Clinical Commissioning Group

Clinical Commissioning Group Title of Meeting: NHSR Medicines Management Committee Meeting Time: 9.00am to 11.00am Date: Wednesday 26 April 2017 Venue: 2.08, Oak House Reference: NR/DM Chair: Ravi Nalliagounder Present: Ravi Nalliagounder (RN) Avanti Gunasekera (AG) Stuart Lakin () Julie Kitlowski (JK) Raz Saleem (RS) Sally Webster (SW) Deborah McGarvey (Notes) GP GP, Commissioning Executive, RCCG Head of Medicines Management, RCCG GP Pharmacy Advisor, RCCG Prescribing Technician, RCCG Administration Officer, RCCG Agenda Items and Action Points 1 Apologies Judith Wilde, Sue Cassin, Surrinder Ahuja 2 Declarations of Interest Dr R Nalliagounder and Dr J Kitlowski- declared an interest- item 9 of the agenda -17/18 QIPP Work Programme and Incentive Scheme. 3 Minutes of the Meeting held on 29 March 2017 Minutes were accepted as a true record. 4 Matters Arising 4.1 EPS (Electronic Prescription Service) Kiveton Park is the only remaining practice that has not signed. NHS England and NHS Digital have set a target for electronic prescriptions as 80% of patients have repeat prescriptions their target is 56%. Rotherham electronic prescribing is 61%. Action RS 29/31 surgeries have stopped third party ordering. If agreement is reached to employ Waste Technicians then one of their roles will be to support practices with repeat dispensing. The Training Community Pharmacy Event held on the 3 April 2017 by Rotherham and Doncaster CCG had an excellent turn out - there were speakers from the NHS England and NHS Digital along with members of the Medicine Management Teams available to have 1:1 talks. A one page flow chart will be issued for repeat dispensing for display in clinicians rooms. The next Training Community Pharmacy Event is on 3 May 2017. Gateway Surgery has a 52% take up of online registering. 4.2 Anticoagulation Previous Minute 1

Right Care in Rotherham has increased by of 20%. TRFT have a new anticoagulation GP who going to carry out 2 audits for patients that have had a stroke or a bleed. RCCG Right Care performance is low and it will show if other areas are over anticoagulating. All the policies and guidelines are in place. It was suggested that the results from the audits are circulated via the monthly Bitesize Prescibing Newsletter. RCCG results are following the national trend with their cost savings which are 321,000. SA advised that the NICE guidance is due to change. and Rachel Garrison sent out a smart survey to GP s which had poor results. The issue with venous sample was at one locality that had not handed out all the Accucheck meters - this has now been done. RG is redesigning the question form with a clear question to be ticked if a venous sample is required or not. 4.3 Prescribing Responsibility for Transgender Medications has been in contact with Porterbrook and sent queries regarding hormone monitoring and Porterbrook have listed the questions on a clinical forum to seek advice because they don t know the answers. has concerns about this and has spoken to NHSE and pointed out that this is why GP s are expressing concerns about prescribing these medications and this demonstrates the complexity of these treatments when the specialists are seeking advice via a clinical forum. will bring the latest protocol update to the next meeting. 4.4 Waste Management Campaign and Gordon Laidlaw (Head of Communications RCCG) met with Councillor Roche and Councillor Cowle to explain why RCCG are doing what they are doing, it was agreed that communications need to be improved, and GL provided the council of the logged engagements RCCG have attended the council have sent a strong response to this meeting which and GL have sent a reply. is liaising with GL with regards to the final communication programme for the new Self- Care Campaign. The first one will be for paracetamol. AG is presenting at the May PLTC, agreed to chase GL. 29/31 GP practices have stopped third party ordering and there has been very little negative feedback received. confirmed that the campaign is still up and running. LPC are not happy about being targeted for waste and argue that they have not been provided with enough training for EPS, electronic dispensing and argue that vulnerable patients will suffer. RS confirmed that GP Surgeries are beginning to see the saving made due to this campaign. RCCG Medicine Management Team work is being recognised and being looked in to being used in other areas. is waiting for authorisation to appoint 3 band 5 s to look after EPS, online ordering, repeat dispensing and nursing homes. 4.5 Rotherham Drugs Affecting Bone Metabolism Summary Report 2014/15 Outstanding Action Item from LM said that she is currently working on the Osteoporosis SCP and has a draft Pathway which she agreed to share with AG/RN for their comments. LM 2

