National Midwifery Formulary Project
Governance subgroup
Thursday 7 October 2010
11.30 – 13.30
Third floor meeting room
Elliott House, Edinburgh
Note of Meeting
Present
Geraldine Butcher, KCND Consultant Midwife and former Midwife Supply Order Project
Manager, (NHS Ayrshire and Arran)
Jenny Carson, Pharmacist, NHS Lothian
Dorothy Finlay, Consultant Midwife, Greater Glasgow and Clyde
June Grant, Pharmacist, NHS Greater Glasgow and Clyde
Lucy Powls, NHS Education for Scotland
Sherry Wright, Pharmacist, NHS Lothian
Fiona Dagge-Bell, Team Leader, Clinical Development and Improvement, NHS QIS
(Chair)
Eleanor Stenhouse, Lead midwife, NHS Greater Glasgow and Clyde
Mary Vance, LSAMO and author Midwives and Medicines
Maria Wilson, Chief Midwife NHS Lothian
Apologies
Laura McIver, Pharmacy Advisor, NHS QIS
Margaret Nichol, Pharmacist and Pharmacy Manager, NHS Ayrshire and Arran
In attendance
Rosemary Hector, Programme co-ordinator
1. Welcome and Apologies
Fiona welcomed Maria Wilson who had joined the group who had remained from the
previous meeting on education.
2. Minutes of previous meeting and update on action points
The action points from the meeting of the group on April 14 were reviewed; most had led
to the framing of the current meeting.
An error in the minute was noted; the revised midwife exemptions were issued from the
MHRA (not the NMC as noted in the minute).
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3. Governance – what are the issues?
There was some discussion around the drugs list which is to be sent to the group for
final approval.
It was also acknowledged that a monograph, particularly for a complex drug with training
requirements for those supplying it, should not be framed in isolation from the context of
its use. It was agreed that a contextual flow or scenario that showed the progress of a
situation and the decision making process that would lead to this drug being used would
be helpful. It was agreed that the individual drug monograph could be linked to this
contextual information (particularly straightforward in an electronic document).
The future of the formulary document was discussed and it was agreed that it should be
produced with the aim of being refreshed and updated regularly. This process of
maintaining its currency would also contribute to the buy in and ownership of the
document. It was accepted that in some areas with dedicated pharmacy support for
maternity and neonatal services the updating of any pharmacy documents in maternity
units is part of the pharmacy role. It was suggested that a long term view of the
formulary could be its potential to sit with the BNF rather like the paediatric formulary.
The positioning of this work on NHS Board agendas also requires consideration and it
was agreed that the Directors of Nursing were a significant and strategic group from
which the heads of midwifery could secure support. Another key group from which to
seek support for the formulary is the RCOG. It was also acknowledged that NHS
Education for Scotland’s has a key role in
• supporting the work at undergraduate level and
• in supporting current midwives to maintain their skills and thus their fitness to
practise.
It was noted that if the Heads of Midwifery could approve and support this initiative it
could be taken to the next level for support, as appropriate in a local context. The
potential to use other initiatives such as service redesign, and other drivers such as
achieving cost savings to support the formulary was observed.
Action: The drugs list sent to the group for their final approval – questions from
pharmacist identified and then sent to the midwives on the group who are in touch
with operational concerns for answers and consensus.
Action: FDB to secure slot for promoting this at Scottish Executive Nurse
Directors’ group with support from MW and ES..
Other issues discussed included the incidence of drug-related errors and the potential
use of this information for demonstrating impact of any formulary introduced into a
service area. It was agreed that the Heads of Midwifery would consider some means of
producing benchmark indices with would allow the introduction of the Midwifery
Formulary and associated education resource to be evaluated in the light of measurable
indices of practice. Possible indices suggested were;
• A metric on how quickly a woman could leave hospital with the relevant
medications
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•
•
An index on pain control
A measure around the identification and addressing of constipation
Action: FDB to secure collective benchmarking indices with Heads of Midwifery
to assess practice prior to the intervention of the Formulary.
The branding of the monographs and use of the term ‘formulary’ was discussed since
this had been raised within NHS QIS. This was not perceived as a problem by the group
and it was agreed that June Grant would discuss this with the NHS QIS Pharmacy
Advisor, Laura McIver.
Action: June Grant to discuss terminology with NHS QIS Pharmacy Advisor.
Other issues considered were the lack of knowledge across midwifery practice
particularly in those supervisors and mentors who support operational midwives. Any
improvement and education initiative would be required to address these midwifery
leaders first.
Action: Mary Vance to take this forward with her LSAMO colleagues
The monitoring of the use of the mechanisms and procedures for the supply of
medicines by midwives (application of knowledge) beyond registration was considered
an area of concern. It was agreed that training of midwives currently in practice in
Scotland (62% of whom are part time) is potentially costly and that if all midwives are to
undertake this as a one off exercise then central funds will be required.
Action: Lucy Powls to take this forward with Mr Parry at NHS Education for
Scotland.
In addition the traditional education issue of the tension between assessment and
practice (securing a pass in the test, and subsequently demonstrating competence) was
observed. The group concurred with the education subgroup which had met earlier that
a performance in the final test at the end of the learning session of 100% was
necessary. Although it is part of core practice, the supply and administration of
medicines by midwives remains an area of variable practice across Scotland.
