Quality and Safety Committee

Betsi Cadwaladr University Health Board Committee Paper 4.10.12 Item QS12/105 Name of Committee: Subject: Summary or Issues of Significance Quality and Safety Committee BCUHB Controlled Drugs Local Intelligence Network (LIN) Annual Report 2011-12 Summary of Report This report provides the Board with information regarding the role and responsibilities of the controlled drug Accountable Officer, Anne Bithell, as specified under the Health Act 2006 and Regulation 4 of the Controlled Drugs (Supervision of Management and Use) Regulations 2006. The report provides an update on the key activities relating to the safer management of controlled drugs undertaken in 2011-12 and those anticipated for 2012-13. Assessment: Overall *RAG status against Group s annual objectives / plan: Amber Strategic Theme / Priority / Values addressed by this paper Healthcare Standard addressed Equality Impact Assessment(EqIA) The report will provide oversight, scrutiny and a governance function in relation to the safe management of Controlled Drugs across North Wales. Standard 15 of the Healthcare Standards for Wales is relevant to the management of controlled drugs. Not applicable Recommendations: 1. The Committee is asked to RECEIVE and APPROVE this annual report. 2. The Committee is asked to NOTE the significant amount of work that has been undertaken in relation to controlled drugs during 2011-12. 3. It is RECOMMENDED that the Committee know that the organisation is fulfilling its responsibility in relation to controlled drugs. An action plan is place to further strengthen implementation of the Author(s) Presented by Anne Bithell, Susan Murphy, and Ruth Daniels Susan Murphy Date of report July 2012 Date of meeting 4 th October 2012 BCUHB Committee Coversheet v5.02 Page 1 of 6

BCUHB Controlled Drugs Local Intelligence Network (LIN) Annual Report 11-12 Final 1 Title of Group: BCUHB Controlled Drugs Local Intelligence Network (LIN) 2 Name and role of person submitting this report: Anne Bithell, Chief of Staff Pharmacy and Medicines Management CPG who is the BCUHB Accountable Officer for Controlled Drugs. The Accountable Officer This is the person in a healthcare organisation who takes formal responsibility for all Controlled Drug handling and governance issues in their organisation. This is a requirement under the Health Act 2006. Details of the role are set out in the Controlled Drugs (Supervision of Management and Use) Regulations 2006 3 Dates covered by this report: April 2011 to March 2012 4 Number of times Group met during the year: The Group met 4 times over the year. 5 Assurance/s this Group is designed to provide: The Group will undertake and provide oversight, scrutiny and a governance function in relation to the safe management of Controlled Drugs across North Wales. Background The Government s response to the Fourth Shipman Inquiry report included new legislation and regulations to tighten governance of CDs which are predominately narcotics with potential for abuse (such as morphine) in the community. At national level, in Wales, the new arrangements are subject to external scrutiny by Health Inspectorate Wales (HIW). HIW will ensure that local governance arrangements, intelligence networks and provisions for incident panels are satisfactory. Where appropriate HIW will use its existing powers to inspect or investigate systems failures, or registration issues in the private and voluntary sector. HIW will monitor national trends and innovation in the management of controlled drugs, publish its findings and promote improvement. 6 Overall *RAG status against Group s annual objectives / plan: Amber 7 Main tasks completed / evidence considered by the Group during this reporting period: The Local Intelligence Network (LIN) has continued to meet on a quarterly basis, led by the BCUHB Accountable Officer, with representation from the NHS and private healthcare providers, including hospitals, primary care independent contractors; CSSIW, WAST and HIW. The key purpose of the LIN is to share information about the use of CDs and about individuals who give cause for concern. Where several agencies are concerned, the LHB Accountable Officer may consider setting up an Incident Panel of relevant agencies or individuals to consider specific serious concerns. Each agency will retain responsibility for taking appropriate action where required. See Appendix One for LIN membership. The process has been maintained for the Accountable Officer to receive Occurrence Reports from Non NHS organisations on a quarterly basis, which are reviewed at the LIN meetings. An annual declaration and self assessment was completed by GPs and Dentists in 2011-12. This information has been used in the risk assessment process prior to clinical governance visits to contractors. Across North Wales, members of the Pharmacy and Medicines Management CPG have received training as Authorised Witnesses for the destruction of Controlled Drugs and been approved to destroy wasted medication as required. A database has been established to monitor which drugs and what quantities are destroyed. Appendix Two. Incidents and significant events have been recorded and managed using the BCUHB Datix system. Independent contractors and care homes have continued to use the legacy systems up to March 2012 (electronic or paper) until they are able to access the new Datix system. Page 2 of 6V1 2

