Medicines Management Joint Executive Team

16 April2015 2.00pm–4.00pm

Small Committee Room, Chiltern District Council

MINUTES

Attendees
Dr Raj Bajwa (RB) (Chair) Clinical Commissioning Director for LTC, Endof Life and Prescribing, Chiltern CCG
Jane Butterworth (JB)Head of Medicines Management, AV & Chiltern CCGs
Julie Horslen (JH)LPC Representative
Raj Patel (RP) (part)LPC Representative
Elaine Sharpe (ES)Prescribing Support Pharmacist, AV & Chiltern CCGs
Sarah Crotty (SC)Interface Pharmacist, AV & Chiltern CCGs
Alison Smith (AS)Prescribing Support Dietitian, AV & Chiltern CCGs
Julie Breakspear (JMB)Medicines Management Support Officer, AV & Chiltern CCGs
Nikki Malin (NM)Head of Communications & Engagement, CSCSU
MMJET_2015/049Apologies:
Dr Stuart Logan (SL)Executive Clinical Lead for Chronic diseases,Medicines Management and End of Life Care, AV CCG
MMJET_2015/050 Conflicts of Interest
There were none other than the discussion on gluten free products could possibly be a conflict of interest for members of the LPC
MMJET_2015/051Minutes and Matters Arising
The minutes of the meeting held on 19 March 2015 were approved as an accurate record.
Matters arising not included on the Action Update
There were none
From Action Update:
  • Mar15/036b –Community Pharmacy - SOPs – A query had been raised by a number of GPs because some pharmacies have refused to dispense certain drugs without the patient having the relevant lithium passport, warfarin yellow card, methotrexate booklet etc. as laid out in their SOPs. This is a change in practice relating to the patient safety alerts for drugs which are high risk and require monitoring. It was agreed that it was good practice and quality-based adviceto request sight of the booklet, but refusing to dispense prescriptions could cause a significant problem for patients who may experience a delay in receiving their medication,and for GPs who also become involved. Currently, it is not routine practice in every surgery to send blood test results with prescriptions and not all patients carry these booklets. It was noted that although it is good practice to offer all patients on these medicines a patient held document, some patients decline to carry these booklets. The objective should be to encourage greater use of patient held passbooks and involve patients in the importance of carrying these with them. It was agreed that the matter should be discussed at forums with a view to developing a model for lithium and methotrexate in the first instance as fewer numbers were involved. A discussion could be held at forums on the way GPs would like to work with Community Pharmacists on this and wider issues to improve quality overall. Some information about this should be sent out prior to the forum meetings so that attending GPs have had time to give the matter some thought, and a report brought back to the June meeting of MMJET.
Action 036b –Action 1 - Communication to forums prior to the meeting asking them to give thought to what would reflect good practice when working with Community Pharmacists, particularly with reference to medication that involves a patient held passport for lithium or methotrexate – Action SC
Action 036b – Action 2 – JMB to add to forum agendas
  • Mar15/036f – Community Pharmacy – GP practice issue – This concerned Community Pharmacists signposting patients back to GPs who then insisted that the pharmacist had said that they must be seen the same day. A suggestion was put forward that perhaps for urgent cases, the Community Pharmacist could phone the GP practice to pre-warn them that a patient needed an urgent appointment. This again linked in with the broader aspect of GPs and Community Pharmacists working and communicating more closely, which was an area of development discussed previously and would be better discussed at a later meeting when feedback from forums would be available. Two further suggestions were put forward which included community pharmacists attending forums once a year and consideration given to a dedicated telephone line in practices for Community Pharmacists and similar professionals. This item can be closed as it will be picked upunder the broader aspect of communication.
  • Mar14/039 – Gluten Free Guidance –NM and AS had been communicating over the option to go to public consultation with regard to the proposed changes in the prescribing of gluten free foods. NM had produced an options paper which was circulated as hard copy at the meeting.
