Y Pwyllgor Cyfrifon Cyhoeddus / Public Accounts Committee

PAC(5)-17-17 P1

Cwm Taf UHB Response To The Auditor General For Wales Report - Managing Medicines In Primary And Secondary Care, December 2016.

Written Evidence for Public Accounts Committee June 2017

The Welsh Audit office (WAO)Report into Medicines Management in Acute Hospitals in 2014-15 concluded that for medicines management in Cwm Taf:  “Overall corporate arrangements are strong and working relationships are good but opportunities exist to strengthen some medicines management processes, increase the use of technology, address some facilities issues and broaden performance monitoring”.

1. What action is your Health Board taking in minimising medicines wastage?

Some medicines waste is inevitable as medicines may have to be stopped due to adverse effects or patients conditions change and require different or no medicines.

Medicines legislation and regulation does not support the reuse of medicines once dispensed to a patient.

In 2007, the National Audit Office in England estimated the value of waste medicines to potentially be as high as 10% of the overall NHS drugs bill in the community.  In 2010, this gave rise to an estimate for NHS Wales of £50m per annum or £5M for CTUHB. Other studies have estimated a 4% value of waste medicines and of that less than 50% is economically recoverable/cost effectively preventable.

Cwm Taf UHB recognised that medicines waste is an indicator of:

· patients not taking their medicines as intended (non-adherence) and

· Efficiency of medicines prescribing & supply systems in both primary and secondary care.

Actions being taken to address each of these issues are:

Patients not taking their medicines as intended

CTUHB has established a medicines campaign: Your Medicines Your Health (YMYH).

TAKE THEM IF YOU CAN, TELL US IF YOU CAN'T

YMYH uses behavioural science to inform a structured range of interventions. The purpose of these is to increase the responsible use of medicines by patients and the public. In doing this YMYH promotes self-care, self-reliance and independence.

Key objectives:

· Improve medicines compliance/ adherence

· Improve communication and encourage co-production

· Reduce medicines waste

· Improve patient outcomes

The WAO Report identified Cwm Taf YMYH as good practice “A national campaign called Your Medicines, Your Health is being led by Cwm Taf University Health Board on behalf of all health bodies, with the aim of changing public attitudes to their medicines. Actions taken in Cwm Taf have included a campaign to persuade patients to return unwanted and out-of-date medicines to community pharmacies (see Exhibit 10), the inclusion of campaign messages on bags used to dispense medicines to patients and awareness raising sessions with schools. Cwm Taf is currently evaluating the campaign and discussions are ongoing between Chief Pharmacists in Wales about how to further bolster approaches to minimising wasted medicines”.

The Chief Pharmacists have recently agreed to roll out elements of the YMYH campaign across Wales.

Key deliverables are:

YMYH schools art project– this is a collaborative scheme with Artis Cymru and the artist in residence of the HB using creative practice to promote life-long learning about safe and effective use of medicines.

 A teaching pack for years 5 & 6 has been developed and approved by education leads in RCT and Merthyr Tydfil. It is currently being rolled out to all Cwm Taf primary schools by school nurses.

Positive discussions are also taking place with the WG education curriculum leads which will hopefully see it included in the Welsh national curriculum for healthy living education across Wales.

Awareness Campaign and public messaging – This is a mulitfactorial campaign approach to raising awareness of good medicines use and management. Methods such as face to face talks, promotional posters and aids, social media . YMYH brand identity underpins all work. There have been over 30,000 face to face contacts to date.Evaluation has been done via public surveys (questionnaires) to 500 people who have had contact i.e came to a promotional stand or attended YMYH face to face sessions. This has been repeated once with a 6 month interval. Results indicate a positive awareness of the YMYH brand which increased after 6 months and also demonstrated understanding of the key message take them if you can tell us if you can’t.

See Appendix 1 for examples of media campaign

Spring Clean Your Medicines Campaign – A targeted, repeated, time specific campaign to increase awareness of medicines adherence and cause a measured action of returning any stockpiles of medicines waste to your community pharmacy. 3 years of measures have indicated increasing returns of waste medicines following the campaign compared to the years prior to the campaign. This campaign highlights to the public where they are accruing more medicines than they need, supports them to talk to a healthcare professional about it and prompts community pharmacy to conduct an MUR or discuss the medicines use with the person. CTUHB has a domiciliary MUR service supporting pharmacists to visit patients in their own homes/care homes.