AG said that she had started the audit of 273 patients at her practice and was currently working through these and would bring back results to a future meeting. LM to provide an update. 4.6 Melatonin for Sleep Disorders in Children LM Action Item from LM was still waiting for a response to her email to Dr Suri. A request had been made for Dr Suri to attend an APC meeting but this hasn t happened yet. AG/ will email Osman Chohan to make a further request to see if Dr Suri can attend the November meeting to discuss. LM agreed to collate practice data and would attach this to the SCP. APC would also be informed that we would be switching patients over to Circadin. Practice data still awaited LM to action. Ongoing awaiting a response from Dr Suri to AG email. LM AG Currently working with Emma Royle/Richard Cullen regarding proposed funding for sleep clinics by offsetting cost of drugs. As previously minuted in RMOG, Steve Davies from RDaSH had mentioned that RDaSH consultants had not responded to produce a Rotherham wide shared care procedure. Ongoing. 4.7 ADHD Branded Generics has drafted a survey monkey and emailed this out for ideas/comments. Members were asked to forward these to asap. All RS has a meeting with the consultants on the 15 March for the CCG RDASH Mental Health QiPP meeting. RS attended a QIPP meeting where RDASH Consultants confirmed that following the work that RCCG Medicine Management team carried out in 16/17, mental health will make a saving of 84,000 which will go into the joint RCCG/RDaSH budget. RDaSH will start to use System One from October 2017. SW has agreed to provide RDaSH with support. SW 4.8 Prescribing of Anti-epileptic Medication in Doncaster Sheffield have 24 issues JW is waiting for them to confirm the number of issues just for Rotherham. It was agreed that the SCP s would be shared with an Epilepsy Shared Care Nurse for comments. JW This is still in draft form JW has been trying to rally people to get the document approved. JW has also been finding out what is in the contract regarding provision of Epilepsy Shared Care Nurses and their role and had found that there are outreach epilepsy clinics each week. The tariff says that we pay for 90 patients to be seen per week and JW is now finding out what the actual numbers are and would share this information at a future meeting. Ongoing 4.9 ScriptSwitch: Assisting Medicines Optimisation in Rotherham CCG - Simon Chipperfield and Richard Clarey 3

Comparison of Scriptswitch and OptimiseRx Paper would be going to SCE next week. RN had spoken to AG and felt that it would be good if a GP/GP s would be able to see the systems in operation before a decision is made and RN felt that perhaps the OptimiseRx might be a better system as it may be more future-proof. A long discussion took place about this re advantages and disadvantages of both of the systems and after discussion it was felt that the number of pop-ups which appear with OptimiseRx may be off-putting for a lot of GP s and they may turn these off. With the Scriptswitch system there is the ability to manage the pop-ups and changes to medications could be made straight away whereas it was a two-week wait for OptimiseRx. Overall it was felt that the simpler system would be the better one to go with. /SW /SW will email the finance department today and confirm to that that the order for Scriptswitch can go ahead for a 1 year pilot this is a simply system. GP will be advised of this by the Bitesize Prescribing Newsletter. Scriptswitch has now been purchased and SW will be meeting with them again next week to talk about setting-up the profile. SW said that we would start small and build-up the profile gradually. A paragraph will be put in Bitesize to inform GPs that they will receive a call from the Scriptswitch team to arrange practice visits. An email will also be sent out to all practice managers. SW SW and will be having training with Scriptswitch on Friday 28 April. CCG IT has confirmed that they have no issues with the system being installed. SW confirmed that the installation will start in May and GP Surgeries will start using the new system in June. 4.10 Self-Care Campaign The government had released a proposal for some medications not to be prescribed on the NHS and products on our list corresponded with their proposals. Medicines of no clinical value were also on the list, for example, omega 3 and Tadalafil and a robust discussion took place about this. After a robust debate it was decided that we needed to keep abreast of what was happening in the Urology Department regarding staffing changes etc. After discussion it was decided that an article about Tadalafil would be placed in the Bitesize newsletter. chasing GL. 4.11 Diabetes Prescribing and Outcome Data This will be discussed at OE next week. The GLP1 Pathways have all been updated and we also have the Quality Contract. Rotherham still has high prescribing costs and he felt that the Quality Contract incentives wouldn t make much difference to these costs. had looked at what happens in neighbouring CCG s and found that two of them have Diabetes LES s in place. Discussion occurred about this and it was felt that this could be beneficial for Rotherham i.e. fund more Diabetes Specialist Nurses and introduce a LES and this could generate savings which could be ring-fenced and reinvested. Better dosage titration would be what we would be seeking so practice nurses would need training. Discussion took place about how this could work and it was felt that it would be better to start with an initial 5/6 practices. would discuss this at the OE next week and put forward the suggestion. is responding to emails that have arisen from the LMC meeting on 28 February regarding dealing with diabetes in the community and the Super 6 model and he will take this back to OE. Nothing to add. 4.12 Tiotropium GB had obtained a sample Braltus, Teva Inhaler and had reviewed this and found that the Tiotropium was a hand inhaler which looked very much like the Braltus, Teva it is comparable i.e. no better or no worse/not inferior. It was agreed that if GP s wanted to initiate Tiotropium then this was fine but it wasn t felt that there would be any benefit in switching current patients. GB 4