This paper identified advantages, disadvantages and risks involved. The experiences of and decisions made by neighbouring CCGs were also discussed as was the interpretation of the ‘statutory duty to consult’. Concern was expressed that by going to public consultation on gluten free foods, a precedent would be set for many future decisions that had to be made by this MMJET. Concern was also expressed about how robust a public consultation would be as patients potentially affected by this decision would be encouraged to respond which would not provide a representative cross-section of the public. NM suggested using the Let’s Talk Bucks Health forum as the basis for the consultation but there would need to be media notification that this consultation was taking place to enable others to join the forum and voice their opinions. With certain reservations, NM was asked to go ahead with the public consultationtaking all stepsto minimise the biasand to work with AS in this respect. A suggestion to mail existing members of the Let’s talk Bucks Forum initially and then new members subsequently and to analyse these two groups separately was agreed by MMJET.
Action 039a – AS to prepare wording for public consultation canvassing views on the potential reduction of monthly items permitted on prescription of gluten free foods
Action 039b – NM to mail out survey to the 2 cohorts as agreed, starting as soon as possible and feedback the results at Sept 2015 MMJET
(Post meeting note: Survey cannot be mailed until after General Election vote, so to be mailed out 9May 2015)
  • Mar15/041a -– Patient Letter for Adrenaline Autoinjectors – This letterhad been formatted and circulated to practices so the item can be closed.
  • Mar15/042a –Warfarin in Care Homes – The guidance had been uploaded to the extranet and circulated to practices so this item can be closed.
  • Mar15/048c – End of Life Paperwork – This item can be closed as a working group has been formed.
(AS left the meeting)
MMJET_2015/052 Budget & Contract Monitoring
  • Budget update –The January forecast outturn still shows anunderspend. There will be no changes to the model before the year end so no significant changes are expected. The CCGs still compare well nationally.
  • PBRexcl drugs –This expenditure should come in as a slight underspend at the year end. There are still some historical challenges being discussed concerning Homecare drugs. These costs will be built in as a set price for the next financial year and arewritten into the BHT contract. This is not the case for Heatherwood & Wexham Park for next year but would be included in their contract for 2016/17. It was suggested that the outstanding queries with should be written off which would still allow expenditure to come within the PBRexcl drugs budget.
  • Nursing Homes dressing scheme– The cumulative spend for this scheme was showing a slight overspend but this is to be expected with the addition of three new nursing homes in the county.
  • QIS– RB explained that the 2015/16 Quality Improvement Scheme for Chiltern CCG would support the clinical priorities of the CCG and are proposed to cover three areas the prevention agenda, diabetes and end of life care. It is yet to be agreed by the Exec.

MMJET_2015/053 Community Pharmacy
(This item took place after the Action Update – item 051 – but is recorded here for consistency with the agenda)
RP was keen to promote how pharmacists can support GPs and thought it would be advantageous to have the same support information as GPs for antibiotic awareness. He endorsed some of the guidance available on antibiotics which would be discussed later in the meeting but emphasised that it should be kept quite simple. It was agreed that possible leaflets would be taken to the next LPC meeting for discussion on length and content and the reports of that discussion would be brought back to MMJET next month as a quick turnaround on this was required.
Action 053a – RP to take potential support resources to next LPC meeting and identify potential ways that the LPC can support the reduction in antibiotic use in Bucks, the result of these discussions should be reported to the May MMJET
  • Pharmaceutical Needs Assessment – The final Pharmaceutical Needs Assessment has been signed off by the Health & Wellbeing Board. It is not due to be reviewed for three years but JB will meet with the lead from Public Health every six months to identify any issues and maintenance going forward.
