Chester City and Rural Prescribing Leads Meeting Wednesday 1 st October 2014 Room A 1829 building

Chester City and Rural Prescribing Leads Meeting Wednesday 1 st October 2014 Room A 1829 building Dr Andy Dunbavand () (chair) Dr L Davies (LD) Dr A Ojeda (AO) Dr C Fryar (CF) Dr P Davis (PD) Dr R Brooks (RB) Dr J Berry (JB) Dr H Gillies (HG) Dr C Schofield (CS) Dr J Hinds (JH) Dr S Leitch (SL) Dr C Jones (CJ) Dr N Shergill (NS) Dr D Foreman (DF) Dr G Chappell (GC) Dr M O Shea (MS) Dr A Bland (AB) Sally McLaren (SM) (minutes) Gill Hughes (GH) Barbara Perry (BP) Attendance Key points for dissemination Topic Further Information 1 Practice Prescribing budgets 14/15 2 Medicines Management Team Oxycodone to Longtec / Shortec switch will commence in October Qipp priorities 3 NICE CG 181 (Lipid modification) : local lipid guidelines under review 4 Practice policy for dealing with Drug Alerts 5 Midwife pethidine Advised that pethidine for home delivery should requests 6 Phytomenadione for reversal of high INR not be prescribed by GP Advised that practices should stock Phytomenadione 2mg/0.2ml for provision directly to patients with raised INR according to COCH policy Management of high INR on MM website 1

7 Sildenafil reclassification National amendment to SLS status of generic sildenafil. Can now be prescribed on NHS for all ED indications. Advised to continue to restrict quantities on prescription to 4 doses / month in accordance with current CCG policy. Actions List Created from Meeting Actions By Whom Timescale 3. Dutasteride to finasteride switch to be followed up with /BP urology consultants. 3. Inclusion of head lice preparations in minor ailments scheme to be discussed at task and finish group 3. MM team microsite to be circulated to all prescribers in GP ALL practices 3. Reason for datixing C Diff incidents to be queried with A Miskell and then circulated to all Oct 14 4. to discuss the need for non-fasting bloods in light of new NICE lipid modification guidelines with Shirley Bowles. 4. Circulation of NICE bites to all clinicians in practice. ALL Oct 14 5. Formulary application for GlucoRx pen needles GH 6. to send on details as requested of practice based scheme to review AF patients to those who want it. Oct 14 6. To follow up actions taken by CCGs achieving low BP prescribing in both overall antibiotics and cephalosporins Jan 15 and quinolones 6. Monthly list of medication recalls and alerts to be BP/ GH disseminated. Include an action plan to identify who is Ongoing responsible for actions. BP to progress. 1. Apologies Dr M Lowrie, Dr S MacDonald, Dr I Minshall, Dr H Asteriades, Dr P Milner, Dr J Dancy, Dr A Adey, Dr D King. 2. Minutes from meeting held on 30 th July 2014 Accuracy agreed as an accurate record. 3. Matters Arising Dustasteride to finasteride switch to be followed up with urology Meeting was held but there were no urologists present. Agreed that need a separate meeting with consultants to discuss this switch and also solifenacin vs. darifenacin. At present the consultants are reluctant to use darifenacin but agreed that need to encourage it s use in line with NICE. When price decreases it will become more significant. Feedback on Minor Ailment scheme suggestions including possible addition of head lice solution GH updated group. BB had fed back to Marilyn Knass. explained about use of Task & Finish group. Head lice was taken off the list due to huge uptake and concerns regarding inappropriate use. Query on what was product of choice at present, /BP 2

