barnet cepn prescribing clerk training session 6...barnet cepn stoma products case study answer note...

Barnet CEPN

Prescribing Clerk Training Session 6

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CEPNIntroduction

Group 1 Joanna Yong – Barnet GP Femeeda Padhani – Practice based Pharmacist

Group 2 Namrata Gandhi – Barnet GP Saijal Ladd – CCG Pharmacist

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CEPNContact Information

Kyra Rowlatt – Barnet CEPN Non Clinical Lead kyra.rowlatt@nhs.net 07951 822820 (for any urgent matters or queries)

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Sessions so far: Session 1

IntroductionGetting to know youPrescription journeyCommon prescriptions

Session 2Acutes vs repeatsSafe prescribingMedicines wastage

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Sessions so far: Session 3

Medication ReviewsDrugs that need monitoringCommunication Skills

Session 4Electronic Prescribing SystemElectronic Repeat Dispensing

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CEPNToday’s aims

Introduction to CCG Medicines Optimisation Team

Roles of the CCG Practice Support Pharmacists (PSPs)

CCG Decisions on Drugs

Roles and Responsibility of the Prescribing Clerk in helping to manage the Drugs Budget

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BARNET CCG MEDICINES OPTIMISATION TEAM

Lead Pharmacist

Deputy Lead

Practice Support Pharmacist (PSPs)

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Practice Support Pharmacists (PSPs)

Sheldon Russell - sheldon.Russell@nhs.net Shobhna Rokad - shobhna.rokad@nhs.net Rochelle Bye - rochelle.bye@nhs.net Gita Karia - gita.karia@nhs.net Suzanne Wong - suzanne.wong@nhs.net Cynthia Agbenyegah – c.agbenyegah@nhs.net Saijal Ladd – saijal.ladd@nhs.net

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CEPNMedicines Optimisation Leads

Colin Daff is Lead

colin.daff@nhs.net 0203 688 1833

Suzanne Lever is Deputy Lead

suzannelever@nhs.net 0203 688 1841

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CEPNDrugs Budget

Medicines are a significant cost to the NHS Barnet CCG spent circa 48 million in 2018/19 Medicines optimisation team is responsible for

allocating a drugs budget and helping the practices to spend within the budget

Practices are incentivised each year to NOT overspend on the drugs budget

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CEPNMedicines Optimisation Team Roles

Practice Support Pharmacists (PSPs)

Specialist pharmacists e.g. diabetes, respiratory, specials, care homes etc

Representation on North Central London and mental health joint formulary committees (JFC)

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CEPNWhat does a PSP do?

Reviewing high cost drugs, appliances and specials

Answering queries from GPs and other clinicians

Answering queries from prescription clerks

Conducting audits

Ensuring cost effective prescribing in Barnet CCG

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CEPNMedicines Optimisation site:

To access Medicines Optimisation site:

http://gp.barnetccg.nhs.uk

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CEPNReviewing High Cost Drugs and Specials

Each month we receive data from Prescription Pricing Authority (PPA)

PSPs review high cost drugs and specials in all their practices on a monthly basis

Better to prescribe the appropriate medication at start Very important for GP or prescribing clerks to highlight

or check with PSPs prior to prescribing if unsure

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Red/Amber/Purple/Black list

Important list that gives the clinician an idea of how prescribing should be done for drugs that they may not have much experience of or may need monitoring.

Clinicians should always check with the medicines optimisation team if they are unsure of any drugs in these categories

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Red/Amber/Purple/Black list

Red drugs only to be prescribed in secondary care Amber drugs can be prescribed in primary care but

may need shared care protocols after patient has been stabilised in secondary care

Purple drugs usually have a fact sheet or guide to help the clinician decide on how and when to prescribe

Black drug is NOT recommended for prescribing within our trust due to it’s low clinical value or not approved by the North Central London JFC

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CEPNQueries from GPs

New drug that GP is unsure if they should prescribe- prescribe if under NHS pathway

An existing medication that may need to be reviewed

Scriptswitch may give GP message not to prescribe and contact Medicines Optimisation Team

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CEPNQueries from GPs

Private specialist recommendation- only prescribe if on formulary. Do not feel pressurised to sort this out on the spot unless genuinely urgent! Always check if unsure.

NHS specialist recommendation- only prescribe if on formulary (exceptions are from tertiary hospitals like GOSH). Again check if unsure.

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Prescription Clerks- how can you help? Get to know your Practice support pharmacist Do not hesitate to send queries that you are unsure

about Queries such as stoma companies ordering directly and

you are unsure of quantities or frequency of orders Oral Nutrition Supplements ordering Dressings quantity and frequency Branded Medicines: Is it a patient need or preference?

(Letter to patient to be done by PSP)

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CEPNConducting Audits

New decisions made by NICE (National Institute of Clinical Excellence), local JFC (Joint Formulary committee or MHRA (Medicines and Healthcare Products Regulatory Agency) alert then we conduct audits e.g.