Self referral to Medicines Use Review in community pharmacy- This is a Bevan Exemplar project to encourage the public to self refer to community pharmacy for a medicines use review.

Other actions in the HB include: CTUHB has cluster based pharmacists and primary care advisor pharmacists and pharmacy technicians working in and with GP practices. They provide medicine reviews with patients in practices and in home/care homes. The review will identify medicines no longer required, reducing poly-pharmacy and will also support patients to better manage their medicines and medicines adherence.

Through research the HB is also exploring the barriers and enablers to the

re-use of medicines. An initial paper has been published as part of an MSc and has stimulated ongoing research with Cardiff University: The redistribution of medicines: could it become a reality?, IJPP, vol 26, issue 6, Dec16.

Efficiency of medicines supply systems in both primary and secondary care

In Secondary care the HB has established medicines logistics systems managing the procurement, supply and storage of medicines across all the HB wards and departments. The percentage of medicines waste as a total of medicines cost is 0.085%. From NHS benchmarking, CTUHB has a very low medicines waste average per admission compared to other HBs and Trusts in Wales and England, Cwm Taf is the red line:

Medicines waste is reduced to a minimum through efficient stock management systems to ensure high stock turnover and reduced ward stock levels, monitoring through KPIs. Automated pharmacy storage systems are in place in each pharmacy department in the HB and automated ward storage systems are in place in all A/E & ITU departments with a plan to install in ward areas and tracking of medicines use, regular review of medicines prescribing and close working with prescribers by pharmacy staff.

The HB encourage the use of patients own medicines on admission to hospital, through collaborative work with Welsh Ambulance using the green bag scheme and the “message in a bottle” scheme.

Primary care prescribing advisor pharmacists and technicians support GP practices to develop and implement repeat prescribing procedures and processes. Arrangements such as repeat dispensing schemes with community pharmacies are in place, where patients are contacted prior to each repeat to check if they need that medicine or not.

The Prudent prescribing Group lead is based in CTUHB and is developing a new Batch Repeat Dispensing service in Wales. The Rhondda locality will pilot the new service. This aims to reduce the potential for medicines waste, reduce the burden on GPs and provide a streamlined service for patients.

CTUHB has commissioned a community pharmacy medicines waste reduction scheme, where community pharmacies are incentivised to stop medicines no longer required, if appropriate. This scheme saved over £50K in 2016-17.

In acute care waste is minimised through use of dose banding for aseptically prepared medicines, which will further increase with the adoption of this model across Wales.

2. What actions is your Health Board taking to implement prudent prescribing principles?

CTUHB has provided the lead for the prudent prescribing implementation group in Wales (PPIG). PPIG identified actions have all been implemented in CTUHB:

Care for those with the greatest health need first, making the most effective use of all skills and resources -

Primary care Cluster pharmacists: Cwm Taf contributed to the development of an all Wales Job description and models of care document for the implementation of new pharmacist advanced practitioner roles working in GP practices and primary care clusters.

In Cwm Taf we initially recruited 5 WTE pharmacists to 2 primary care clusters, due to their success we now have over 12 WTE pharmacists across three clusters. Their work to date has focussed on care home residents and addressing polypharmacy, medication reviews, triaging acute requests, managing transfer of care medicines issues and engaging in innovations such as the virtual ward scheme in a practice.

Cwm Taf provided short term secondments to the Welsh Centre for professional pharmacy education (WCPPE: who develop and deliver postgraduate training to pharmacists) to enable early, consistent and now on-going development & training for these new Cluster pharmacists across Wales.

All the cluster pharmacists are either Independent prescribers or working towards this qualification.

Cynon Valley community pharmacist Independent Prescribers:

Cwm Taf secured funding from WG to train five community pharmacists as independent prescribers. They all successfully completed their training in 2016-17 and have continued to supplement the cluster pharmacists and support medicines management initiatives. This makes better use of the community pharmacy workforce and enables them to become more integrated with primary care colleagues and health board.

In addition CAMHS have implemented an innovative role for pharmacist prescriber in the specialist area of ADHD prescribing.

Urinary Catheter supply service redesign:In 2013 Cwm Taf redesigned the way in which urinary catheters are prescribed and supplied to patients. Previously catheters and associated products were prescribed by GP’s with little specialist clinical review and follow up. Specialist nurse practitioners were recruited and trained and independent prescribers. The responsibility for prescribing and review was transferred from GP’s to the specialist practitioners over a period of several months. Analysis of prescribing data has shown that expenditure has been reduced by approximately £200k over the two years following implementation and patient satisfaction studies have indicated that patients are happy with the new service.