Nothing to add. 4.13 Year-End Review of Prescribing Incentive Scheme 2016/17 confirmed that OE did not agree to scrap the Waste and Minor Ailments schemes. The team will look into a Quality Contract Scheme and into asking GP to encourage self-care to patients in their next team meeting on the 22 March. Nothing to add. 4.14 Generic Fluiticasone/Salmeterol MDI Change to Sirdupla GB had brought along the switching programme and said that the aim was to change all appropriate non-branded Fluticasone/Salmeterol MDI inhalers to the Sirdupla brand. There are now two brands (Seretide and Sirdupla) of Fluticasone/Samleterol combination MDI, and both contain exactly the same type and amount of Fluticasone and Salmeterol. The inhaler devices of each brand however look different. If a generic prescription is given, it could result in the patient getting one device one month and a different looking device the next, leading to confusion. Current BTS/SIGN guidelines recommend prescribing inhalers by brand, as do the updated GOLD guidelines. Patients currently on Seretide will be OK but patients on the generic brand will be switched to Sirdupla. This will be one of our generic brands for this year. After discussion the proposal was agreed. GB/ Nothing to add. 4.15 Right Care Primary Care Prescribing is working with Lydia George and looking to do a presentation in April on Respiratory and Right Care and where we think our efficiencies are. is doing a presentation on Wednesday 26.04.2017 and will give feedback at the next meeting. 4.16 Tinzaparin: Transfer of Prescribing and Monitoring from Hospital to GP Previous Minute Document had been slightly changed after Mr Poku said that they wanted to prescribe the whole six week course for pregnant women. RN said that if they are going to do this should they be contacting the Waste Department needle disposable should start from the hospital and initiation of treatment. suggested that the onus should be placed on the patient to contact the Waste Department but RS said that he thought this had to be started by a clinician as patients weren t allowed to do this themselves. After discussion it was agreed that the waste service should be started from the start of the treatment by a clinician. would take this point forward. made a note of several other points which were raised during the discussion and agreed to email these to Surinder. would also query whether notifications could be sent electronically to GP s rather than by fax. The amended document would then be placed on the agenda for the next RMOG meeting for discussion/ratification. Once agreed it would be sent out to GP s via Bite Size. Ongoing. 4.17 Pharmacy First Complaint A pharmacy had contacted the MMT to say that they had recently had a customer who became verbally abusive when they were unable to issue paracetamol and ibuprofen for their child because the child wasn t present at the time. Customer then said the pharmacy didn t know what they were doing because I neighbouring pharmacy issued products without the child being present. Another incident had been reported by a member of staff who had seen a pharmacist issuing medication and was heard to say just in case they needed it in future. After discussion it was decided that RS would keep a log of all incidents which were being reported and he would also prepare a report showing activity over the last 12 months and share this with the group. RS No further action remove from minutes. 4.18 NUMSAS (NHS England National Scheme) 5

RS said that this is the national emergency supply scheme which comes into effect on 1 April 2017. When patients ring 111 they will be redirected direct to participating pharmacies. It was disappointing that there are only four pharmacies in Rotherham who have signed up for this and there are only 12 in South Yorkshire. agreed to email Nick Hunter to convey the Committee s disappointment at the lack of pharmacy sign-up. has been liaising with Jo Martin regarding the new Emergency Centre and she has told him that patients will be asked to contact 111. RS confirmed that there are two pharmacies signed-up - Rawmarsh and Wickersley. No services will be provided on the Bank Holidays. 4.19 Drugs Affecting Bone Metabolism Report Quarters 1 and 2-2016/17 LM went through the data in Rotherham we are very low prescribers but also have low hospital admissions which is surprising. Discussion took place about why and there were several theories shared. As a result of looking at the data LM was asked to look into this item 4.20 refers to this piece of work. 4.20 Fragility Fracture Risk Assessment and Prevention in Primary Care LM performed a search within one of her practices and asked colleagues to run the search in their practices as well. Findings were that looking at typical fractures associated with fragility fractures it would appear that the majority of those patients were not currently taking a biphosponates and had never been offered one. On the basis of that LM has devised a decision making tool to help GP s identify their patients who are at risk and she shared the first draft which was discussed and comments were shared and various amendments were suggested and LM agreed to amend this. Discussion had taken place at previous meetings about a Fragility Nurse post at the hospital but LM hadn t managed to track this down. AW said that he thought the lady s surname was Nuttall and that she works in the Fracture Clinic ie part of Orthopeadics rather than A&E. LM would try to make contact with her. LM Ongoing. 4.21 Quarter 3 Cost Growth went through the data and discussion took place about this. 12 month cost growth is 3.93% compared to a year to date cost growth of -1.4%. Whilst there are some acknowledged strong cost pressures, the measures introduced in 2016/17 such as the medicines waste initiative and branded generic programme will contain these. 4.22 Acupins These are a non-pharmaceutical aid for treating nausea in pregnancy and are currently being used at TRFT and they have shown really good results. AG had received a request from GB to amend the pathway to include these in the pathway for use in primary care. After discussion this was agreed training would be given to primary care staff on how to use these and procedure for disposal of sharps would be clarified. GB AG wants a pathway and confirmation where acupins can be ordered from and confirmed that they can be dispose of as sharp. AG confirmed that acupins can issued by nurses. agreed to look into setting up the pathway and to discuss with finance. It is not a drug it is a piece of equipment, cost is 16p each issued every 3 rd day. agreed to get GB to update the website. Ongoing. 4.23 Individual Funding Request Stelara Ustekinumab Previous Minute 6

