BHR CCGs AREA PRESCRIBING SUB-COMMITTEES Thursday 5 th October 2017 Boardroom, 3 rd Floor, Imperial Offices, 2-4 Eastern Road, Romford, RM1 3PJ

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1 BHR CCGs AREA PRESCRIBING SUB-COMMITTEES Thursday 5 th October 2017 Boardroom, 3 rd Floor, Imperial Offices, 2-4 Eastern Road, Romford, RM1 3PJ PRESENT Dr G Kalkat (GK) Oge Chesa (OC) Belinda Krishek (BK) Dr S Raza (SR) Dinesh Gupta (DG). Kam Takhar (KT) Sanjay Patel (SP) Julia Taylor (JT) Mohamed Kanji (MK) Saiqa Mughal (SM) Dr K Kugathas (KK) Denise Baker (DB) APOLOGIES Dr A Tran (AT) Diane Meid (DM) Olufunlola Apakama (OA) Dr Uzma Haque (UH) IN ATTENDANCE Veer Patel (VP) Busola Daramalola (BD) Sue Perry (SuP) Tracey Burch (TB) 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 Assistant Chief Pharmacist, Barking, Havering and Redbridge University Hospitals (BHRUT) Deputy Chief Pharmacist, North East London Foundation Trust (NELFT) QIPP Pharmacist, BHR CCGs Prescribing Advisor, BHR CCGs Prescribing Advisor, BHR CCGs Prescribing Adviser, BHR CCGs GP, Londonwide (Redbridge) Local Medical Committee (LMC) Representative Business Manager, BHR CCGs GP, Clinical Director Prescribing Lead, Havering CCG Lay member Prescribing Advisor, BHR CCGs, representing Barking & Dagenham CCG GP, Barking & Dagenham and Havering LMC Representative Contracts and Performance Officer, Partnership of East London Co-operatives (PELC) Chief Pharmacist, PELC Prescribing Support Dietitian, Redbridge, NELFT Respiratory Physiotherapist, Respiratory Lead Barking & Dagenham, NELFT 1 P a g e

2 37.1 Welcome / Introduction / Apologies A list of apologies was received as shown on page 1. Patient Representative and Barking & Dagenham and Havering LMC had advised that they did not have any comments to be considered for the agenda items. Introductions were provided. Action and by whom 37.2 Declarations of potential conflicts of interest Completed declarations of potential conflicts of interest were requested. None were received Minutes of previous meeting The minutes of the previous meeting were agreed. Approved for addition to the websites Matter Arising Disease Modifying Anti-Rheumatic Drugs (DMARDs) Share Care Guideline (SCG) BHRUT are currently revising the shared care guideline to incorporate the new guidance produced by the British Society of Rheumatology that had been NICE endorsed. It was highlighted that GPs had a lack of capacity to support shared care and medicines management representative advised that discussions were taking place to find a resolution to the issue. BHRUT representative noted the lack of capacity within Barking & Dagenham, Havering and Redbridge CCGs to support shared care. It was anticipated that the revised DMARD SCG would be considered at the November APC meeting. Factsheet: Sacubitril valsartan for chronic heart failure with reduced ejection fraction Contact details for the document were still awaited and BHRUT representative agreed to liaise further with colleagues to ensure the document was finalised. Podiatry Services management of Diabetic Foot and referral letter to GPs/A & E The committee were advised that the Planned Care team were currently in discussion with NELFT colleagues to identify a multi-disciplinary team to support the service. It was confirmed that for the present time patients should continue to be referred to A & E for appropriate treatment. Apomorphine Shared Care Guidelines for Patients with complex Parkinson s disease suitable for therapy and supporting relating to infusion lines and needles The following update was received from the Planned Care team: As we do not currently have the opposite community provision to undertaken the required ECGs for the patients it has been suggested that to comply with appropriate practice and guidance the necessary work up/investigation should be undertaken by the secondary care consultant neurologist to initiate apomorphine for the small cohort of patients. It was mentioned that the specialist clinicians would prefer patients to be seen via outpatient appointments. NELFT - Update shared care guideline to reflect this aspect of the pathway 2 P a g e

