Minutes of the Meeting of the WPCT Clinical Effectiveness and Medicines and Management

held on 5th August 2009 at 3-5pm in room 1 in WBH

Present: / Dr Josephine Ruwende- Consultant in Public Health Medicine - Chair
Nick Beavon – Chief Pharmacist
Ken Abhayaratna – Non acute Commissioning Manager
Amanda Cranston - Consultant in Public Health
Donald Roy – Lay member
Crystal Stewart, Exceptional Circumstances Administrator
Joshua Bull, Service Improvement Management WPCT
Rod Ewen, GP, PEC Member
Nicole Riordan, Matron, Outpatients at QMH
Panna Sehmi, GP VTS Trainee
Robert Pears, Locum consultant in PH, SMPCT
Shaneez Dhanji, Pharmacist
09/01 /

Welcome and Apologies for Absence

The group welcomed PS to the group Also welcomed NR, who presented item 4.
David Selwyn, Lay member
Fiona Hicks, Clinical Governance Manager WPCT
Ross Anderson, St George’s Medical School
David Finch, Medical Director
09/02 /

Minutes of the Meeting held on 3rd June and Matters arising

Minutes of previous meeting were found to be a true record of the meeting.
Matters Arising – Off-Label Prescribing of Miconazole oral gel and fluconazole. NB has given advice.
Baseline Assessment by Mental Health Trust – AC informed the group that Ian Petch will be attending the CEMMaG instead of Chris Gilleard and Ian will need a formal request to attend these meetings.
Revised TOR – Quoracy been amended. DR requested that more than one lay person be on the group. JR assured that David Selwyn is still a member.
Rivaroxaban – NB has made some enquiries and this is still being discussed at SGH.
Baseline Assessments – Glaucoma. JR informed the group that Fadi Dexter, Primary Care Support Manager, has met with a consultant from Moorfields, Gus Guzzard, and Tom Coffey Wandsworth GP, to discuss implementation of guidance. Linda Troy, Chair, Sutton, Merton, Wandsworth Local Optometric Committee, has submitted business case to WPCT.
ECI – Notification of forms will be audited every month by the PCT in the form of a tick box questionnaire.
09/03 /

Latest NICE Guidelines

CG88 – A review of the management of lower back pain will be undertaken by the Clinical Effectiveness Facilitator, Alisi Mekatoa.