Specialist Cardiology Pharmacist Primary Care Arrhythmia clinics: The Merthyr Tydfil primary care Cluster is developing community cardiology clinics. A secondary care advanced practice cardiology pharmacist and independent prescriber is currently training to provide an innovative role in the arrhythmia clinic which otherwise is undertaken by consultant cardiologists or GPs.

Smoking cessation: Cwm Taf have led the development of community pharmacy smoking cessation services across Wales.  50 pharmacies within Cwm Taf now provide this service, and from June 2015 pharmacists have been able to offer Varenicline in addition to Nicotine replacement therapy as a treatment option to patients accessing the service. There is strong evidence to support community pharmacy as a cost effective way of encouraging citizens to stop smoking. Prescribing costs of smoking cessation products have reduced in Cwm Taf by £140k over the last two years and quit rates via the pharmacy service are comparable with other NHS smoking cessation services. Cwm Taf health board are looking to further expand this service focussing on those areas with the greatest need.

Common Ailments Scheme (CAS) – Choose Pharmacy

CTUHB was an initial pathfinder site for this initiative. The Choose Pharmacy IT platform has been installed in all the HB 70 community pharmacies and the Common Ailments scheme has been commissioned in two localities in 2016-17, with the roll out to the remaining localities underway. The HB is expected to be the first in Wales to offer this scheme for all its areas by summer 2017.

The CAS will divert patients away from GP practices for appropriate common ailment conditions; community pharmacists will provide advice, treatment or referral as needed.

Do only what is needed, no more, no less; and do no harm:

Medication Safety Indicators Dashboard

Cwm Taf has led on all Wales development of Medication Safety Indicators which are reported on the Health and Care Monitoring System (formerly fundamentals of care system).

The four indicators are: allergy documentation, VTE risk assessment documentation, medicines reconciliation within 24 hours of admission and omitted medication.  The data is collected by pharmacy staff once a month by randomly sampling 10 in-patient medication charts on each ward.  The data is collated electronically using the “Teleform” software and automatically uploaded into the system. Cwm Taf has the highest level of compliance with VTE risk assessment documentation in Wales (>85%)

Reduce inappropriate variation using evidence based practices:

NICE do not do’s:  As part of the work of the prudent prescribing implementation group (PPIG) Cwm Taf worked with colleagues in the all Wales toxicology and therapeutics centre (AWTTC) to develop a list of therapeutic products that are being prescribed in Wales despite the fact  that there is little or no evidence base for their use. Fourteen products were identified and Cwm Taf led on the development of all Wales procedures and protocols that will allow clinicians to review patients being prescribed these medicines.

 Across Wales expenditure has reduced by £576k (25%) over a 2yr period. In Cwm Taf costs have reduced by approximately £82k (31%). The costs continued to decrease in 16-17.

Another example of a drug which is not recommended due to patient safety concerns is co-proxamol. CTUHB has the lowest prescribing:

Antibiotic prescribing: Cwm Taf have employed two antimicrobial pharmacists.

They have a remit to manage antibiotic prescribing in primary and secondary care.

The initial focus has been to improve the choice of antibiotic prescribed to support

controlling C.difficle and antimicrobial resistance. CTUHB has the lowest C.Difficle rate

in Wales.

New antimicrobial guidelines for all clinical and primary care areas have

been implemented and installed on a Microguide telephone APP. Secondary care KPIs

have been developed and are reported to clinical directorates on a regular basis.

CTUHB has an action plan in response to Public Health Wales AMR Implementation

Plan and is engaged in the implementation group (AMRIG).

The AMS agreed plan identified the top ten highest prescribing GP practices and these were prioritised for specific interventions in response to their audit results. This strategy was prioritising those with the highest variation from the Cwm Taf average, with the intention to reduce variation first and then reduce the average. Prescribing patterns for the first GP practice in which the intervention was implemented demonstrated a 10% reduction in antimicrobial items prescribed and a 50% reduction in cephalosporins and quinolones (see table 1).