3 Vitamin Drop/tablet supplies Healthy Start Nelft representative advised that the list of clinics supplying healthy start vitamins was to be added to the websites and a supportive leaflet for the Redbridge area had also been received. The GP practice patient information relating to Vitamin D had been received and would also be forwarded to Nelft representative. The supply of Chlorphenamine The outstanding action was to be considered by both PELC and NELFT colleagues to ensure that the decommissioning agenda was reflected within their organisations. - Medicines Management representative to forward Vitamin D patient information documents to BHRUT representative PELC/NELFT - Recall all relevant PGDs impacting on the outcomes of the decommissioning consultations (local/national) 37.5 Chairman s Action Items approved by Chairman s action in between meetings were circulated to the group for information. - Maximising the opportunity from Pregabalin s full patent loss including patient template letter. Approved Letter to doctors regarding non-compliant blood glucose monitors. Approved Osteoporosis guideline. Approved Management of the discontinuation of Strontium. Approved Agenda Items 37.6 Guidelines for Management of Common ENT conditions in Primary Care including additional information to be considered The document had initially been presented to the Redbridge Protected Learning Event (PLE) and comments had been received following the circulation of this version for APC consultation. Therefore the comments and feedback received from the attendance to the PLE were outlined to the committee. Further amendments to the documents were requested by committee members. Planned Care Team To amend the document with the amendments already requested following the Redbridge PLE and with the amendments requested below by the committee: - Page 3, Introduction, 2 nd paragraph, remove last sentence We are planning. In the section How to use the guidelines Remove the from the sentence and add an s to practitioner Include a link to the Antibiotics guidelines - Page 4, Check if the telephone number should be the same for all specified times and if so provide just one box Formatting issue at the bottom of the page heading for Page 5 - Page 11, top blue box, last bullet point remove the word easily and include Ticagrelor and Direct Oral Anticoagulants (DOACs) in list of medicines Green box, In light of antimicrobial stewardship why the option of naseptin and not just vaseline offered? Please reference the evidence for this - Page 12, 3 P a g e

4 Review history box, first bullet point include ticagrelor and DOACs to list of medications Following box, why the option of naseptin and not just Vaseline offered? - Page 16, light yellow box, amend eliminating to emanating remove arrow to pink box Refer to Community as this should be an information box only Pink box add a and an apostrophe to the word Extern First dark yellow box to sign post to antimicrobial guidelines Light blue box and information box on the bottom right to be switched so that information is provided before Note Note box to include that ciproflaxin eye drops are to be used off label in the ear Question to clinicians as to why Flumetasone/Clioquinol which is expensive is suggested and not Betnesol/Neomycin ear drops 37.7 Alexander Court Care Home Pilot Project Report: Improving management for malnutrition Redbridge Prescribing Support Dietitian was welcomed to the meeting and provided a brief outline of the pilot project that had been undertaken at the Alexander Court Care Home. The clinical indicators and costs on page 3 of the report were discussed and the committee was impressed with the outcomes highlighted. In addition, the chef s commitment to producing more nutritional food for all patients within the home was mentioned and it was suggested that his enthusiasm could inspire other care home chefs to pick better food items and improve their food menus. The pilot also included reviewing management systems in the home, kitchen appliances/equipment and all patient care plans, not just those patients who had been identified as suffering from malnutrition. It was explained that Alexander Court Care Home had received a poor rating from their recent Care Quality Commission (CQC) visit and therefore all staff at the home were keen to support the pilot and improve the overall nutrition for their care home patients. The next stage of the project was to identify a further two homes who would benefit from the support and guidance provided within the pilot, although limited resources were highlighted. It was confirmed that the dietetics team would work with the safeguarding team to identify appropriate homes where the nutritional status of residents was an area of concern to either commissioners or CQC. It was suggested that it would be useful to capture the GP time saved by the pilot being introduced within a care home and therefore this should be included for the next stage if possible. It was requested that once the pilot project had been completed in three care homes a Project Initiation Document (PID) should be produced for BHR CCGs to consider resourcing wider rollout. Approved. 4 P a g e

5 37.8 Formulary addition of Acapella Choice A Respiratory Physiotherapist, Respiratory Lead Barking & Dagenham, was welcomed to the meeting and presented a request to add the Acapella Choice, a Positive Expiratory Pressure (PEP) device to formulary. This is to assist with clearance of secretions in select patient as an adjunct to chest physiotherapy. NELFT - Await feedback from the COPD working group as to the use of PEP devices and any preferred choice The committee were informed that the device which could assist with clearance of secretions in select patients as an adjunct to chest phyisiotherapy, would only be a patient choice within Barking and Dagenham. The patient numbers and availability for Havering and Redbridge patients was unclear. The reported support for the device by NICE was questioned and it was highlighted that NICE recommended patients be taught the use of PEP masks. The cost effectiveness of the Acapella device was also not NICE endorsed and it was noted that alternative devices were available at a lower cost. A case study reported in the British Thoracic Society guideline for non-cf bronchiectasis did not find outcomes from the use of Acapella statistically significant. As preference for the Acapella Choice could not be demonstrated it was agreed that the alternative PEP devices should also be considered as options. The Chronic Obstructive Pulmonary Disease (COPD) working group would be requested to consider the Acapella Choice and alternative PEP devices and provide feedback as to place in therapy and preferred choice of device. In the meantime it was agreed that further Acapella Choice devices should not be provided to any BHR patients as they were not currently on formulary. Not approved Shared Care Guidelines (SCG) on Melatonin for sleep disorders/difficulties in children until their 18 th birthday Nelft representative advised that the version of the guideline circulated has subsequently received further comment from the NELFT Drugs and Therapeutic Committee (DTC) and the document was to be revised. It was therefore agreed by the committee to consider the version circulated so that any comments could be incorporated along with the DTC comments. Once all requested amendments had been made a final draft version would be submitted for approval. Not approved. NELFT To amend the document with the following comments: - Removal of approval dates - Page 3, Dosage and Administration table, dose titration amend incrementally to increments To ensure that responsibility for initiating the drug holiday is clear within the document - Page 4, Remove Cautions section Page 5, Pregnancy and Breast Feeding, remove the note that has been left for the author add a statement that.. Consultant responsibilities, point 9, detail how drug holidays will occur and who monitors GP responsibilities, point 2, remove Max review 6 months 5 P a g e

