Medicines Management Joint Executive Team
18 June 2015 1.30pm – 3.30pm
Small Meeting Room, Chiltern CCG
MINUTES
Attendees
Dr Stuart Logan (SL)
Dr Raj Bajwa (RB) (Chair)
Jane Butterworth (JB)
Raj Patel (RP)
Carol Durrant (CD)
Elaine Sharpe (ES)
Sarah Crotty (SC)
Nikki Malin (NM)
Derys Pragnell (DP) (Part)
Julie Breakspear (JMB)
Executive Clinical Lead for Chronic diseases, Medicines Management
and End of Life Care, AV CCG
Clinical Commissioning Director for LTC, End of Life and Prescribing,
Chiltern CCG
Head of Medicines Management, AV & Chiltern CCGs
LPC Representative
LPC Representative
Prescribing Support Pharmacist, AV & Chiltern CCGs
Interface Pharmacist, AV & Chiltern CCGs
Head of Communications & Engagement, CSCSU
Public Health Principal
Medicines Management Support Officer, AV & Chiltern CCGs
MMJET_2015/082 Apologies:
Julie Horslen (JH)
LPC Representative
Carol Durrant was welcomed and introductions made.
MMJET_2015/083 Conflicts of Interest
There were none.
MMJET_2015/084 Minutes and Matters Arising
The minutes of the meeting held on 21 May 2015 were approved as an accurate record.
Matters arising not included on the Action Update
There were none
From Action Update:
 Jun14/104 – Making Medicine-taking a better experience – This action concerned communication between
GPs and community pharmacists and the development of a SurveyMonkey questionnaire to establish the
preferred method of contact. In September 2014, a six month extension had been requested. RP
confirmed that the LPC had decided not to pursue the SurveyMonkey questionnaire so this item can be
closed.

Jun14/83c – Pharmacy Assistance/BUC – JB had finally been successful in co-ordinating a meeting of all
the appropriate people to discuss the correct pathway that should be followed by Community Pharmacists
and Out of Hours GPs if a patient has problems or a Community Pharmacist has issues with a prescription
regarding addiction drugs. Although there was a very useful wide ranging discussion the resultant action
went back to DAAT. JB had followed up last week but had still not had a response. The expected
completion date for this should be identified as September 2015 by which time it is thought the outstanding
action should be resolved.

Jul14/100b – Wound-care non-formulary applications – SC commented that there was an established
Wound Care Group which is in the process of revising the form. The ePACT data on wound care, some of
which includes non-formulary requested items for wound care, amounted to approximately 22% of the total
wound care cost in 2014/15. It was requested that the accurate figures are recorded in the minutes. The
actual proportion is 21% (May 15 MMJET). The question was raised as to whether consideration should be
given to reviewing the more common non-formulary requests. The non-formulary requests go through the
tissue viability nurse so it was decided to take no further action. There is a process in place for the wound
care group (a subgroup of FMG) to review frequent use. The item could be closed but SC was asked to
review wound care spend every six months and bring back to the MMJET on an annual basis.
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Action 100b – SC to review non-formulary requests every six months and bring back to MMJET on an
annual basis – ongoing action but put as an agenda item for May 2016 (one year after last review)

Feb15/018iii.a – Dashboard for 2015-16 – MMT had been asked to produce some trend data for a couple
of black and red listed drugs to establish whether or not it was worthwhile to continue to have red and
black list data included in the dashboard. Graphs were circulated to those present at the meeting.
Esomeprazole (black list) showed a good decline over a three year period but this was also probably
influenced by its recently reduced cost. In the last year prescribing had plateaued. Pregabalin (black list)
showed a slight increase and it was accepted that this would be expected. However, Bucks is significantly
better when benchmarked against other areas. SC could look on PrescQIPP for further data on pregabalin
if required. The red listed drugs chosen, fluticasone and Flixonase® combined and hydroxycarbamide also
showed a slight upward trend. Following discussion, it was decided that red and black listed drug data
should continue to be on the dashboard as it is used by practices. SC commented that she is in the
process of putting together information to explain why a particular drug is red listed, which should help
practices when they wish to query use for a specific patient with hospital clinical staff.

Feb15/018vi.a – ONPOS spend comparison – This action referred to asking the community tissue viability
nurse to undertake a short audit of those items identified with significant growth to ascertain if treatment is
appropriate. SC confirmed that this action had been completed and currently an investigation is being
carried out with regard to silicone foams which has shown a significant increase in spend since their
introduction to the formulary in April 2015. The action can therefore be closed.

