Attachment 1 POWYS TEACHING HEALTH BOARD

PRIMARY CARE PRESCRIBING & THERAPEUTICS COMMITTEE PRESCRIBING & THERAPEUTICS COMMITTEE

Minutes of the joint meeting held on Tuesday, 05 March 2013 at 9:30am in Caer Beris Manor Hotel, Builth Wells

Present: Consultant, Care of the Elderly, Powys tHB (Chair) Head of Pharmacy & R&D, Powys tHB Dr Brendan Lloyd, Medical Director, Powys tHB Prescribing Lead, Builth Practice LES Pharmacist, Newtown Practice Technician, Llanfyllin Practice Prescribing Lead, Llanfyllin Practice LES Pharmacist, Llandrindod Wells and Rhayader Practices Prescribing Lead, Knighton Practice , LES Pharmacist, Llanidloes Practice Prescribing Lead, Cemmaes Road Practice , LES Pharmacist, Machynlleth and Cemmaes Road Practices LES Pharmacist, Brecon Practice Prescribing Lead, Brecon Practice Prescribing Lead, Haygarth Practice Medicines Management Pharmacist, Powys tHB , Medicines Management Pharmacist, Powys tHB Medicines Management Pharmacist, Powys tHB , Medicines Management Technician, Powys tHB Medicines Management Technician, Powys tHB , Pharmacist, Nevill Hall Hospital , Technician, Welshpool Medical Practice LES Pharmacist, Builth, Ystradgynlais and Crickhowell Practices , GP, Ystradgynlais Practice Prescribing Lead, Presteigne Practice Prescribing Lead, Welshpool Practice , Prescribing Lead, Rhayader Practice GP, Montgomery Practice , Prescribing Lead, Llandrindod Wells Practice , Prescribing Lead, Llanfair Caereinion Practice LES Pharmacist, Haygarth Practice LES Pharmacist, Knighton and Presteigne Practices , Prescribing Lead, Machynlleth Practice , Chief Pharmacist, Bronglais Hospital Brecknock & Radnor CHC Representative

Page 1 of 10 J:\Information_Governance\FOI\FOI requests\FOI - received\2015\15.R.005 Medicines Management\Att 1 Primary Care Joint Minutes 050313.doc Attachment 1 In Attendance: Jackie Jones, Medicines Management Secretary, Powys tHB (minute taking)

Item Note Action 1 Welcome and Apologies welcomed those present and members introduced themselves. Apologies were received from , Prescribing Lead, Llanidloes Practice; , Medicines Management Nurse, Powys tHB; , Prescribing Lead, Newtown Practice; , Prescribing Lead, Crickhowell Practice; Technician, Montgomery Practice; and , Pharmacy Manager, Nevill Hall Hospital ( representing). 2 Structure of the Committee and way forward The Medicines Management Team had received an audit visit from the Welsh Audit Office and will get feedback from them later this year, one aspect of which will be this committee. It had been noted that members do not hear much in-between meetings and it was suggested that more could be done between meetings. Members need to think about how documents are approved and asked those present for their comments. Upon investigation, it appears that this committee is rather large compared to equivalent committees in other Health Boards. It was queried whether some items usually dealt with by this committee should go to locality meetings, as the work of this committee impacted on work within the localities. stressed that this particular meeting worked well and represented a democratic environment. However, thought that there was a need to determine some performance outcomes. Agreement regarding prescribing was very important on a wider level and may not work at a locality level. indicated that also at this meeting, clinicians were present which was very helpful in decision making. asked if figures were available to indicate that the committee’s work was reaping rewards. BL indicated that there was strong evidence that the group was working well, as part of the medicines management process. suggested that no decision be made with regard to the meeting until feedback from WAO has been received and reported back to members. In the meantime, suggested that some documents could be approved by a group made up of certain members of the committee, which could then be presented to the quarterly meetings for information. indicated that for certain formulary items it would be good to know of members’ specialties and a sub-group could be formed to approve such items in between full meetings. BL suggested formulating a WIKI to support the process and reduce the need

Page 2 of 10 J:\Information_Governance\FOI\FOI requests\FOI - received\2015\15.R.005 Medicines Management\Att 1 Primary Care Joint Minutes 050313.doc Attachment 1 to physically meet as a sub-group. However, it was mentioned that some GPs may have trouble accessing a WIKI. indicated that the main meetings were good for information for pharmacists, as anything agreed on a locality level was not reported back to pharmacists. BL stressed the importance of sending a message to localities to enable pharmacists to access such information.

indicated that there was a need to get an agreement for the whole of Powys regarding prescribing to reduce unhelpful variation. agreed, indicating the need for an overview of evidence based guidance. BL stressed the importance of having a clear message of quality perspectives for all of Powys. noted that there are individual needs in each locality. BL agreed there could be some appropriate reasons for variations in prescribing, but stressed the need to have Powys wide quality and central expertise.