6 37.10 RE-AUDIT Clinical Audit Report: Local summary with SMART Action Plan The committee s attention was directed to Page 3 of the document and the increase in the use of the Summary Care Record as a source of information for the medicines reconciliation process. An increase from 24% to 63% within Mental Health Services (MHS) and 39% to 86% within Community Health Services (CHS) provided assurance of NELFTs compliance to ensure patient safety through the safe and appropriate reconciliation of medicines on admission. - To consider melatonin 3mg/4mg capsule/tablet review as a future PSO work-stream Noted Methotrexate SCG for Psoriasis, Crohns Disease and Ulcerative Colitis Updates to the SCG since its initial submission to the committee had taken place and these were highlighted in red. Further amendments were requested including information relating to missed doses and how late could a missed dose be taken. It was agreed that once these had been incorporated the document could be approved for the specified indications. It was mentioned that Respiratory clinicians would also want to add their shared care requirements for methotrexate to the existing document. Once a draft document was available this would be considered at a future APC. BHRUT The following amendments were requested to the document: - Page 4, Monitoring Standards table, remove U & E from three monthly monitoring Remove once stabilised from Monitoring by GP Psychotropic Drug Formulary The Psychotropic Drug Formulary that had recently been updated and approved by the NELFT MHS DTC was presented to the committee and agreed for addition to the CCG websites. - Add Psychotropic Drug Formulary to CCG websites Approved for addition to websites End of Life and Palliative Care: Quick Reference Guide The committee was advised that the document circulated had since received further update and would therefore be presented at the next APC. It was highlighted that the new revised guidance would advocate a move away from the use of diamorphine to morphine as first line and from cyclizine to levomepromazine as second line options, with effect from the 1 st November It was also noted that presentation of information on page 17 was so much easier to follow. Further minor amendments were requested to the version of the document circulated. Not approved. NELFT The following amendments were requested to the document considered at the APC - Page 7, large box to the far left, add asterisk at the end of the information - Page 9, signpost to appendix 1 on page 24 - Page 11, Transdermal patch preparations, final bullet point, spelling of caution Shared Care Prescribing Guidance for treatment of Gender Dysphoria ( including Q&A document) 6 P a g e

7 Transmen (Female to Male Transsexuals) and patient leaflet Transwomen ( Male to Female Transsexuals) and patient leaflet The committee discussed the documents and concerns were raised regarding the capacity and competency of some GPs to provide the care requested in both shared care documents. It was acknowledged that the documents had not been submitted for approval but were a GMC/NHSE requirement of all GP practices to support patients requiring gender dysphoria treatment. Subsequently training to support GPs professional development for this treatment was requested. Medicines management representative agreed to feedback the request for local training to NHSE along with the request that that reference to PCT within the documents be amended to CCG. - medicines management representative to feedback request for local training and amendment of PCT to CCG - To add the SCGs to the website It was agreed that only the SCGs would be added to the CCG websites. Noted Third party prescribing for AF: Recording medication as hospital issue The committee were informed that the document had been produced to support the recording of third party anticoagulation prescribing using the GP computer systems within BHR. It was confirmed that warfarin patients were not currently being identified on the systems. Amendments were requested to the document which once amended would be endorsed by all three CCGs and disseminated by the Primary Care Team. - Replace Redbridge CCG logo with that of BHR CCGs - Medicines Management tel no. should be corrected to 0203 instead of Remove the contact details of the Haematology pharmacist from the CCG document Approved for addition to websites North East London (NEL) Management of Infection Guidance for Primary Care Medicines management representative provided background to the above guidance and advised the committee of the collaborative working that had taken place across NEL in its production. All individual organisations were currently submitting the document to their respective boards for adoption within their local area. - Add Management of Infection Guidance for Primary Care to websites Approved for addition to websites Primary Care Rebates Schemes in operation across BHR CCGs Details of current rebate schemes (October 2017) were provided to the committee for information. It was agreed that these details would be added to the BHR CCG websites. - To upload details of the rebates schemes currently in existence to the CCGs websites Noted. 7 P a g e

