Prescribing Advisor for BHR CCGs, representing Barking & Dagenham (B&D) CCG Prescribing Advisor for BHR CCGs, representing Redbridge CCG

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1 BHR CCGs AREA PRESCRIBING SUB-COMMITTEES Thursday 5 th November 2015 BOARDROOM A, BECKETTS HOUSE, ILFORD, IG1 2QX PRESENT Dr G Kalkat (GK) Oge Chesa (OC) Belinda Krishek (BK) Dr C Okorie (CO) Dr K Kugathas (KK) Imran Khan (IK) Sanjay Patel (SP) Olufunlola Apakama (OA) Mohamed Kanji (MK) Saiqa Mughal (SM) Imran Jan (IJ) Sarla Drayan (SD) Kam Takhar (KT) Denise Baker (DB) APOLOGIES Diane Meid (DM) Dr A Tran (AT) IN ATTENDANCE Veer Patel (VP) Paul Barratt (PB) Chair, GP, Clinical Director Prescribing Lead, Barking & Dagenham (B&D) Clinical Commissioning Group (CCG) Deputy Chief Pharmacist, Barking & Dagenham, Havering and Redbridge CCGs (BHR CCGs) Chief Pharmacist, BHR CCGs GP, Clinical Director Prescribing Lead, Redbridge CCG GP, Redbridge Local Medical Committee (LMC) Representative QIPP Pharmacist & Prescribing Advisor for BHR CCGs QIPP Pharmacist, BHR CCGs Prescribing Advisor for BHR CCGs, representing Barking & Dagenham (B&D) CCG Prescribing Advisor for BHR CCGs, representing Havering CCG Prescribing Advisor for BHR CCGs, representing Redbridge CCG Pharmacist, North East London (NEL) Local Pharmaceutical Committee (LPC) Chief Pharmacist, Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) Deputy Chief Pharmacist, (Communiyy Health Services) North East London Foundation Trust (NELFT) Business Manager, BHR CCG s Lay member GP, Clinical Director Prescribing Lead, Havering CCG Pharmacy Coordinator, Partnership of East London Co-operatives (PELC) Ltd Clinical Lead for Urgent Care (PELC) 1 P a g e

2 26.1 Welcome / Introduction / Apologies A list of apologies was received as shown on page 1. Chief Pharmacist at BHRUT was welcomed to the meeting and introductions were provided. Action and by whom 26.2 Declarations of potential conflicts of interest None were received Minutes of the previous meeting The minutes of the previous meeting were agreed. The redacted minutes for the September 2015 meeting were agreed for addition to the BHR CCG websites. - Add the agreed redacted minutes to the BHR CCG websites 26.4a Prescribing in alcohol detoxification regimes (item 25.4a in September minutes) Medicines Management Team advised that a response from the Local Authority regarding a service in Barking and Dagenham was still awaited and therefore it was agreed that this item would be removed until an update was availalble. 26.4b Shared Care Guideline Checklist (item 25.4b in September minutes) BHRUT Consultant dealing with this item had been contacted requesting an update on the progress of the e-platform for shared care guidelines (SCG), however he had responded advising that due to a change in role this was no longer within his remit. We have been advised that the Trust was currently undergoing an upgrade to its IT service and once this had been completed, the feasibility of an e-platform for SCGs would be considered. BHRUT - To provide an update on the progress of the e-platform for shared care guidelines Update for the January APC meeting. 26.4c New drug evaluation for DuoResp Spiromax (item 25.4c in September minutes) Despite liaison between the Medicines Management Team () and the BHRUT Respiratory Team a meeting was yet to be agreed to discuss the draft formulary of preferred devices for the management of asthma. Due to the urgency of the meeting previously stated at the APC, it was agreed that there would be a discussion at the BHRUT Respiratory Team to try and expedite the meeting aforementioned. 26.4d Evidence behind the proposed amendments to the Dementia Share Care Guideline (SCG) (NELFT) (item 25.4d in September minutes) A revised draft shared care guideline incorporating the agreed amendments had been presented at the recent NELFT Drugs and Therapeutic Group (DTG) meeting and further comments had been received. Once the additional comments had been considered the revised document would be included in the January APC agenda for approval. BHRUT/ - To liaise regarding the meeting and ensure that the draft formulary is considered by the and agreed before submission to the BHRUT DTC NELFT - Provide the revised draft SCG for consideration at the January APC meeting Agenda item for the January APC meeting. 2 P a g e

