3. Minutes, action log and attendance list of Last Meeting and Matters Arising. The minutes of the March meeting were accepted as accurate.

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1 South East London Area Prescribing Committee (APC) 23 June 2016 at Lower Marsh Approved minutes 1. Welcome, and Introductions 2. Conflicts of Interest declarations The Chair requested any interests, either general or relating to the meeting agenda be declared. There were no declarations made. Members were reminded of the need to submit up to date declarations of interest for 2016/ Minutes, action log and attendance list of Last Meeting and Matters Arising. The minutes of the March meeting were accepted as accurate. Matters Arising: There were no matters arising. 4. Results of election process for Medicines and Pathways Review Group (MPRG) co- Chair/APC Vice Chair Nominations for the roles of MPRG co-chair/apc Vice Chair were invited earlier this year and one nomination was received from Dr Di Aitken, a Lambeth CCG GP. Dr Aitken was formally elected unopposed and the committee members extended their congratulations. 5. Pathway updates Ophthalmology The group is meeting in July to finalise the pathways and the final draft will be presented to MPRG in August. Psoriasis The British Association of Dermatologists (BAD) is currently developing national guidelines in this area. The national development work is being led by the Chair of the SEL Psoriasis Pathway Development Group. In light of this the SEL pathway is on hold pending the national guidance, which is due in Autumn The SEL guidance will be aligned with the national guidance and will be more expansive, looking at commissioning issues and specific cohorts of patients, for example individual funding requests, use of fumeric acid and biologics. The committee was asked to note that the local pathway work has yet to gain any patient representation, which is a vital component of pathway redesign. It is hoped that an expert patient will be found from GSTT s dermatology patient group. Haematology - idiopathic thrombocytopenic purpura (ITP) The group is chaired by a Lewisham and Greenwich Haematologist and Southwark is the lead CCG, supported by Lambeth. There have been two meetings to date and a rough draft of the pathway is currently out for consultation with secondary care clinicians. The Chair will collate comments received from secondary care, after which the draft will be circulated for wider SEL consultation. The committee was informed that a pathway for Thrombotic thrombocytopenic purpura (TTP) is also planned but is development has not yet started. It was noted that it has been suggested that haematology may become the responsibility of NHS England (NHSE) in the future.

2 6. Sodium valproate and the risk of abnormal pregnancy outcomes South London and Maudsley (SLAM and Oxleas NHS Foundation Trusts presented the results of a national audit into prescribing sodium valproate for bi-polar disorder. Valproate is a known major human teratogen and the Medicines and Healthcare Regulatory Agency (MHRA) has recently reminded prescribers of the association of in-utero exposure to valproate with birth defects such as neural tube defects, cardiac malformations, childhood autism and reductions in IQ. Audit results showed that Oxleas is a comparatively low user of valproate while SLAM has a higher rate of use, in women of childbearing age. Oxleas demonstrated a lack of written information given to women of childbearing age and this is being reviewed with a view to improving in this area. It was noted however that despite this the trust has performed better than the national average. Both trusts performed well in carrying out physical monitoring checks. The presenter commented that SLAM and Oxleas were both in the upper quartile and hoped that the audit outcomes gave reassurance to commissioners that the trusts are identifying and working to resolve any gaps. Questions from panel: Do SLAM and Oxleas discuss the audit outcomes? Yes the outcomes are discussed. Will future audits be able to look at what monitoring GPs have done? Yes but the trusts stance is that monitoring should be done within the mental health services setting to ensure that the results are considered when developing treatment plans. Are action plans put in place to address identified gaps? Results are fed back at clinical team level to allow discussion and planning for action to resolve These drugs are often initiated at point of crisis. Is there a process to revisit and review the consent to confirm that patients remember the information given when the crisis point has passed? There is an absolute duty of care to ensure this is done and MHRA resources provide a mechanism to support this. Are there any plans to do a similar audit on use of antidepressants in pregnant women? Antidepressants are not a major risk in pregnancy in fact women would be more at risk from a relapse into depression. The committee thanked SLAM and Oxleas for presenting an interesting and useful audit. 7. Antibiotic Campaign for South East London A summary of the planned SEL antibiotic campaign was presented to the committee for review. The campaign is planned to coincide with European Antibiotic Awareness Day (EAAD) and World Antibiotic Awareness week in autumn of The proposal is to develop a pack containing resources to help support South East London CCGs/ Trusts to raise public and professional awareness on antibiotic resistance. Resources will include the Public Health England (PHE) toolkit, patient information leaflets, posters for display in surgeries and information on delayed prescriptions. There is also an elearning element for healthcare professionals (HCP). The following suggestions were made by the committee: Consult with the acute trusts infection control and antimicrobial stewardship committees