Monitoring of Schedule 2 Controlled Drug prescriptions via on line CASPA on a monthly basis has been established in each area across N Wales. This includes mostly injectable Controlled Drugs. Each prescription is reviewed for legality, clinical appropriateness and unusual patterns of prescribing. It is a statutory requirement to keep monitoring records for seven years. 8 Main action plan themes / tasks due for completion in forthcoming year (12-13): Standard Operating Procedures (SOPs) for the management of Controlled Drugs by contractors are expired and need updating. The BCUHB Hospitals Medicines Code will be extended over time to incorporate independent contractor issues. An annual declaration and self assessment is required by primary care independent contractors in 2012-13. Community pharmacy contractors will be included in this process if Controlled Drugs are not included in the All Wales Clinical Governance Practice Self Assessment. Schedule 2 (non-injectable formulations), and Schedules 3, 4 and 5 Controlled Drug prescriptions are monitored quarterly as a minimum via on line CASPA in each area across N Wales. Due to the number of drugs to be reviewed a targeted approach has been agreed. Reviewers look at the prescribing data and bench mark to identify high prescribing. Individual drugs are then reviewed in depth. Each prescription is reviewed for legality, clinical appropriateness and unusual patterns of prescribing. It is a statutory requirement to keep monitoring records for seven years. A process to manage escalation of any concerns needs to be established. Establishment of systematic monitoring of Controlled Drug usage is required for this year to fully comply with the new legislation. It is anticipated that an All Wales approach with national IT support is being taken forward in the near future. To establish a uniform system across North Wales of recording and investigation of concerns related to Controlled Drugs in partnership with the clinical governance teams across BCUHB. The electronic Datix system has been rolled out to GP practices and this will capture concerns around Controlled Drugs. A paper reporting system will be continued for other contractors who do not have access to web based reporting. To ensure that the safer management of Controlled Drugs is included in the monitoring visits undertaken for primary care independent contractors. Additional adhoc visits will be undertaken when Controlled Drug incidents arise. To ensure risk registers for individual CPGs and where appropriate corporate functions include assessment of CD risk. 9. If appropriate, have these new risks been escalated as an issue of significance, or to the relevant Chief of Staff for consideration? Yes 10 Further comments: An action plan has been developed to progress out standing issues. See Appendix Three. *Key: Red = not on target to achieve all actions, and may not achieve these actions by the next quarter Amber = not on target to achieve all actions, but has plans in place to see these actions achieved by the next quarter Green = on target to achieve all actions Page 3 of 6V1 3

Appendix One Controlled Drugs Local Intelligence Network MEMBERSHIP Membership will include, but will not be limited to: Accountable Officer (Chair) - BCUHB Assistant Medical Director, Primary Care (Deputy chair) Associate Chief of Staff (Nursing) - BCUHB Locality Lead for Medicine Management (East) - BCUHB Locality Lead for Medicines Management (Central) - BCUHB Locality Lead for Medicine Management (West) - BCUHB Hospital Operations Lead BCUHB (This may become the Governance Lead Tier 5) Head of Clinical Governance, Quality & Improvement PCSU Controlled Drugs and Chemical Liaison Officer North Wales Police BCUHB/BSC Head of Counter Fraud Officer Care and Social Services Inspectorate Wales representative - CSSIW Professional Standards Inspector, General Pharmaceutical Council Health Inspectorate Wales Independent hospitals and hospices representative Local Authority Representative Substance Misuse Action Team representative Welsh Ambulance Services Trust representative Admin support - BCUHB Page 4 of 6V1 4