After further discussion it was AGREED that would send out an email asking for expressions of interest for GPs with specialist interest to work on formulary chapters. 3 Minutes of the joint meeting held on 04 December 2012 wished to see the minutes amended to reflect the view that errors may have resulted from patients prescribed normal release Sinemet being inadvertently switched to the controlled release preparation. It was questioned if this was due to errors in drug selection on GP prescribing systems, and could anything be done to assist with this.

Subject to this amendment, the minutes were AGREED as a correct record. 4 Matters arising from the minutes of the joint meeting held on 04 December 2012 is carrying out ongoing work on mental health prescribing in children. She will update members on progress soon. Sinemet –Following on from comments in 3 above, indicated that it was easy for people to get switched either direction and there was a need to be vigilant. Psoriasis – enquired on progress since the last meeting. BL indicated that a meeting had taken place and further meetings could take place in the mid and south locality, but not in the north. asked if there was anything further to report on erectile dysfunction. reported instances of one patient getting treatment and perhaps the next door neighbour being refused treatment because the new guidelines do not allow GPs to

Page 3 of 10 J:\Information_Governance\FOI\FOI requests\FOI - received\2015\15.R.005 Medicines Management\Att 1 Primary Care Joint Minutes 050313.doc Attachment 1 prescribe for severe distress. Members discussed this and it was AGREED that they could prescribe for severe distress and Medicines Management would prepare guidelines and a definition of what constitutes severe distress, also which drugs to prescribe.

Emergency Ward Boxes review – reported that this would be discussed at the Resuscitation Committee meeting and she would report back any agreements at the next meeting in June.

Warfarin – indicated that the pathway was to be presented at a north locality meeting by . BL indicated that he had hoped that would have been able to report. He stressed the need to have a Powys policy for warfarin usage. indicated that he had encountered situations where patients had been discharged from hospital and GPs were expected to pick this up without knowledge of what medication patients were discharged on. asked to send details, which will do.

There were no other matters arising. 5 Shared Care (a) NPT Drugs – Azathioprine, Leflunomide, Ciclosporin indicated that the document presented did not contain these drugs but nothing had changed from the GP point of view. However, they would be included in the LES and Shared Care produced for them. 6 Regular Updates: (a) AOF/AQS gave a powerpoint presentation on indicators (AWMSG national indicators). These were for the December 2012 Quarter, which included the following: Top 9 Antibacterial usage. Top 9 antibiotic changes – some practices showed improvement. Co-amoxiclav Ibuprofen and Naproxen - Powys is in the middle for NSAID usage for Wales as a whole. stressed the importance of using the safest NSAID. Hypnotics & anxiolytics – Overall usage in Powys is decreasing. mentioned that there were two consultants using Dosulepin – BL would investigate. Statin usage – Llanidloes was doing particularly well.

(b) ScriptSwitch There was no update on ScriptSwitch.

Page 4 of 10 J:\Information_Governance\FOI\FOI requests\FOI - received\2015\15.R.005 Medicines Management\Att 1 Primary Care Joint Minutes 050313.doc Attachment 1 (c) Community Pharmacy informed those present that the total flu vaccination numbers were quite low (34 vaccinations to date). The most successful was the service within a supermarket. The Welsh Government was looking to extend the services. was liaising with Public Health on the way forward. Gluten free – indicated that consideration was being given to the scheme based in Cardiff & Vale, as it seemed to be simple, fair and cost-effective. EHC in pharmacies – there will only be Levonelle supplied, not Ella One. However, feedback showed a strong case for using Ella One. asked for this to be fed back to Welsh Government and could we have a LES including Ella One to run alongside. Minor Ailments – Powys had not been chosen as a pilot site because it is not thought to be large enough, i.e. pharmacies nationally will be included in a pilot, with a view to rolling out in 2014/15, probably 2016 for Powys.

