Page 1

Agenda Item 04 Enclosure CKWCB/12/102

Report To:

Cluster Board

Title of Report:

Controlled Drugs Governance for CKW Cluster

FOI Exemption Category: Open

Responsible Director: Report Author and Job Title:

Dr Matt Walsh

Julie Landale, Head of Medicines Management

Executive Summary:

To propose a new governance structure for the management of controlled drugs across the CKW footprint

Finance/Resource Implications:

Marginal increase in travel expenses for staff required to travel further to attend meetings.

Risk Assessment:

Proposed governance arrangements rely on existing medicines management capacity across the cluster any further loss in capacity of medicines management teams may affect assurance process.

Legal Implications:

Statutory responsibilities, Misuse of Drugs Act 1971 and its related regulations and the Health Act 2006

Health Benefits:

Timely access to Controlled drugs administered, supplied and prescribed in a safe and secure manner.

Staffing/Workforce Implications:

Medicines management teams to work co-operatively across the cluster.

Outcome of Equality Impact Assessment:

No Impact

Sub Group/Committee:

CD Local Intelligence Network (CD LIN)

Recommendation (s):

To appoint Dr Matt Walsh as the Accountable Officer for controlled drugs for the CKW cluster. To agree to the formation of a West Yorkshire wide CD LIN. Approve that Leeds PCT is nominated as the legal entity which is accountable for the leadership of the West Yorkshire LIN.


Purpose of Report

To outline a proposal for the Cluster Board Executive Team on the future governance arrangements for the management of Controlled Drugs (CDs) across the CKW Cluster and the formation of a West Yorkshire wide Local Intelligence Network for the sharing of information and implementation of good practice.



The use of CDs are an essential part of providing high quality healthcare to patients. However the law relating to CDs must be upheld at all times and without exception by all providers of health or social care. The Health Bill 2006 contained a series of clauses intended to strengthen the monitoring and inspection of controlled drugs in health and social care settings as a result of the Shipman enquiry. These are statutory requirements for PCTs. This paper outlines the basis upon which the CKW Cluster will comply with the requirements of the Misuse of Drugs Act 1971 and its related regulations and the Health Act 2006 (Part 3). The key elements of the provisions are: The appointment of an accountable officer” (AO) Each healthcare organisation, NHS or private has a statutory responsibility to nominate an officer of sufficient seniority to ensure that the organisation has robust arrangements for the safe and effective management and use of controlled drugs. The named Accountable Officer is responsible to the board (usually an executive director), and should have knowledge in relation to controlled Drugs. In NHS primary care, PCTs will exercise this responsibility on behalf of all the contractors with which it has contracted to provide services. Organisations have a duty of collaboration to share intelligence and agree joint action where there is evidence of misuse of Controlled Drugs, with PCTs leading a local intelligence network (LIN). Authorised officers have a right of entry into all health and social care settings including GP premises in relation to Controlled Drugs. The Care Quality Commission is required to assess the performance of all healthcare organisations, public and private, in relation to these responsibilities. Authorisation of individuals to act as “authorised witnesses” for CD destruction by the Accountable Officer. Monitoring CD usage , assess and investigate concerns Powers to require declarations and self assessments


Current Arrangements

Currently each of the three PCTs in the Calderdale, Kirklees and Wakefield District Cluster have an identified Controlled Drugs Accountable Officer. Details of these individuals are registered with the Care Quality Commission on their website. The three PCTs in the CKW PCT cluster have been operating a Controlled Drugs Local Intelligence network over the area encompassed by the three PCTs since early 2007.


Proposal for new governance arrangements

With the formation of the Calderdale, Kirklees and Wakefield District Cluster Partnership which has a single board and governance structure it is sensible that a single executive director could take up the role of CD AO for the whole of the CKW cluster. For this to operate successfully it is essential that the nominated AO for the cluster has a robust infrastructure to support the function and legislative duties in each PCT with a named senior pharmacist having responsibility across the cluster to co-ordinate activities on behalf of the AO. 3.1

Accountable Officer for CKW

It is proposed that Dr Matt Walsh becomes the named AO for each PCT and is registered as such with the CQC so that he takes on responsibility for controlled drugs for the Cluster. This is necessary as Clusters are not recognised as the statutory body. 3.2

