Vaughan Gething AC/AM
Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau
Cymdeithasol
Cabinet Secretary for Health and Social Services
Ein cyf/Our ref VG/1287/18
Nick Ramsay AM
Chair – Public Accounts Committee
National Assembly for Wales
Cardiff Bay
Cardiff
CF99 1NA
2 May 2018
Dear Mr Ramsay,
PUBLIC ACCOUNTS COMMITTEE REPORT MEDICINES MANAGEMENT RESPONSE TO THE REPORT
I have pleasure in enclosing a copy of the Welsh Ministers response to the above report which will be laid before the Table Office.
On behalf of the Cabinet, I would like to thank you and the Committee for the careful and considered way in which you undertook the investigation and produced the report.
Yours sincerely,
Vaughan Gething AC/AM
Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol
Cabinet Secretary for Health and Social Services
Canolfan Cyswllt Cyntaf / First Point of Contact Centre:
Bae Caerdydd • Cardiff Bay 0300 0604400
Caerdydd • Cardiff Gohebiaeth.Vaughan.Gething@llyw.cymru
CF99 1NA Correspondence.Vaughan.Gething@gov.wales
Rydym yn croesawu derbyn gohebiaeth yn Gymraeg. Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd gohebu yn Gymraeg yn arwain at oedi.
We welcome receiving correspondence in Welsh. Any correspondence received in Welsh will be answered in Welsh and corresponding in Welsh will not lead to a delay in responding.
Response to the recommendations contained in the report of the National Assembly for Wales Public Accounts Committee entitled Medicines Management
We welcome the findings of the report and offer the following response to the 17 recommendations contained within it.
Recommendation 1. The Committee recommends that the Welsh Government produce an annual report detailing information of improvements in medicines management across all the Health Boards, to increase accountability and ensure that the profile of medicines management remains high on the agenda of Health Boards.
Accept
We do not consider an additional annual report published by Welsh Government is the most appropriate means to achieve the Committee’s objectives. As an alternative to an additional annual report published by the Welsh Government, we will require the All Wales Medicines Strategy Group (AWMSG) to undertake work to inform and develop their existing annual report and quarterly reporting of progress against national prescribing indicators to ensure the content and format is more relevant and accessible to Board members of NHS bodies.
This work will be completed in time for the publication of AWMSG’s 2018-19 annual report.
In addition we will continue to develop medicines management indicators as part of the NHS Wales Delivery Framework and hold NHS bodies to account for performance against the framework.
Recommendation 2. The Committee recommends that the Welsh Government issue a national directive that all Health Boards need to develop campaigns to raise the profile of medicines management. These campaigns should be based on examples of best practice from the existing campaigns which have been built up from a local level.
Accept
The Welsh Government is providing funding to health boards to support communication activities which promote new models of primary care and its benefits for citizens. Citizen responsibility including their responsibilities in respect of prudent use of medicines is a core component of that work.
We recognise there have already been successful local campaigns which raise the profile of medicines management in particular the Your Medicines Your Health campaign in Cwm Taf University Health Board. In addition to the funding being provided to health boards for primary care, we will make a further £50,000 available to health boards in 2018-19 to undertake local activity to promote the most successful elements of the Your Medicines Your Health campaign.
Recommendation 3. The Committee recommends that the Welsh Government sets out a plan to maximise the use of pharmacy resource, including developing the modules for delivery in choose pharmacy and enabling independent pharmacists. This plan should build on the recommendations in the Royal Pharmaceutical Society report.
Accept
We will work with the NHS Wales Informatics Service and health boards to develop further modules within Choose Pharmacy which support community pharmacists delivering an increased range of clinical services. To that end further modules are in development within Choose Pharmacy to support the national emergency contraception service and a sore throat test and treat service from community pharmacies. It is intended that both modules will be available later in 2018-19. In addition to modules supporting service commissioning, Choose Pharmacy is being developed to improve communication between community pharmacies and other NHS providers, these developments include the transfer of electronic letters from pharmacies to GPs and secondary care (to be delivered by March 2019), and systems to allow Wales’ NHS 111 service to refer appropriate patients to a community pharmacy.
Independent prescribing by pharmacists has grown considerably in recent years, facilitated by the increase in GP practice based roles. In January 2018 in primary care, 65 pharmacist independent prescribers issued 50,484 prescriptions from 111 GP practices. This represented an increase of 150 percent in the number of active pharmacist independent prescribers , a 640 percent increase in pharmacist prescriber prescriptions and a 171 percent increase in GP practices utilising pharmacist independent prescribers in the two years since January 2016.
In April, we confirmed funding for up to 100 community pharmacists to take up independent prescribing courses in the next two years and to provide funding to health boards to support establishing up to 40 independent prescribing pathfinder sites in community pharmacies.