3 26.4e Formation of an outer NEL Antimicrobial Resistance Strategy Group (AMRSG) (item 25.4e in Septenber minutes) Medicines Management Team advised that the discussions at the AMRSG meeting on 1 st October 2015, had focused on preparations for the forthcoming European Antibiotic Awareness Day (EAAD) on 18th November and the World Antibiotic Awareness Week (WAAW) commencing on 16th -20 th November. All stakeholders which included the local authorities, BHRUT, Barts Health NHS Trust, NELFT, NHSE and Public Health England (PHE) were planning to circulate press releases and various resources supporting the events. It was mentioned that it would be beneficial for the material to be available in various languages, however this would depend on the resources availalble within teams to produce locally. - To invite local community leads to the next AMRSG meeting - Include AMRSG minutes in future APC agendas for information It was suggested that local community leads should be invited to the next AMRSG meeting. It was agreed to include the minutes of the AMRSG meetings for information purposes in future APC agendas. 26.4f Prescribing guidelines of infant formula for infants with Cow s Milk Protein Allergy (CMPA)(item 25.4f in September minutes) Medicines Management Team advised that the NELFT dietitians had received further comments from the neo-natal nurses in BHRUT, however comments from the paediatric nurses regarding the guidance were still awaited It was anticipated that the document would be available for inclusion in the January APC agenda. NELFT - To produce the revised CMPA guidance for consideration and approval at the January APC meeting Agenda item for the January APC meeting. 26.4g Labelling of Insulin pens by community pharmacies (BHRUT)(item 24.6 in July minutes) A summary was provided of this previous agenda item which had been deferred awaiting Local Pharmaceutical Committee (LPC) comment. It was highlighted that the concern regarding the labelling of insulin pens had been raised by BHRUT and not the CCGs. An prior to the meeting had been received from the Secretary of the LPC on the 3 rd November and this was relayed to all. The LPC representative in attendance, expressed the concern that community pharmacists would not have the capacity to label each patient s individual pen when dispensed by the pharmacy. However it was explained that unlabelled pens on hospital wards was a safety issue that needed addressing and as part of good practice community pharmacists should be providing labels for all medicines dispensed in line with GPhC regulations. This could therefore refer to individual devices and not just the box that patients received their medication in. It was stated that some patients within a care home setting have their individual pens labelled, and therefore the labelling of insulin pens should now be extended for all patients. It was requested that further discussions take place outside of the meeting between BHRUT, BHR CCGs and the LPC to discuss how the safety issue could be implemented; a timeline LPC - To co-ordinate a meeting as a matter of urgency wth BHRUT, and CCG representatives to discuss the implementation of the labelling of insulin pens by community pharmacies - Update to be provided at the January APC meeting 3 P a g e