Omacor (NHSE drugs of limited clinical value) Liothyronine (NHSE drugs of limited clinical value) Sodium Valproate (MHRA alert harm to unborn child)

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CEPNSwitching Medicines

Savings to the NHS Helps practices to achieve on budget targets in order to

earn money from incentive schemes Clear message will be written on the notes to highlight

the switch Speak to your PSP and ask them to inform you

whenever a bulk switch is to be done e.g. Spiriva handihaler to Braltus Zonda

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CEPNWhat Do you Do?

If patient is over ordering?

If patient is under ordering?

If patient hasn’t ordered any repeats for over 6 months?

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CEPNOver ordering

Check with Community Pharmacist who is ordering? Alert GP (patient may need a review) e.g. if overusing

inhalers or painkillers etc Tell the Practice Pharmacist/PSP Ask patient reason for over ordering

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CEPNUnder Ordering

Check with patient reasons for this (could be elderly and forgetting to order or may not need the medication any longer or poor compliance etc)

Alert GP (Patient may need a medication review) Alert Practice pharmacist/PSP Let community pharmacist know as sometimes patient

will give them more information.

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CEPNNot ordered for over 6 months

Check if it is a regular repeat item Alert GP as per practice policy Has the patient been visiting the practice for anything

else within the 6 months If patient has left the practice or moved abroad then

deal with it as per practice policy

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CEPNCare Homes ordering

Always check that only 28 days quantity is prescribed Change to 28 days if certain items are given as 30

unless the pack cannot be broken due to medication getting unstable.

Patient on Rivastigmine patches costs £78.00 for 30 patches therefore each month 2 patches are left over and discarded! How much is that per patient per year?

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CEPNRivastigmine Patch

2 patches cost £5.00 Per year that would be £5.00x13= £65.00

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CEPN15 min break

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Oral Nutrition Supplements (ONS)

What is recommended for Barnet CCG

Has it been reviewed regularly, ONS is mostly used acutely and should generally not be added to repeats.

Care homes can fortify foods

There are exceptions to this rule e.g. palliative patients, complex patients

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CEPNHow can you help?

If a patient has been taking ONS for a month and requests another script then alert either GP, practice pharmacist or PSP for a review.

In Barnet we have had cases of patients becoming obese as they kept taking the ONS plus a normal diet!

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CEPNONS pictures

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CEPNDietitian Contact Details

CLCHT.BNUTRITIONSUPPORT@nhs.net

Tel: 0208 937 7121

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CEPNDressings

Rule of Thumb only prescribe 2 weeks supply of dressings and then review- exceptions can be some very complex patients under tertiary care

High quantities being ordered consistently should be queried with the GP/practice pharmacist/practice nurse/CCG pharmacist

Know how to access the formulary dressings guide

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CEPNDressings Case Study

Care Home patient and GP prescribed 30 Aquacel Ag dressings

Anything Wrong with this prescription?

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CEPNDressings Case Study Answer

Aquacel Ag dressings are non formulary, check with your PSP before prescribing

They are expensive! 30 dressings cost £625

Minimum supply should be 2 weeks, so only 14 dressings should have been given and then reviewed.

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CEPNStoma Products

Barnet CCG has a specialist stoma nurse who all new patients should be referred to. Patients recently discharged from hospital with stoma items should also be referred to this service

Stoma service will manage the patient and advise the practice on quantities of products per month.

Stoma nurse is Louise Foulds

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CEPNStoma Nurse Contact

Louise Foulds Stoma Care Nurse Finchley Memorial Hospital Granville Road N12 0JE Louise.foulds@nhs.net

Tel 0208 3497529 Fax 0300 0083170

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CEPNStoma Products Case study

Stoma products Patient DC

Novalife 1 ileostomy bag, midi 9230-10 cut to fit 10-55mm/70mm Opaque (60 bags per month)

Novalife 1 ileostomy bag, midi 9230-10 cut to fit 10-70mm/90mm Opaque (30 bags per month)

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CEPNStoma Products Case Study Answer

Note the code is the same, hence it was the same product being ordered twice!

Sometimes the sizes change or product gets discontinued and the code is changed to the new size/product so always look at the code

If unsure about any stoma script please contact either your PSP/stoma nurse

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CEPNBaby Milk

Number of tins to be prescribed

What Age range?

Barnet CCG have a dedicated paediatric dietitian who helps to review baby milks and if in doubt you can always contact her.

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CEPNPaedatric Dietitian Contact Nicole Rothband Specialist Paediatric Dietitian Paediatric Appropriate Prescribing Nutrition and Dietetic Service Children’s Health and Development Division Central London Community Healthcare NHS Trust Oak Lane Health Centre, N2 8LT Tel: 020 8349 7076 Mobile:07554 459324 Secure email: nrothband@nhs.net | Web: www.clch.nhs.uk Working days: Monday, Wednesday, Thursday.