We will ask the Welsh Pharmaceutical Committee to work with stakeholders including the Royal Pharmaceutical Society to develop a plan describing the future roles of pharmacy professionals in Wales and the steps to be taken by all stakeholders to maximise their use. The plan will be completed in the early part of 2019-20.
Recommendation 4. The Committee recommends that the Welsh Government develops a data management system to track the number of pharmacists working in Wales and the roles being undertaken. This can also be utilised to plan training needs and requirements. Consideration should also be given to extending this to include information on wider pharmacy staff such as technicians who also have evolving roles which may impact on the training needs of the sector
Reject
A number of existing sources of information are available which provide a basis for identifying training requirements for pharmacy professionals in Wales. These include:
1. The All Wales Pharmacy Database (AWPD) – containing information on the accreditation of pharmacists and pharmacy technicians providing additional clinical services in community pharmacies;
2. The Electronic Staff Record (ESR) – containing information on pharmacists and pharmacy technicians employed by NHS organisations;
3. Registers, maintained by every NHS body in Wales, of non-medical prescribers employed by those bodies; and
4. The database of pharmacy professionals registered with the Wales Centre for Pharmacy Professional Education (WCPPE).
In addition the Welsh Government is working towards introducing a tool to collect GP practice workforce data, which will include data about pharmacy professionals working in GP practices.
Given the limitations of collecting data about pharmacy professionals working in the private sector, we do not believe the benefits of a new data management system would outweigh the costs of its development and maintenance.
In future, planning to meet the training needs of pharmacy professionals will be a function of Health Education and Improvement Wales (HEIW). We will work with HEIW to ensure existing sources of information are fully utilised, and where necessary developed to support this function.
Recommendation 5. The Committee recommends that the Welsh Government undertake an evaluation of cluster pharmacists, which evaluates the funding model and recruitment model for pharmacists within the cluster model.
Reject
The £10m which the Welsh Government has allocated from the national primary care fund for clusters to decide how to invest is recurrent. It can therefore, be used to fund short or long term appointments. The Welsh Government expects clusters to undertake reasonable and proportionate evaluation of their initiatives. Successful initiatives should then be mainstreamed, releasing cluster funding to be reinvested in other new and innovative initiatives. Mainstreaming these posts may be through independent GP practices employing them directly on behalf of the cluster or via health board discretionary funding.
Investment by clusters in additional pharmacists as an integral part of a prudent multiprofessional primary care workforce has been wide scale and is now accepted good practice across Wales. The Welsh Government, therefore, does not support the need for a nationally led formal evaluation of this now well established role.
Recommendation 6. The Committee recommends that the Welsh Government amends the Community pharmacy contract to achieve the necessary changes to release the full potential of the pharmacy sector and realise the aim of moving from a quantity to a quality based set of arrangements, and implementation timescales.
Accept
In October 2016, I announced the Welsh Government’s intention to make new contractual arrangements for community pharmacies which ensure in future they provide a greater range of clinically focused services and demonstrate a commitment to improving service quality. In 2017-18, we introduced new contractual arrangements which included 1) increased and ring-fenced funding for local commissioning of additional clinical services by health boards; 2) funding to support collaborative working between pharmacists and other healthcare professionals; and 3) a new quality and safety scheme for community pharmacies. Changes were funded through redistribution of £3.5million of contract funding from volume driven arrangements (i.e. dispensing) to the new quality focused elements.
For 2018-19, agreement has been reached with Community Pharmacy Wales to redistribute a further £3million to support further service commissioning, to strengthen and expand the collaborative working and quality and safety schemes and to support developing the community pharmacy workforce.
We will continue to transition to new community pharmacy contractual arrangements through annual negotiations with new arrangements fully in place by the end of 2020-21.
Recommendation 7. The Committee recommends that the Welsh Government plans for the emerging technologies in prescription packages facilitating the use of unopened medication when it does not compromise patient safety including the necessary legislative changes that may be needed, to ensure maximum advantages for any savings can be achieved.
Reject
Health boards already have local policies and procedures in place to maximise the reuse of medicines within hospitals in Wales. The controlled environment and limitations on access to medicines within hospitals allows medicines to be reused with a high degree of confidence that their integrity has not been deliberately or inadvertently compromised. The NHS Chief Pharmacists’ Peer Group is undertaking work to standardise these policies and to quantify the value of medicines reused within hospitals.
However, in the community, once a medicine has left the pharmacy, its safety and quality cannot be guaranteed. For example, there is a risk that the medicine container may have been tampered with, or the packaging may have been exposed to extremes of temperature and moisture, rendering it ineffective.