ES explained that this was to treat a patient who had a rare skin condition similar to eczema and various other treatments had been tried but had not been effective. This drug had shown good results for treatment of the particular condition and after discussion it was decided that the request would be approved for 12 months and the clinician would be asked to demonstrate its effectiveness prior to a further funding being agreed. Remove from minutes. 5 AGENDA ITEMS 5.1 Terms of Reference Wendy Allot has replaced Ian Atkinson as Lead Director and Sophie Holden is replacing Avanti Gunasekera as NHS Rotherham CCG GP Lead for Medicine Management. will confirm that two members of the Medicine Management Team must be in attendance, one being the Head of Medicine Management or Deputy plus one pharmacist. Amendments will be made to the Terms of Reference. 5.2 (Pink) Community Drug Card JAA Due to a recent serious incident all cards in the community have been withdrawn, the original version 1 on A4 is to be used for the next 3 months. AG and GB have been looking to into redesigning the card - it will be version 3 and a light blue/green colour, 3 pages with smaller boxes with DONOT FAX at the top. AG is taking it to next LMC meeting. It must be made clear that when issuing controlled drugs the completed form cannot be faxed or copied, only the original signed prescription form can be accepted. AG has asked all district nurses to remove all the cards from their surgeries. AG AG will provide bullet points for the May newsletter. RN advised that it would be prudent to wait until the critical incident meeting has taken place, where this can be introduced and explained. would raise this at the next RMOG meeting. 5.3 May Bank Holidays - Community Pharmacy Emergency Supply Service RS Andrew Cook, Head of the 111 Scheme, requested the LIS to be de-registered due to the confusion caused over the Christmas Bank Holiday. The pharmacies signed-up to the scheme did not open on the Bank Holidays as the LIS agreement requires them to. In Rotherham there are two pharmacies that have signed up for this scheme - one in Rawmarsh and one in Wickersley. pointed out that both are independent pharmacies. None of the large pharmacy companies eg Lloyds, Boots, Wells or Weldricks signed-up for the scheme. The scheme is set-up to help patients and the service is not being fully provided. Victoria Lindon (Primary Care), NHS England, has sent an email out through the LPC to get more members to sign-up to the scheme. 5.4 16/17 Year to Date Performance Report RCCG have hit the target 3.2 Million and looking to overtake Wakefield CCG 5.5 17/18 QIPP Work Programme and Incentive Scheme The CCGs MMT QIPP agenda for 2017-18 has been was discussed and agreed. 7

Several projects are to start running from May - things like antibiotics, calcium, waste, vitamin D and the branded generic switch. 6 Traffic Light Update No update. 7 NICE Guidelines No update. 8 Horizon Scanning No update. 9 ANY OTHER BUSINESS 9.1 STP Transformation Partnership SYB Programme is attending a meeting with Keely Firth from Finance regarding the above. An up-date will be provided at the next meeting. 10 For Information Barnsley APC Ratified Minutes no update Barnsley APC Memo no update Doncaster and Bassetlaw APC February and March 2017 Doncaster APC Memo no update Doncaster APC Memo no update RDASH MMC Draft Minutes no update Sheffield Area Prescribing Group no update 11 Items for APC, Items for Escalation or Additions to the Risk Register None discussed. 12 Date and Time of next Meeting: The will be held on Wednesday 10 May 2017 from 9.00am to 11.00am in the Cedar Room, Oak House. Agenda Deadline: By close of play on Friday 5 May 2017. 8