Apr15/053d – Supplies from multiples – The problem experienced by patients when told by a community
pharmacist that a drug was unavailable when it was not a national supply problem but a supply problem
particular to the pharmacy concerned was discussed by the LPC. This mainly affected the multiples and
RP explained that for a non-multiple it is possible to see if the supply is a national problem but it is not
always possible for multiples to see this in the same way. Nevertheless, community pharmacists would be
encouraged to signpost the patient to another pharmacy, the only problem being if there was more than
one drug on the prescription. This action can be closed as all possible action had been taken.

Apr15/059d – Resources and Patient Leaflets – NM was to include antibiotic prescribing in the demand
management leaflet. NM commented that the leaflet had been sent to the designers but she had not
received it back yet. NM was asked to forward a copy of the leaflet to the team (SC) when she had
received it from the designers.
Action 059d – NM to forward a copy of the demand management leaflet to SC when she had received it
from the designers

Apr15/060b – Prescribing of H Pylori Tests – SC thanked the GPs for sending her a copy of the H Pylori
order form used by practices. She had updated this (revised form embedded on agenda) and sent to
pharmacy at SMH to ensure it was acceptable to them before uploading to the extranet. However, as the
BHT pharmacist felt that funding for H Pylori kits was not in place, SC has been in touch with contracting
who are going to resolve the finance issues. In the meantime, the form can be uploaded to the extranet
and possibly DXS for Chiltern practices. The form has already been sent to those practices that had been
identified as prescribing the kit through an FP10 to make them aware of the correct process.
Action 060b – H Pylori test order form to be uploaded to the extranet and forwarded to
NadineIdris@nhs.net (cc SC) for consideration of upload onto DXS – action JMB

May/069b – Antibiotic Resources – NM had been asked to look at the situation regarding the use of
presentations for Envisage screens particularly if audio is included which is not appropriate for surgery
waiting areas. NM reported that it is not so much that audio is the problem but more that these films are
live You Tube films which cannot be used as they need a live web lead. Comms have been in touch with
the Department of Health/NHS England to request these films in a suitable format that can be used. NM
had not yet received a response so the item should be left open.

May/072d – 28 Day Prescribing PIL – SC had requested a 3 month extension to update this patient
information leaflet. In the meantime it was agreed the guidance should be recirculated to practices but
informing them that the patient information leaflet was in the process of being updated.
Action 072d – JMB to circulate the 28 day prescribing guidance and inform practices at the same time
that the PIL is in the process of being updated

May/073e – Metformin for IGT – This action has been completed so the item can be closed.
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
May/074a – Risk Register – LTM12 (Gender Dysphoria) - This is an outstanding action for JB to follow up
with NHS England although JB now has the details of who to contact.

May/078b – ScriptSwitch Q4 Performance Dashboard – JB had spoken to the locality clinical leads during
their meeting on the previous day, not only about the ScriptSwitch dashboard but also about what
prescribing data in general practices would like to receive on a monthly basis. This item can now be
closed.

