Pharmacy and Medicines Optimisation Team Plans
Herts Valley CCG (HVCCG) have a Pharmacy & Medicine Optimisation Team section on their website which can be accessed here.
The Pharmacy and Medicines Optimisation Teams send regular updates to Herts Valleys CCG (HVCCG) Locality Community Pharmacies to help inform community pharmacies of their plans within the practices of HVCCG. Copies of communications sent to the LPC can be accessed below:
Generic macrogol oral powder sachets and brand Movicol® switch to Cosmocol® sachets
Herts Valleys CCG is promoting switching from Movicol® and generic macrogol oral powder sachets to Cosmocol® sachets. Please note that Laxido® remains as a first-line product but Cosmocol® is an alternative first-line option due to range of flavours and the ‘half-strength’ product available. In GP practices the switch will be active on ScriptSwitch from 12 April 2019.
Stoma Accessories: deodorants, skin cleansers, filters, bridges and bag covers
Herts Valleys CCG does not support the prescribing of the following stoma accessories: deodorants, skin cleansers, filters, bridges and bag covers. Please see the following link to a stoma accessories position statement, which has been developed in collaboration with the stoma care nurses at West Herts Hospital Trust. Patient letters to support this work can be found on the CCG website.
Oxycodone Prolonged-release (PR) preparations to Oxypro® PR capsules
Herts Valleys CCG aims to deliver savings in prescribing through promoting clinical cost effectiveness. The following switch has been agreed for implementation at the latest Herts Valleys CCG Medicines Optimisation Clinical Leads meeting:
- Oxycodone prolonged release (PR) preparations to Oxypro® PR capsules
The CCG is giving community pharmacies 56 days’ notice of this change as this is a controlled drug and understand storage facilities may be limited. The notice period will end on 31 May when the message to GPs will go live on Scriptswitch.
Gluten Free Foods policy update
Following revised regulations which allow for no gluten free products to be prescribed at NHS expense other than certain gluten free breads and mixes, the Herts Valleys CCG Gluten Free Foods Policy has been updated. The principles of this policy remain unchanged, i.e. routine prescribing of any gluten free products is not recommended. The only change is for those patients who are exceptions to the policy as pasta products are no longer prescriptible. The updated policy can be found here.
Please note: Patients with metabolic disorders such as phenylketonuria (PKU) are excluded from Herts Valleys CCG’s Gluten Free Foods policy. These patients require prescriptions of low protein foods, which happen to be gluten free, as it is important that they follow a low protein diet. Therefore patients with metabolic disorders who require low protein foods should not have their prescriptions stopped.
Food for Thought; Nutrition and Hydration at End of Life Study Day
Here is a leaflet for the upcoming Food for Thought study day, focussing on nutrition and hydration at end of life.
The study day is to take place on Thursday 14th March 2019, 9:30am – 4:30pm. Details of how to reserve your place are contained within the flyer.
Falsified Medicines Directive
The consultation regarding the final features required of the Falsified Medicines Directive (FMD) has been completed and published.
Below is also a recent update on the FMD from Keith Farrar, Senior Responsible Owner, Value from Medicines, NHS England:
“The consultation about penalties and sanctions talked about a 2 year custodial sentence and an unlimited fine … but this was for individuals engaged in the production of counterfeit medicines. There is widespread understanding that the introduction of FMD will have a long ‘lead-in’ period, in that products manufactured and supplied into the market before Feb-2019, do not need to comply with the packaging regulations and, even if they did, would not (necessarily) have shared the relevant data with the European Medicines Verification Organisation (EMVO) or the UK’s National Medicines Verification Service (NMVS) to support any ‘verification’ process; and there is no legal requirement to ‘decommission’ such products.
The most logical approach is for this functionality (ability to verify and decommission) to be incorporated into normal workflow through changes to existing ‘dispensing’ and related systems. This work is underway and is making good progress and should ideally obviate the need for the purchase of standalone systems.
The contract to provide the link to the central NMVS (provided by SecurMed) was awarded to Arvato in July 2018. There are approximately 30,000 organisations that need to link to this service and the process of ‘on-boarding’ all of these organisations will take time (and may not be complete by Feb-2019).
Should the current Brexit negotiations fail to reach an agreement (no-deal Brexit) the government would need to repeal the FMD regulations (as data from the EMVO would not be available) and introduce an alternative national system (which will take time).
Organisations need to be making their best endeavours to ensure that they can comply with the directive and we continue to work with suppliers to ensure that a solution is available to meet user needs.”
Also see the letterfrom Keith Farrar providing further information. The MHRA Implementing the Falsified Medicines Directive: Safety Features contains additional information and resources. Please contact your PMR supplier to find out more about the FMD software and equipment available. Alternatively, you may contact NHS Digital if you have any further concerns.
EU Exit Preparations
Please see the letter which requires no immediate actions but details national contacts in the event of a no-deal Brexit.