(d) Q&E Update (i) Corticosteroid Audit. gave a powerpoint presentation. The LES pharmacists would meet after this meeting asked for a flowchart to be devised regarding the use of bisphosphonates and indicated that there was a good American one available. , agreed to be part of a working group to produce guidelines. suggested getting to give a talk at a meeting. However, has now taken over, as has retired. Members NOTED the information on the summary sheet. (ii) Changes to Quality & Effectiveness Scheme. gave a powerpoint presentation showing changes to the scheme. There are imminent changes for the year 2013/14. indicated that it would be a good idea to have a strategic focus for the next year and have defined roles and responsibilities. Pharmacists would now need to sign up to the scheme, as part of the governance arrangements. explained that part of the work for next year would be looking at national and local indicators. Discussions ensued about Morphgesic, which along with Zomorph, is included in the All Wales Palliative Care Pathway. Should this have been a formulary submission? Some concerns were raised over effects on dispensing profits. indicated that there could be

Page 5 of 10 J:\Information_Governance\FOI\FOI requests\FOI - received\2015\15.R.005 Medicines Management\Att 1 Primary Care Joint Minutes 050313.doc Attachment 1 delays in obtaining it, as not all pharmacies stocked morphogesic. went on to explain that QRS payments will depend on scores achieved for reaching targets. suggested trying this for the next year and see how things progress. indicated that it was getting more difficult to calculate cost-effectiveness, as much good work had already been carried out. gave options for the future, which included advantages and disadvantages. The options were: stopping altogether; continuing; modify the scheme; or re- engineer the scheme. asked for members’ views. Suggestions included: • Practices doing individual audits. • Going into patients’ home and do medicines optimisation reviews. indicated that the MMT were developing supporting information for this, to ensure safety of all concerned. • Doing different things practice by practice, identified by individual practices. • Allow time past audit to implement change. • Audits need to be more holistic. • Need to have workplan for next 3-6 months.

asked all those present to think on this further and let the MMT know of any suggestions.

(e) Adverse Reactions/Significant Events (i) Simvastatin and Clarithromycin Interaction indicated that an interaction had lead to the death of a patient in Shropshire. It was important that when a patient is taking Clarithromycin, statin usage must stop. This may also be duration related. The death was reported to the Shropcoc Hub. asked if the situation had been extensively investigated. stressed the need for this to be flagged up within community hospitals, i.e. instructions on the pack. also suggested that community pharmacies and Shropdoc could ensure warnings were clearly visible on packs.

(f) Horizon Scanning & Drug Safety went through the paper presented. The pointed out that Tredaptive no longer has a licence, so stressed it was not to be prescribed. also pointed out various new products and a new diabetes drug, which NICE provisionally does not recommend, but is requesting

Page 6 of 10 J:\Information_Governance\FOI\FOI requests\FOI - received\2015\15.R.005 Medicines Management\Att 1 Primary Care Joint Minutes 050313.doc Attachment 1 updated costings from the manufacturers.

(g) NICE Updates Included in (f) above.

There were no more regular updates. 7 Formulary: (a) Application for Flutiform gave a powerpoint presentation outlining advantages and disadvantages for using Flutiform. After an extensive discussion, it was AGREED not to add Flutiform to the formulary because of the limited licence for Flutiform, short-term trials showing non-inferiority and the fact that Seretide patent is due to expire (although a generic may be some time off). Therefore, Flutiform does not offer any additional benefit to the three combination inhalers, Seretide, Symbicort and Fostair, already on the formulary. GPs would concentrate on making sure patients are on the correct step of SIGN/BTS guidelines and GPs to help support patients make best use of these medicines.

(b) Joint Working (i) RSH Minutes - asked those present whether they thought that the papers presented were of any use. stressed the importance of doing a pregnancy test every time Isotrenin was prescribed. Those present considered that it should be prescribed by a specialist anyway. (ii) Working with Hereford had been invited to the Hereford Drugs & Therapeutics Committee meeting and will report back to the committee matters of interest from those meetings. offered to forward to minutes of their D&T meetings and offered to send minutes of CCG minutes of the Shropshire CCG Prescribing Committee.

(c) Not included in Part 8 Drug Tariff Schemes indicated that had made the MMT aware of this. A number of drugs are not contained in the drug tariff. A pharmacy/GP gets a rebate whilst the Health Board has to pay full cost, possibly much more than the price for alternatives. indicated that this practice is spreading and asked if we should consider branding non-tariff drugs to prevent profiteering in this way. pointed out that that this is not an illegal practice, but

Page 7 of 10 J:\Information_Governance\FOI\FOI requests\FOI - received\2015\15.R.005 Medicines Management\Att 1 Primary Care Joint Minutes 050313.doc Attachment 1 was potentially very expensive for Health Boards. It was suggested to ask those taking advantage of the situation to stop doing so initially before considering other possible actions.