previously there was a list of products that were rotated; confirmed that is the bug busting kit. Group said that demand for treatment had dropped and was agreed that will ask task and finish group about the inclusion of this to the list again. List of drugs and pharmacies participating in minor ailments scheme to be circulated Available on Medicines management web site. epact to be run on commonly prescribed specials where there is a licensed preparation and circulated if appropriate completed. Sent to appropriate practice pharmacist for action in one particular practice. Has been included in Tablets newsletter. Link to MM team microsite to be recirculated completed. SM confirmed that medicines managers have link. asked group members to circulate to registrars etc. BP to ask OOH team about supply of medicines for palliative patients CCG palliative care work stream reviewing provision of palliative care drugs. Dr S Shaw looking at system adopted by Central & Eastern for a service commissioned from community pharmacy that could be used here. Would make the service more structured. Script Switch message to be added to drugs included in new Drug Driving guidance Drug driving guidance is available on MM microsite C Diff report from A Miskell to be circulated completed. AMiskell to feedback reason for completing Datix reports relating to C Diff. Outstanding. Group asked if incidents already picked up then why have to Datix as this is duplicating work. LD felt that should not need to do both and could we say no? thought not. Answer to be circulated electronically. Palliative care drug stocks to be reviewed as above. 4. Standing agenda items Prescribing budget and QIPP Update Papers 2 & 3 GH talked through budget data. CCG prescribing budget reduced by 260,000 this year. Individual GP practice prescribing data will be incorporated into dashboards to compare to last year s spend and to budget. Gareth James coming to next joint meeting to talk about how budgets are set. QIPP comparators talked through. JB queried value of ACE vs ARB target. Discussed. Omega 3 indicator is still red for WCCCG though medicines management team have done a lot of work on this by discontinuing in ACS patients. Wound care target may be affected by transfer of budget to District Nurses. NICE guidance July 2014 has TAG 317 prasugrel with percutaneous coronary intervention for acute coronary syndrome which is unlikely to result in a significant cost increase because of the small population. TAG 318 lubiprostone for treating chronic idiopathic constipation currently non formulary item. CG 181 Lipid modification and risk modification - big implications for primary care as discussed in previous meeting. Lipid guidelines are being updated in line with this guidance. Discussion on treatment of new cohort of patients and which practices were treating them. Noted by some practices that there is not much uptake when patients are asked but agreed that need to ensure that declination is recorded in notes. BP said that NICE says if already treating patients then OK to continue but 3 All

consider new guidance at their next medication review appointment. BP asked HG if there was any benefit of atorvastatin 20mg over simvastatin 40. Confirmed that there is a bigger percentage reduction but that guidance is unsupported. Atorvastatin might be a slightly cleaner drug but confirmed that any dose of any statin is better than nothing. JB queried no longer needing fasting blood test. to discuss the need for non-fasting bloods with Shirley Bowles. Script switch messages need to change. August 2014 has TAG 320 dimethyl fumarate for treatment of relapsing remitting multiple sclerosis. NICE Bites asked the group to ensure that these are circulated within practices to all prescribers. Drug Safety Update Papers 8 & 9 July 2014 summary of drug/driving guidance and warning on fentanyl patches. Information leaflet for patients using Fentanyl patches is available as a link within DSU. August 2014 article on Emergency Hormonal Contraception and high BMI report says that link is unproven. E learning on oral anticoagulants. APC/CDC Committee Feedback Paper 10 and BP talked through these. Discussion on Yasmin, Zoely and Qlaira and the fitting of Mirena coils instead. LD said that they get paid for fitting these for Welsh pts. Qlaira is black for contraception. Emergency Hormonal Contraception guidelines talked through. No compelling evidence to switch from current guidance. Cheshire and Wirral MH Partnership Nothing to report on this. No meeting. 5. Medicines Management QIPP Priorities Insulin pen needles cost effective choice GH explained that the CCG strategy group have asked MM team to prioritise cost saving measures and switching to the use of GlucoRx needles is one such piece of work. Other option is to brand the oxycodone to Longtec and Shortec. Has been done in other areas without problem; query about guaranteed stock holding but confirmed that brand is rumoured to be produced same factory so shouldn t be a problem. Insulin needles have been looked at before but was not a large uptake because diabetes team had not agreed to the switch. This has now changed and the diabetes team are in agreement with the agreed to switch to GlucoRx fine point. They are compatible with all pens, company have guaranteed price and will generate about 40,000 savings. GH to write a formulary application so switch will be on hold until the application has been approved. Will need to let community pharmacies know so that they can adjust stock holding. JB asked about the use of Unifine needles as they are cheaper? GH said that Omnican also match GlucoRx price wise but don t have a sheath so less acceptable to patients. GH to check. Group agreed to switch. HG asked about their welsh pts but GH confirmed that it is unlikely to be a problem. ALL GH Senna price has increased substantially for 60 tablets to approximately 12. Bisacodyl is much cheaper so an application will be submitted for this for addition to formulary. CCG savings for this will be approximately 110,000. 4