Appendix 2- Authorised Witnesses for the destruction of Controlled Drugs in North Wales Name Base Name Base Anglesey YG Dewi Morris Anglesey Ian Baker YG Conwy Alison Jones YG Trudy Anderton Conwy Christina McCrea YG Gill Boothman Conwy Alan Hughes WMH Teresa Bushell Conwy YGC Olga Forsyth Conwy Jane Dawson YGC Amanda Hughes Conwy Lis Dubourg YGC Susan Murphy Conwy Penny Evans YGC Joy Stagg Conwy Wendy Mailer YGC Rory Wilkinson Conwy Richard Wynne YGC Fiona Jones Conwy Eryri Ysbyty Denbighshire Danielle Lewis Eryri Julia Blakeman Denbighshire Vicky Clayton Denbighshire Joanne Dudley Denbighshire Bill Duffield Denbighshire Jacqueline Duffield Denbighshire Nick Lloyd Denbighshire Helen Markey Denbighshire Claire Spencer Denbighshire Flintshire Jo-ann Bradley Flintshire Simon Gill Flintshire Trevor Hinstridge Flintshire Sarah Ferguson Flintshire Sarah Jones Flintshire Ann-Marie Brund Flintshire Gwynedd Teena Grenier Gwynedd Bethan Pritchard Gwynedd Melissa Roberts Gwynedd WMH Helen Dickin WMH Pat Dunning WMH Marie Hampson WMH Brenda Haymer WMH Wrexham Liz Davies Wrexham Rob Davies Wrexham Dave Etchells Wrexham Ann Gaulton Wrexham Louise Howard- Baker Wrexham Sue Lord Wrexham Ruth Owen Wrexham Sue Randles Wrexham Alison Coats Wrexham Page 5 of 6V1 5

Appendix 3 - Controlled drug work plan July 2012 Action required Target date Responsible officer Progress Appointment of accountable officer MB Complete 1. Development of a North Wales Local Intelligence Network Facilitate quarterly meetings On going AB/SM Complete Information sharing 2. Set up process for occurrence reports from Non NHS organisations On going SM/EP Complete 3. Update template SOPs for primary contractors for 2012-13 Dec 2012 SM TH Ali-H 4. Development of a medicines policy for all BCUHB April 2013 Al-H 5. Develop, disseminate and Annual declaration for contractors 2012-13 GPs and dispensing doctors Dentists Community pharmacists (if necessary) 6. Destruction of controlled drugs Training and updates Establish a BCUHB register of authorised witnesses and when update is due Establish process for contractors and record wastage Contribute to All Wales standards March 2012 On going SM TH Ali-H SM/JR SM/admin 7. Primary care contractor monitoring visits On going RD Head of CG PCSU 8. Controlled drug monitoring of CASPA data On going SM TH Ali-H Al-H Identify staff to support Dec 2012 SM TH Ali-H Al-H Local monitoring agree an SOP final draft Complete SM TH Ali-H National support 9. Annual report for the BCUB Board 2011-12 Presentation to DTg and the Quality and Safety committee 10. Recording and investigation of concerns Roll out of Datix across CPGs and corporate service functions. Development of escalation of concerns with controlled drugs, utilising the Datix report system 11. Development of risk register for controlled drugs within each CPG and corporate department within BCUHB 12. Communication AO and contact process Sharing learning from concerns Sept 2012 AB November 2012 November 2012 AB/RD/SM AB/RD/SM On going AB/SM Complete Complete Page 6 of 6V1 6