8 37.18 End of Year Report 2016/17 cost Avoidance from Use of Outpatient Parenteral Antibiotic Therapy (OPAT) in conjunction with the Royal Nation Orthopaedic Hospital (RNOH) Medicines management representative advised that 9 patients had benefited from the use of the RNOH OPAT service during 2016/17 which had enabled a total cost avoidance of 97,582 across the three CCGs. The utilisation of the OPAT service with the RNOH was to continue and the service monitored. Noted Reviewing and implementing a change in the local prescribing of Doxazosin MR Medicines management representative presented the revised document to support the review of Doxazosin modified release formulation to the standard release formulation which now included a letter from the GP practice to the patient, informing of the change in medication. The work-stream which would be undertaken by the Practice Support Officers was approved by the committee. Approved Patient Group Direction (PGD) for the administration of Lidocaine (Lignocaine) Injection in the Partnership of East London Co-operatives Ltd (PELC) Emergency and Urgent Care Centre The above PGD had previously been considered by the committee and the revised document now incorporated the requested amendments. Further minor amendments were requested by the committee, however it was agreed that once the changes had been made the document could be approved PGD for the supply of Antibiotics by Emergency and Urgent Care Practitioners working for PELC The above PGD had previously been considered by the committee and the revised document now incorporated the requested amendments. Further amendments to the PGD were requested and it was agreed that once the changes had been made the document could be approved. PELC - Page 2, remove reference to ONEL - Page 7/8 to include age specifics in the exclusion criteria - Page 9, to combine the information in the Dosage/Frequency and Quantity boxes NELFT - KT to share the NELFT version of this PGD PELC - Page 10, Inclusion Criteria, last statement to read We would advise patients on anticoagulants to notify their anticoagulant clinic that they are on antibiotics. - To replace previous statement throughout the document - Page 16, ensure that BNF references are up to date throughout the document - Pages 45-51, to amend this section to highlight Pivmecillinam as second line option to Nitrofurantoin 100mg MR BD tablets remove Trimethoprim from the PGD PGD for the supply of Levonorgestrel 1.5mg Emergency Contraception (LNG-EC) by Emergency and Urgent Care Practitioners for PELC PELC - Page 2, remove reference to ONEL 8 P a g e

9 The above PGD had been received further amendments to its previous submission to the committee and was reconsidered in its entirety. A further amendment was requested and once the change had been made the document could be approved. - Page 8, Exclusion Criteria, Other conditions, bullet point relating to Ullipristal to be removed - To submit the Ullipristal PGD for consideration at a future APC In light of Ullipristal being second line after intrauterine device (IUD) and Levonorgestrel being third line, the need for a Ullipristal PGD was noted For the administration of low-dose diphtheria, tetanus and inactivated poliomyelitis vaccine (Td/IPV - Revaxis to individuals from 10 years of age in accordance with the national immunisation programme The above PGD was considered by the committee and was approved subject to the minor amendment identified on page 2 of the document. PELC - Page 2, remove reference to ONEL Diagnostic Tools and impact on NEL Management of Infection Guidance for Primary Care Medicines management representative advised the committee of the following diagnostic tools that had been produced by PHE to support the information presented within the antimicrobial guidelines. - To produce a designated repository for the PHE diagnostic tools and include a link to the antimicrobial prescribing guidance Urinary Tract Infections (UTIs Quick Reference guide for primary care: Summary table Fungal skin and nail infections: Diagnostic and laboratory investigation quick reference guide for primary care: summary table The committee was asked to consider a sustainable process for the update of the NEL Management of Infection Guidance for Primary Care in light of new NICE or PHE tools in support of antimicrobial stewardship. It was agreed that the diagnostic tools would be collated separately from the antimicrobial prescribing guidance, however a link to the document would be included. Approved. Any other business Spending NHS money wisely 2 medicines management representative circulated an A4 sheet outlining the proposals to be considered as Phase 2 of the Spending NHS money wisely consultation. It was highlighted that the consultation process had commenced and that all colleagues and members of the public were encouraged to respond by the closing date of 5pm on Wednesday 15 th November Meeting closed at 3.10pm Date of next meeting: Tuesday 23 rd November 2017 at 12.30, Barking Hospital, Large meeting room (upstairs) Upney Lane, Barking IG11 9LX All - To respond as part of the consultation process by the deadline specified 9 P a g e

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