Cruse Funding Request

Cruse Funding Request


Rhondda Cynon Taff Local Health Board / And
1.Name of Scheme: Supervised Consumption of Methadone
Location of Scheme: Community pharmacies within RCT LHB locality
Brief Outline: The Rhondda Cynon Taf Community Safety Partnership’s acting on expert advice has developed a local strategy for the treatment of patients who are dependent on illicit opioid drugs. A key component of this strategy is to commission from Community Pharmacies a Supervised Consumption Service for methadone.
2.Name of Person Responsible (commissioner)
Tel No: /
Name of Person Responsible (provider)
Tel No
3. Client Group:
The term client in this context means a patient registered either with a Community Addiction Team or a GP within the boundaries of Rhondda Cynon Taff Local Health Board. Patients with prescriptions generated by clinicians outside the boundaries of the Rhondda Cynon Taff Local Health Board will not be eligible for inclusion in this service.
3.0Client Contract
All new clients will be asked to visit the pharmacy prior to the commencement of supply together with their key worker (unless prior agreement received). If the pharmacist agrees to accept the client, the pharmacist will ask the client to complete a patient contract provided by the LHB.
The contract will specify:
  • That the client must attend alone at the pharmacy premises unless accompanied by their children or a scheme worker.
  • Any indication of shoplifting, intimidation of staff or other inappropriate behaviour will render the contract invalid
  • The preferred time for the collection of the medication.
  • The arrangement for weekend and Bank Holiday doses.
  • That the supply may not take place if, in the opinion of the pharmacist; the client is intoxicated by alcohol or other substances.
  • That the prescriber will be informed of regularly missed doses.
  • That missed doses cannot be supplied at a later date.
  • What is required if a patient is unable to attend.
  • If an agreed number of consecutive doses are missed that no further supply will take place until the prescriber has reviewed the situation.
  • The pharmacist reserves the right to limit the number of clients receiving the service from the pharmacy and to refuse to enter into a contract with an individual client.
An example of a patient contract is listed in Appendix C
4.What are the specific objectives of the Services?
Provide service users with regular contact with health care professionals and to help them access further advice or assistance. The service user will be referred to specialist treatment centres or other health and social care professionals where appropriate.
Reduce the risk to local communities of:
  • over usage or under usage of medicines;
  • diversion of prescribed medicines onto the illicit drugs market
  • accidental exposure to the prescribed medicines
Ensure compliance with the agreed treatment plan by:
  • dispensing in specified instalments
  • ensuring each supervised dose is correctly consumed by the patient for whom it was intended.
The ‘Substance Misuse TreatmentFramework for Wales’ contains the following important requirements:
‘Because of the risks associated with the misuse of opiate substitutes (particularly methadone) and because of the benefits to users, every Community Safety Partnership has to have contractual arrangements in place with community pharmacists for the provision of supervised consumption’.
‘Agreements must be in place between specialist team, client and pharmacist (shared care) before any prescription is written or dispensed.’
This service seeks to support the above treatment framework and to provide supervised administration support for other health interventions such as the supervised administration of medication for mental health.
5.What are the expected outcomes for Service Users?
  • Assist the user to remain healthy and achieve a drug-free life
  • Stabilise the user, where appropriate, on an appropriate dose of substitution medication
  • Reduce the use of illicit drugs
  • Address other drug-related problems
  • Reduce the risks of HIV, hepatitis B and C and other blood borne infections.
  • Reduce the need for criminal activity to finance drug use.
  • Reduce the risk of prescribed drugs being diverted into the illegal drug market.
  • Improve the users’ overall personal and family function.
  • Maximise the access to the service and the retention of service users, especially the highly socially excluded.