  Table 1 – First GP practice AMS actions Headline Results

Antimicrobial Prescribing January to August 2016 vs 2015
Total antibacterial items DOWN	-9%
Broad spectrum penicillin items DOWN by a QUARTER	-23%
Cephalosporin Items HALVED	-53%
Quinolone Items HALVED	-58%
Nitrofurantotoin items UP by a QUARTER	27%

There has been a positive change in the prescribing of targeted antimicrobials:

National Primary Care Prescribing Indicators 2016-17

Summary Of Cwm Taf Position For Primary Care Prescribing:

Indicator	Target / Prescribing aim	2016/17 quarterly trend	Cwm Taf position in Wales (1^st = best performing HB)		Cwm Taf change Dec qtr 15 v 16
			Dec qtr 2015	Dec qtr 2016
Antibacterial items per 1,000 STAR-PU	Decrease	p	6th	7th	1.34%
Co-amoxiclav items per 1,000 patients	Decrease	q	6th	6th	-17.5%
Co-amoxiclav items  % of total antibacterial items	Decrease	q	7th	6th	-18.7%
Cephalosporin items per 1,000 patients	Decrease	q	7th	7th	-0.61%
Cephaloproin items  % of total antibacterial items	Decrease	q	7th	7th	-1.99%
Fluoroquinolone items per 1,000 patients	Decrease	p	3rd	3rd	4.53%
Fluoroquinolone items  % of total antibacterial items	Decrease	p	2nd	2nd	3.08%

An innovative pack for nurses to understand their role in antimicrobial stewardship was recognised by the AMRIG as best practice in Wales and CTUHB achieved funding from AMRIG to implement their novel “Antimicrobial Myth Busting” education session for the public using behaviour change science.

The more significant challenge is to reduce the volume of prescribing. Work in secondary care to reduce surgical prophylaxis continues for longer than 24 hrs has begun. We are working with 1000 Lives on a behaviour change project to support the introduction of an antimicrobial sticker encouraging the clinical review of prescribing.

CTUHB has the highest volume of antimicrobial prescribing in Wales. Engaging both the public and prescribers is essential.

Hypnotics and Anxiolytics

CTUHB has historically been the highest prescribers of this class of medicines. Targeted interventions by pharmacists and GPs have resulted in decreasing prescribing rates. The table shows CTUHB moving from the highest to a third highest prescribing rate:

Targeted interventions in a GP practice can have significant outcomes as below:

CTUHB has collaborated to implement the innovative Valley Steps Scheme. This scheme has the reduction in antidepressant prescribing volume growth as one of its objectives. The prescribing of antidepressants are closely related to anxiolytics and hypnotics and we predict a reduction in all these medicines.

Tramadol

CTUHB has high prescribing rates of this medicine which has patient safety concerns and is a prescribing indicator for decreased prescribing rates.

Interventions in both secondary and primary care are required to produce a decreased Tramadol burden across the HB. The chart details the secondary care use reduction:

3. What actions is your Health Board taking to address issues associated with medicines administration, storage and recording that originated from the Trusted to Care Report?

CTUHB developed an action plan in response to the Trusted to Care Report and progress is monitored through the Quality and Patient Safety Committee.

Actions completed include:

· All pharmacy staff received an update on professionalism and patient dignity, which is included in induction of all new pharmacy staff

· Implementing medicines safety KPIs and dashboard,

· Revising and implementing the medicines management policy and administration procedure

· implementing a self administration policy for insulin,

· Implementing a covert medicines policy

· Implementing automated storage on high risk ward areas

CTUHB developed and led on the All Wales Medicines Safety Dashboard a screen shot is below:

A risk assessment on medicines storage on wards has been conducted and found to be low risk, with cupboards deemed safe and secure. The Health and care standards audit demonstrated 99% compliance with medicines storage: drug trolleys and cupboards locked and secure.

Automated medicines storage cabinets have been installed in areas of higher risk such as A&E departments.  Enhanced medicines stewardship (including antimicrobials, opiates & drugs liable to misuse) will be facilitated by automated medicines storage.  Bids have been made to the all Wales Pharmacy Modernisation Fund for additional cabinets for these higher risk drugs.

There is a standard operating procedure in place for recording and monitoring ward fridge temperatures.  A further business case has been submitted to the Pharmacy Modernisation fund for automated monitoring systems, which will provide robust governance and timely reports.

The storage of medicines within the pharmacy is robust utilising automated storage units, restricted access, temperature controlled environments and electronic monitoring of fridge temperatures with direct alerts to pharmacy staff both within and out of hours.

