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MINUTE of MEETING of the
AREA PHARMACEUTICAL COMMITTEE
Board Room, Assynt House /
25 August 2008 – 10.00 am
PresentDr David Raeburn (Chair)
Ms Catherine Beaton
Mr Gareth Dixon
Mr Alex Kelso
Ms Emily Macintyre
Ms Sandra Melville (via video link)
Ms Claire Morrison
Ms Fiona Nicholas
Mr Thomas Ross
Mr Ian Rudd
Ms Fiona Thomson(via video link)
In AttendanceProf John Cromarty (from 10.10 am)
Mr Brian Mitchell, Board Committee Administrator
Mr Peter Mutton
Ms Sharon Pfleger
1WELCOME AND APOLOGIES
An Apology was received from Ms Mary Morton.
2MINUTE OF MEETING OF 26 MAY 2008
The Minute of Meeting held on 26 May 2008 was Approved.3MATTERS ARISING OR ONGOING
3.1Production of a Risk Register
Prof Cromarty advised that a range of approximately 50 risks had been collated and prioritised to produce a Pharmacy Risk Register, and would be fed into the NHS Highland Risk Register. Mr Ron Ward was coordinating this activity and the Register would be brought to the Committee when complete. It was advised that a number of significant Risks had been identified including issues relating to Staffing and IT. On the point raised it was confirmed that the draft Register would be circulated for comment.
The Committee:- Noted the position in relation to production of a Risk Register.
- Noted the draft Register would be circulated for comment.
- Noted the formal Register would be brought to a future meeting of the Committee.
3.2Strategy for Non-Medical Prescribing
Mr Ross advised that the Strategy for Non-Medical Prescribing had yet to be ratified, and on the point raised confirmed this would be applicable to all Non-Medical Prescribing, including in all care settings. It was stated that there had been significant change to the Strategy with regard to the hospital setting, that such change related to conditions ensuring good governance, and that the Raigmore Management Team were to ensure this would be disseminated to individual Directorates. The Chair sought confirmation that a register would be held of all staff that were to operate as Non-Medical Prescribers and it was confirmed that a database would be maintained. During discussion, the view was expressed that the role of the Area Pharmaceutical Committee required to be established prior to the finalisation of the proposed Strategy, such as in determining where this would be introduced. Prof Cromarty stated that such consideration would require to be on a multi-disciplinary basis and include consideration of such issues as training requirements. It was stated that primary Care uptake was very low and there was a suggestion that locum cover issues for independent contractors should be scoped.
Discussion moved on to the issue of increasing the number of Non-Medical Prescribers in Highland and it was suggested that a survey be undertaken to establish why numbers were so low, although this would require to be resourced. In context it was stated that a £5k budget was available in the current year for training purposes. Mr Kelso suggested that numbers may be low as a result of Independent Prescribers not wishing to participate, given a potential dip in their own level of prescription allocations, and Ms Pfleger stated that the Committee would have a role to play in establishing the position and providing appropriate advice where necessary. Mr Ross emphasised that there should be separation between prescribing and dispensing and the Committee acknowledged that this posed particular issues in a remote and rural setting such as Highland. On the point raised, Mr Ross advised that the issue of Pharmacist Prescribers operating as mentors has still to be addressed. The view was expressed that a number of barriers existed to a range of potential prescribers, including required levels of experience, and access to patient records. Prof Cromarty advised that through the Chronic Medication Service, access to data and records, for emergency supplies, would be available electronically.
The Committee:- Noted the position in relation to Non-Medical Prescribing documentation.
- Noted the need for clarification of the role of the Committee.
- Noted the suggestion that locum cover issues be scoped.
- Noted the issues in relation to increasing the number of Non-Medical Prescribers.