6.How will the Service be provided? (Methods, Practices etc.)
6.1 General
  • Acting on the written instruction of a registered medical practitioner a pharmacist will supervise on a daily basis the consumption by the client of the prescribed dose of methadone in the pharmacy. The written instruction must form part of a NHS prescription.
  • With the exception of Bank Holidays the service will operate Monday to Saturday inclusive. Patients will be dispensed on Saturday the dose of methadone that is due on Sunday. Similar arrangements will be made to cover Bank Holidays.
  • The responsible pharmacist will ensure that all staff involved in providing the service have been suitably trained and are aware of the need to respect patient confidentiality.
  • The responsible pharmacist will ensure that the equipment and facilities necessary for the provision of the service are available in the pharmacy.
  • The pharmacist on duty, together with the key worker, should explain the contract to all new patients who are to receive daily administration of methadone. The patient should agree and sign the patient contract. This should be countersigned by the pharmacist. A copy of the contract should be given to the patient, together with a practice leaflet.
  • The pharmacist should ensure that all new patients are entered on the Patient Medication Record (PMR). Minimum data should include name and address, date of birth, GP, supervised/unsupervised and any other therapy the patient is receiving.
  • The pharmacist should introduce the patient to the counter staff, so that the patient can be dealt with promptly each day. A PMR card with the contract number may be issued.
  • The pharmacist should make any locums who may be asked to provide this service in their absence, aware of the protocol before they are employed. There should also be a senior member of staff who is able to assist them in identifying the client.
  • On any occasion where the service cannot be provided e.g. no pharmacist is available due to lack of locum cover, then every effort should be made to contact the client and prescriber to advise them that other arrangements will need to be made. This is important as the prescription cannot be “split” and dispensed at two different locations.
  • The pharmacist will provide to clients any LHB approved health promotion leaflets or advice.
  • Have adequate insurance cover before they commence providing a Methadone Supervised Consumption Service.
6.2 Presentation of client
When a patient requiring supervised consumption of methadone presents, the pharmacist should:
  • Check the legality of the prescription and that quantities and patients details are correct
  • Check the identity of the patient and that they have signed a contract.
  • If new, register the patient on the Patient Medication Record (PMR) System and explain the patient contract.
  • If appropriate, introduce the patient to key members of staff.
  • Should refuse to dispense the dose of methadone if the patient appears to be intoxicated or is otherwise incapacitated to such an extent that dispensing the dose would place the patient at risk of harm.
  • If the pharmacist considers the patient’s behaviour to be unacceptable, the patient appears intoxicated, or the pharmacist has any concerns, the prescriber should be contacted immediately and the dose withheld.
6.3 The Dispensing Process
In preparation for and when supervising the consumption of methadone, pharmacists should ensure:
  • Dispensing procedures comply with RPSGB good practice e.g.the guidance contained in the latest edition of the RPSGB ‘Medicines, Ethics and Practice’ is complied with.
  • Confirm that the legality of the prescription and that the dose and patients details are correct.
  • A Patient Medication Record (PMR) is maintained for each patient receiving a Methadone Supervised Consumption service. The record should be updated as soon as possible following each dispensing/supervised consumption episode.
  • Measure, double check and dispense in a suitable container.
  • Attach dispensing label to container detailing patient name, directions, quantity and date of dispensing.
  • Ensure that any ‘take home’ doses are fitted with child-resistant closures.
  • Ensure Ddoses for Sundays and Bank Holidays are labelled appropriately and supplied in child resistant containers.
  • Seal each labelled container in a dispensing bag, with the patient’s name and address label attached. Clearly mark the bag with the surname in bold and the day and date when the dose is to be administered.
  • Store the bag in a suitable safe location until the client calls to take their medication.
  • At such times e.g. Bank Holidays when the methadone may be dispensed rather than administered, the patient is given advice on the safe storage of the methadone in the home.
  • Ideally, the patient should have a drink of water before the dose to moisten the mouth. In such cases, provision must be made for safe disposal of drinking cups. Patients should not be allowed access to opened containers of drinks whilst consuming the methadone.
  • Daily doses may be prepared in advance and stored in the Controlled Drugs cabinet, to avoid undue delay when the patient presents in the pharmacy. Doses should only be prepared one day ahead or in the morning of the day of issue. The controlled drug register should not be completed to show supply until the supply has actually been made. This is in case the client fails to attend. Any uncollected pre-prepared dose may be issued for the next instalment. Where it cannot be issued, it may be returned to the original stock bottle provided that it has not been contaminated in any way. If this is not possible e.g. the current stock bottle is a different batch and expiry, then the pharmacist will need to contact an authorised person to witness the disposal of the methadone. The item should be clearly marked not for dispensing, awaiting destruction and separated from other CDs in the CD cupboard.
  • The instalment section of the prescription should be completed with the date and quantity measured, at the time of dispensing.
  • Uncollected doses will be forfeited and all doses must be personally collected by the named patients unless a prior agreement has been reached.
6.4 Supervision of Consumption of Methadone Mixture
In preparation for and when supervising the consumption of methadone, pharmacists should ensure that:
  • The patient’s identity must be checked and the pharmacist satisfied prior to the dose being issued.
  • The supervision process should take part in a quiet, approved, semi-private or private area and never take place in the dispensary
  • The dose of methadone is measured and transferred into a disposable cup or suitable container prior to consumption.
  • After swallowing the dose of methadone the patient is requested to swallow some water or engage in conversation to demonstrate that the methadone has been swallowed.
  • Doses of methadone for Sundays (Saturdays where appropriate) and Bank holidays, which will not be consumed in the pharmacy, should be dispensed in child-resistant containers and labelled appropriately.
  • Supervision is discreet, efficient and mindful of the patient’s dignity.