Co-ordinating CD Officer for CKW

It is proposed that this role is conducted by the Patient Safety Pharmacist based in Calderdale. This arrangement has been discussed and agreed in meetings held with Heads of Medicines Management and senior pharmacists across the Cluster. This role will include: Co-ordination and provision of a strategic overview of all legislative activities across the Cluster related to CDs Ensuring annual self assessments for CD management are completed by independent practitioners (GP’s and dentists) Collating summary reports of issues arising from self assessment reports Providing advice for investigation of incidents to Provider organisations Responsible for updating CD policies and documentation for CQC assessments Support for random CD inspections where relevant


Senior Pharmacist with operational responsibility at PCT level

This role is currently filled by senior pharmacists in place at each PCT. It is proposed that the regular monitoring of Controlled Drugs, incidents and random CD inspections continues to be provided by Medicines management teams in place at PCT level. 3.4

Community Pharmacy CD incident investigations

Investigation and follow up of general community pharmacy incidents are being co-ordinated across CKW by the senior pharmacist (community pharmacy) based in Calderdale. There is no reason why this cannot be extended to CD incident advice and follow up. It is therefore proposed that community pharmacy CD incidents are reported to the CD coordinating officer who will then involve the senior pharmacist (community pharmacy) as appropriate. 3.5

CD Local Intelligence Network (CD LIN) management

Locally there are two CD LINs in West Yorkshire one covering CKW and one covering Airedale, Bradford and Leeds (ABL). Local Intelligence Networks for Controlled drugs can cover more than one PCT as long as it is clear which PCT is leading. Combining the operation of the West Yorkshire LINs and the supporting infrastructure would have significant advantages being: Intelligence will be collated and analysed from a wider area. Elimination of duplication of effort. Retention of the organisational memory for the clusters’ legacy to the CSO or NHS CB. Resilience generated by pooling expertise. Uniformity of procedures. Information sharing at the LIN is underpinned by a culture of openness and trust. The operation of a single LIN for West Yorkshire will require a period of managed transition to ensure this culture is maintained. The framework of operation used by each LIN in West Yorkshire is essentially the same being based upon a common template produced by the National Prescribing Centre. Initial discussions at both ABL and CKW LINs have been supportive of this approach. 3.5i

Operation of WY wide CD LIN

Membership of the group would contain key representatives of relevant organisations as it does now but there would only be the need for one senior pharmacist representative for ABL and one for CKW cluster rather than one representative for each PCT as is the current arrangements. There is a need to ensure information is held centrally rather than fragmented

across the CD LIN area so it would be ideal if there were a single reporting point. This would facilitate trend analysis. In addition it would avoid confusion as to where reports are sent, and how lines of communication are effectively maintained. It is proposed that the Leeds Senior pharmacist takes on operational responsibility for this.


CD LIN Chair

It is proposed that CD Lin meeting venues are rotated between ABL and CKW and that the accountable officer (or their deputy) in the respective geographical area will chair the LIN. It is proposed that there will be 6 meetings per annum, three in each respective location to enable easy access for provider organisations to attend and share learning. 4.0

Next Steps

4.1 A workshop has been arranged between the ABL and CKW existing CD LINs to facilitate closer working relationships and sharing of best practice. 4.2 A meeting has been arranged for all Heads of Medicines Management (HoMMs) and their IT colleagues to obtain consistent CD reporting and monitoring across West Yorkshire 4.3 Agreement has been obtained from all HoMMs to share CD polices and documentation and amalgamate to form one set of policies and procedures across West Yorkshire. 5.0


The PCT Governance Committee considered this paper at its meeting on 15th February 2012. It accepted the recommendations made in the paper and asked that the paper be submitted to the PCT Cluster board for formal approval. The board is asked to: i.

Approve the appointment of Dr Matt Walsh as the Accountable Officer for Controlled Drugs for the CKW cluster PCTs.

ii. Indicate support for a move to a West Yorkshire LIN. iii. Approve that Leeds PCT is nominated as the legal entity which is accountable for the leadership of the West Yorkshire LIN. 6.0


A flow chart which depicts the governance arrangements for CD legislation in the CKW cluster.

Accountable Officer CKW (Matt Walsh)

WY CD LIN (ABL Cluster CKW Cluster)

Occurrence Reports to West Yorkshire CD Lead (Tony Jamieson ABL)

Deputy Accountable Officer (Julie Landale)

Coordinating CD Officer CPCT (Helen Foster) Monitoring CD’s, follow up investigations and incidents, CD visits

Head of Medicines Management WPCT (Joanne Fitzpatrick) Monitoring CD’s, follow up investigations and incidents, CD visits

Senior Medicines Management Advisor KPCT (Eric Power) Monitoring CD’s, follow up investigations and incidents, CD visits

Health and Social Care Providers CKW Provider Organisations, Hospices, YAS