4MEMBERSHIP AND ROLE OF THE COMMITTEE
Ms Pfleger expressed concern as to the current profile of the Committee and queried as to whether the NHS Board was fully cognisant of relevant National issues etc. The suggestion was made that the Committee should be more proactive in seeking matters for discussion, including from senior management such as the Board Nurse Director. It was stated that the Committee could write to Board Directors highlighting its role within the NHS Board, advising as to current issues, advising as to services offered, and seeking interaction on a more formal basis. It was stated that ex-officio members have a key role in identifying matters for discussion and the suggestion was made that members be canvassed on upcoming issues. There was aneed to consider issues and give appropriate advice on matters emanating from the NHS Board as well as Circulars etc. One example of this related to the Access to Emergency Care Summary, which included mention of Pharmacy although the Service or Committee itself had not been involved.
The Committee:- Agreed that the Chair, Secretary, Mr Mutton, Ms Morton, Ms Pfleger, and Ms Morrison
5COMMUNITY PHARMACY IMPLEMENTATION
Prof Cromarty advised that NHS Circular PCA(P)(2008)17 had recently been received and that this related to additional Pharmaceutical Services, specifically the Minor Ailment Service (MAS) and Public Health Service Directions, Service Specifications and Payment Arrangements. Ms Morton and Ms Thomson were to consider the document, identify key issues to implementation, and issue appropriate guidance and advice to Community Pharmacies. Ms Morrison advised that the main points related to smoking and sexual health matters under Public Health; remuneration in relation to Core elements, set up costs and new patient services; and changes to capitation payments relative to MAS. On the point raised with regard to appropriate training, Ms Morrison advised this would be through NES packs and added that Public Health Service (PHS) campaign documentation had also been included. Reference was made to relevant data capture and it was stated that this would most likely be used for payment purposes. Mr Ross referred to contact tracing, and Ms Nicholas stated that this point had been raised by GPs as being extremely important and required highlighting to the NHS Board. It was confirmed that the Smoking Cessation element would replace the existing services and as such would be discussed at a forthcoming Contractors meeting.
The Committee:- Noted that NHS Circular PCA(P)(2008)17 had been received, and the key elements referenced.
- Noted that GPs had highlighted contact tracing as an issue for consideration by the NHS Board.
- Noted that Smoking Cessation requirements would be discussed at a future Contractors meeting.
6SCOTTISH PATIENT SAFETY PROGRAMME
Mr Rudd gave a presentation to the Committee, advising that the Programme, which had been developed in partnership sought to shift the focus of care from quantity to quality, with the overall aim of reducing harm to patients. The programme followed methodology garnered from motor/aviation industry improvement and generally utilised low tech interventions. Therewas a number of work streams involved, including Medicines Management and the methodology employed was to utilise small scale, bottom up driven interventions which were ramped up with a rapid turnaround, and operate with surrogate markers and Run Charts. The three work areas involved included medicines reconciliation, oral anticoagulation, and failure mode effect analysis and would be applied initially in Raigmore and rolled out into Rural General Hospitals (RGHs), then Community Hospitals, and General Practice, Community Pharmacy, and District Nursing thereafter. Medicine reconciliation testing was outlined and would occur at admission, patient transfer, and on discharge where information was to be presented to patients on the reasons and changes for medication prescribing, this also being provided to GPs, and consideration as to whether IDLs were being updated. An ‘on admission’ form, an example of which was shown, was being trialled in a number of areas within Raigmore. With regard to oral anticoagulation, this was the first of the high risk medicines to be considered and moving forward there was to be one protocol established, a single prescribing form, inclusion of prescribing algorithms, and provision of a Pharmacy consultation service. In terms of Failure Mode Effect Analysis, this is a tool where a process can be evaluated to identify the possible failures and the consequences of these, thereby identifying the most important areas for improvement. This tool would seek to reduce medication errors and initial consideration was being given to Warferin dosage. In summary, Medicines Management was a complex work stream that cut across all disciplines, and affects all areas of care. This would require significant system changes across NHS Highland and would require extra resource to implement effectively. Moving forward, the challenges for Pharmacy would include raising relevant profile and influence levels, consideration of the additional work requirement without extra resource, issues relating to patient transfers across care ‘boundaries’, the applicability to primary care and generic services, and the utilisation of the methodology in other areas to reduce harm. Mr Kelso advised that he was to act as a patient facilitator on behalf of QIS and in general the Programme was about introducing small changes, in a bottom up approach, to gain maximum benefit. In this regard engagement would be very important as there was a need to identify good practice and roll this out.