4 was requested for the arrangement of this meeting. The LPC representative in attendance advised that he would feedback the comments from the APC members to the LPC secretary and then liaise with the Trust and the CCGs as a matter of urgency. Update for the January APC meeting. 26.4h Novel Oral Anticoagulants (NOACs) in Primary Care / Transfer of Care documents Further to the request at the previous APC meeting for Transfer of Care documents to be produced to support the shared care of NOAC prescribing in primary care, the BHRUT Consultant Haematologist had since advised that due to a lack of capacity he had been unable to prepare the required documents for consideration. BHRUT Pharmacist acknowledged that the development of the documentation was a priority and would therefore liaise further with the anticoagulation team. However, she confirmed that in the meantime the status quo of providing the full shared care guideline to the relevant GP by the specialist clinician, was to be maintained. BHRUT - To ensure that the production of the Transfer of Care documents is a priority and are available for the January APC meeting Agenda item for the January APC meeting Lidocaine Patient Group Direction (PGD) (PELC) A revised PGD for the administration of Lidocaine (Lignocaine) Injection in the Emergency & Urgent Care Centres incorporating the amendments that had been requested at a previous APC meeting had been submitted for approval. Unfortunately, it became apparent that not all the revisions had been made to the document and therefore it was requested that the PGD was further amended to reflect the previous comments. There was a discussion regarding use of the PGD for the treatment of children, however it was confirmed that each child would have their own specific nurse within a paediatric team. A number of further amendments were requested to the document. Approved subject to amendment GP access to carbon-13 urea breath test in re-testing for helicobacter pylori infection (BHR CCGs) Medicines Management Team explained that currently a urea breath test service was not PELC - Amendments requested from July APC meeting: Consider inclusion of reference to LAT gel as an alternative sterile gel for children no longer relevant as PGD is for adults to consider BHRUT comment regarding the need for a resuscitation trolley for lignocaine Emergency and UCC are based in Acute setting where resuscitation trolleys exist Page 6, define what maximum safe dose equates to page 7, clarify quantity statement dependent on procedure by outlining the different procedures and respective quantities include training requirements if lidocaine was to be given intravascularly - Additional amendments: Page 1, the title to include in Adults after injection Page 4 & 8, amend NMC and BNF to current versions Page 6, to define maximum safe dose to include mg/ml equivalent Page 7, Quantity - include age and size of wound Express all strengths in mg/ml of the 1% injection - To invite the three manufacturers of the urea breath tests to a future meeting to demonstrate and interpretate the results, possible infection control issues and 4 P a g e

5 available for GP practices to access at either BHRUT or Barts Health Trust. It had therefore been agreed that costs were to be sought relating to both the stool antigen and the urea breath tests and establish the number of postitive stool antigen tests undertaken during the past year. Medicines Management Team had secured the information and this had been circulated for consideration. Discussions commenced regarding how eradication could be verified and the feasibility of patients completing the test themselves. Concern was raised regarding the patient numbers provided within the information circulated as it was felt that these should be higher than those reported. disposal - GP Members - To audit numbers of positive stool antigen tests in the past year and outcomes post eradication treatments within their practices It was finally agreed that the three companies who provide the breath tests should be invited to a future meeting so that demonstrations and explanations could be provided as to the interpretation of the tests, infection control issues and the disposal of the samples. Some GP members agreed to audit numbers fo the stool antigen tests within their practices. Agenda item for a future APC meeting Smoking Cessation (NELFT) A revised version of the Guidance on Medication and Smoking had been circulated together with the Smoking Cessation Dosing Schedule. Although the revised version incorporated the amendments previously requested, there remained concern that the Maudsley Prescribing Guidelines (page 6 )that were included referred to blood monitoring for olanzapine. As copyright did not allow any change to the table a statement should be added highlighting that the actions stated were not a requirement locally and GPs should refer back to specialist services when necessary. It was also suggested that an existing plasma monitoring service may have been commissioned within a tertiary centre and therefore this possibility should be explored with the local authorities and reported back. NELFT - Amend the document with the following: Add a reference to Appendix 1 within the document Add a statement beneath the Maudsley table advising GPs to refer back to specialist services when necessary - Liaise with the three local authorities to establish if an existing plasma monitoring service was available in a tertiary centre that GPs could refer to if advised - Add a recommendation on what GPs should do in primary care if patients are on antipsychotics It was agreed that this item would return to the APC for further discussion Switch programme for patients to be considered from Quetiapine modified relase (XL) to Quetiapine Immediate Release (IR) tablets Medicines Management Team had circulated a NELFT Pharmacy Memorandum (June 2014) and a briefing paper on IR and XL quetiapine formulations by the London Procurement Partnership (LPP) to support the discussion regarding a possible primary care switch programme for 2016/17 within BHR CCGs. - To produce a document to support the switch programme which will include: An appropriate algorithm which will include referral contact details Clearly defined patient selection criteria Medicines Management Team provided approximate numbers of patients receiving the XL formulation of quetiapine within each CCG including approximate costs. 5 P a g e

