GREATER MANCHESTER MEDICINES MANAGEMENT GROUP Minutes

GREATER MANCHESTER MEDICINES MANAGEMENT GROUP Minutes Date: Thursday 20 th April 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 Richard Darling (RD) Gp Prescribing Lead and PaGDSG Chair NHS HMR CCG Kenny Li (KL) Head of Medicines Management NHS Manchester CCGs Dr Alison Lyon (AL) Clinical GP Prescribing Lead NHS Bolton CCG 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 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) Barry Robertson (BRo) Lead Pharmacist North West Boroughs Healthcare. Additional Adam Irvine (AI) CEO GM LPC Rachel MacDonald (RM) Community Pharmacy Representative PCT Health Care Ltd. (Professional Services Pharmacist) 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 Item Topic Action 1 General Business 1.1 Apologies for Absence K Kinsey, J Brown, A Walker, N Dunkerley, L Lord, L Smith, C Skitterall, C Vaughan, Vicci Owen Smith, Phillip Burns, J McDonald. 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. There were some updates to Job titles and organisations. RDTC to publish on website Matters Arising from Minutes: Minutes and Subgroup Items had been published. GM Meds Strategy Update (also on agenda) There is an action for the shared service to scope any barriers to implementation of GMMMG guidance and review decision making routes. It was noted that this hadn t yet been done however it would be brought back to a future meeting once the strategy board was up and running and the GMMMG remit clearer. ACTION: to add to action log. An example of implementation of GMMMG guidance locally. It was agreed at the last meeting that this item should be taken to AGG as an example of good practice, however JT fedback that after discussions with KP it was felt that this may not be useful and a different approach was required. It was agreed that several other examples could be put forward instead if required. GMMMG Chair and Co-Chair. Discussion took place around appointment to the above two roles. The last nomination process had been for a period of 6-8 months which had now expired therefore nominations for both posts were now required. It was agreed that an email would be sent out by the secretary asking for nominations for both GMMMG Chair and Co-Chair. If more than one nomination was received for either post this would need to go to a secret ballot, where there is one vote per CCG as per the current terms of reference. There are two votes available for Secondary Care representatives (one for Mental health and one for Chief Pharmacists) however the remaining membership i.e. support, AHSN, GM LPC, Community Pharmacy and NHS England would not be able to vote. Post Meeting Note: HB was nominated by several people to continue as GMMMG Chair. No other nominations for Chair had been received so HB would continue as GMMMG Chair till the end of the year. Three nominations for GMMMG Co-Chair had been received so this decision would need to go to a vote at the next meeting. Pre-printed papers would be brought to the meeting and an email would be circulated to members prior to the meeting so that internal discussions within organisations could take place. All other actions had been completed or were on the agenda. 2

1.4 Long Standing Actions Action log. Shared Care Consultation: AW fed back that this is one of the items that he is discussing with Philip Burns with the intention that it is taken to AGG for further input/feedback. Post meeting note: see later. This item would no longer need to be progressed as the new GMC guidance makes it clear that GPs should be opting into shared care. All GMMMG paperwork will be updated to reflect this position. This item will be removed from the action log GM Antivirals Scoping This item was taken over by KL from the shared service. This will be updated in the action log. KL reported that had attended an initial meeting with a public health representative regarding this. A guideline was in development and this would be brought back to GMMMG once available; ACTION KL to forward guideline to BR for June/August meeting. Botulinum Toxin Policy This policy was still being updated however it would go to the HCDSG for discussion and would only come to GMMMG for ratification. This item can therefore be removed from the GMMMG action log. It was noted that two items were on hold GMMMG Pharmaceutical Industry Policy and the Appeals policy. These items had been updated and were available however they would be re-looked at once the changes to the group had been carried out and the medicines strategy board is up and running. They were currently tabled for August however this may change. 2. Strategic Direction 2.1 Delays to amending performers list The group noted that this item had been referred to the group from the CCG leads meeting. Over the last 18 months, there have been delays to amending the performers list by Primary Care Support England (PCSE) (who commission Capita to do this on their behalf). This is now impacting on prescribing data as it has resulted in the prescribing costs for prescribers who have moved practices, continuing to have their costs attributed to the previous practice, whilst the new practice appears to be demonstrating a lower weighted spend in comparison. This has an impact on quality indicators such as antibiotics. GMMMG was asked to escalate this concern to NHS England. There are numerous examples of this which can be shared if needed. It was agreed that BR would draft a letter for Chairs action. It was noted that in GM there would be no cross charging back to GM CCGs if the prescribing has been charged incorrectly to a GM CCG from another GM CCG if a GP has moved. However incorrect costs relating to out of GM area prescribing should be charged and reimbursed. There was some discussion around the above policy of not cross charging within GM as JM stated that she was not aware of this policy. JM agreed to draft letter for HB to send to NHS England. JM to check finance policy/statement around GM 3