Good Practice Guidance in Care Homes – Medication Cycle
The Good Practice Guidance for Medication Cycle and monthly medicines ordering via FP10 paper prescriptions & electronic prescriptions (EPS) has been published by the CCG. This guidance provides a framework for care home staff, pharmacy and GP practice staff responsible for ordering and processing of medications for patients in care homes. This is to ensure a safe and efficient monthly prescription process that ensures compliance with NICE guidance on managing medicines in care homes, minimises errors and waste in ordering and timely delivery of medicines. This guidance will be circulated to care homes and GP practices within HVCCG.
17.12.2018 – Further update on adrenaline auto-injector supply issues
Last week an update was issued on the supply disruption of adrenaline auto-injectors. Stock positions are now sufficient to allow further relaxation of the prescription validation protocol for Jext® and Emerade® paediatric devices, whilst prescription validation will still be required for EpiPen® Junior devices. Pharmacies will no longer need to use flowcharts to determine if a patient should receive a supply of AAIs (including EpiPen® Junior) and can fulfil prescriptions as they are received.
For prescriptions that were partially dispensed in October using the original protocol, these will have been marked ‘closed’ with the quantity supplied clearly marked and sent to the NHS Business Services Authority. These cannot be used to get a further supply for the patient. The patient will need to get a new prescription to obtain any further supplies. GP practices in Herts Valleys have been advised in these scenarios to issue one device only via the ‘acute prescription’ route.
02.11.2018 – European Antibiotic Awareness Day (EAAD; 18th November 2018) and World Antibiotic Awareness Week (WAAW; 12 – 18 November 2018)
Community Pharmacists are important partners in the work to tackle Antimicrobial Resistance (AMR); Herts Valley CCG THANK YOU for your on-going effort in tackling AMR. Its is European Antibiotic Awareness Day (EAAD; 18th November 2018) and World Antibiotic Awareness Week (WAAW; 12 – 18 November 2018) and you are encouraged to use EAAD, WAAW and Antibiotic Guardian materials to help improve antimicrobial stewardship locally and launch plans for awareness raising or educational events at your pharmacy.
12.10.2018 – Benzodiazepines and risk of suicide – memo from HMMC. In a recent letter to mental health providers from NHS England and NHS Improvement, the potential risks of suicide associated with benzodiazepine prescribing and withdrawal were highlighted. In view of this letter, please find here a memo from HMMC. This reminds all prescribers of good practice when prescribing and withdrawing benzodiazepines and encourages consideration of the need to seek specialist advice from the local substance misuse service, CGL Spectrum.
Update on EpiPen® and EpiPen® Junior supply issues. Unfortunately, supply issues with EpiPen® and EpiPen® Junior continue and look to continue for some months. Supply of alternative adrenaline auto-injectors (AAIs), i.e. Jext®, Emerade®, are in flux. Here is a supply disruption alert about EpiPen® and EpiPen® Junior recently issued by the Department of Health and Social Care. Actions for healthcare professionals regarding prescribing of AAIs during this time are contained with the alert. Please note the following advice within the alert: Patients should be advised not to dispose of their expired devices until they have replaced them. This is because AAIs will not actively cause harm if used after expiry but they may be less effective at treating the anaphylactic episode as the potency of the adrenaline gradually reduces (and is also dependent on the conditions they were stored in). It is still preferable to use a device even if it has expired, rather than no device at all, if an in-date device is not available. A dedicated page on the Specialist Pharmacy Service website (https://www.sps.nhs.uk/articles/shortage-of-epipen/) contains information about the EpiPen® supply situation, as well as recommended courses of action, which will be posted and maintained as new information becomes available.
31.08.2018 – Diamorphine injections – Supply issues update and patient information
Update on the diamorphine supply issues from the Department of Health.
Diamorphine 5mg and 10mg Injection
Accord: are still out of stock of diamorphine 5mg and 10mg injection, but have advised that new stock of both strengths will be available during the w/c 27th August. There are further deliveries scheduled for both strengths through September, October and the coming months.
Wockhardt: still have supplies available, but they cannot support the full demand for primary and secondary care.
Supply issue should hopefully be resolved by early September.
Until this time therefore please continue with the management plan:
Primary care and drug misuse centres will be able to continue to order diamorphine in line with historical demand.
Secondary care will have access to limited supplies of diamorphine
Recommended Local Action – Primary care and drug misuse centres
- Although you will be able to access diamorphine as per historical demand , prescribers are encouraged to be aware of the supply issues and reduce prescribing where appropriate.
- Please order responsibly during this time, in line with historical demand and do not stock pile to avoid lengthening the stock out period.
- In the case that diamorphine cannot be accessed, please refer to the clinical guidance issued by UKMI which provides more information on suggested alternatives to diamorphine: https://www.sps.nhs.uk/articles/shortage-of-diamorphine-5mg-10mg/. The first-choice is morphine which is given in detail in this link. If you require clinical guidance locally – please liaise with secondary care prescribing partners in substance misuse services or pain specialist services.