The use of different doses of medicines in different NHS boards and how this might be
recorded in the monographs was noted. It was observed that the proposed design of
having monographs on the web to download and take through local committees for
approval would allow local amendments to be made, prior to local approvals being
sought.
The discomfort many more mature midwives have in using IT was also noted as a
challenge. It was acknowledged that some midwives struggle with their professional
obligations to keep their knowledge current. The pre reading in the education course
addresses this by reminding readers of this responsibility. It was acknowledged that the
original publication supported by NHS Education, Midwives and Medicines, and
authored by Mary Vance, covers all the considerations of governance and provides
excellent foundation information and clear guidance for midwives. It was noted that this
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document, well written and accessible for its target audience, contained nearly all the
knowledge and support a midwife would require in using a formulary. The group agreed
that it would be an efficient and effective step to have this document updated since is
would support the work admirably. Mary Vance expressed a willingness to update this
noting that there is a requirement to incorporate recent legislative changes. It was
agreed that this would be a solution to providing the governance and additional
information for those using the formulary, rather than reinventing a parallel document
such as that drafted and sent out by RAH in advance to the group. It was agreed that
this would be taken to Rob Parry at NHS Education as a relatively straightforward
solution to the issue of providing surrounding information for the formulary and the
education pack.
Action: FDB to follow up suggestion for an updating of ‘Midwives and Medicines’
with NHS Education for Scotland
Ways of incorporating the learning on the formulary into current learning and
development structures was discussed. The use of KSF, supervisory structures,
management structures, the Midwifery Passport and revalidation were all discussed as
means of incorporating and implementing the learning and it was agreed that Lucy
Powls would investigate the progress of the Midwifery Passport project. It was
acknowledged that using any of these mechanisms would require local agreement and
careful application to be employed successfully.
Action: Lucy Powls to research progress of Passport project.
4.
Towards a specification for the form (this acts as a means of requesting
the drug, its control and the communication between the midwife, her
supervisor and the pharmacist)
At the outset it was noted that NHS QIS cannot be responsible for the design and
subsequent printing of any forms and templates used across NHS Scotland but that a
specification, stipulating what should be presented in such a document, could be
secured. The potential for such a form to accommodate self-administration of drugs was
also recognised.
It was agreed that rather than invest energy in identifying components of an ideal form,
good examples of current forms currently in use could be uploaded as part of the
package addressing governance. This would assist NHS boards attempting to redesign
their forms and systems.
Action: RAH to request sample forms from Maternity forum members in NHS
boards in Scotland.
5. Towards an agreed governance arrangement (this determines how drugs
on the list are obtained by the midwife - or establishes principles which
should be observed when these arrangements are made).
Mary Vance informed the group that the current Midwife Supply Order for the controlled
drugs is currently at the Scottish Government. This is being taken forward by the
LSAMOs in Scotland as a consequence of discussion with the UK wide group of
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LSAMOs. The group agreed that the use of this mechanism, although intended originally
for opiates, could be extended to cover all medicines.
It was agreed that the interface with Community Pharmacies and the current confusion
around arrangements for midwives to access drugs for women should be taken to the
Maternity Services Action Group (MSAG). It was observed that resolution of the current
issues has the potential to make cost savings in NHS Scotland and that MSAG might be
supportive of this, particularly if the CNO’s office is in support of this. It was agreed that
key members of the group would refer this to MSAG and it was suggested that the NHS
QIS Pharmacy Advisor, Laura McIver could also be invited to attend this meeting.
Action: FDB to invite Laura McIver to MSAG and secure slot for all, including Mary
Vance and Maria Wilson to take community pharmacy issues to MSAG.
Action points/Agreements
Action point
Send the drugs list to the group for their approval.
Who
RAH
To secure slot for promoting this at Scottish Executive Nurse
Directors’ group.
FDB
To secure collective benchmarking indices with Heads of
Midwifery to assess practice prior to the intervention of the
Formulary
To discuss terminology with NHS QIS Pharmacy Advisor
FDB
To discuss and progress education of supervisors and other
midwifery leaders in medicines with LSAMO colleagues
To raise suggestion of support for education for all midwives with
Mr Parry at NHS Education for Scotland.
To follow up suggestion for an updating of ‘Midwives and
Medicines’ with NHS Education for Scotland
To research progress of Passport project – update to RAH at
NHS QIS
RAH to request sample forms from Maternity forum members in
NHS boards in Scotland.
FDB to invite Laura McIver to MSAG
File name: 2010 10 07 Midwifery
Formulary Whole group meeting Gov
Minute
Produced by: RAH
JG –
ASAP and prior to
RAH to Directors of
facilitate Pharmacy meeting
16 December
MV
LSAMO meetings
LP
ASAP
FDB
ASAP
LP
ASAP
RAH
In line with forum
agenda – by early
December.
Suggest MSAG
following Directors of
Pharmacy meeting
on 16 December
FDB
FDB to secure slot for Mary Vance, Maria Wilson and Laura
McIver to take community pharmacy issues to MSAG.
By when
a) 8 Oct (list a)
b) 15 Oct
Suggest new year
once work under
progress
Next HOMs meeting
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