  • MAGs–JH had thought that attendance at the MAGs (Multi-Agency Group) meetings would be advantageous for community pharmacists. It waspointed out that GPs do not run thesemeetings although they do host them. The meetings are convened by the MAGS facilitator. It was suggested that perhaps the MAGS facilitator could be asked to invite local pharmacists to attend. It was agreed to ask forums whether a pharmacist at the MAGs meetings would be helpful. JH commented that a Facilitator from MAGs had been invited to the next LPC meeting as it was thought a strategic approach may be the best way forward.
Action 053b – Discussion to be held at forums as to whether the presence of a pharmacist at MAGs meetings would be advantageous – JMB for agenda
  • Care Planning–JH queried the approach to the Year of Care. It was explained that Aylesbury Vale CCG were developing it as part of co-commissioning. A presentation is to be held in the marquee at Chartridge Conference Centre on 13 May 2015 as part of PLT. JB willsend an invitation to the LPC.
Action 053c – JB to invite LPC to PLTon 13 May 2015
  • Supplies from Multiples –A communication had been received from a GP practice whereby patients are being told that a medication is not available when in fact it is not available from a particular supplier not that there is a supply issue. Two multiples were quoted in the communication. RP agreed to take this back to the LPC as it should not happen and an alternative supply source should be sought for the patient.
Action 053d – RP to take to LPC meeting the concerns about multiples saying a medication is not available when it is only not available from their particular supplier and feedback to MMJET
(RP left the meeting)
MMJET_2015/054 Risk Register
Following review of the risk register at the last LTC/EOL JET, JB had removed all those risks with a residual risk of less than 8. There are two more risks with a residual score of 6 that should also be removed –LTM6 and LTM10. The cover sheet highlighted some further risks for discussion as to whether they should be added to the Risk Register. These were:
  • Covert administration of medicines in care homes – action plan could include a training session with Seema Gadhia and a safe-guarding representative at a PLT
  • Inappropriate use of thickeners – risk of aspiration – needs an action plan put in place
  • Catheter maintenance solutions – improved in one care home but still going on in others
  • Safety alert 2014/004 – transition to new ISO connectors for medical devices – first devices to be fitted with the new ISO connectors will be enteral feeding tubes
It was agreed that these risks would not achieve a high enough risk rating for them to be added to the Medicines Management Risk Register but it was essential that an action plan was put in place to address each of the areas of concern listed above. They could perhaps be identified on the Care Homes workplan as a risk, and then mitigating factors could be explained in this document.
Action 054a – JB to remove two risks on the Risk Register with a residual risk of less than 8
Action 054b – JB to speak to Seema Gadhia with regard to recording ‘risks’ and resultant action plan on care home workplan.
MMJET_2015/055 AQP Anticoagulation
JB explained that the AQP went live on 1 April 2015 with a transition period of 3 months. Only six practices went fully live on 1 April 2015. A Comms pack was produced with leaflets and posters.
MMJET_2015/056PGD Governance
Agreement was sought that it was in order for Lynn Wallis to amend the PGD governance document in the light of NICE information issued in December 2014 and bring back to the next MMJET for approval. This was agreed.
Action 056 – Lynn Wallis to amend the PGD Governance document in accordance with the latest NICE information
MMJET_2015/057DropList
The DROP list (Drugs to Review for Optimal Prescribing) lists the top 30 items of items that PrescQIPP believe should not be prescribed. The spreadsheet embedded on the agenda highlighted those products where the benchmark was not in the top third of performers (yellow) and the expenditure that was greater than £10,000 thus identifying the areas to address for the greatest savings (orange). It was agreed that Omega 3 should be taken forward with potential savings in excess of £25,000
Action 057 – SC to develop an intervention on Omega 3 fatty acid prescribing
MMJET_2015/058 PrescQIPP Software
Having reviewed the quality of the data and ease of use by the CCG, Chiltern CCG has decided that the PrescQIPP software provides value for money and wishes to commission for a year. PrescQIPP should be put on the agenda as a standing item once a quarter following the end of a quarter’s ePACT information being available - starting with July 2015.