09/04 /

Baseline Assessments – Nicole Riordan

NR explained that the current situation is that there is an inappropriate demand on urology clinics arising from the referral of female incontinence patients who have not had the necessary primary care assessment prior to referral to secondary care. The current Female Continence Service is provided at QMH with SGH and Kingston both running consultant led clinics. This increases the likelihood of a breach of 18-week waiting times as the 18-week clock starts as soon as the referral is made to secondary care.
Service model – The Female Continence Service is for female patients (<16 years of age) with both urinary and faecal incontinence. The service will also manage women with mild to moderate pelvic organ prolapse. The service will be ran by 2 personnel:-
·  Women’s Health Physiotherapist (Band 8a)
·  Continence Nurse Advisor/Urology Nurse (Band TBC)
The triage process will be done jointly by the KA and the nurse to distinguish which patients need direct secondary referral and those requiring conservative management. GPs would refer directly to the Female Continence Service for appropriate triage.
Currently some GP refer directly to secondary care in the absence of a nurse specialist triage of referrals is done by the consultant. A bid for funding of a nurse specialist has been declined last year (KA to follow up). The service is otherwise consistant with NICE 18 week guidance.
The proposal has been compared with NICE and it agrees with their 18 week guidelines. Theresa Lennard has been sent the timelines for outcomes. Sutton & Merton are interested in commissioning a funded service, and paperwork has been sent to their commissioners. RE suggested using other sites such as SGH, and referrals will come from practice nurses with appropriate training. RE has also found that female patients may not present themselves to male GPs.
09/05 / Lipid modification prescribing guidelines and costing – Nick Beavon
The South London Cardiac & Stroke Network (SE & SW have merged) has produced guidelines on:
Lipid Management for primary and secondary prevention of cardiovascular disease
Lipid Management in patients following an Acute Coronary Syndrome (ACS)
Prescribing of Beta-blockers
Prescribing of Eplerenone
Prescribing of Ivabradine
All PCTs in SWL, except WPCT have signed up to these guidelines. Thus, these guidelines are being presented at the meeting for approval.
These guidelines have been discussed with Dr Nicola Jones, GP and Clinical Lead for CVD. Dr Jones chairs the PCT CVD Clinical Reference Group and mentioned that this group has already developed local guidelines for primary prevention. These are largely similar to the Network guidelines. Dr Jones confirmed that the group supported the ratification of the Network guidelines, by the CE group. However, the format of the local guidelines was preferred as it is more user-friendly. Hence, the Network guidelines would be used a reference.
The Network guidelines recommend using Atorvastatin 40-80mg daily second-line for secondary prevention. NICE recommends titrating upto simvastatin 80mg, however, concerns have been expressed about the adverse effects at this dose. Atorvastatin 40-80mg will give greater reductions in cholesterol levels and trial data indicates a better safety profile at these high doses.
Recommending atorvastatin is associated with significant additional cost. Thus, as a way of managing this, the Network has defined 2 groups of patients that can be switched to using atorvastatin instead of simvastatin 80mg.
There has been a proposal sent to NICE to reconsider the recommendation of simvastatin 80mg.
Action: It was suggested that, using the Network guidelines for secondary prevention, local guidelines to be developed (if not already done) in a similar, user-friendly format as the primary prevention.
Acute Coronary Syndrome (ACS):
NICE recommends that following an ACS, patients should be treated with a higher intensity statin. Since there are safety concerns about simvastatin 80mg, atorvastatin is therefore recommended.
STG DTC has accepted using atorvastatin 40-80mg daily, post ACS. It is thought that the numbers of patients with ACS is relatively small.
A cost modeling for WPCT was briefly discussed and with assumptions, the estimated cost pressure is approx. £200K
09/06 / Beta – Blockers – Nick Beavon
The NHS Wandsworth hypertension guidelines are aligned with the Network Beta-blocker guidelines.
Dr Jones has proposed that the local guidelines be distributed and implemented at the same time as the launch of the NHS Health Check in October. The Network guidelines will be used for reference.
Eplerenone and Ivabradine:
Action:The group felt that these guidelines needed further discussion and consideration by the CVD group as there was discomfort around the appropriateness of use in general practice. If the CVD group was satisfied with these guidelines- they could approve them on behalf of the CEMMaG possibly adding further clarity for GPs. The guidelines could be edited to a more user-friendly format, if needed.
09/07 / Vascular Risk Assessment Guidance – Amanda Cranston, Guidelines were approved by the group.
1)  LES in final stages-to be confirmed and sent to GP surgeries ready for signing by start of October 2009
2)  Template for NHS health check has been designed and is in the final stages of completion
3)  LES costings still to be finalized
4)  HCA and practice nurse training sessions 7th and 9th September
5)  Community outreach events due to occur in January 2010 (diabetes UK/ Blood pressure assoc)-exact dates TBA
6)  Currently discussing the implementation of the programme with practices: practice visits arranged to engage GP’s and clinical practice staff. These will be on-going and the respective federated groups will also be involved
7)  Awaiting input on cut-off values for fasting plasma glucose level
8)  Poster currently being designed
Leaflets for GP’s surgeries available now
NHS Health Check, Statin and Hypertension guidelines finalized and these were approved by the group.
09/09 / NHSW Policy on open MRI – Josephine Ruwende
Diagnostics have other techniques to help patients who have e.g claustrophobia. Charing Cross hospital have bigger machines to aid those who are obese. However if there are patient who still cannot have their MRI then the Exceptional Circumstance panel would consider. Policies were approved.
09/10 /

Proposed dates for 2009

Date / Time / Room
October 1 / 3-5pm / 1
December 2 / 3-5pm / 3
February 4th 2010 / 3-5pm / 1

Approved as a correct record:

Signed: ……………………………………………..

Chairman

Date: ……………………………………………..

O:\Corporate\Public Health\Public Health Group\_NEW SYSTEM\CLINICAL EFFECTIVENESS\CLINICAL EFFECTIVENESS GROUP\Minutes\Draft minutes\2009\WPCT CEG Minutes 050809.v1doc.doc

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