Huw Vaughan Thomas

Auditor General for Wales

24 Cathedral Road


CF11 9LJ


Our Ref: AG/AE/SB

5 January 2017


Dear Huw


Response to the Report of the Auditor General for Wales entitled managing medicines in primary and secondary care


Thank you for report entitled ‘managing medicines in primary and secondary care’ which was published earlier this month.


We welcome the findings of the report and in particular its recognition both that there are many good aspects of medicines management in Wales, and that NHS bodies are collaborating well to make further improvements. 


We note the ten recommendations contained within the report and our detailed response is set out in the attached annex.  A number of the recommendations contained within the report are aimed at health boards and NHS Trusts, in the case of these recommendations we have indicated how we intend to support those bodies in implementing the recommendations.


Yours sincerely


Dr Andrew Goodall


cc:       Nick Ramsey AM, Chair, Public Accounts Committee

Andrew Evans, Chief Pharmaceutical Officer, Welsh Government

            Frank Atherton, Chief Medical Officer, Welsh Government

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Annex A


Response to the recommendations contained in the report of the Auditor General for Wales entitled managing medicines in primary and secondary care


Recommendation – The Welsh Government, NHS Wales Informatics Service (NWIS) and all health bodies should agree a detailed, time-bound plan for implementing electronic prescribing systems in secondary care, along with a clear process for monitoring the delivery of the plan.


Response – Accepted.


The NHS Wales Informatics Service (NWIS) has established the Welsh Hospital Electronic Prescribing and Medicines Administration project to develop and implement the national plan for electronic prescribing in secondary care and the inaugural meeting of the project board was held on 23 November 2016.


The project team is currently working with stakeholders to define the exact scope of the project and the system requirements.  Once this is complete the business case for procurement of a replacement hospital pharmacy system and an electronic prescribing and medicines administration solution will be completed by NWIS and considered by Welsh Government.  Subject to the completion of the business case, it is expected that the procurement of these systems will be completed during 2018-19 with implementation beginning in the early part of 2019.


Recommendation – The Chief Pharmaceutical Officer for Wales should lead national reviews to assess each health body’s compliance with the MARRS policy, to assess the effectiveness of the new mandatory training programme on medicines management and to assess the long-term sustainability of actions taken in each health body to address all medicines-related findings from Trusted to Care; and


Each health body should develop a time-bound plan for improving storage and security of medicines on hospital wards, including specific consideration of the benefits of implementing automated vending machines.


Response – Accepted.


The Chief Pharmaceutical Officer for Wales will re-convene the Medicine Administration, Recording, Review and Storage (MARRS) working group to undertake a review of each health body’s compliance with the MARRS policy.  Due to unforeseen circumstances there has been a delay in implementing the e-learning programme on medicines administration. The working group will therefore give further considerations as to how the e-learning programme can be rolled out most effectively.  We envisage the first meeting of the re-convened MARRS working group will be in April 2017 and that it will complete its review by March 2019.


Patient Safety Notice PSN 030, issued in April 2016 set out the expected standards for safe and secure storage of medicines on hospital wards.  We have identified the need to review the requirements contained in the notice in light of concerns that the cost of replacing the storage on all hospital wards, regardless of current condition, would be disproportionate to the anticipated benefit; given the low level of risk presented by storage facilities on the majority of wards.  The MARRS working group will, as part of its work, review PSN 030 and updated guidance will be issued before the end of 2017. 


The Chief Pharmaceutical Officer will, with the Chief Pharmacists in local health boards and Velindre Cancer Centre, complete an audit of the current use automated ward vending machines in NHS hospitals in Wales and develop a prioritised list of sites in which automated ward vending should be implemented.  This work will be completed by June 2017.


Recommendation – Health bodies should ensure their Chief Pharmacist is, or reports directly to, an executive director; and


Health bodies should have an annual agenda item at the Board to discuss an annual report covering pharmacy services, medicines management, primary care prescribing, homecare medicines services and progress in addressing the issues identified in Trusted to Care.


Response – Accepted in part.