Action 058 – JMB to put PrescQIPP on the MMJET agenda at the end of every quarter, starting with July 2015 and with a contract review Feb16
MMJET_2015/059 Guidelines
  • NHS England Targets for Antibiotics –The Quality Premium targets for antibiotics set by NHS England include
A)The reduction in total CCG antibiotic prescriptions items by 1%.
B)Maintenance of % high risk antibiotics such as cephalosporins and co-amoxiclav below the national median
C)Hospital data being run so NHS England can verify if IMS data is accurate
There has been an ‘across the board’ reduction of use of antibiotics in Bucks,and Bucks also benchmark well below the median for high risk antibiotics currently. However there is still scope for improvement and the variance between practices is significant. Therefore a fresh drive for reducing unnecessary antibiotic prescribing is needed. A project plan was put forward. There was discussion about CCG targets. The principle of not overwhelming practices with data and additional targets at the present time was agreed, and so a drip feed approach was deemed to be a realistic plan.
The dashboard would need to be amended for next year to reflect antibiotic prescribing by STARPU rather than ADQ Usage which is recorded at present. In addition the data needs adjusting for high risk antibiotics to reflect the national dataset which combines cephalosporins and co-amoxiclav (current dashboard reviews these separately). It was noted that there are national tags already available.
Action 059a – JMB to amend dashboard for 2015/16 to reflect antibiotic prescribing by STARPU rather than ADQ usage and the high risk antibiotics to reflect the national targets
  • Resources and Patient Leaflets–The selection of resources embedded on the agenda was reviewed and it was generally thought the content of these was clear and user friendly. These were all available from either the Target website or from PrescQIPP. In particular, ‘Treating your infection’ was thought to be very useful asit addressed the fact that there was no harm done in delaying antibiotics and it dealt with the issue of delayed prescriptions. There was a need to move swiftly on getting resources together as the data is being measured from April 2015. Ideally each practice should have an antibiotic champion as posters and leaflets alone would not work. It was agreed that the graphs showing the variance in prescribing should be presented at the next forums and resources to support changes in prescribing should be promoted. SC would also work with JH with regard to what leaflets would be suitable for pharmacy use and whether any amendments needed to be made to make them more appropriate. NM mentioned that Comms were currently working on a demand management leaflet and asked whether it would be worth including antibiotic prescribing. This was agreed.
Action 059b – SC to co-ordinate circulation of national resource posters and leaflets for practices to use to encourage more appropriate antibiotic prescribing which can be taken to forums for a discussion on which of these may be of use to be printed as hard copy.
Action 059c – SC to work with JH with regard to what leaflets would be suitable for pharmacy use and whether any amendments needed to be made to make them more appropriate
Action 059d – NM to include antibiotic prescribing in the demand management leaflet
Action 059e – JMB to put antibiotic prescribing on forum agendas
  • OTC medicines patient leaflet –JMB explained that the list of over-the-counter (OTC) products that would not routinely be prescribed had previously been agreed at MMJET and subsequently a copy of a leaflet used by Berkshire had been approved as a model to producing something similar for Bucks. Comms had produced the first draft of the wording for the Bucks leaflet for comment. It was noted that the Berkshire document was very much about making difficult decisions and it was necessary to decide whether the Bucks leaflet should address only OTC products that will not routinely be prescribed or whether it should cover wider low priority issues. Certain changes to the wording was suggested, eg replace ‘results’ with ‘healthcare’ in the first sentence of the second paragraph; change ‘specialisms as well as experts in subjects such as ethics’ in the first sentence of the third paragraph to read ‘specialist health professionals’. A typo was pointed out in the fourth paragraph ‘once’ should read ‘ones’. SC agreed to work on the document and bring a revised version back to MMJET next month.
Action 059f – SC to bring a revised draft of the wording of the leaflet to support GPs in encouraging patients to purchase medicines available over the counter to the May MMJET