South East London Area Prescribing Committee (APC) 26 January 2016 at Tooley Street 1. Welcome, and Introductions Approved minutes 2. Conflicts of Interest declarations The Chair requested any interests relating to the meeting agenda be declared. There were no declarations noted. Members were reminded of the need to submit up to date declarations of interest. 3. Minutes, action log and attendance list of Last Meeting and Matters Arising. The minutes of the October meeting were accepted as accurate. 4. Matters Arising IBD monitoring framework has been embedded in the contract monitoring arrangements for NHS Lambeth, NHS Southwark and NHS Bromley with King s College Hospital (KCH) and Guy s and St Thomas s (GSTfT). 5. Pathway updates Ophthalmology More time for consultation and further investigation into costs and local commissioning variations is required. The Commissioning Support Unit representative is to meet with Medicines Management CCG leads and the outcome will be fed back via the Ophthalmology group. Psoriasis The dermatology specialists are due to meet in the next two weeks and this will be followed up by a meeting of the full pathway development group in March 2016. The committee was asked to note that the existing Lambeth guidance has been well received by the group. 6. NICE guideline on Medicines Optimisation and baseline assessment The baseline assessments for each organisation across SEL have been collated and rag rated. The main outcome is to confirm there is a good system of reporting errors/safety issues in secondary care organisations. However there is no one good mechanism for reporting in primary care. The committee discussed the National Reporting and Learning system (NRLS) but felt this was not fully utilised by general practice. Various options to improve the situation were discussed including: Sharing of the monthly GSTfT Medicines Information newsletter with primary care Attendance at acute trust Medicines Safety Forums (already in place in some CCGs) Reporting safety issues via the yellow card system Nhs.net email accounts for community pharmacies The committee discussed various local processes and schemes which have raised awareness of safety issues but agreed this is a concern in primary care due to the voluntary nature of reporting and variation in reporting systems..
ACTION: Chair to raise lack of potential improvements in reporting processes in primary care with Care Quality Commission (CQC) Inspector of General Practice 7. South East London Interface Policy and NHS and Private Interface Prescribing Guide i. Interface Policy The policy has been updated in line with comments received and the committee approved the revision. ii. NHS and Private Interface Prescribing Guide The following amendments were agreed: Page 1 section 2 add for the same condition Appendix 2 amend wording to You will always be required to pay for the first private prescription from your consultant while your GP considers if continuing the prescriptions on the NHS would be appropriate. The committee noted that the letter to the consultant should also be seen by the patient and that guidance on prescribing outside of the formulary should be strengthened, both in the letter and section 3.7. ACTION: Author to revise in line with discussion and policies to be sent for Chair s action to ratification. 8. SEL APC Terms of Reference The terms of reference are due for annual review and have been discussed at the January NDP meeting. The committee was asked to focus on the declaration of interests (DOI) process in particular, considering the following questions: How often should the DoI form be completed and how should DoIs be updated through the year? Annually in line with the financial year. How far back should the DoI go? Currently the previous 12 months is requested is this sufficient? How far back should the Register of Interests cover? 2 years maximum How detailed should the DoI record be? For example: Dates of the meetings attended Should the actual payment made for each also be declared? The committee felt the level of detail on the current form is enough. Where members declare an interest it should be at the Chair s discretion as to whether further detail is necessary. How should DoI for new members joining part way through the year be recorded? New members will be required to complete a declaration on joining and will then join the rolling programme. How should DoI for those in attendance at the meetings be recorded? Submitted DOIs should be summarised by the Business Support Officer and the summary presented at each meeting. Attendees to sign the summary to confirm that the details held are correct and update as necessary. How should DoI for pathways/sub-groups be recorded? The DOI process for pathway groups should align with the APC/NDP process.
What process should be used for members/participants failing to complete their DoI by specified deadlines? If members fail to respond by the initial deadline they should receive 2 email reminders one week apart, followed by a letter from the Chair. Failure to respond at this stage will result in a sanction banning the individual from attending committee meetings. Hard copies will also be provided at meetings and the Chair updated on failure to submit. In the case of applicants for drug submissions it was agreed that the formulary submission form will be revised to include the DOI and submissions will not be heard unless this has been fully completed by the applicant(s). What should the process be if a member makes a declaration in a meeting? Should they remain part of the discussions? Can they remain in the meeting room and hear the discussions but not contribute to them? Should they leave the room whilst the decision is made? It will be the responsibility of the Chair to decide the appropriate process on a case by case basis. Should the register of DoIs be noted at regular intervals at NDP meetings (eg quarterly)? This is covered by the summary to be presented at each meeting Should all DoI forms be signed or is email acceptable? DOIs sent from the individual s nhs.net mail account will be accepted as signed. Any further comments on the TOR should be directed to the APC Support Pharmacist. ACTION: APC Support Pharmacist to update the TOR in line with discussions. 