discuss with AW and check minutes of the finance meeting to clarify this arrangement. 2.2 GM Medicines Strategy Board update and GMMMG re-development. This would be a standing agenda item for the foreseeable future. AW gave GMMMG an update on the medicines strategy workshop on the 4 th April. There was a broader mix of people who attended this workshop, with 28 people attending with representatives from the following groups: DOC s, DOF s, and Chief Pharmacists, NHS England, AHSN, GP s and CCG Medicines Management leads. The intention for the work shop was to prioritise what is most important to do at a GM level, to share best practice and to look at what can be stopped but also what needs to continue. AW agreed to put the outputs of the workshop into a format that can be shared with GMMMG and its members. cross charging. ACTION: AW to share workshop outputs with GMMMG. There was a discussion around the lack of communication around this whole process and members raised the fact that there was little communication on how this item is progressing in between workshops or GMMMG meetings and that not all communications had been shared with GMMMG membership who should be considered a key stakeholder in this process. AW noted that this is due to a lack of resource as there was no separate support for better communications. The Strategy board is still a work in progress and membership of the group is in draft form only so cannot be shared yet, however the first meeting will take place on the 31 st May 2017. The Group will be chaired by the GM H&SCP Executive Lead for Quality/Medical Director - Dr Richard Preece. This group would be more strategic in nature and provide more senior input into managing medicines use across Greater Manchester. It would also act as a conduit for taking forward issues raised by GMMMG and its Subgroups whilst providing some direction and support. The Chair of GMMMG would also be a member of the strategy board. The draft terms of reference are available however these are currently with the H&SCP as this Board is being set up under their remit. Medicines optimisation will still be addressed via GMMMG. GMMMG would need to consider how it can highlight variation what are the key priorities for the group and how will it take these forward. It was noted that this will be discussed in more detail later on in the agenda. It was noted that the next steps were to get more AGG input and to take a paper to the next AGG meeting. This would also outline GMMMG remit on medicines optimisation and variation and the next steps for this group. PB is the sponsor for AGG so AW is arranging a meeting with him first to agree how to progress this item. The group noted that there wouldn t be a separate innovation board as innovation would be considered by all groups. There was also some discussion around the request from AGG that all industry projects or rebates etc. should be kept separate from the clinical decision making around medicines use made by GMMMG; this was seen to be the main reason for the development of a Medicines Strategy Board as this board can consider industry involvement and the memorandum of agreement and this wouldn t raise any conflicts of interest ACTION: AW to share draft AGG paper with GMMMG. 4

for GMMMG or its Subgroups. Members asked AW whether he required any support writing this paper for AGG and they suggested that a task and finish group maybe a better way to get feedback and engagement rather than just writing the paper in isolation. Members were encouraged to get in touch with AW should they be interested in contributing. A draft paper will be circulated to GMMMG membership and work shop attendees as soon as possible. Kenny li and Roger Roberts volunteered to support AW with this work. 3. Medicines Optimisation 3.1 Low Value Prescription Items (NHS CC and NHS E) The group discussed the recent press releases from NHS Clinical Commissioners and NHS England regarding the ten low value prescription items. NHS England will take a national approach to these items which were put forward by NHS Clinical Commissioners and are considered to be ineffective, unnecessary, unsafe or inappropriate for prescription on the NHS. It was noted by GMMMG that many of these items are already on the DNP list and work has been done already to reduce spend in these areas. It was felt that it would be useful to start work on these early by identifying how much prescribing still exists. It was therefore agreed that BR and AM will work together to pull some data on CCG spend in each of the identified areas for the June meeting. A summary of work done so far would also be useful. This will give GMMMG an idea of what further work needs to be done in these areas. It was noted that several other items could be added to this list including homeopathy and looking at items for Self Care. It was agreed that these could be tackled in the future, once the national list had been looked at. A GMMMG policy for self-care would be useful and this will be added to the work plan for the group. 3.2 Gluten Free Consultation This item was related to item 3.1 and is the consultation on the availability of Gluten Free foods on prescription in primary care. GMMMG agreed that a response should be sent from the group, members agreed that they would prefer option 2 to end the prescribing of gluten free prescribing in primary care for the following reasons: Gluten free foods are not medicines or treatments for the condition and as such shouldn t be allowed on prescription. Allowing items on prescription medicalises the condition rather than encouraging a change in lifestyle. Patients should be encouraged to eat a naturally gluten free healthy diet and should have access to dietetic help to do this. Dieticians could be funded by freeing up monies from prescribing. This in turn would provide a better quality of service to coeliac patients. 3.3 Rebate Schemes ACTION: BR and AM to pull together data highlighting spend at CCG level for next meeting. draft consultation response for approval by the group at the June meeting. The group was informed that the following rebate scheme had met the GMMMG criteria for approval: OneTouch Select Plus Blood Glucose Test Strips Rebate Scheme. This rebate scheme was now available for local CCGs to adopt if they wished. 5