The Falsified Medicines Directive (FMD) supplemented by Delegated Regulation
(EU2016/161) from the European Parliament and Council which comes into force in February 2019, will require the packaging of medicines entering the supply chain on or after 9 February 2019, to be fitted with an anti-tampering device (in the form of a security seal). Whilst such anti-tampering devices address concerns regarding the deliberate adulteration of medicines, they do not address the concerns related to inappropriate storage of medicines and loss of effectiveness which may result. At the current time, the costs associated with temperature sensitive packaging are likely to be prohibitive to their widespread use, particularly when the low mean and even lower median cost of prescribed medicines is taken into account[1].
Furthermore, the FMD introduces new barriers to reuse of medicines. The FMD requires that at the point of supply to a patient, dispensers verify the authenticity of a medicine against a national data repository which contains details of legitimate medicines in the supply chain. Once this verification takes place, details of the medicine are removed from the repository and cannot be re-entered. This means where a medicine is returned to a pharmacy or re-dispensed by a pharmacy its authenticity cannot be verified, undermining the benefits of FMD.
Finally, the recommendation would require changes to the way in which both medicines and pharmacy professionals are regulated in the UK. Such matters are reserved to the UK Government.
Recommendation 8. The Committee recommends that the Welsh Government investigates ways of harnessing the academic expertise in Wales to understand the scale of Medicine Related Admissions and how to reduce them.
Accept
In January 2018, the Chief Pharmaceutical Officer established a short life working group (SLWG) comprised of medicines safety experts from across Wales to advise on the overall approach and programme required to drive improvements in medicines safety in the NHS in Wales. The SLWG, which brings together experts both from practice and academia, met in January and March and further meetings are planned for 2018.
The SLWG is currently examining sources of data, including but not limited to admissions to hospital, to determine an appropriate suite of measures of medicines related harm as the focus for a programme of work to improve medicines safety in Wales.
We recognise significant harm results from medicines related admissions (MRAs) but are concerned that a focus on post hoc quantification of MRAs would detract from actions to stop harm before it occurs. The identification of MRAs is made difficult by the presence of confounding factors in many cases, and robust assessments of the prevalence of MRAs have been limited to research studies. There is however, a good understanding of the medicines and situations most frequently associated with MRAs; the priority for reducing medicines related harm will be to address these.
The SLWG will conclude its work by October 2018 after which it will perform the role of steering committee for the national medicines safety programme.
Recommendation 9. The Committee recommends that the Welsh Government provide an update on the automated vending evaluation work which was due to have been completed by June 2017
Accept
A stocktake of the current use of automated ward vending machines in NHS hospitals in Wales was carried out in February 2017. In May 2017, a prioritised list of investments for automated ward vending was agreed with the NHS Chief Pharmacists’ peer group. We will write to the committee with details of the stocktake and the prioritisation exercise by the end of May 2018.
Recommendation 10. The Committee recommends that the Welsh Government coordinates a piece of work to share best practice from Health Boards relating to automated vending to help inform future decisions on medicine storage approaches.
Accept
A workshop on automated ward vending arranged by the NHS Chief Pharmacists peer group, took place in November 2017 and involved a wide range of stakeholders from across all NHS bodies in Wales. The workshop allowed participants to share the experience of implementing automated ward vending in Welsh hospitals and to discuss future approaches to utilising ward automated medicines storage. An initial report of the workshop has been produced and will be shared with the Committee as part of the comprehensive update on progress against the recommendations made by the Auditor General for Wales, in May 2018. Further work is now being undertaken to agree a set of principles for the further roll out of automated medicines storage. It is envisaged this work will be completed by October 2018.
Recommendation 11. The Committee recommends that the Welsh Government identifies whether any lessons could be learnt from NHS England relating to guidance on items which should not be usually be prescribed and the potential savings this approach may deliver.
Accept
The Welsh Government has reservations regarding the approach being taken by NHS England to restrict the prescribing of some medicines on the basis they are available to purchase ‘over the counter’ from pharmacies. Such measures have the potential to limit access to effective treatment particularly amongst people on low incomes, and therefore to widen inequalities. The Committee will wish to note the final guidance on this matter from NHS England, included a number of exemptions to allow GPs to continue to prescribe these medicines in specified situations.
We encourage NHS bodies in Wales to take measures to reduce unwarranted variation in prescribing and to restrict the prescribing of medicines of limited clinical value.
In June 2017, the Chief Medical and Chief Pharmaceutical Officers wrote to NHS Medical Directors requiring health boards to identify all GP practices in their area and any clinical area within secondary care, where co-proxamol was being prescribed, and to instigate the urgent review of patients with the intention of switching them to alternative, safer treatments
Subsequently in October 2017, the AWMSG issued guidance supporting restrictions to the prescribing of a further four medicines, with a combined annual expenditure of £5.4million in
2016-17) identified as low priority for funding in NHS Wales. Progress to reduce expenditure on these medicines will be tracked by the NHS Chief Pharmacists’ Peer Group and reported to the Welsh Government’s Efficiency, Healthcare Value and Improvement Group.
