Venue: Salford St James House Present: Name Designation Organisation CCG members

GREATER MANCHESTER MEDICINES MANAGEMENT GROUP Minutes Date: Thursday 16 th February 2017 Time: 1pm 3pm Venue: Salford St James House Present: Name Designation Organisation CCG members Dr Helen Burgess (HB) GP Prescribing Lead and GMMMG (Co-Chair) NHS South Manchester CCG Liz Bailey (LB) Medicines Optimisation Lead NHS Stockport CCG Dr Phillip Burns (PB) Chair South Manchester CCG NHS South Manchester CCG Kenny Li (KL) Head of Medicines Management NHS Manchester CCGs Jackie Murray (JM) Deputy Finance Officer NHS Bolton CCG Jeanette Tilstone (JT) Head of Medicines Optimisation NHS Bury CCG Dr Sanjay Wahie (SW) Clinical Director NHS Wigan CCG Ben Woodhouse (BW) Head of Medicines Optimisation NHS Bolton CCG Claire Vaughan (CV) Head of Medicines Optimisation NHS Salford CCG Regional and Secondary Care members Petra Brown (PB) Chief Pharmacist Greater Manchester Mental Health (GMMH) Bernadette Bernie (BB) Senior Pharmacist Shared Care Greater Manchester Mental Health (GMMH) Additional Peter Marks (PM) Member Greater Manchester LPC Support Sue Dickinson (SD) Director of Pharmacy RDTC Andrew Martin (AM) Strategic Medicines Optimisation GM Shared Service Pharmacist Bhavana Reddy (BR) Head of Prescribing Support RDTC Andrew White (AW) Head of Medicines Optimisation GM Shared Service Minutes by: Bhavana Reddy, RDTC Chair: Dr Helen Burgess In attendance: Professor Jørgen Vestbo, Professor of Respiratory Medicine, Manchester University in attendance for first 30 mins only. Item Topic Action 1 General Business 1.1 Apologies for Absence K Kinsey, J Brown, R McDonald, A Walker, N Dunkerley, L Lord, L Smith, A Irvine, C Skitterall. 1.2 Conflicts of Interest Declarations It was noted that there had been no conflicts of interest declared by members currently present. 1

1.3 Minutes of the Previous Meeting. These were approved. It was noted that CV had attended the last meeting but wasn t included in the persons present. This would be updated. RDTC to publish on website Matters Arising from Key Actions and outstanding matter arising log: GM Antivirals. It had been agreed at the December meeting that the shared service should update the previous scoping document with the above information and share this with CCGs. This was still an outstanding item. GM Vaccines Statement It was noted that the statement had been published. Some felt that it was slightly late however others stated that orders had been amended following the publication of the statement so it had been useful and did have an effect. A few localities had been contacted by manufacturers of the quadrivalent vaccines asking them to re-consider the position. Development of GMMMG into a Clinical Standards Board. It was noted that this item hadn t progressed as had been intended. This was because AGG had yet to approve the re-structure of the main group. The restructuring of the subgroups was within GMMMG s current remit so these had now already taken place to change the focus of the outputs. AGG were supportive of this. However support was needed to progress the development of GMMMG. This would be discussed further in the main agenda under agenda item 2.2. Task and Finish Group for Gluten Free The group agreed that this was no longer necessary as this item was being taken up nationally. The group therefore agreed to remove this agenda item from the outstanding matters arising log. Botulinum Toxin Policy Update It was noted a large number of comments had been received therefore this was still being updated and would be brought to the next meeting. All other items were on the agenda. A discussion took place around having a more comprehensive action log rather than a matters arising table. BR agreed to pull something together for the next meeting. CV agreed to forward an example from the CCG. 2. Strategic Direction 2.1 Presentation on Real World Data and the Salford Lung Study Professor Vestbo had been invited to speak to the group about the Salford Lung Study but mainly focusing on the real world data clinical trial and the differences with RCTs, real world clinical trials and observational studies. The group found the presentation very interesting and informative. Key points from the presentation were: The Salford Lung Study was the first study of its kind initiated with a 2