The Reletrans (Buprenorphine) 7 Day transdermal patches rebate was not approved as this drug is currently non-formulary. 3.4 Highlighting Variation In July 2016 GMMMG approved four high priority areas for further work these were: Biosimilars Respiratory - COPD Antibiotics Mental Health shared care CQUIN. Discussion took place around how these items could be progressed. The following decisions were agreed: Biosimilars This would be delegated to the high cost drugs subgroup and a quarterly update on biosimilar use, benchmarking Trusts across GM should be shared. A GM invest to save scheme should be scoped. Audit/Feedback on any switches to biosimilars that have already taken place should also be encouraged. Biosimilars are a high priority area nationally and will be a focus of the RMOC s once established. Antibacterials It was agreed that work done in this area should be reviewed at a future meeting; feedback from CCGs on how they have tackled antibiotic prescribing at a local level would be useful. It was noted that there has been some progress in agreeing a GM wide antibiotic formulary. The shared service fed back that there is work ongoing around training and evaluation of prescribing in this area and a template audit pack is in development. This will be shared with CCGs once developed. It was also noted that having a local antibiotic champion can help with reduction. Respiratory COPD. The group noted that a lot of work had been carried out in this area already. The COPD pathway and accompanying tools (detailing aid, inhaler guide etc.) were available however there has been a varying degree of uptake. The COPD subgroup is due to meet again soon and the question around review of patients already on treatment and whether they should be switched or remain on current choices will be tackled. An Asthma pathway has also been developed and is on the agenda later for approval and accompanying materials for this are also in development. Once the COPD subgroup has met, data should be reviewed by GMMMG so any variation can be highlighted and tackled locally. AI agreed to share these with community pharmacy so they could access these pathways. Mental Health CQUIN Shared Care PB presented a paper on work done so far on the shared care CQUIN for antipsychotics and physical health. This was a good summary of the work that had been carried out over the last year. It also outlined the challenges that lay ahead. It was noted that BB shared care CQUIN pharmacist will be finishing this role in June. There was therefore only one month left of the project. It was agreed that BB should pull together some ideas around feed back to HCDSG and request a quarterly report on biosimilar uptake/impleme ntation. ACTION: Antibiotics to be tabled at a future meeting for further discussion. ACTION: BB to scope other ideas of what mental health areas GMMMG could focus on. 6

what could be done within mental health other than shared care. There were some suggestions around antipsychotics in dementia and in LD as per the national call to actions. It was agreed that these should be scoped. GMMMG could monitor the actions on shared care however the majority of these issues (e.g. 12 week transfer pathway, funding etc.) need to be tackled locally by CCG commissioners so not much more could be done at present as this will take some time. Requesting of Shared Care RD also raised the issue around shared care and acceptance of shared care by GP s. Within the updated standard NHS contract, there is clear guidance that hospitals must only initiate shared care arrangements where the patient s GP is content to accept the transfer of responsibility i.e. the opt-in option in last year s consultation. This will start from April. Post meeting note for information: Link to the Standard Contract: https://www.england.nhs.uk/wp-content/uploads/2016/11/2-service-condit ions-fl.pdf and the relevant section 11.4 is on page 13. In addition the BMA has produced a series of template letters for GPs to send out in the event of them identifying instances where hospitals have not implemented this year s changes to the Contract including when they have been asked to prescribe without proper communication and there is therefore a possibility that both Commissioners and Providers may soon be receiving these from GPs. All BMA materials may be found linked from this webpage: https://www.bma.org.uk/collective-voice/committees/general-practitioners -committee/gpc-current-issues/nhs-england-standard-hospital-contract-g uidance-2017-2019 3 Subgroup Reports 3.1 Formulary and Managed Entry Subgroup (FMESG) BR and AM gave the group an overview of the 2 nd meeting of the group. The group then approved the items for ratification as below: Chapter 2 of the formulary will be amended to include a link to the PCSK9 recommendation for hypercholesterolaemia. Rosuvastatin will be added to the formulary as an alternative statin (Green RAG status) in line with the PCSK9 recommendation. It was noted that the patent for rosuvastatin will expire in December of this year. Eyelid cleansing preparations were added to the DNP list. The following RAG status decisions were approved: imiquimod for AK (green) and imiquimod for genital warts (green specialist initiation) A statement for inclusion on top of the RAG list regarding all NHS England commissioned services was approved. Ticagrelor and NICE TA420 summary for prescribers. This information had been drafted to aid prescribers and CCGs in implementing the NICE TA. The shared service agreed to set up a MiQuest query with specific search criteria that CCGs could use to identify patients that may be suitable for ticagrelor. CCGs raised the issue of needing further implementation tools to implement this contact NICE re: Implementation tools for TA 420. 7