6 If the switch programme was approved, it was requested that the patient selection criteria be clearly defined and an option included that patients could be referred back to NELFT should the GP deem necessary. After further discussion it was agreed that the switch programme could be included as a workstream for 2016/17. Approved switch programme within primary care for 2016/17 workstream Directing of Prescriptions (LPC) The LPC requested that the following documents regarding the rights of patients to choose freely which pharmacy dispenses their prescriptions be considered for circulation to the BHR CCG GP practices: - To circulate the poster via to all BHR practices a) Covering letter to General Practices and Pharmacies (NHS England) b) Prescription direction update: patient choice poster now available (PSNC) c) Your prescription : your choice poster (NHSE) It was acknowledged that the letter had already been circulated to all GP practices by NHS England and it was confirmed by the GPs present at the meeting that this had been received. Subsequently the letter would not require further distribution, however it was agreed that the poster would be ed to all BHR practices. Agreement for poster only to be circulated via to BHR practices Rivaroxaban proposal for the preventions of stroke and embolism in adults with non valvular atrial fibrillation(af) in the NELFT (BHR CCGs Health Economy) Further clarification had been required regarding this item which had previously been discussed at the APC meeting in September. NELFT Pharmacist provided additional information which explained in more detail the reasoning for the proposal and a supporting statement had also been circulated from a NELFT Clinician. It was clearly stated by NELFT Pharmacist that the proposal was only for patients who had been diagnosed with atrial fibrillation (AF) and unable to receive warfarin due to intolerance, inability to attend regular INR monitoring or restricted mobility; thereby requiring a NOAC such as rivaroxaban. Due to current delays in clinic appointments within BHRUT, currently 4-8 week wait, it was suggested that with the support of the BHRUT clincians, initiation of NOACs in these patients could be undertaken by NELFT specialist consultants. NELFT - To liaise with BHRUT anticoagulation service to ensure that level of service to patients is maintained - Provide assurance that the BHRUT consultant haematologist is in support of this proposal - Audit the process to support any further service provision for 2016/17 - Proposed patient numbers and costs to inform the case for inclusion in 2016/17 commissioning intentions After discussion regarding patient numbers, costs and the use of alternative NOACs such as apixaban it was decided that Option 1 should be agreed to. However, reassurance was requested that the NELFT service would be of a similar level to that provided by the BHRUT 6 P a g e

7 anticoagulation service. This was to include the availability of patient information and NELFT agreed to liaise with BHRUT and visit the service to establish the current process. It was highlighted that NELFT clinicians were not commissioned or had the funding available to prescribe rivaroxaban however this proposal could be considered as part of the commissioning intentions for 2016/17; NELFT Pharmacist agreed to refer this issue to the NELFT commissioning lead. Option 1 agreed subject to assurances of service level provision Funding application for North East London Medicines Management Network (NELMMN) Medicines Management Team provided a summary of the business case presented for funding of the NELMMN which involved primary and secondary care organisations across North East London. Previously the NELMMN had been supported by the good will of colleagues within several organisations, however this was no longer sustainable and funding was subsequently requested to support its continuation. - To report at the NELMMN meeting that BHR CCGs have approved the funding application A brief explanation of the workstreams currently undertaken by the NELMMN was provided and it was confirmed that funding on behalf of BHR CCGs had already been sought and confirmed. Concern was highlighted by BHRUT Pharmacist as to future arrangements should not all organisations agree to the funding request, however assurance was provided that previous discussions at the NELMMN meeting had confirmed that all stakeholders were in agreement to the proposal. Further discussions would take place at the NELMMN meeting on Thursday 12 th November when all organisations had been requested to provide updates regarding funding availability. It was also requested that a supporting paper defining the NELMMN workstreams more clearly be made available. It was agreed to approve the funding application on behalf of BHR CCGs of approximately 5000 each. Funding application approved on behalf of BHR CCGs Shared Care Guideline for Mercaptopurine & Azathioprine in Inflammatory Bowel Disease (BHRUT) BHRUT Pharmacist was in attendance on behalf of BHRUT colleagues but advised that she was unfamiliar with the previous discussion pertaining to this shared care guideline. Amendments were requested on behalf of the CCGs and these were discussed and agreed where appropriate. The content of shared care guidelines in general was considered, and it was reiterated that BHRUT - To amend the shared care guideline with the following: Page 2, Cautions - to include Shingles as a bullet point Monitoring table to include reference to clinic appointments? Page 3, Blood Result and Action Remove IBD nurse or 7 P a g e