- Further information which you may wish to review includes the Patient Safety Alert on high dose morphine and diamorphine http://www.nrls.npsa.nhs.uk/resources/?entryid45=59803
- Diamorphine 5mg and 10mg will only be available to order from Alliance. No minimum surcharges will be levied
- Morphine 10mg injection (Martindale) available to order from AAH only.
- Diamorphine 30mg injection (Wockhardt), diamorphine 100mg (Accord) and diamorphine 500mg (Accord and Wockhardt) – usual wholesalers.
For further information on ordering processes please contact:
Alliance – Phone Number: 0330 1000 448 – email@example.com
AAH – Phone Number: 0344 561 8899
10.08.2018 – Updated guidance on Prednisolone for patients requiring soluble tablets or liquid formulation, attachment
Herts Valleys CCG aims to deliver savings in prescribing through promoting cost effective use of medication. Crushing and dispersing plain prednisolone tablets offers the lowest cost option where patients need a liquid formulation and is therefore the first line recommended option. In clinical situations where it is inappropriate to disperse plain tablets or where patients or carers are unable to crush and disperse tablets soluble prednisolone may be offered by the prescriber.
Due to price changes Prednisolone 5mg/5ml oral solution unit dose is no longer cheaper that soluble prednisolone and therefore soluble prednisolone replaces the unit dose solution for second line choice. GP practices will use the updated guidance for new patients and to review existing patients. We look forward to your continued support with this change in ensuring that patients receive consistent messages. For further details please see the attached position statement.
01) AMOXICILLIN to AMOXIL® switch (no attachment)
Herts Valleys CCG needs to deliver savings in prescribing. As you may be aware, currently Amoxil® capsules (250 and 500mg strengths) are significantly cheaper than Amoxicillin capsules. Therefore, Herts Valleys CCG have agreed with all GPs in Hertfordshire to start recommending Amoxil® brand from 7th June 2017. The timing of this switch is aligned with a similar piece of work being undertaken from that date in E&N Herts CCG.
02) SPIRIVA® HANDIHALER® TO BRALTUS ZONDA® switch (no attachment)
In accordance with Herts Valleys CCG local incentive scheme (LIS) for 2017/2018, a rise in the prescribing of Braltus Zonda® (a branded generic of Spiriva® HandiHaler®) is anticipated. To support patients during this switch, a leaflet has been designed for pharmacies to hand-out (accessed via http://hertsvalleysccg.nhs.uk/publications/pharmacy-and-medicines-optimisation/medicines-optimisation-1/local-incentive-scheme-2017-18-supporting-information/tiotropium). Patients who are switched from Spiriva® HandiHaler® to Braltus Zonda® would be eligible for the ‘New Medicines Service’ (NMS), provided there a clear clinical need for it.
03) ALZAIN® to GENERIC PREGABALIN switch (no attachment)
- Summary of Alert Card Requirements 31 March 2017
- New Palliative Care Referral System
- Out of pocket expenses endorsement claims for denosumab 60mg/1ml Pfs (Prolia®).
- QIPP April 2017
Herts Valleys Clinical Commissioning Group (HVCCG)’s Quality, Innovation, Productivity and Prevention (QIPP) work stream for 2017-18, aims to deliver savings in prescribing through promoting clinical and cost effectiveness. Through some extensive scoping work involving looking at successful switches implemented by other CCGs, new switches have been identified to assist GP practices in delivering prescribing savings. Below details the latest drug switches that will take place in GP practices in HVCCG (this is in addition to any previously agreed switches for the 2016-17).
HVCCG continues to support the increased use of generic medicines in a way that is appropriate for patients, recognising that there are still some more cost savings to be made in this area. In a small number of cases, a branded generic might be promoted.
Cost-Effective Prescribing – Commencing April 2017
|REDUCED used of||INCREASED use of|
| Lyrica® and pregabalin (All strengths ) capsules|| Alzain® (All strengths )capsules
(Licensed indication only)
| Spiriva® Handihaler (tiotropium)|| Braltus® (Zonda device) and Spiriva® Respimat|
Brands to Generic
| Brands|| Generics|
HVCCG GP practices will be implementing these changes from April 2017. Our previous experience with similar workstreams shows that it takes approximately two months before the change in prescription is dispensed. We trust this information will help you with your stock holding for these products. We look forward to your continued support with these changes in ensuring that patients receive consistent messages.
These changes have gone through extensive process including reviewing for supply, price guarantee, availability, strengths and formulations. Copies of a patient letter and position statement will be available on our public website shortly: http://hertsvalleysccg.nhs.uk/publications/pharmacy-and-medicines-optimisation/medicines-optimisation-1 .
- Co-proxamol November 2016
The Pharmacy and Medicines Optimisation Team has circulated by email a letter from David Buckle, Medical Director HVCCG, highlighting and reinforcing HVCCG’s current position with regards to co-proxamol prescribing. This letter has been circulated to all GP practices in HVCCG and is being sent to pharmacies for information only.