guidance. BR agreed to contact NICE to enquire as to whether they planned on developing anything as the summary was in response to the NICE TA. Further implementation guidance was not part of the subgroups remit and so wasn t discussed by them. 3.2 The Pathways and Guidelines Development Group (PaGDSG) It was noted that there wasn t a member from the group available to feedback. Therefore in the absence of a subgroup member BR fedback on behalf of the group. Feedback was based on the report produced for the meeting. The group is still seeking a commissioner. It was suggested that if JM is attending high cost drugs then DD (Stockport) may be able to attend pathways instead. JM stated that currently they were alternating meetings as the HCDSG is meeting monthly, at least initially. GMMMG noted the minutes, update of the meetings and current work plan of the group. The following items were ratified: LHRH Analogues for Prostate Cancer. Gender Dysphoria supporting information it was requested that a statement should be included to say that this applies to NHS England funded patients only. It was also noted that an SCP is available so a link to this should be included. Asthma Management Plan for Adult patients. An accompanying inhaler guide is in production. 3.3 High Cost Drugs Subgroup In the absence of any group members BR fed back on the HCDSG. The group did not meet in March but were due to meet next week. The following items had been discussed by the group in February: Development of a process for the approval of Blueteq forms, this process is currently being trialed with the recent GM consultation for Blueteq forms for Adalimumab, Golimumab, Infliximab and Vedolizumab for UC and CD Scoping of the Homecare service provision across GM High Cost Drug Challenge Process and reporting Changes in commissioning arrangements of PBRE drugs Horizon scanning and financial planning for new high cost drugs. 4 Reports from Associated Committees 4.1 The Chair asked for important items to be raised under this agenda item as there was limited time remaining: The following items were discussed: Mental Health PB fed back that as discussed earlier the CQUIN is now coming to an end and BB would be moving on to other work. It had been suggested that individual CCGs speak to individual providers to tackle the issues raised however this would lead to variation in provision. Several recommendations on what work needs to take place following this project were outlined in the paper that had been drafted. This would need escalating to CCGs via AGG. AW indicated that he would be taking this to AGG is an example of variation in the system that needs tackling. 8

Local Professional Network. The GM H&SCP Pharmacy strategy had been shared with group members for information only. 6 AOB Purdah The group discussed the NHS guidance on Purdah and fact that they GM mayoral election was due soon, as was the general election. It was agreed that a statement would go on the website and only general updates or clinical guidelines would be published in the meantime. The next GMMMG is not till after the election anyway so the agenda and minutes wouldn t go on the website until then. Staff within GM will continue to receive documents via the password protected section of the website or via email. Meeting Frequency/Length The group also discussed the length of the meetings as now that meetings were bi monthly they do tend to run over. BR stated that the room was booked until 3.30pm so there was the facility to extend the meetings if required. HB suggested that monthly meetings may be necessary however members felt that this wasn t required. It was however agreed that as work was needed on the strategy a task and finish group meeting to discuss the GM strategy and GMMMG re-development should be arranged for next month. send out dates for task and finish strategy meeting in May. GMMMG Subgroups HB noted that the transition to the new subgroups had gone well and mostly seamlessly; she thanked everyone involved for ensuring a smooth transition and for getting the new subgroups up and running. 7 Items for Information 7.1 Date, time and venue of next meeting Meetings are bi-monthly and next meeting is: 15 th June Thursday 2017 1-3pm. Salford Suite, St James House, Salford. 9