8 GPs did require the availability of a full guideline to support prescribing of medications requested by secondary care clinicians. However, it was highlighted that Trust clinicians did not receive timely responses from GPs agreeing to the request for shared care. It was suggested that a review of shared care communications should be considered, and to support the process Medicines Management prescribing forums attended by BHR GPs would be used to ascertain if a learning need existed. It was agreed that the shared care guideline should be amended and return to a future APC meeting for approval. Submission of a revised shared care document to be considered for approval at a future APC meeting. Third box under Action referring to reducing dose, GPs may not wish to titrate but should they decide to what %? Could details be provided? Symptoms and Action First box under Action to state Refer to secondary care as it was stated that primary care do not have access to urgent FBC Page 4, Shared Care Responsibilities Consultant Add to check any interactions with existing therapy before initiating treatment 7. Add within two weeks 8. Remove Additional point Provide appropriate written or verbal information to patient including the need for regular blood monitoring. General Practitioner 6. Could a pathway be in place to avoid the referral process for patients whose disease has deteriorated could concerns be raised with Dr Gyawali and feedback sought for this Costs It was requested that the information relating to costs for treatments be checked Page 5 Amend NHS ONEL Prescribing Team to BHR Medicines Management Team tel. no To also check the fax numbers provided for both KGH and Queens Hospital Update the references to ensure they are current Appendix 3 The statement that It is safer for monitoring and prescribing to be done by the same clinician is this appropriate as it seems to be the source of concern around monitoring being shared? - To ask the following questions at future prescribing forums with respect to the shared care agreement form: Are BHRuT and Barts Health clinicians sending these out? If received, is it acted upon by the GP? Is prescribing taking place without the relevant monitoring? 8 P a g e

9 26.13 Primary care rebate schemes in operation across BHR CCGS Medicines Management Team presented the Primary Care Rebate Schemes (PCRS) that have been signed up to by the Medicines Management Team on behalf of the CCGs since the last presentation to the Committee. - To upload the PCRS lists to the CCG websites It was confirmed that the London Procurement Partnership (LPP) principles had been used to support the process of local rebate scheme implementation. The information was noted and the lists approved for upload to the BHR CCGs websites Proposed Meeting Dates Proposed dates and venues for 2016 APC meetings had been circulated and these were agreed Any other business B & D and Havering LMC representation -It was requested that should a B & D and Havering LMC representative not be available to attend the APC meeting then comments are submitted prior to the meeting date, for the Chair to consider. All - Requested to ensure the dates and venues were added to diaries B& D and Havering LMC - To ensure that comments are submitted on behalf of the LMC if a representative is unable to attend the APC For information a. Barts Health NHS Trust & Local GPs Joint Prescribing Group minutes for July 2015 b. BHRuT DTC minutes for May & June 2015 c. BHR CCGs APC final minutes for July 2015 d. Important new evidence relating to prescribing and medicines optimisation September Documents approved subject to amendments since last BHR CCGs APC meeting: Safe and legal driving for people on medicines with health problems handy fact sheet Vaccine Fridge Temperature Out of Range Guidance Guidelines for the diagnosis and management of Vitamin D deficiency in adult patients 2014/15 Medicines Management End of Year Report Date of next meeting: Thursday, 7 th January at 12.30, Boardroom A, Becketts House, Ilford It was mentioned that due to the forthcoming holiday period, papers would be requested to be submitted earlier than usual for consultation. 9 P a g e