pre-licence medicine. Maintains the scientific rigour of an RCT but keeps it as near to everyday clinical practice setting An innovative collaboration between the University of Manchester, GSK, and the entire regional NHS health care community (pharmacies, Gp Practices, CCGs, hospitals etc.) Uses an integrated electronic health care record that facilitates data collection without direct patient contact. There were no disease exclusions unlike in other RCTs so it is likely to be more representative of the COPD patient population. It was noted that this type of trial could not have taken place elsewhere as other regions did not have seamless data integration between primary care and secondary care which was instrumental in gaining agreement from the MHRA. The knowledge gained from running this trial in Salford and then later South Manchester is still available to the system and so should be utilised by taking part in other research that will be of benefit to GM and patients. The group thanked Prof Vestbo for his informative talk and agreed that real world RCT data are a good method of assessing efficacy of medicines. The Salford Lung Study has raised the profile of Salford and Manchester as a centre for real world research and the group agreed that we should be aiming to extend this to include the whole of GM. 2.2 GM Medicines Strategy Update AW gave GMMMG an update on the medicines strategy workshop which took place last month. The session was attended by 20 people, the majority of whom were pharmacists. This has helped shape the medicines optimisation section of the strategy however more engagement is required to shape the innovation aspects of the strategy. It was noted that the Medicines Strategy Board will be supported by two subgroups a Clinical Standards Board for Medicines (GMMMG) and a Medicines innovation Board. The medicines innovation board is in the process of being set up. However it is intended that GMMMG will provide leadership and deliver on the medicines optimisation aspects of the medicines strategy. The medicines strategy board will report up to the Joint Commissioning Board which is a decision making body and covers commissioners and providers. The group discussed the challenges in moving GMMMG towards a clinical standards board and gaining agreement and engagement from all parts of the system. It was noted that the delegated decision making was not approved by AGG but that this may not be required nor the best approach and better engagement and implementation of guidance issued at local level should be sought instead. Some localities felt that there wasn t a problem with unwarranted variation. AW indicated that whilst GMMMG support and Chairs can put the case forward this lack of understanding also needs tackling at a local level. While the strength of the MO teams in CCGs was acknowledged, it was proposed that there may be too many recommendations coming out of GMMMG which meant that not all of it could be implemented at a local level due to capacity issues. It was agreed that GMMMG should concentrate on the 4 key areas identified in previous meetings. Any scoping must identify how localities implement current ACTION: Shared Service to scope barriers to implementation of GMMMG guidance and decision making routes. 3

GMMMG recommendations including the formulary but it should also identify what GMMMG could do (within its current funding and capacity constraints) to support teams at a local level in implementing their guidance. The group was also encouraged to participate in the next Medicines Strategy Workshop once arranged. 2.3 Industry Memorandum of Understanding (MoU) update AW gave the group an update on the above agenda item. It was noted that Strategic Partnership Board Executive feedback was very positive from providers and GM HSCP. This MOU was described as unique nationally. GMMMG were asked to: Support the development and principles of the MoU and propose any enhancements to the final draft which will be presented at the Strategic Partnership Board. 2.4 GM Minor Ailment Service Evaluation HB presented this agenda item and noted that a cost benefit analysis of the minor Ailment Scheme had been carried out by NHS England. It was noted that 6 out of the 12 CCGs had signed up to this service. The analysis was positive, however the group noted that there had been some challenges with the service which hadn t been noted in the write up. The group also felt that the minor ailments scheme should be looked at as part of the wider GM strategy on self-care. CCGs were therefore encouraged to feedback to NHS England on this. 2.5 AN example of implementation of GMMMG guidance locally JT and KP presented this item. The paper that had been shared was a write up of work done locally to implement the GMMMG Self-Monitoring of Blood Glucose guidance across Bury and HMR CCGs. It was noted that on implementation of the guidance there was a 15.8% reduction in spend in HMR CCG and a 13.9% reduction in spend in Bury CCG. The group congratulated JT and KP in getting this piece of work written up. It was a good example of where GMMMG guidance had been implemented and had made a difference to spend within the CCG. The group agreed that a summary of this to go to AGG would be really useful to highlight the kind of work that can be done by utilising GMMMG guidance. 2.6 Seeking Compensation for the excessive cost of phenytoin capsules. AM updated the group on the response received from the DH regarding the above. It was noted that the compensation around the excessive pricing will be carried out by the DH nationally on behalf of the whole NHS and it will only be started once the appeal process has been completed so this may take some time yet. The group thanked AM for following this up and agreed to keep any paperwork pertaining to phenytoin within organisational archives. 3 Subgroup Reports 3.1 Formulary and Managed Entry Subgroup (FMESG) BR gave the group an update on the first meeting which had been well attended. There were equal numbers of primary care and secondary care members in the group however there was a plea for more GPs as the ones ACTION: ALL to feedback to AW. ACTION: CCGs to feedback on minor ailments scheme. ACTION: JT to write summary for AGG and send to BR. 4