9. Horizon scanning new drugs and indications for 16/17 The GSTfT Medicines Information representative presented a summary of horizon scanning of CCG commissioned drugs for 2016/17. The key points were: IBD drugs increased use of biosimilars and more patients treated in optimally in primary care Lipid modification drugs carry a high financial risk for 2016/17due to the NICE guideline issued in July 2014. Heart failure carries a moderate to high financial risk Licensed medicinal e-cigarettes carry a high financial risk, with the potential to increase prescribing costs by 1.1m per 100,000 population per year, if a health economy accepts that these are prescribable. House dust mite allergen immunotherapy is anticipated to be licensed in the uk in 2016. Anticipated costs would be 200,000 per 100,000 population and it is expected to be tariff included. IF pregabalin generic become available with the full set of licensed indications, and this leads to a 70% decrease in the Drug Tariff cost for generic this would decrease prescribing costs by 317,000 per 100,000 population assuming that the NHS in England currently spends about 240m on this medicine. Diabetes drugs carry a high financial risk following the release of new NICE guidance. The availability of biosimilar insulin glargine may mitigate this anticipated increase to an extent. SEL guidance on diabetes will be developed in 2016/17. Insulin pump use
has the potential to increase and is tariff excluded meaning local funding decisions will need to be made. Macular oedema has a high financial risk with treatment with both aflibercept and dexamethasone implants for DMO having a significant cost impact. The SEL Ophthalmology pathway is in development and it is recommended that a local formulary is agreed for ophthalmology specials. 10. Are there any quality focused areas that the APC can work on collaboratively in 16/17? It was suggested the SEL APC focus on an antibiotic stewardship campaign for distribution in autumn 2016. The focus of the campaign would be on targeting the message appropriately, using existing materials and covering all parts of the system. The Communications team would cost out and map the campaign. It was suggested a task and finish group be set up, led by a microbiologist. It was suggested the director of the Hurley Group and A&E consultants be invited to participate. The Lewisham GP representative volunteered to lead on setting up the group. The GSTfT clinical representative will talk to the relevant colleagues re microbiologist representation on the group. ACTION: Task and Finish Group to be set up Lewisham CCG to lead 11. Antipsychotics in patients with learning disabilities (LD) SLAM and Oxleas representatives delivered a presentation on the use of antipsychotics in patients with learning disabilities. The key points were: Oxleas Prevalence (in Oxleas) of antipsychotic prescribing for people with LD is low Indications for such treatment are clearly documented in the majority of cases, and most patients are reviewed annually Few prescriptions (in Oxleas) are for the management of aggressive behaviour which suggests that other strategies are put in place and are effective. Monitoring of EPS and metabolic parameters is good (in relative terms) but still some way short of the audit standard (absolute terms) Findings discussed by LD services with a focus on regular assessment of side effects There are practical barriers associated with phlebotomy in the Greenwich LD team and interface issues with the pathology system in both Bexley and Greenwich. Action plans focus on these areas. SLAM Around half patients in sample were prescribed an antipsychotic Indication for prescription was noted for all patients Testing for extrapyramidal side effects (EPS) and metabolic testing were not evident for all patients Plasma glucose and lipid testing was more evident in SLAM than nationally. We suspect that assessments (BP, weight) documented on paper MEWS charts are not recorded in epjs. MEWS not checked for audit Results have been discussed with the LD clinical governance group and leads. A quality improvement plan (QIP) is in place to improve practice across trust LD services. Started November 2015
Pharmacy has completed a QIP aimed at improving EPS monitoring. Completed December 2015 Electronic MEWS currently being discussed in trust CQC reported SLAM LD services to be outstanding 12. Items for information/ratification i. New/revised formulary recommendations and position statements a. New recommendations 38-43 b. Revised recommendations 10 and 24 c. Position statement 002 ii. Shared care guideline: Disease Modifying Anti-rheumatic Drugs (DMARDs): Azathioprine, Hydroxychloroquine, Leflunomide, Methotrexate, Mycophenolate and Sulfasalazine for the treatment of autoimmune rheumatic diseases in Adults VB declared attendance at RA advisory boards (see submitted declaration for details) iii. Shared care guideline: Nebulised mucolytic and antibiotic solutions for the treatment of Cystic Fibrosis in existing patients only iv. Over Active Bladder (OAB) Care Pathway for adults in primary care v. Treatment pathway for chronic constipation in adults vi. Pharmacological Management of Neuropathic Pain in Adults Review date to be amended to 6 months (May 2016) vii. Rheumatoid Arthritis Biologic Drug Treatment Pathway The committee noted that section numbers on page 8 of the pathway have been amended to align with the revision. The pathway was ratified. viii. ix. Seronegative Spondyloarthropathy Biologic Drug Treatment Pathway South East London Responsible Respiratory Prescribing Group (SEL RRP) Terms of Reference x. New Drugs Panel minutes Sept-Nov 2015 xi. NICE Technology Appraisal Guidance Summary xii. Correspondence to Bromley CCG/Bromley Healthcare/Greenwich CCG re administration of depot injections by nurses xiii. Correspondence to SLAM/KCH/Lambeth Council re treatment pathway for drugs used in alcohol dependence All items were noted/ratified as required. 13. AOB BNF errors: the committee was asked to note there are a number of dosing errors in the paper version of BNF70. A cover sheet is to be issued detailing the errors. In the interim members were advised to consult the digital copy of the BNF which is correct. The BNF app is also correct. Public health has informed the Chair they will not be sending a representative to APC on a regular basis. They will attend only if invited for a specific item on the agenda or if an item is of interest to PH. 2016 meetings: Thursday 24 March 2016 2.00pm-4.00pm Room 407, 1 Lower Marsh Thursday 23 June 2016 2.00pm-4.00pm Room 407, 1 Lower Marsh Thursday 13 October 2016 2.00pm-4.00pm Room 407, 1 Lower Marsh