern or risksto note are:

a) Increase in fraudulent activity by patients to access medicines

b) Decreased level of reporting of mental health related medication incidents and low levels of reports in a proportion of the service lines

RESPONSIBLE DIRECTOR: ANNE TYRRELL, CHIEF PHARMACIST ACCOUNTABLE OFFICER FOR CONTROLLED DRUGS

DATE: MAY 2012

  1. Medicines Management Work Programme 2012

A work programme based on the medicines management strategy is reflected below:

  • Review and redesign of both patient and healthcare professional medicine related resources
  • Ensure the roll out of the competency assessment for administration of medicines
  • Medicines QIPP agenda
  • Re-engineering of clozapine clinics that can provide a ‘one stop shop’
  • Completion of the business plan to centralise pharmacy dispensing services
  • Development of a pharmacy clinical trials facility at St Charles.
  • Organisational development review of pharmacy services in light of service lines and community health service integration (Appendix 1 for pharmacy involvement).
  • Implementation of a new medicines committee structure and reporting arrangements
  1. Regulatory Issues

CQC Essential Standards Outcome 9 (medicines management) is rated low green (safest rating) for March 2012. There were six positive comments stated from compliance visits.

A trust wide safe and secure handling of medicines audit is currently in progress. The Department of Health has mandated all non-Foundation Trust acute trusts to undertake this audit and submit an action plan to Care Quality Commission (CQC). CNWL although not mandated to do this will submit to the CQC in the course of our normal audit plan.

Extensive work with all our registered CQC locations is ongoing in respect of outcome 9 provider compliance assessment (PCA) documentation. Key areas of work include Offender Care, Addictions and Older People and Healthy Aging service lines along with the community provider services.

  1. Summary of Medicines Expenditure 2011/12

3.1 Mental Health Spend (hospital and FP10)

Year / Hospital / FP10 / Total / % Change
2011/2012* / 3,287,959 / 1,629,644 / 4,917,603 / (6%)
2010/2011** / 3,439,226 / 1,766,596 / 5,205,822 / (7%)
2009/2010 / 3,282,283 / 2,329,303 / 5,611,586 / 2%
2008/2009 / 3,162,214 / 2,318,356 / 5,480,570 / 4%

CNWL medicines expenditure within mental health decreased by 6% compared to 11/12 and is 12% under spent against budget.

3.2 Expenditure against budget by 2011/12 by directorate

Directorate / Budget (£) / Actual (£) / Variance (£)
Addictions / 1,861,331 / 1,628,257 / (233,075)
Brent / 669,947 / 594,792 / (75,155)
CAMHS / 81,154 / 84,795 / 3,641
Older Adults / 273,475 / 296,448 / 22,973
Harrow / 514,898 / 470,187 / (44,711)
Hillingdon / 360,186 / 315,567 / (44,619)
Horton / 267,824 / 154,565 / (113,259)
Kensington & Chelsea / 775,048 / 575,433 / (199,615)
Learning Disability / 48,615 / 32,864 / (15,751)
Offender Care / 222,376 / 180,320 / (42,056)
Eating Disorders / 10,500 / 7,082 / (3,418)
Westminster / 498,699 / 577,294 / 78,595
Total / 5,584,054 / 4,917,603 / (666,451)

3.3 Medicines supplied through hospital pharmacy

Medicine / 2010/11 / 2011/12
Total expenditure (hospital) / £3,439,226 / £3,287,959
£ / % of spend / £ / % of spend
Risperidone & paliperidone long-acting injection (LAI) / 1,250,112 / 36 / 1,116,659 / 34
Clozapine / 358,147 / 10 / 471,950 / 14
Quetiapine (IR) / 256,868 / 7 / 195,544 / 6
Olanzapine / 458,178 / 14 / 150,501 / 5
Aripiprazole / 135,127 / 4 / 143,645 / 4
Donepezil / 70,065 / 2 / 60,190 / 2

There arethree key areas, which account for £578,082 of reduced expenditure.

