Medicines Management Joint Executive Team

Thursday, 2nd June 2016, 4 - 6 pm

Small Meeting Room, ChilternCCG

MINUTES

Attendees
Dr Raj Bajwa (RB) (Chair)Clinical Commissioning Director for LTC, EoL and Prescribing, Chiltern CCG
Jane Butterworth (JB)Head of Medicines Management, AV & Chiltern CCGs
Sarah Crotty (SC)Interface Pharmacist, AV & Chiltern CCGs
Elaine Sharpe (ES)Prescribing Support Pharmacist, AV & Chiltern CCGs
Gill Beck (GB) LMC representative
MMJET_2016/082 Apologies
Julie Horslen (JH) LPC Representative
Sally Aldridge (SA) LPC Representative
Dr Stuart Logan (SL)Executive Clinical Lead for Chronic diseases, Medicines Management and End of Life Care, AV CCG (electronic comments have been received)
MMJET_2016/083 Conflicts of interest
  • GB handed in her annual declaration for Conflicts of Interest
  • No other new declarations of interest were declaredthat were not already recorded

MMJET_2016/084 Minutes and Matters arising
  • Approval of minutes for meeting held in May 2016 unchanged.
    LMC website GB highlighted that it may be useful for locums. The LMC is happy to host CCG documents. CCG Locum guide to be sent to Gill to add to LMC website. GB also commented that it would be useful to have information on how to sign up to safety alerts. Action 084 - SC to liaise with Paul Roblin to ensure suitable things are offered to add to LMC website and to send Locum Guide.
  • Action update – has been updated according to the meeting discussion

MMJET_2016/085 Budget and Contract Monitoring
  • Quality premium for antibiotics. Practices should be congratulated for their improved performance in this area
A congratulatory note should be put into both Chiltern and AVCCG bulletins Action 085a - SC.
SC also to ask communications lead if a press release can be made as a “good news story”. Action 085b SC.
  • High Cost Drugs List for 2016-17
    – Additions were agreed
-Principles were agreed (for new additions)
Tracked changes to be removed by SCand item to be uploaded to the extranetaction 085c -by admin table at forums action 085d - JBu
MMJET_2016/086Controlling Spend on Wound Dressings
  • Potential discount on Aquacelfor discussion
  • There was a long discussion on the principles. Discount was agreed on the basis that there are already discounts agreed on this non prescription supply service and that the original choice of Aquacels inclusion on the formulary was made not based on the discount.Action 086 - SC to organise that this discount is collected

MMJET_2016/087 Community Pharmacy
Out of Pocket expenses is an area we need to explore further as across both Bucks CCGs we are spending a large amount (c. £120K) and not all issues appear to be reasonable or within the principles of drug tariff and PSNC. The CCGs MMT will seek to work with NHSE & LPC to develop some principles (about frequency and exceptionality) and to challenge excessive charges and those that are not allowed under the drug tariff & PSNC rules

Action 087a - SC (6 months)
Electronic prescribing – HSCIC has offered to do some training, which could be offered to practice staff. JBu to ask at the prescribing forums if there is a need for this training. Action 087b - JBu
MMJET_2016/088 Documents for Final Ratification
  • Diabetes Blood Pressure Guidance
Guidance was approved subject to some minor changes. Final document is here:

MMJET_2016/089 Documents for discussion
  1. Interventions Overactive Bladder updated intervention was approved with minor change to title and term OAB syndrome, changed to Overactive Bladder.The use of the recommended brand of Tolterodine mr is to be promoted at Prescribing forums.Changes to be made by Action 089a - ES. Upload to be done by Action 089b - admin staff
Action 089c: Overactive Bladder intervention to be added to Prescribing forum agendas - admin
  1. Minocycline revised amber guideline
    Minocycline was felt by MMJET to be 4th line in acne not 3rd line.
    The group noted that monitoring has doubled from every 6/12 to every 3/12. SC had investigated why the frequency of monitoring has changed as 3 monthly monitoring has always been recommended in the BNF. The cited reason given by the consultant dermatologists for the changed frequency in the monitoring is because of the BNF recommendation. The question was posed as to whether the doubled monitoring added value. Autoimmune hepatitis is rare: (≥1/10,000 to <1/1,000). It is also dose related. Doubling the GP workload for monitoring was deemed onerous and required further discussion with the dermatologists as to whether this was necessary.
    Unlicensed uses. Members of MMJET felt unable to support the unlicensed uses with this frequency of monitoring. It was suggested that we need to understand the number of patients involved, duration of therapy and frequency of specialist visits to assess if these patients could be managed in secondary care instead. It was raised that the existing amber guidance for minocycline includes these patients. However members felt that the original decision to include these patients as amber initiation was an error. These issues will require further discussion outside MMJET with the specialist consultants. Action 089d - SC to feedback to BHT comments on minocycline amber guidance
  2. Psychotropic drug prescribing in learning disabilities - Standards Document is an important document. Included herefor awareness. Within the new Bucks CCG federated structure there will be a new mental health GP lead who will lead and co-ordinate mental health issues.
  3. Azithromycin in CF draft amber guidance
    Initiation should be at the recommendation of a respiratory consultant only. Add the 1st prescription of the initial month of therapy must be made in secondary care

Suggested monitoring includes,
LFT at month 1, and annually
ECG at 3 months and annually
Check for tinnitus or hearing loss annually
All of this monitoring was felt by MMJET to be the specialist’s responsibility.
MMJET noted Chris Wathen’s response: “I am rather surprised as clearly the aim of this therapy is to reduce exacerbations and therefore GP work”, however the MMJET consensus remained that this monitoring should not be transferred to primary care. The members believed that the prescribing could be done by GPs but patient visits would need to be re-modelled to ensure this monitoring was undertaken by the specialist. GPs present felt that patients taking azithromycin for this indication should not be discharged from secondary care follow up even if stable while taking long-term antibiotics and that the specialist was also best placed to review and stop this therapy, and therefore all patients will require an annual specialist review.
It was also suggested that it is more cost effective to check ALT rather than LFTs.
Action 089e - SC to feedback to BHT comments on azithromycin amber guidance
MMJET_2016/090 Risk Register
  • Gender dysphoria document from Specialist Commissioning
    This document suggests that GPs should initiate treatment and prescribe for gender dysphoria. It breaks many of the Bucks principles for shared care. The document does not help us with the service gap that has been previously identified. We still have some patients in Bucks who cannot find a prescriber for this condition. This item is on our risk register because of the risk to our good reputation is high.
  • Risk register
    AVCCG are considering inclusion of a gender dysphoria service for Bucks in the re-tendering of the Mandeville GP practice service. There will need to be specification developed for this. MMJET felt this would be an excellent solution. However, as this service is not yet appointed to, the MMJET felt that the risk register coding for gender dysphoria could not be downgraded at this time. There is still a very high current risk of reputational issues until a service is formally in place. Action 090 -JBu to add a note onto RR documenting the intention to add gender dysphoria to Mandeville GP service specification
    GB as LMC representative confirmed that the Clinical and Prescribing Committee of General Practitioner Committee (GPC) are unhappy about gender dysphoria prescribing being expected of GPs. GPC are actively against the whole principle of making GPs prescribe for this vulnerable group of specialised patients. They have taken this up with the highest authorities including GMC and NHS England. It is difficult for GPs to gain adequate experience with the low volume of gender dysphoria patients. Clinical safety could be an issue- especially because in date written shared care documents detailing the necessary monitoring are not currently available from our local services.