Query about CoCH and their choice of preparation. JC not here to ask. Won t be removing senna from formulary. GH/BP to ask CoCH to encourage use once added to formulary. Query if this affects QIPP target but confirmed not the case. 6. Medicines Optimisation dashboard New dashboard from NHS England. GH talked through the individual dashboards. NOAC numbers of interest as prescribing generally low in North West including West Cheshire, much higher in other areas. explained an industry-sponsored piece of work has been undertaken in two GP practices involving a secondary care cardiologist reviewing anticoagulation in AF patients. City Walls looking at this. can provide details if requested. BP confirmed that she had met with Dr L Appleton (GP clinical lead for CCG on Cardiovascular) who is not supportive of using this service. Feels it is a primary care issue that primary care should be dealing with. Concerns expressed by if NICE AF Guidance may not have been actioned in all GP Practices. Some practices have not undertaken any reviews as yet of those patients on aspirin or no treatment. LD asked about the article that suggested that dabigatran needs monitoring. No further news on this. HG talked about lunchtime meeting she had attended on those patients who are stented. Warfarin pts can continue and have the dual anti platelets as per guidelines but NOACs are not licensed for this and would need to switch to warfarin once stented. BP pointed out the dashboard data on antibiotics as there are CCGs who are low in both targets (number of prescription items for antibiotics and percentage of cephalosporins and quinolones) and it might be worth asking them how? Noted that OOH still prescribing cephalosporins. 7. Practice Policy for dealing with Drug Alerts talked through back ground of this. CQC looking for evidence that alerts have been actioned by a practice and not just received. Talked through City Walls process using presentation prepared by Diane Hornsby, practice pharmacist at City Walls. Query if all alerts go to all prescribers? LD confirmed that they disseminate them via Docman in their practice and each GP has to annotate it to say that they have seen it. AB commented on time taken to action each alert and is there a better way of doing this e.g. Script Switch messages or cascaded to Medicines Managers? Confirmed that messages added to Script Switch when team knows about them but don t always get to know about them. Agreed that medicines manager could run searches to find patients; use of MMs discussed are not clinical staff so limited input for some alerts. Messages added to Tablets where appropriate and content of significant alerts discussed at Prescribing Leads meetings. Governance and availability issues cannot all be actioned. MM team don t get all alerts e.g. ones from NHS England. Availability issues are sometimes looked at the by the team but noted that sometimes responses from team aren t quick enough. LD asked how to get on cascade list; confirmed would need to ask NHS England. Could have a monthly list compiled and disseminated. Include an action plan to know who doing what e.g. MM s or MM team to review. BP to progress. Ideally sent out as email to all clinicians. PD talked through their CQC inspection; was questioned about domperidone. BP BP 5