During 2018-19 the AWMSG will work with the NHS bodies in Wales to identify further opportunities to reduce expenditure on medicines of limited clinical value. The NHS England guidance will be considered in this work.
Recommendation 12. The Committee recommends that the Welsh Government produces a report on best practice on repeat prescription ordering by cluster groups within the care home settings to help inform policies and actions on repeat prescriptions.
And
Recommendation 13. The Committee recommends that the Welsh Government provides an update on the work of the prudent prescribing group in relation to its work on the various models for repeat prescribing systems in September 2018 to allow the Committee to monitor progress on this.
Accept
The work of the prudent prescribing implementation group (PPIG) was instrumental in identifying areas where repeat prescribing systems could be improved. Subsequent to Welsh Government officials giving evidence to the Committee in March 2016, the PPIG was stood down and responsibility for implementing the recommendations of the group and testing the various approaches recommended to improve repeat prescribing and reduce waste passed to the NHS Chief Pharmacists’ peer group.
The Welsh Government will collate, from each health board and Community Pharmacy Wales, evidence of the outcomes of various pieces of work being taken forward to improve repeat prescribing, including work to improve repeat prescription ordering within care homes, and provide the committee with an update on this work in January 2019.
Recommendation 14. The Committee recommends that the Welsh Government evaluates the roll out of Medicines Transcribing and e-Discharge system to consider the progress and the benefits of this approach.
Accept
There is a substantial body of evidence that shows when patients move between care providers the risk of miscommunication and unintended changes to medicines are a significant problem. Improving the transfer of information about medicines across all care settings reduces incidents of avoidable harm to patients, improves patient safety and contributes to a reduction in avoidable medicines related admissions and readmissions to hospital.
Evaluations of the benefits of the Medicines Transcribing and e-Discharge (MTeD) system have been undertaken previously by NWIS[2] and by Cwm Taf University Health Board[3] which demonstrate improvements in the quality and timeliness of discharge information being shared with patients’ GPs.
During the course of the Committee’s inquiry the availability of MTeD across NHS bodies in Wales has increased significantly with MTeD implemented in five and pre-existing edischarge solutions in place in two health boards. Further enhancements to the MTeD system are planned which will then facilitate its implementation in the two remaining health boards starting later in 2018-19.
We expect NWIS and health boards to have appropriate evaluation arrangements in place which ensure the anticipated benefits of the MTeD system are being realised. We will work with NWIS to ensure these evaluation measures form part of routine progress reports in relation to MTeD roll out.
Recommendation 15. The Committee recommends that the Welsh Government provide an update on the progress against the Auditor General’s recommendation on the GP record and the other outstanding recommendations in the Auditor General’s report.
Accept
Historically, access to the Welsh GP Record (WGPR) was restricted to emergency care settings such as accident and emergency departments. However since November 2016, pharmacists and pharmacy technicians working in hospitals in Wales have had full access to WGPR in planned as well as emergency care settings. This means doctors and pharmacists are now able to access the WGPR on elective wards and in outpatient clinics as well as in unscheduled care settings.
In November 2017, access to the WGPR was extended initially to four and subsequently to 11, community pharmacies providing the emergency supply of medicines national enhanced service. The results of this pilot are being evaluated by NWIS prior to rolling WGPR access out to all community pharmacies.
We will write to the committee providing an update on progress against the remaining recommendations made in the Auditor General’s report in May 2018.
Recommendation 16. The Committee recommends that as part of the Welsh Government’s commissioning and roll out of a new e-prescribing system, it develops a supporting plan of action to help achieve the cultural shift that needs to accompany the introduction of a new system.
And
Recommendation 17. The Committee recommends that the Welsh Government shares its action plan and key milestones for the Electronic Prescribing and Medicines Administration (EPMA) system with the Committee.
Accept
NWIS has established the Welsh Hospital Electronic Prescribing, Pharmacy and Medicines Administration (WHEPPMA) project to develop and implement the national plan for electronic prescribing in secondary care.
The project team is currently working with stakeholders to complete the business case for procurement of a replacement hospital pharmacy system and an electronic prescribing and medicines administration solution. The business case will be considered by the Welsh Government in due course. Subject to the completion of a satisfactory business case, it is expected that the procurement of these systems will be initiated during 2018-19 with implementation beginning in 2019. The action plan, including the actions required by NHS bodies to deliver the necessary business change to maximise the benefits of e-prescribing, and key milestones will be established by NWIS through the WHEPPMA project and subject to approval of the business case, we will ask NWIS to share their plans with the Committee.