MMJET_2016/091 ScriptSwitch vs Optimise Rx
Optimise Rx is being piloted in four practices. We believe it has advantages over ScriptSwitch. The trial is for 4 weeks. Cross keys, The Hallpractice, Trinity, Little Chalfont surgery are the pilot sites.
The profile on Optimise Rx for the pilot is not Bucks specific but in general the messages are tailored to specific patients and so not as non-specific as with ScriptSwitch. Optimise is updated nationally which has advantages.
ScriptSwitch have not delivered on promises to have STOPP_START in place by Q1 of 2016-17 and this has contributed to the decision to pilot Optimise Rx.
MMJET_2016/092 Care Homes
  1. Medication ordering process notapproved
    Multiple suggestions. SC to work with the authorand resubmit the medication ordering process documentto next MMJETAction 092a - SC
  2. Medicines reconciliation guidance -
    Overall the feeling was it uses many complex words and concepts. However, it was approved for Nursing Home use.
    For Care Homes (without Nursing) – it needs to be trialled on some carers to see if they understand it & bring feedback to MMJET before roll out.
    Action 092b - Unoma Okoli (UO)– update to state Nursing Home Guidance not all care homes.
    Action 092c - admin upload document
Action 092d UO to trial guidance in residential care home and feed back to MMJET (Oct 2016)
  1. Medicines Administration in Day Care – deferred to July 16 as Mitta Bathia unable to attend.

MMJET_2016/093 NICE guidance
  • NICE May 2016 – was noted
  • Medicines Optimisation QS120 wasfor consideration of its impact locally
    Page 13 outlines the main 6 statements
Statement 1 – Patients are given the opportunity to be involved with decisions about their medicines
Statement 2 – Patients know how to identify and report medicines related safety incidents
Statement 3 – Local Health providers monitor patient safety incidents and learn from them
Statement 4 – Reconciliation in hospital
Statement 5 – Reconciled list of meds at discharge are in GP notes within 7 days of receiving them and before a prescription is issued by the GP
Statement 6 – Local healthcare providers identify people taking medicines who would benefit form a structured medication review.
It was noted that many of these are aspirational targets, which are hard to measure.
There wasa long and constructive discussion on discharge issuesaffecting quality of care. The issues are many, multicomponent and varied. Specific examples of crucial missed medicines on discharge were mentioned. This issue is time-consuming for GPs to sort out, especially if the consultant is not named on the discharge summary. Poor quality of discharge information was felt to be a patient safety issue. It was agreed that poor quality of discharges from hospital - MMJET should feedback to quality as an important safety issue. Action 093 -JBu to inform Quality team of MMJET concerns around documentation at discharge (via sending quality leads the key issues report)
MMJET_2016/094 Safety
  • Fentanyl patch alert was deemed urgent and tabled

Bathing in hot water increases bioavailability of fentanyl patches. This was noted on a coroner’s reportwhere the increased bioavailability contributed to her death from an opiate overdose.
Make forums aware of this safety alert, not suitable for ScriptSwitchAction 094 - SC Add to forum agendas
MMJET_2015/095 Any Other Business
BBC news recently reported on taking HIV medicines as a prophylactic way of preventing HIV +ve status developing. It was confirmed by the MMJET that this use is not currently available locally as an NHS treatment. It was felt that this would be a public health issue if funded & so is not within the current remit of the Medicines Management Team.
MMJET_2016/096Key Issues Report (2 meetings May and June 16)
  1. Discharge Issues Discussion on discharge issues which are many and varied. Specific examples of crucial missed medicines on discharge were mentioned. This issue is time-consuming for GPs to sort out, especially if the consultant is not named on the discharge summary. This was felt to be a patient safety issue. Feedback to quality.
  1. The anticholinergic initiative– intervention designed and to be circulated which highlights the anticholinergic burden of medicines & encourages review of high risk patients. Anticholinergic drugs pose a risk of falls, increased risks of dementia and other significant effects on morbidity so the impact of this piece of work could be very significant for improving quality.
  2. Gender dysphoria – remains high risk on the risk register until a provider is found. LMC representative reported concern and actively has been feeding back concerns to NHS England.
  3. Antibiotics Great performance on national antibiotic targets15/16(all met)
  1. Improvement in outcomes achieved by QIS – AVCCG QIS has resulted in overall improvements in care in all monitored parameters. There was no medicines management QIS in Chiltern CCG and so much less of an effect(or no effect) on some monitored parameters.

Date of next meeting 14July 2016