3 Ensure that out of hours services, SELDOC, GP access hubs and urgent care are included in the distribution Consider asking SLCSU to support the distribution of the resource pack as in the waste management campaign The Oxleas representative noted that a specific practice has developed an award winning poster with information for patients on reducing antibiotic use Lambeth surgeries are having Wi-Fi installed and will be able to send tailored messages to patients mobile phones Consider use of mobile phone apps for distributing the guidelines to HCPs. The trusts are already using these and there is potential to customise for community use. Outcome measures will be via epact data and achievement of national quality premiums ACTION: CCG Lead to steer through Trust committees and consider addition of resources as discussed. 8. South London Health Innovation Network (HIN) - Community of Practice (CoP) for Medicines Optimisation A CoP is social learning forum to pull together different professions to share knowledge and good practice around medicines optimisation in long term conditions. Members are self invited and there is no formal achievement target, it is up to the group to steer the process on a codesign basis. The CoP is being launched on 1 July and any committee members who wish to attend will be very welcome. Chief Pharmacists, Heads of Medicines Management and Local Pharmaceutical Committees are among those invited. 9. The Quality, Innovation, Productivity and Prevention (QIPP) challenge across South East London how should we respond? The CCG Chief Pharmacists have been approached by OHSEL to identify high impact areas. The starting point was to summarise the work of the APC with particular reference to the collaborative nature of the work, consulting with primary and secondary care clinicians as well as external organisations such as the local authorities and Commissioning Support Unit (CSU). Key tasks identified are: Financial savings on prescribing Medicines Quality and Safety Antimicrobial stewardship Prioritising 10 high impact QIPP initiatives New models of working include: Patient engagement and involvement via pathway groups, patient participation groups and Healthwatch. Links to Public Health and wider clinicians & clinical specialties via working groups and SEL consensus guidelines & implementation: CVD, Diabetes, Respiratory. Task-finish pathway groups involving medicines in Gastroenterology (IBD and IBS), Rheumatology (RA and SpA), Ophthalmology, Dermatology. Carter Review, Hospital Pharmacy Transformation Project HIN Medicines optimisation Communities of Practice

4 Regional Medicines Optimisation Committees (in development) The committee noted that the national 2015/16 spend per head on medicines was 250 and that intervention needs to be at patient rather than drug level. ACTIONS: CCG and acute pharmacy leads to meet to begin planning discussions and regular meetings to be scheduled Proposal to drafted for wider SEL consultation 10. Our Healthier South East London (OHSEL) Community based care setting the scene The Social Programme Director for OHSEL gave the committee an overview of the 5-year project. The project is defined as proactive with a focus on planned care and prevention of emergency admissions. The aim is to increase access to community based co-ordinated care, with a strong focus on self management. The model is based on local care networks working collaboratively. A successful example in end of life care resulted in 80% of the patient cohort dying at home where previously 60% would have died in hospital. This has high impact benefits on for both patients and financially. The outcome was achieved by working with a 24- hour provider with self managed access to equipment and by collaborating with other organisations to identify the patient cohort on a timely basis. Medicines are a core part of all areas of health and there are patient and financial benefits to extending the project to medicines optimisation. The APC are asked to work with OHSEL to develop processes to reduce emergency admissions, 5% of which are due to adverse drug reactions, and length of stay in hospital. The objective will be to assimilate resources, coordinate into a pack and disseminate across SEL. OHSEL can provide support to produce business cases but funding will be at a local level. It was stressed that it is not about reducing spend but about capping growth. Questions from panel: Information sharing is key how will this be managed? Bromley used Co-ordinate my Care. The local care record will also be critical. The greatest need is for patients in own home with complex needs and the biggest issue is staffing levels. What is needed is staff with the skills and time to manage these needs. Can OHSEL offer any support in this area? OHSEL can support work on developing non-clinical staff competencies which could free up time for clinical staff to deal with more complex areas and to identify systems that reduce admin burden. Local organisations would need to supply detailed plans on who /what /how and the time required and as discussed any funding needed would be local. 11. Items for information/ratification NICE Technology Appraisal Summary New/revised formulary recommendations and position statements 003 dapagliflozin type 2 diabetes (withdrawn) - ratified

5 004 mirabegron for OAB (withdrawn) 048 Tiotropium Respimat in Asthma 049 botulinum toxin in hypersalivation - ratified New Drugs Panel minutes March-April 2016 SEL APC Terms of Reference revised 2016 SEL APC 2015/16 Annual Report and 2016/17 Workplan The terms of reference and annual report have been ratified by the Commissioning Strategy Committee who gave positive feedback and thanks for the valuable work of the APC SEL APC Integrated Respiratory Guidelines Management of Asthma Management of COPD Risk of adverse patient safety incidents due to the replacement of yellow books with Dawn software payslips in the outpatient anticoagulation clinic The Dawn software payslips have been reviewed by the South East and South West London Cardiovascular Working group who suggested making them available in large print and other languages. Regional Medicines Optimisation Committees (RMOC) Workshop Outputs from April 20th 2016 All items for information were noted. 12. Any other business (AOB) There were no AOB items meetings: Thursday 13 October pm-4.00pm Room 407, 1 Lower Marsh