The electronic discharge Advice Letter system (MTeD/eDAL) has been implemented on all acute medical and surgical wards and community wards in the HB, specialist areas such as Mental health and paediatrics are in progress. The screen shot below is taken from a Qlick App where the eDAL data is loaded to allow clear information regarding use and patient flow to be easily extracted. The graphs demonstrate the increasing number of electronically produced DALs, when they are completed and the discharges before midday.

The number of discharge MURs completed by community pharmacists continue to rise in the HB area and this will be supported when the eDAL connects to the choose pharmacy system across the HB community pharmacies.

The table shows an increasing number from 15-16:

4. The progress for your Health Board for considering or implementing the Auditor Generals recommendations (recommendations below)?

The report in appendix 2 was presented to the CTUHB Audit Committee in April 17. Regular updates will be provided for identified actions.

Appendix 1: Your Medicines Your Health Cwm Taf TV slides

Cwm Taf Response to the recommendations contained in the report of the Auditor General for Wales entitled “managing medicines in primary and secondary care” 2016

Recommendation	Welsh Government Response	Health Board Response Feb 2017
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.	The HB is engaged in the All Wales project and has included the resources required (as detailed by NWIS) in the medicines management IMTP. The HB is ideally placed to pilot the project building on the track record for implementing and developing the eDAL system. CTUHB will have completed the roll out of eDAL to all acute medical and surgical wards and community wards by July 2017. Specialist wards such as mental health are being addressed individually to tailor to their needs.
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.	The HB will develop a time bound plan for improving storage and security of medicines on hospital wards. The HB has installed automated vending machines in higher risk ward/dept areas. The 17/18 plan is to focus on improved automated storage for high risk medicines in general ward areas. Further capital investment will be sought from WG pharmacy modernisation fund for more automated vending machines as identified in the prioritisation plan. A SON has been submitted to capital for  and automated fridge monitoring system for ward fridges. A risk assessment of all ward medicines storage areas has been conducted. No high risk issues were noted.
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.	The Chief Pharmacist directly reports to The Executive Director of Primary Care and Mental Health in CTUHB. There is a specific medicines management IMTP section which details the all areas in the recommendations. The Primary Care Committee receives a regular medicines management primary care report and the Q&PS Committee receives an exception report at each meeting – which has a specific section on Trusted to Care. The Medicines Management and Expenditure Committee is the main governance group of the HB. It reports directly to the Q&PS Committee.
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.	CTUHB has initiated, developed and leads on the all Wales resource mapping process. This annual data collection allows comparison of staffing levels and activity across all HBs in Wales. The workforce requirements are detailed in the IMTP for medicines management. CTUHB will engage with WEDs in a more robust pharmacy workforce assessment process.
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.	CTUHB Chief Pharmacist is engaged in the All Wales Chief Pharmacists collaborative work in the six areas described. CTUHB provides the leadership to deliver the Prudent Prescribing implementation group actions. A revised repeat prescribing model will be piloted in CTUHB in 2017. A care home enhanced service will be included in the community pharmacy development strategy review. A primary care prescribing plan is included in the financial efficiencies plan. A revised Primary care prescribing incentive scheme is being progressed to include quality interventions. CTUHB is the pacesetter for Your Medicines Your Health Campaign and will focus on evaluation to support a wider roll out in the next year. The All Wales Chief Pharmacists have agreed the roll out of YMYH. A briefing on the national prescribing Indicators has been provided to the Primary care Committee and Executive Board. GP practices have a local view included in their annual prescribing review meeting.
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.	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.	No action required from HB
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.	CTUHB will engage and undertake an audit of homecare services (delivery of specific medicines directly to patients by external providers). An invest to save case has been approved by the HB to further develop and ensure compliance with standards for homecare services.
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.	The CTUHB Medicines Safety officer will engage with 1000 Lives in this process.
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.	CTUHB pharmacists and technicians access the GP record for patients on admission, data shows an increasing trend. The eDAL is increasingly being sent to community pharmacies as the Choose Pharmacy IT system is rolled out across the HB. The Choose Pharmacy system has been installed in all CTUHB community pharmacies allowing all community pharmacies to be in a position to access the GP record as access is increased.
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.	The HB Chief Pharmacist works closely with the CPhO and other Chief Pharmacists in Wales to enable improved planning and preparation for access to new medicines. In response to the New Treatment Fund the Chief Pharmacist has submitted a case for resources to ensure the timescales for access to new medicines are complied with. The current monitoring shows compliance with NTF requirements in all but one new medicine ( 2 days over the target).