During discussion, the Committee was advised that the number of incidents involving adverse drug reactions etc had remained constant for a number of years, that it was difficult to quantify the percentage of harm to patients in this regard, and as such evidence-based data was required when introducing interventions. Mr Rudd advised that monthly meetings of the Senior Leadership Team considered appropriate trigger tools. There was discussion as to the involvement required from Pharmacy and it was agreed that the Senior Leadership team be approached to establish exactly what was required and at what level. The issue of Data Protection was raised with regard to Medicines reconciliation and Mr Rudd advised that this point was being addressed and further guidance sought as required. Ms Melville welcomed the sound approach being taken to Medicines reconciliation and advised that issues existed with regard to Team walkrounds that were undertaken as, in her experience, staff tended to give a positive impression and not necessarily advise as to underlying issues. The Chair raised the issue of mechanisms for raising suggestions as part of the Programme process and was advised that it was hoped that a culture would be established where that took place. Mr Rudd also confirmed that progress reports would be brought back to the Committee.
The Committee:
- Noted the work being undertaken in relation to the Pharmaceutical aspects of the Scottish Patient Safety Programme.
- Noted that initial Failure Mode Effect Analysis work would relate to Warferin dosage.
- Agreed that the Senior Leadership Team be approached to determine the responsibility level and involvement required from Pharmacy.
- Noted that progress reports would be submitted to future Committee meetings.
7‘JUST IN CASE’ ANTICIPATORY CARE PROJECT
Prof Cromarty spoke to a circulated paper, which had been produced as a Guide to managing emergency symptoms including pain, nausea/vomiting, anxiety/convulsions/restlessness, breathlessness, confusion/agitation at end of life, respiratory secretions, and acute terminal events. ‘Just in Case’ was a process for ensuring provision of a small core stock of medicines within a patient’s home so as to provide quick and easy access to those that would most likely be required. This initiative related to end-stage palliative care patients and to date pilot exercises in Skye, Beauly and Invernesshad proved positive. There was a need to raise awareness of this initiative in advance of training and rollout of the project in Autumn 2008. With regard to intravenous medicines, Mr Ross advised that this aspect had been piloted in Inverness through provision in a locked box to which only health professionals had access, and had resulted in a move away from GP prescribing in this area. Ms Nicholas questioned the assumption that District Nurses would be involved in administration of medicines and stated that initial consultation had established this may not be the case in some areas. Mr Ross advised that District Nurses had been commonly involved in the Inverness area although acknowledged that training issues may exist, especially with regard to syringe drivers. Mr Mutton raised the issue of associated drug costs for wasted medicines and was advised that the matter of supply levels would require to be considered.
The Committee:
- Noted the ‘Just in Case’ Anticipatory Care Project initiative.
- Noted the project would be rolled out in Autumn 2008.
- Noted the issue of drug supply levels was to be further considered.
- Noted thecirculated Guidance summary, which forms Appendix 1 to these Minutes.
8APPLICATIONS FOR INCLUSION IN THE PHARMACEUTICAL LIST
8.1Application by Assura Pharmacy Ltd for premises at Units 2 & 3 Cradlehall Shopping Centre, Cradlehall Court, Inverness, IV2 5WD
Members of the Committee were asked to note that a copy of this application was circulated electronically to members on 4 July 2008, due to the date for returning any written representation being 1 August 2008, and that a copy of the Committee’s response to the Community Pharmacy Contracts Manager was circulated with the agenda papers.