We agree fully that the Board of every health body in Wales should regularly scrutinise all aspects of medicines management.  To that end and prior to the publication of your report, in 2016-17 we included six national prescribing indicators, covering a range of areas including antimicrobial prescribing, adverse drug reaction reporting, high risk medicines and the efficient use of resources, in the NHS Outcomes Framework. 


To maintain focus on improving medicines management within NHS Wales, we will continue to develop medicines management indicators as part of the outcomes framework.  We will also raise medicines management issues through the Joint Executive Team meetings between Welsh Government and NHS Wales bodies.


The UK-wide rebalancing medicines legislation and pharmacy regulation programme, supported by the Department of Health in England on behalf of the four UK administrations, is considering various changes to medicines legislation which are likely to impact on the role of health body Chief Pharmacists.  We do not consider it would be appropriate to make a commitment regarding the reporting arrangements for Chief Pharmacists until the outcome of that programme is known.  We anticipate the implications for Chief Pharmacists will be clearer in early 2018.  In preparation we will undertake an audit of the reporting arrangements for NHS Chief Pharmacists in Wales, this will be complete by September 2017.


Recommendation – Chief Pharmacists should seek the support of the NHS Wales Shared

Services Partnership’s Workforce, Education and Development Services to strengthen current resource mapping approaches to facilitate robust comparisons of pharmacy staffing levels across Wales and to produce a generic service specification. The specification should set out the typical resources required to deliver key pharmacy services, such as clinical pharmacy input and patient education on the wards. The specification should also be flexible enough to recognise that different types of wards will require different levels of resource.


Response – Accepted.


During 2017-18 we will work with the NHS Wales Shared Services Partnership’s Workforce, Education and Development Service and Chief Pharmacists of NHS Wales bodies to undertake a robust assessment of the current and future needs for the pharmacy workforce.  This work will be completed by March 2018.


Recommendation – To drive further improvements in prescribing, health bodies should ensure they have a targeted plan of action to achieve cost and quality improvements in prescribing in primary care and in secondary care, in line with prudent healthcare principles. The plan of action should be informed by regular analysis of prescribing data to ensure that attention is focused on the areas where the greatest scope exists to secure cost and quality improvements;


In line with the need to increase the profile of medicines management at Board level, health bodies should ensure that performance against the National Prescribing Indicators is considered regularly by the Board, alongside progress in delivering wider cost and quality improvements in primary care prescribing;


The Welsh Government should ensure the work of the Efficiency, Healthcare Value and Improvement Group takes an all-Wales view on the cost and quality improvements that should be achievable through better prescribing and medicines management, and uses mechanisms such as the twice-yearly Joint Executive Team meeting between government officials and each individual health body to ensure that the necessary progress is being made in securing these improvements.


The Welsh Government should work with NHS bodies to develop and implement a clear national plan of action aimed at reducing medicines wastage, building on the findings from the ongoing evaluation of the Your Medicines, Your Health campaign. Reducing waste leads to cost savings whilst at the same time helping patients to take their medicines as prescribed, thereby helping to secure maximum benefit from the medicine; and


Linked to the above points, the Welsh Government should ensure that there is a clear and time-bound plan in place to roll out improved repeat prescribing systems that are being tested by the Prudent Prescribing Implementation Group.


Response – Accepted.


The Efficiency, Healthcare Value and Improvement Group have agreed an all-Wales approach to cost and quality improvement in medicines management in primary and secondary care will be a key area for 2017-18. 


During 2017-18 we will agree with health board Chief Pharmacists and other stakeholders, key priorities in the following six areas: driving efficiency; reducing medicines related harm; improving patient experience and outcomes; workforce modernisation; collaborative working, better use of technology and improved estates; and benchmarking.  These priorities will be taken forward on an all-Wales basis and progress overseen through regular meetings between the Chief Pharmaceutical Officer and health board Chief Pharmacists, and Joint Executive Team meetings.