May/081b – Headache Management Guidelines – As the LTC/EOL JET had commented that the best
patient information leaflets for this condition are available on line, this action is not required and the item
can be closed.
MMJET_2015/085 Commissioning Intentions
(This was the fourth item to be discussed at the meeting following item 088 – Community Pharmacy)
RP asked if this was something that community pharmacists could contribute to. Community pharmacists
were welcome to contribute to suggestions but today was the last opportunity to decide on the short list for
2015-16. However, as it is an annual cycle, suggestions can be made throughout the year for consideration
for the following year.
(RP left the meeting)
The cover sheet that had been embedded on the agenda identified some ideas from the Medicines
Management Team about possible ideas for commissioning intentions for 2015-16. These were as follows
against which it was decided which was the relevant JET:
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Adult ADHD – Adult JET
Asthma – possible change in practice in diagnosis mandated by NICE would require funding of FeNO
testing to be commissioned – Right Care
Care Homes work – MMJET/Right Care
COPD – Gold (education will be required) – Right Care/MMJET re change in pathway
Dermatology – Right Care
Diabetes re-design/Care Planning/educational initiatives - LTC
End of Life – LTC reviewing Single Point of Access (SPA)
Housebound/domiciliary care – Urgent Care
MSK – Right Care
NPT LES review – MMJET review payment structure
PBR excluded drugs – audit - MMJET
Stoma and incontinence – MMJET
Gender dysphoria – MMJET for medication
It was agreed that diabetes would be the main focus for next year. Also the near patient testing LES, now
called a direct reward contract, needed to be reviewed particularly with regard to GP payment to ensure
continued engagement. This involves tests not covered by the GMC contract and is available to pharmacists.
It was necessary to decide on a short list and SL commented that for Aylesbury Vale CCG he would suggest
diabetes and care planning. The education element of COPD would need some funding but it was identified
that this may be covered by the current Respiratory Project monies. It was also recommended that some
respiratory funding for workforce planning should be added to the list. There is always a need for additional
money for PBR excluded medicines but a different source of funding needs to be identified for this. Stoma was
discussed but was discounted as the project was complex.
MMJET_2015/086 Nalmefene review of Traffic Light Position
(This item was discussed after item 084 (Minutes and Matters Arising) but left here for consistency with the
agenda.)
The meeting was joined by Derys Pragnell, Public Health Principal
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Nalmefene is currently RED on the Bucks Formulary but a request was being made by Public Health that
consideration be given to reclassifying as AMBER RECOMMENDED.
NICE guidance recommends nalmefene for patients who are drinking at both moderate and high drinking risk
levels. Just over 300 patients per annum could be eligible for nalmefene with counselling and DP stated that
these costs will be funded by Public Health.
DP explained that alcohol and drug abuse service was re-commissioned just over a year ago which resulted in
two local services being set up
– SMART which offers a counselling support service and has no staff who are able to prescribe and
– STARS which is service for more intensive and structured treatment programmes operated by doctors and
nurses. STARS does include prescribers.
NP suggested a pathway that could be followed. A GP would refer a patient to SMART having completed the
necessary assessment. The patient, who would be at a level where they felt they could not stop drinking
(mildly dependent), would then be given two weeks of support during which time brief interventions would be
followed such as keeping a drinks diary. If the patient was unable to reduce drinking levels with this support
after two weeks, then the SMART service would contact the patient’s GP to suggest that the patient may
benefit from taking nalmefene which the GP would need to prescribe. Counselling support would continue be
given by SMART but it was identified that the GP would be responsible for counselling the patient on the drug
and outlining the side-effects. It was further pointed out that under the amber recommended classification, a
GP could choose not to prescribe. It is necessary to ensure that the commissioned pathway is robust. STARS
have not yet added nalmefene to their formulary and therefore primary care is being approached about
bridging the gap in the service.
The MMJET consensus was that the proposed pathway with the GP prescribing nalmefene was not the best
patient pathway. MMJET were of the opinion that requesting the GP to prescribe the drug added nothing to
the patient’s treatment. Patient safety is the most important factor. Concerns were raised about how the
communication between SMART and the GP could be adequately speedy and robust. It was concluded that
nalmefene should remain red on the Bucks Formulary.
It was thought that counselling and prescribing should go hand in hand with prescribing the medicine. For this
to happen the SMART service may need to change so that it incorporates a prescriber. In order to introduce a
prescriber into the SMART arm of the service, Public Health could consider an ‘arms-length’ arrangement with
Vale Health or Oxford Health.
SL was happy to ask GP prescribing leads in Aylesbury Vale at their joint meeting next month for their views to
ensure that comments made in the MMJET meeting were representative.
Action 086a – JMB to add the query about the prescribing of nalmefene to AV forum agenda
Action 086b – SL to ask the opinion of GP Prescribing Leads in Aylesbury Vale at the Joint Medicines
Management Forum in July with regard to prescribing nalmefene and feedback to DP
(DP left the meeting)
MMJET_2015/087 Risk Register
(This was the sixth item to be discussed at the meeting following item 085 – Commissioning Intentions)
The risks were reviewed paying particular attention with those who were categorised as red.
LTM4 – Variation in Diabetes Care – Mitigation was needed for diabetes care within primary care to be
sharper, focussed and with appropriate milestones and until this was put in place the scoring should remain
unchanged.
LTM12 – Gender Dysphoria – The difficulty is that a service needs to be locally commissioned but there is no
one willing to provide the service locally as it is a rare speciality which requires specialist skills. NM expressed
concern that this is something that could hit the media and it was confirmed that there is that potential.
LTM16 – BCCR Transfer to MIG – The actions required for this risk are now complete so the score needs to
be adjusted accordingly which potentially will remove the risk from the register.
Action 087 – JB to amend the score of LTM16 as actions are complete
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MMJET_2015/088 Community Pharmacy
(This was the third item to be discussed during the meeting after item 086)