  1. Expenditure of risperidone/ paliperidone long-acting injection is £133,453 (10%) less than spend on LAIs for the previous financial year. This reduction in expenditure is largely attributable to the VAT savings made through our polarspeed delivery service.
  2. Spend on olanzapine has decreased by £307,677 (67%). This is largely attributable to the part year savings made when the purchasing contract was switched to generic olanzapine at the beginning of November 2011. However, this does not account for all of the reduced expenditure, and part of reduction may reflect reduced usage.
  3. Medicines supplied through community pharmacy (FP10s). This supply route is offered when our clinical services are not located near any trust pharmacy dispensing sites. Most of the FP10 spend is within the addictions service line. Expenditure against FP10s has decreased by £136,952 (8%), largely attributed to the drive to transfer physical medicines prescribing back to the GP within Addictions.
  4. Other savings initiatives 11/12 included repatriation with primary care services through transferring of prescribing within community teams back to GPs.

3.4 Provider Care Expenditure 11/12

Budget (£) / Actual (£) / Variance (£)
CPS – non sexual health / 125,110 / 105,707 / (19,403)
CPS Sexual Health/HIV / 20,124,270 / 20,103,972 / (20,298)
Hillingdon Provider Services / 117,800 / 140,250 / 22,450
Total / 20,367,180 / 20,349,929 / (17,251)

There is small expenditure for the community provider services. The CPS HIV service is managed through anSLA with UCLH and is managed through the UCLH HIV team and London Commissioning.

4. Controlled Drugs

All healthcare organisations are required to promote safe and secure use of controlled drugs and to ensure they comply with relevant legislative and regulatory requirements. This is with the ultimate aim of driving quality improvements and detecting potential concerns. This section provides an update on the monitoring, management and use of controlled drugs across the trust. It also provides information on controlled drug incidents reported during October 2011 and March 2012.

4.1Controlled drug incidents

There have been a total of 85 trust wide controlled drug incidents reported within the last 6 months. Of the total, 81 reportedwere rated level 1 or 2 and no harm to patients.

4incidents were considered to be serious incidents.

  • Fraud: 2 service userson separate occasions defrauded an outpatient hospital prescription in an attempt to obtain a controlled drug from ChelseaWestminster pharmacy. This incident has been formally investigated through the acutehospital with appropriate action plan
  • Unaccounted/missing medicines: Monitoring of stock levels of benzodiazepines revealed unaccounted/missing medicines as the levels did not correspond with the prescribed medicines. This investigation is currently being investigated
  • Missing FP10 prescription forms from the GordonHospital. Although, unable to identify any particular individual, local and trust wide guidelines have been reviewed and revised

For all CD incidents, lessons learnt are shared with the relevant teams and trends are documented in the trust safe medication bulletin.

4.2Controlled drug handling audit

The CNWL pharmacy department carries out CD audits quarterly across all CNWL sites where CDs are supplied, delivered or stored. These checks aim to ensure CDs are being handled and used appropriately and to monitor and check to ensure that all stock is being reconciled.80 siteswere audited each quarterand action plans were developed and discussed with ward/site managers and shortfalls were addressed at the time of audit. The key themes of shortfalls were mainly related to CD record-keeping, CD key logs and CD balance checks.

4.3Occurrence report

The Controlled Drugs Accountable Officer (AO) has a statutory responsibility to provide quarterly occurrence reports to the NHS North West London Accountable Officer. This details any concerns regarding management or use of controlled drugs. Reports have been sent to the AOs of NHS Surrey, NHS North West London and NHS Camden & Islington.

4.4Controlled drug prescribing

The electronic reporting system called Abusable Drugs Investigational Software (ADIoS) is analysed on a monthly basis. This highlights any deviations from the usual prescribing of CDs at all sites across the trust, including controlled drug prescribed on FP10 prescriptions. ADIoS raised a total of 45 reports over the last 6 months. These were analysed and none required formal investigations.

4.5 Controlled drug training delivered by the Pharmacy Department

All new Trust staff receives a medicines management session as part of Trust Corporate Induction. All staff are made aware of the Trust Medicines Policy, the Controlled Drug Policy and procedures, who is the Controlled Drugs Accountable Officer and the processes for raising any concerns regarding controlled drugs. In addition, all staff involved in handling and prescribing controlled drugs are encouraged to complete the e-learning package on controlled drugs available via At-learning. This training package is also recommended for staff at sites where there are shortfalls in policy adherence or if the training need has been identified in an individual’s development.