that had put themselves forward were now not able to make the scheduled dates for meetings. The group had discussed the remit of the group which now encompasses the management of the formulary, new drugs, the RAG list and DNP and grey lists. The group had discussed the NPC competency framework which they would carry out in 6-12 months time once the group was up and running as the framework was designed to be used on a functioning group. The group had also discussed the NPC gap analysis results which had been repeated, the main gaps appeared to be around the implementation side of things so a clearer picture around what happens locally is required. This will be scoped further. The group approved then approved the items for ratification as below: Addition of Treclin gel to the formulary Amendment to the aripiprazole entry: 5, 10, 15mg tablets to move to first line. RAG status decisions were approved. The group noted that degaralix was assigned an amber RAG status. There was a NICE TA available for this drug and it would be up to localities to ensure use in line with this which includes getting the drug at a discounted price and therefore signing up to a rebate scheme in primary care. ACTION: To be published on the GMMMG website. 3.2 The Pathways and Guidelines Development Group (PaGDSG) RD was not at the GMMMG and did not attend regularly so another member would need to be invited to feedback on this subgroup. In the absence of a subgroup member BR fedback on behalf of the group. Feedback was based on the report produced for the meeting. It was noted that Margaret O Dwyer was no longer chairing this group so Dr Richard Darling had taken on the acting Chair role. There was a query around membership and whether this was sufficiently different to the previous interface prescribing group. It was noted that the intention had been to ensure better commissioning representation on the group. It was felt that membership had not changed sufficiently. This needed addressing. GMMMG noted the workplan and the update on the first meeting. The group also approved the minor amendment to the melatonin SCP and the extended review date. A query was raised regarding the 6mg maximum dose included in the SCP and whether Trusts were adhering to this maximum dose. It could not be answered as no one from the subgroup was present. Post meeting note: The PaGDSG responded to the query from GMMMG regarding the maximum dose of 6mg within the SCP. It was noted that this was being adhered to by Pennine Care and CMFT. WWL had indicated that they may want to use a higher dose, however when asked to put forward evidence to support use of the higher dose no information had been forthcoming so they too would now need to adhere to the 6mg maximum dosage within the SCP. 3.3 High Cost Drugs Subgroup CV fed back on the first meeting from the HCDSG. The following points were noted: The group will look at reducing variation in spend across high cost drugs across GM however its focus won t just be on spend; it will look at different commissioning models also and will be strategic in its output and won t be looking at operational problems. 5

There will be a subgroup looking at the data and aligning the NHS E and CCG principles, so that the data received is more useful. In particular the group will be reviewing all aspects of high cost drugs work including new drugs and high cost drugs pathways. The first meeting was spent looking at the vision and direction and membership. GP representation was felt to be needed and this had subsequently been agreed. The group was also keen to look at an innovative GM approach to homecare. The group was meeting monthly in the first instance however the intention is to move to bi-monthly once processes and direction have been set. 4 Reports from Associated Committees 4.1 GM CCG leads Pharmacists Meeting. Feedback from the January CCG leads meeting included: Hackett Compliance Antimicrobial QP and a GM approach around sharing good practice Approach to the pregabalin patent expiry (significant savings will be available) Centrally allocated drugs Flu outbreak management and sharing lessons learnt. It was felt that there should a standard GM template around management with local appendices highlighting differences. New Practice Pharmacists GM Chief Pharmacists. Work is ongoing to develop hospital pharmacy transformation plans. Mental Health PB fed back that the CQUIN is now coming to an end and BB s post had not been extended so BB would be moving on to other work. It was noted that the CQUIN could not be achieved due to various factors. It had been suggested that individual CCGs speak to individual providers however this would lead to variation in provision. Mental health pharmacy leads were unclear as to how this could not be progressed and requested support from GMMMG. It was agreed that a paper should be drafted highlighting the risks around the current process and GMMMG would progress this up to AGG so a solution can be sought. PB agreed to draft a paper for the next meeting. ACTION: PB to draft paper Local Professional Network. No further update had been received. 6 AOB The issue of needing a new Co-Chair of GMMMG was raised. As CS was now Chair of the HCDSG, this meant she is no longer able to be Co-Chair of GMMMG as good governance processes dictate that you cannot be Chair of a group that receives your own group s recommendations (for which you are also Chair) for ratification. CS would of course remain a key respected member of GMMMG and the group was keen for her to remain ACTION: nominations for Co-Chair of GMMMG to be sought. 6

as the Secondary Care representative for GMMMG. The group thanked CS for her commitment and dedication to GMMMG as Co-Chair and hoped that she would continue to engage with and represent the group in future. It was agreed that nominations for Co-Chair should be sought however it may be prudent to wait until the Medicines Strategy Board is up and running and when changes to GMMMG have been agreed and implemented. To be discussed further at the April Meeting. 7 Items for Information 7.1 Date, time and venue of next meeting Meetings are bi-monthly and next meeting is: Thursday 20 th April 2017 1-3pm. Salford Suite, St James House, Salford. 7