We will work with NHS bodies to develop and implement a clear national plan of action aimed at reducing medicines waste.  Primarily this will be achieved by encouraging NHS bodies to adopt the elements of the Your Medicines, Your Health campaign which the ongoing evaluation, once completed, demonstrates are successful.   We will also encourage health boards to implement evidence based approaches which reduce medicines waste.  These will include implementing improved repeat prescribing systems such as those which have been tested through the Prudent Prescribing Implementation Group or evaluated in other parts of the UK.  We envisage this work will begin in 2017-18 with a time-bound plan agreed by March 2018.


Recommendation – The Welsh Government should develop a plan, in partnership with All Wales Medicines Strategy Group (AWMSG), health bodies and GPs, to evolve the National Prescribing Indicators so that they begin to consider measures of whether the right patients are receiving the right medicines and whether medicines are making a difference to people’s outcomes.


Response – We agree that National Prescribing Indicators are currently too focused on the quantity and cost of medicines prescribed with inadequate consideration given to clinical appropriateness and outcomes.  The availability of data to support more sensitive indicators has been a significant constraint. 


Whilst significant improvements have been made to reduce variation in prescribing, the rate of improvement has slowed in recent years in part as a result of this approach.  We will work with the Wales Analytical Prescribing Support Unit (WAPSU) to establish a project in 2017-18 the purpose of which will be to define a new suite of National Prescribing Indicators utilising additional data sources.  The indicators will be developed during 2017-18 with the intention they are approved by the All Wales Medicines Strategy Group (AWMSG) prior to their use from April 2018.


Recommendation – The All Wales Chief Pharmacists’ Committee should lead a national audit of compliance with the measures set out in the all-Wales handbook on the safe and effective delivery of homecare services.


Response – Accepted.


We note this recommendation is aimed at the All Wales Chief Pharmacist’s Committee.  We will ensure work to improve the safe and effective delivery of homecare services, including an audit of compliance with the measures set out in the all-Wales handbook, forms part of the key priorities agreed with health board Chief Pharmacists and other stakeholders in 2017-18.


Recommendation – The Welsh Government, supported by 1000 Lives Improvement, should work with pharmacy teams, clinical coding staff and clinicians across Wales to develop a programme aimed at identifying and preventing medicines related admissions (MRAs).


Response – Accepted.


This work will be scoped with 1000 Lives Improvement during the early part of 2017-18 with a view to establishing a medication safety programme in 2018-19.


Recommendation – The Welsh Government and NWIS should continue to work with GP representatives to ensure their concerns about information governance are addressed;


Facilitate wider access to the GP Record so that all pharmacists and pharmacy technicians that deliver clinical services on the wards can access the system for patients who are admitted for an elective procedure, as well as those admitted as emergencies; and


Facilitate wider access to, and use of, the GP Record in community pharmacies so that whenever it is clinically appropriate, patients can have their medicines managed in the community without accessing a GP or other NHS services.


Response – Accepted.


We are continuing to work with NWIS to secure wider access to the Welsh GP Record (WGPR).  On 21 November 2016, NWIS announced that access to the WGPR would be extended to hospital pharmacists and pharmacy technicians in planned care settings including outpatients.  This builds on the access in emergency care settings which has been available for some time.


The Chief Pharmaceutical Officer is working directly with the Medical Director at NWIS to put in place appropriate information governance arrangements which will allow use of the WGPR by community pharmacists in specified circumstances to support patient care.  We envisage this work will be completed early in 2017.


Recommendation –Where the Welsh Government makes a decision to make a new medicine available outside the current national appraisal process, it should clearly

explain the rationale underpinning its decision and ensure that health bodies are given sufficient time to plan for the financial implications and service changes associated with introducing those new medicines.


Response – Accepted.


We are pleased the Auditor General for Wales recognises that from time to time it may be necessary for the Welsh Government to make medicines available outside the current national appraisal process.  We recognise that this should happen by exception and only where the rationale for so doing is clear. 


As has been the case with agreements to date, we expect agreements will continue to be made only where there is strong support for the availability of the medicine(s) both from clinicians and patients across Wales.  However we will, with immediate effect and for all future agreements, ensure NHS bodies are more closely involved in the planning arrangements and afforded an appropriate period in which to prepare for the service and financial implications.