4.8Additional Accountable officer for Controlled drugs activities

-Member of the Camden Local intelligence network meetings

-Member of the National Prescribing Accountable Officer national steering group

4.9Further work

Further work currently required over the next 6 months is as follows:

  • To be able to fully integrate the datix reporting system to ensure timely reporting and regular analysis of incidents.
  • Reviewing systems and processes relating to controlled drugs at HMP Holloway including integration of CD policy. This process has already started and early indications as a result of CD audits reveal that there are a number of medicine management risks. Following the review, action plans will be developed in conjunction with key stakeholders.

5. Medication Incidents

A total of 334 medicine related incidents were reported via the trust IR1 system for Q3 and Q4. This figure includes data from Camden Provider Services (CPS) and Hillingdon Community Health (HCH). The table below details the numbers of medicine incidents reported by Service Line.

Whilst the total number of medicines incidents reported annually has increased with the inclusion of figures from CPS and HCH, the total number of medicine incidents reported within mental health, addictions and offender care has decreased by 24% i.e. 577 compared to 758 in 10-11.

There has been a significant drop in reported medicine incidents across all service lines on a quarterly basis. The probable causes for this may include the move to service lines, the introduction of electronic reporting and loss of services particularly within the addictions service line which has seen a 50% decrease in the levels of reporting. Also, the newly created service lines are low reporters and need have this issue on their agenda for improvement.

5.1 Medicines Incidents by Severity and Harm

The chart below shows the number of medicines incidents reported across the trust by their severity.

No severe harm incidents reported for Q 3 and 4

The health of a reporting system can be judged by the proportion of minor incidents to more serious incidents, the greater the proportion of minor incidents reported the better the system is working. These figures suggest comparable reporting rates for Q3 and Q4 in terms of severity, although the overall total of medicines incidents reported in Q4 has decreased by 34% compared to Q3within mental health, addictions and offender care.

5.2 Stages in Medicine Handling Process Where Incidents Occurred

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Administration

The majority of incidents continue to be reported as having occurred in the administration stage. The 125 incidents reported for Q3 and Q4 however represents a 28% increase in incidents occurring at this stage compared to the 2010/2011.

A significant amount of the administration errors have often been linked to missed doses or inaccurate recording of administration. The annual missed dose audit has provided supportive data and as such systems have been adopted trust wide across inpatient areas to ensure that all medication administered or withheld is accurately documented. The Medicines Administration Competency framework has been introduced across mental health, addictions and offender care, with a similar process due to be launched in HCH to provide assurances around the safe administration of medicines by registered nursing staff

Prescribing

This year has seen a significant increase in the reporting of prescribing errors particularly within mental health. There has been an increase from 5 reported in 2010-2011 to 51 in 2011-12. Including CPS and HCH, prescribing incidents account for 9% of all medicine incidents reported. There is still a very low level of reporting by doctors.

Dispensing

There have been 33 incidents reported involving dispensing of medicines for Q3 and Q4. These have occurred at acute trust pharmacies, St Charles pharmacy or community pharmacies. Work continues on robotic dispensing as well as the dispensary at St Charles taking part in a LEAN project where some systems and procedures have been reviewed to improve and streamline dispensing procedures,

Reporting and Learning Mechanisms

The introduction of datix has allowed for timely feedback to individual incidents and has proved beneficial particularly for administration incidents which are now managed locally in a robust manner. Further work is required in medical colleagues reporting incidents and having access to feedback systems.

Further work is required to ensure datix is used to its full potential and that further work with provider services ensures consistency in reporting.

The Safe Medication Practice Group has been revised to include representatives from service lines and is currently looking at suitable and robust ways to improve on organisational learning.

Anne Tyrrell

Chief Pharmacist and Accountable Officer for Controlled Drugs

May 2012

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Board Medicines Management Update 2012

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Board Medicines Management Update 2012