It was AGREED that would write to the practice/pharmacy involved asking them to stop this practice and monitor for three months. If they do not stop, look at branding that particular drug.

(d) Vitamin B Compound Strong Because Vitamin B Co is not listed in the Drug Tariff its cost can vary significantly depending upon the brand supplied by the pharmacy or GP dispensary. The average cost across Powys is now £8.45 for 28 tablets, but can reach almost £24 for the same quantity. The BNF does not consider Vitamin B Co or B Co Strong to be suitable for prescribing on the NHS (there is little evidence that supplementation with such low levels of the constituent vitamins is of real value). However, where prescribers do consider such a supplement necessary, Vitamin B Co Strong does represent a more cost effective option at the Drug Tariff cost of £2.27 /28. 8 Stock Shortages (a) Isosorbide Mononitrate – standard release Advice has been issued from the Department of Health. indicated that the practices were relied upon to report any shortage stressed the importance of doing this, as the MMT were not always aware of any shortages. asked f this could be flagged up on ScriptSwitch. However, pointed out that this is not universal. It was AGREED to keep stock shortage reporting as a standard item on the agenda. 9 Bisphosphonates – course lengths indicated that this has already been touched upon earlier. has been looking at this because has had two patients in the last three months with stress fractures related to bisphosphonate use after 6-7 years duration. has sought local opinion because there are no published guidelines. One consultant advises to stop bisphosphonates after five years, unless multiple vertebral fractures, where 10 years is appropriate. The MHRA now have a dedicated webpage for bisphonsphonates. suggested from RJAH has been doing some work in this area. asked if anyone had suggestions. It was suggested that perhaps could get a address one of the meetings. 10 Medicines Waste Campaign asked those present of their views on medicines waste.

Page 8 of 10 J:\Information_Governance\FOI\FOI requests\FOI - received\2015\15.R.005 Medicines Management\Att 1 Primary Care Joint Minutes 050313.doc Attachment 1 will send out information on what is being considered so far. 11 Antibiotic Policy Update will send out a draft in the next few weeks. expressed concern regarding the situation of having no microbiologist. 12 Cobweb System indicated that all practices should have received a letter containing information about the Cobweb system. The new continence service starts today, 5th March. GPs will no longer need to repeat prescribe continence products and all will be dealt with by the new service. indicated that had been trying to phone the continence nurses about disposal of products, had left messages but no-one had telephoned back. indicated that the new service should improve the situation in due course. 13 Sip Feeds gave a powerpoint presentation. indicated that Powys issues lots of prescriptions for sip feeds and spending on sip feeds is increasing. is working with on a way forward. Aneurin Bevan has a specialist Medicines Management Dietitian working on this, which has reduced spend and improved effectiveness of products used.

indicated that nursing home staff and patients’ families need to be educated in the use of sip feeds. will flag this up with

indicated that the proposals drafted would improve quality for patients and more people would be supported. It was AGREED to go ahead with the proposals. offered to share the ONS form in use in Shropshire. 14 Medicines Incidents None for this meeting. 15 Medicines Vending System indicated that the system would be installed in Ystradgynlais Community Hospital but not in the MIU area. 16 Tinopolis Project – Inhaler Technique Video showed those present the information video made by Tinopolios demonstrating how to use inhalers correctly. This could be shown in practice waiting rooms. Presently it is on YouTube but will be on the Health Board website presently. 17 Gluten Free Prescribing Already discussed earlier in the meeting. 18 Update on 1000 Lives Plus Members NOTED the paper presented. 19 Policies and Procedures to Note There were no policies and procedures to note. 20 Any Other Business

Page 9 of 10 J:\Information_Governance\FOI\FOI requests\FOI - received\2015\15.R.005 Medicines Management\Att 1 Primary Care Joint Minutes 050313.doc Attachment 1 (a) Self-administered medication on wards indicated that this was being trialled on Claerwen ward for patients’ own medication and could move towards self- administration. It could potentially save a substantial amount of money, cutting wastage.

There was no other business to transact. 23 Date and time of next meeting The next meeting will be held on Tuesday 11 June 2013 at 9:30am in Newtown Football Club, Newtown.

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