6.5Record Keeping

Following each supervised consumption episode the pharmacist should ensure:
  • An appropriate entry is made into the controlled drug register.
  • The dispensing must be entered in the Controlled Drugs Register. Isn’t this duplication?
  • The PMR is updated after the administration of methadone has been supervised /collected
  • What about paperwork for audit/payment? Most schemes I have been involved with have a daily recording sheet for the PCO .

7. When/Where will the Service be provided
In registered pharmacies included on the within the boundaries of Rhondda Cynon Taff local health board.
8.Who will provide the Service?
Only those pharmacies included on the Local Health Boards (LHBs) list as being commissioned to provide a supervised administration of methadone service will be eligible for payment.
All pharmacists providing the service must be accredited by the Local Health Board in accordance with the LHB requirements (see appendix D)
9.How will Service users involvement be reviewed and how often?
It is important for pharmacies participating in this service to agree a “patient contract” with each patient. This “patient contract” should outline how and when the Supervised Consumption Service will be provided and the obligations of both the parties. The patient should be provided with a written copy. A duplicate copy should be retained by the Pharmacy.
10.How will Service Users/ Parents/Carers/Guardians be consulted about the Service?
It is essential that there are effective communication links between the various professionals involved in the care of patients receiving methadone substitution therapy. In particular:
  • Pharmacists should develop and maintain close links with the prescriber and key workers.
  • When a patient receiving supervised administration of methadone is admitted or discharged from hospital it is essential that the hospital should liaise closely with the community pharmacist to share information.
  • The prescriber should contact the pharmacist or key workers with patient details as soon as a new patient has been identified as requiring a Supervised Methadone Administration Service.
  • The pharmacist in charge should make, in advance, appropriate arrangements to inform locums of the procedure to be followed when providing the Supervised Administration of Methadone Service.
Any noteworthy incidents or events should be recorded on the patient’s PMR. If in the professional judgment of the pharmacist the prescriber or key worker should also be informed, then the pharmacist should do so within an appropriate time-scale. Serious issues of an urgent nature must be communicated immediately to the prescriber.
The following are some examples of circumstances when the pharmacist should contact the Prescriber.
  • The patient has failed to turn up for one or more daily doses.
  • Whole doses are not being consumed under supervision
  • Patients attempt to avoid supervision
  • The patient exhibits threatening, violent or other inappropriate behaviour.
  • The patient appears to be ill or there has been a noticeable decline in the patient’s health.
  • There is a problem with the prescription
  • At the request of the patient for a clinically important matter.

11.What are the expected Performance Indicators?
All participating pharmacies must ensure that they: -
  • Comply with all relevant current guidance provided by the Royal Pharmaceutical Society of Great Britain (RPSGB) on legal and professional matters including professional indemnity. These can be found in the latest edition of ‘Medicines, Ethics and Practice' and in updates published in the Pharmaceutical Journal.
  • Comply, with reference to Methadone, with all the relevant legal requirements associated with its acquisition, storage, dispensing, destruction and record keeping
  • The pharmacy participates in LHB organised audit of service provision.
  • The pharmacy co-operates with any locally agreed LHB-led assessment of service user experience.
  • The pharmacy has appropriate LHB provided health promotion material available for the user group and promotes its uptake.

12.How will these be measured?
The LHB will arrange meetings with contractors to ensure compliance with the criteria
  • The pharmacy will maintain appropriate records to ensure effective ongoing service delivery and audit.
  • All staff providing this service will be expected to participate in appropriate Continuing Professional Development that complies with the criteria set by the RPSGB or other professional body.
  • Pharmacists wishing to provide this service should have undertaken appropriate training that is recognised by the LHB. Suitable material can be obtained from the Welsh Centre for Postgraduate Pharmaceutical Education (WCPPE).
  • All staff involved in providing the service must be suitably trained and aware of the need to respect patient confidentiality.
  • Locums and all support staff must be fully informed and suitably trained in relation to their involvement in the scheme.