Discussion was held as to the role of the Committee in providing a response on such applications and concern was expressed that these were being used to support/ not support provision. The Chair stated that the Committee provided a response in an advisory capacity only and was not in a position to either support applications or otherwise. Prof Cromarty confirmed that comment was made solely in relation to qualitative aspects. In conclusion the Committee was content to comment on aspects of applications not relating to suitability although it was agreed that Declarations of Interest should be referenced where appropriate.
The Committee:Notedthe application by Assura Pharmacy Ltd for the provision of services from the Units 2 & 3 Cradlehall Shopping Centre, Cradlehall Court, Inverness and the Committee’s representation to the Community Pharmacy Contract Manager.
9REPORTS
(a)Area Drug and Therapeutics Committee
The Minute of the meeting held on 21 May 2008 was Noted.
(b) Area Clinical Forum
Prof Cromarty advised that the NHS Highland Annual Review 2008 was to take place on Wednesday 27 August 2008 and a report would be brought to the next meeting of the Committee.
The Committee so Noted.
(c) Tobacco Strategy Implementation Group
Ms Pfleger advised that Susan Birse had now been appointed to a substantive role and was to write to all CHP areas setting out respective trajectories. It was hoped that the data return rate would be improved. There was a range of prevention resources currently available to the Board and this was being considered in terms of providing advice sessions in schools. A review of Smoking Cessation services was now underway and the results of this would be presented to a future meeting of the Committee.
The Committee Noted the position.
(d)Consultant in Pharmaceutical Public Health
Ms Pfleger spoke to the circulated report advising that the Area Drugs and Therapeutics Committee has been set up and there has been productive output from Sub Groups. Issues remained regarding dedicated administrative support and CHP/Management representation. Work continued on communication issues. The Exceptional Medicines Use Sub Group was developing a Highland-wide Policy on how to handle requests to use medicines which are outwith normal local policy/national recommendations and this was a challenging area of work that was subject to intense political and media scrutiny. With regard to Pandemic planning, work is underway in relation to the pharmaceutical aspects, a major component of which will be continuity planning for community pharmacy services. The Pharmacy Pandemic Management Group has now met and is looking at developing both strategic and operational plans for the distribution and supply of antiviral drugs and vaccines and business continuity plans for community pharmacies and all aspects of the managed pharmacy service. Ms Pfleger added that the Management Group had been of the opinion that the supply of anti viral drugs should not be through community pharmacies in the first instance and as such consideration was being given to alternative mechanisms. The Chair requested that this point be relayed to independent contractors. Mr Ross advised that South East Highland CHP were considering the issue of contingency planning.
The Committee Noted the position.
(e)Director of Pharmacy NHS Highland
Prof Cromartyspoke to his tabled report incorporating an End of Year Performance Review for the Integrated Pharmacy Service 2007/08, which in primary and secondary care had facilitated the achievement of the Board’s targets. Financial and clinical success had been acknowledged and discussion had been held in relation to the introduction of automation in order to free pharmacists’ time for more clinical involvement, and further support the shift in the balance of care. On the issue of safer management of Controlled Drugs (CDs), a GP Information and Support Pack had been prepared and is about to be issued to Dispensing and Non-Dispensing GP Practices who would be required to complete self declaration forms by end of 2008. In this regard CHP Lead Pharmacists had had agreed to offer practices advice and support, pending the appointment of Controlled Drugs Inspectors. In addition, all CHP Lead Pharmacists, along with nominated others, were to act as ‘Authorised Witnesses’ for the destruction of CDs in the transitional phase. With regard to the creation of a Risk Register, as discussed earlier in the meeting, identified risks had been collated and prioritised, with the top priorities being submitted for inclusion in the organisational NHS Highland Risk Register. Prof Cromarty added that he had become a member of the TransCom Reference Group, the first meeting of which had been held, and stated this presented Scotland and its NHS Boards with an opportunity to input at an important time for the Pharmacy profession. Representation on the Reference Group was not to be dominated by any one particular area and a symposium was to be held on 3 and 4 October 2008.