Insulin Passport – A review of insulin errors by BHT identified the difficulty in identifying a patient’s current
insulin product if it was not brought into the hospital and that patients do not always carry the nationally
recommended insulin passport. BHT currently use pharma-produced insulin identification cards which
some patients seem happy to carry with them. It was also reported that some patients have never been
offered an insulin passport. There are 37 different pharma cards and whilst being more compact than the
insulin passports, there is only limited space available to document other medications. There was an ideal
opportunity for community pharmacy to contribute by asking patients if they carry such a card or insulin
passport. If it was found they did not have a card or insulin passport, the pharmacist could suggest that
they ask the GP for one at their next review. Another suggestion was put forward that patients keep a
copy of their repeat prescription in their wallet. It was queried whether or not the BCCR record would be
helpful in this instance as BHT should be able to access it. ES was asked to feed back to BHT that
MMJET continue to support the insulin passport system and does not feel that the product specific system
would work but queried if the information required could be obtained through the BCCR record. It was also
agreed that a pointer should be put in the diabetes bulletin within the next six months.
Action 088a – ES to feedback comments made by MMJET about the pharma-produced insulin
identification cards to BHT
Action 088b – Community pharmacists to encourage patients without a card or insulin passport to
request one from their GP at their next review

LPC Newsletter – It was agreed that this newsletter was a very useful communication document and
MMJET would like it to be included monthly on the agenda for information purposes.

Communication Slip from Pharmacy to GP – Thanks were to be extended to Hughenden Valley surgery
who provided a copy of the form that pharmacists complete when recommending a patient to request an
appointment at their GP surgery. The form was approved for use with the addition of another tick box
under Timescale – ‘At next planned review’. Pharmacist and CCG logos need to be added before
circulating. RP was asked to send the LPC logos to ES for this purpose.
Action 088c – RP to send LPC logos to ES and JMB
Action 088d – JMB to add ‘At next planned review’ under Timeline and attach logos before circulating
MMJET_2015/089 Sick Day Rules and AKI
(This was the seventh item discussed at the meeting following item 087 – Risk Register. After this the meeting
ran in accordance with the agenda)
Sick day rule cards are being developed locally to promote awareness of the risks of Acute Kidney Injury to
patients. The card has been adapted from one developed and successfully used in the Highlands. It is being
developed for use across the whole of Thames Valley and suggestions were needed on how to promote it. NM
commented that the NHS lozenge was incorrect and she would send the correct logo. Also it was pointed out
that it was difficult to read the black writing on a blue background on what would be the back of the card and
NM suggested that white on black would be better. It was agreed that 20,000 of these cards should be
ordered in the first instance for Buckinghamshire.
Action 089a – NM to forward correct NHS lozenge to MMT to update card
Action 089b – Black footer on cards needs to be changed to white in order to be visible
Action 089c – Seema Gadhia to order 20,000 cards on behalf of Bucks once developed
MMJET_2015/090 Local Prescribing Issues
DMARD Monitoring – It was noted that one practice has decided to opt out of the Near Patient Testing service
(Direct Reward Contract). Concern was expressed that others may follow suit. An overview of the general
situation is that practices are running at full capacity and so to prevent other practices opting out it was
recommended that there needs to be an increase in the NPT direct award fee for practices. This situation
needs to be added to the Risk Register as potentially more practices are likely to opt out. MMJET should
recommend an uplift in payment for next year. The topic should be put on the agenda of the September
MMJET for further discussion when the appropriate document should be presented covering what the service
currently costs; the fact that there has been no uplift for 5 years; there is no data on quality of service, etc.
Action 090a – JB to put the risk surrounding NPT direct award - opting out on the Risk Register
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Action 090b – JMB to put NPT direct award payment on the September agenda of MMJET
Action 090c – SC to prepare a paper about updating the NPT direct award service to present at the
September MMJET covering the aspects discussed at the June MMJET
MMJET_2015/091 Care Homes
Risk Management Tool for Medication Errors – Evaluation – The tool, which has been developed to support
decision making by staff when medication errors are identified in the care home setting, has been piloted by
care home pharmacists. A comparison has been made of what risk score the tool gives compared to what
score the pharmacist would have given. Overall the tool was useful to assess level of risk but in some cases
the tool underestimates the magnitude of the error, when compared with the view of a senior pharmacist. The
proposal is to review the actions recommended by the tool, update the tool and take it to the Quality in Care
Homes team for review. The suggested actions in the evaluation were approved.
MMJET_2015/092 Interventions
Reducing the use of High Dose Corticosteroid Inhalers in COPD - Following the FMG agreement that lower
doses of ICS should be recommended first line when an ICS is appropriate and inclusion of Fostair onto the
formulary the COPD guideline was updated. This intervention has been developed to support the
recommended change in practice. ES circulated an amendment suggested by Catherine Tutt and this
proposal was accepted. It was also suggested under the Questions and Answers section that the answer to
question two should be preceded by the word ‘Yes’ to confirm that patients should be switched. With these
amendments, the intervention was approved.
Action 092a – ES to amend the intervention in accordance with the discussion
Action 092b – JMB to upload to the extranet and circulate to practices
MMJET_2015/093 Guidelines
Dermatology referral guidelines – It was agreed that this was a well written document and was approved from
a medicines perspective. The document will require review at BHT committees before upload.
MMJET_2015/094 Hayfever
MIUK document – It was queried whether this document should be uploaded to the extranet and circulated to
practices. It was agreed this document was a little late in the season and not particularly interesting so the view
was taken that it should not be uploaded.
MMJET_2015/095 ScriptSwitch
Proposed Switch Suggestions
Accrete D3 – LW had pointed out that Accrete D3 was better value for money and wondered if it was possible
to request that it was added to the formulary so that it could be used as an alternative to Adcal D3 with Evacal
D3 as an alternative for those patients with a nut allergy. The decision on whether a drug goes on the
formulary is based on evidence, efficacy and cost but there should only be one calcium product on the
formulary. It is not necessary to identify an alternative for patients suffering from nut allergies as this would
have implications for other drugs, but a GP could deviate in the case of an allergy. SC would follow this up.
CD confirmed that Accrete was not a problem for community pharmacists
Action 095a – SC to follow up with BHT on whether Accrete D3 could be put on the formulary as first
choice for calcium and vitamin D
Co-danthramer caps – LW suggested changing the message as the product is to be discontinued. This was
agreed but with the final note being amended to read ‘Transfer to co-danthrusate’.
Lancets – ES is following up
Galantamine MR – LW requested some advice as very limited stock available at present. CD was asked to
check on the situation and advise when freely available.
Action 095b – CD to check on availability situation regarding galantamine and to advise when freely
available
Trimethoprim – LW pointed out that supplies are now available but price concessions mean that cost has risen
significantly and she was seeking advice on what action to take. It was agreed that trimethoprim switch should
be removed altogether.
Action 095c – LW to remove trimethoprim switch
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ISMN MR – There were still supply problems with Monomil MR but CD would check on availability of all brands
and generic ISMN MR 60mg.
Action 095d - CD would check on availability of all brands and generic ISMN MR 60mg
Benefit Tracker – The ScriptSwitch benefit tracker had been embedded on the agenda for information.
ScriptSwitch Dashboard – The dashboard is produced on a quarterly basis by ScriptSwitch and could be a
useful tool to help practices identify where savings could be made. The proposal is to upload to the extranet
and circulate the link to practices. This proposal was accepted.
Action 095e – JMB to upload the ScriptSwitch Dashboard to the extranet on a quarterly basis
MMJET_2015/096 IFR
An overview of Buckinghamshire funding requests for medicines in 2014-15 was presented in pictorial format
with a breakdown of decisions made. It was recognised that this was a good presentation which demonstrated
the work that goes into decision making. Jaron Inward (IFR team, CSCSU) was thanked for his clearly
presented work.
MMJET_2015/097 Safety
 http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/DrugSafetyUpdatePDFarchive/index.htm
 Drug Safety Update – Embedded on the agenda for information
 Drug Safety Summary – A summary had been produced of the information contained in the May 2015
Drug Safety Update.
 Patient Safety Alert – Risk of death or severe harm due to inadvertent injection of skin preparation solution