Domperidone guidance about to be disseminated after a meeting last week. Discussion on denosumab shared care not being adhered to. 8. Palliative Care Service Specification BP talked through this. Service specification in Vale Royal and Eastern Cheshire for a service provided by community pharmacies to hold stock for supply in palliative pts. SAS and palliative care group looking at current service in West Cheshire as currently have a gentleman s agreement here and nothing formal in place. Under current arrangements, 4 pharmacies across patch signed up to supply these specialist medications. Have had access problems with service, mostly in EP&N. New guidance on provision of care at the end of life due out though drugs are the same. Pharmacies only hold minimum stock and most problems occur at weekend. Queries on previous offer for OOH to run the service and why the community pharmacies should be paid for the service. Confirmed that this formalises the service. Pharmacies would be paid 200 to provide service. AB said that cost of drugs is minimal. Agreed that not too many problems in city locality but there have been problems in the rural practices. BP confirmed which pharmacies currently offer the service. SAS looking for support of process to formalise this. JB asked about centralising the supply? In Bunbury practice they try and estimate how much medication will be needed but still leads to waste. A central stock might mean that there is less waste and relatives only collect a small supply each time. DF confirmed that DNs are not allowed to carry drugs for patients. Noted that current service is restrictive for those patients without transport. HG asked if a pharmacy would ring another pharmacy to see if they have stock but this depends on pharmacy; Could write this into agreement. GC asked about drugs left over and what happens to these. Should go back to pharmacy by relative for destruction but concerns expressed that no one checks this. BP confirmed that they are patient property and the process. Why don t CQC pick up on this? Destruction of CDs process confirmed. 9. Pethidine : One to One company practice Issue about a practice asked to supply pethidine to a pregnant lady by a company called One to One in preparation for a home delivery. One to One is a private midwifery service. Query explained by PD; concerns about the dose and amount requested. BP has looked into this further. NHS midwives access pethidine direct from CoCH if necessary. BP has now seen One to One SOP that includes mechanism for midwives to obtain pethidine and has commented on this to the CCG. Incident has been datixed and CCG are investigating. Protocol was quite clear about drug and dose, and detailed that the One to One midwife would contact the second on call midwife to obtain supply from designated building. Confirmed that entitled to say no to these requests GPs cannot take clinical responsibility for a patient who has not been seen by them. GPs raised that communication from company is poor. Query if neonatal vitamin K included in specification; BP will check that all necessary treatments are included. 10. Patient Safety Alert Discharge from secondary care risks Paper 11 GH talked through this to raise awareness of national programme to look at communication problems at discharge. Looking for good practice examples on this. GH attended CCG Brief and this is being addressed 6

11. Phytomenadione for high INR Vitamin K for raised INR GH described a local incident where a patient had a high INR >8 and was given a prescription for oral vitamin K rather than it being supplied directly from surgery. The patient then unable to obtain the medication for 24 hours as the medication was not available at local community pharmacy. Reminder that practices should keep this in and give it direct to patient. A reminder to all practices to be issued and to go in Tablets Medicines Management Team newsletter. CoCH policy for treatment of raised INRs will be uploaded onto web page. 12. AOB Change in status of generic sildenafil - SLS status has been removed from generic sildenafil which means that those patients who have the item on private prescription should now be switched to NHS prescriptions. As a result the erectile dysfunction policy needs to be reviewed. Agreed that can change patients from private to NHS but leave quantities as they are for now in line with current CCG policy. Noted that some patients will pay more for their NHS prescription than they did for a private prescription. MM s are aware but were told not to do anything until further information available. Demeclocyline out of stock until June 2015. Used for SIH- only option is to give unlicensed demeclocyline. CoCH have had trouble sourcing supplies of unlicensed product and may use tolvaptan. Tolvaptan is not for prescribing in primary care and can cause dangerous problems with sodium levels on initiation. Information has been sent out to the medicines management team. One GP has been advised slow sodium for one of their patients. Emis picking list problems AB query about selecting the lowest cost generic drug, EMIS web presents a picking list of drugs with a brand name next to them e.g. Actavis, but can t pick it directly and queried why. BP said that we are being asked not to use branded generics as it alters the global sum. Price changes may not be consistent. Wirral medicines management team have done a lot of work on branded generics. Suggestion made that it is logged as a development request on Emis web. Dates of next meeting Joint meeting with EP&N 18 th November 2014 at Cheshire View. 9-12.30 7