MMJET_2015/098 NICE Guidance
The NICE guidance for May was embedded on the agenda for information
MMJET_2015/099 Budget & Contract Monitoring
The outturn figures for the end of 2014-15 by CCG were embedded on the agenda. A small finance error
meant that Aylesbury Vale had come in on budget. Budget setting was discussed, particularly for those
practices that look after nursing homes and the value of having a practice pharmacist was highlighted. SL
commented that AVCCG were considering putting forward an invest to save proposal for a pharmacist for
practices. There was no data available to compare practices that have responsibility for nursing homes with
those that do not but it was thought that a strategic overview was needed for when queries were raised by
practices. The budget for 2015-16 is more or less the same as last year.
MMJET_2015/100 AOB
A request had been received from a Hertfordshire GP who would like to sit in on an MMJET meeting as he had
been told that Buckinghamshire had a good system for assessing drugs. This was agreed.
MMJET_2015/101 Key Issues Report
 Commissioning intentions
 Nalmefene remains red – PH agree to fund costs
 NPT direct award – requires a payment review (& risks)
 IFR review of cases involving medicines shows robust process and good clinical engagement
Date of Next meeting: Thursday, 16 July 2015 (Virtual Meeting)
Venue:
Time:
Future dates:
20 August 2015
17 September 2015
15 October 2015
17 December 2015
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