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CEPNBaby Milk Case Study

10 month old baby on Neocate LCP, recommended by a private dietitian.

Mum was ordering 12 tins each month at a cost of circa £300 per month

The baby is eating solids and the dietitian had asked to introduce cow’s milk after 3 months

Would you be concerned with this prescription?

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CEPNBaby Case Study Answer

Private dietitian so ideally this patient should have been referred to the NHS dietitian for a review

Should not have been prescribed more than 10 tins and once on solids this could have been reduced to about 8 tins.

Mum had not reintroduced cow’s milk as per dietitian advise. If the baby tolerated the cow’s milk then the milk could have been stopped saving the NHS £4000 annually!

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CEPNCatheters and Incontinence Products

Leg bags are designed to provide discreet storage of urine under clothing and can be attached to either a catheter or a sheath. They are mainly used during the day and are secured to the leg in a convenient position using a range of straps or support devices.

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CEPNLeg bag picture

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CEPNIncontinence Nurse Contact Jane Day Continence Nurse Specialist Clinical Lead Barnet Continence Promotion Service Finchley Memorial Hospital London N12 0JE Tel: 0208 349 7466 Mobile: 07904637462 Fax: 0300 008 3170 Email: jane.day@nhs.net Secure Continence Service email CLCHT.ContinenceBarnet@nhs.net

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CEPNIncontinence Nurses Contact

Bo Yeung

Bladder & Bowel Clinical Nurse Specialist

Central London Community Healthcare Trust

Tel:0208 349 7529

Mobile:07534 101940

Bo.yeung@nhs.net

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CEPNLeg Bags

Leg Bags are often over ordered and used inappropriately

One leg bag should be changed every 5-7 days

Rule of thumb is 5 leg bags are adequate quantity for one month

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CEPNNight Bags

You can give one per night therefore 30 per month is reasonable

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CEPNCommonly ordered Leg Bags

Coloplast_Simpla Profile Leg Bag

Bard_Uriplan Leg Bag 10/30/38cm Inlet Tube

Coloplast_Trident T1 Leg Bag

Coloplast_Simpla Profile Leg Bag Coloplast Simpla Plus Leg bag

Coloplast_Elasctd Leg Bag Strap (Washable)

Bard_Urisac Leg Drain Bag Short Tube 500ml

Coloplast_Conveen Contr Leg Bag

Great Bear_Libra Leg Bag Ster + Tap 500ml Long Tube

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CEPN Leg Bags Case Study

In January 2019 over 50 prescriptions were dispensed in Barnet CCG for over 20 bags on one prescription ( many were for 30-60 bags)

Would you be concerned if you saw such a prescription for leg bags?

Why would you be concerned? What would you do if you have a concern?

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CEPNAnswers to Leg Bag Case Study

YES you should be concerned with the quantity

20 bags is 4 months supply so over ordering

Inform the practice pharmacist/ CCG pharmacist/ GP

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CEPNSpecials

Medicines that are unlicensed and can be sourced by the chemist at very high prices

Always check prior to prescribing any special if unsure of the price or other alternatives

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CEPNSpecials

Specials can be very expensive, hence some of the commonly prescribed specials are included in the drug tariff.

What quantity to prescribe? Check if unsure

Drug tariff specials- how do we calculate?

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CEPNSpecials Case Study

GP has prescribed Melatonin 2mg/5ml oral solution 5ml at night 200ml

What would be the price of Melatonin 2mg/5ml oral solution?

What would be it’s expiry date?

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CEPNSpecials Case Study Answer

Cost is £29.76 Most specials have a month’s expiry In this case 50ml will be wasted If in doubt speak to your practice pharmacist or your

CCG PSP What if GP had prescribed 50ml? What would be the

cost?

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CEPNHigh Cost Drug Case Studies

Patient taking liothyronine 20mcg tablets three times a day.

Prescribed 168 tablets, which she orders every month

Is there anything wrong with the above scenario?

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CEPNHigh Cost Drug Case study cont

The chemist calls you and says patient cannot open one of the liothyronine pots. They are dispensed as 28x20mcg pots.

The chemist asks for a replacement script.

What would you do?

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CEPNHigh Cost Drug Answers

Monthly scripts should be 84 tablets

The clerk should have done an acute script for 28 tablets and not repeated 168 tablets again!

The patient now has almost 4 months supply. 28 liothyronine 20mcg costs circa £200.

Over ordering by circa £7,000 annually

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Self Care OTC Prescribing guidelines

Self care reference guide which can be printed and used within practices

Patient information sheet available Posters are being sourced for GP practices Leaflets being printed CCG wants to deal with one area at a time and

practices will be informed as and when the decisions are finalised via weekly bulletins or Topic of the month (phased approach)

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CEPNOn Demand Drugs

End of life care On demand palliative care drug list On demand palliative care pharmacies- know where to

access this information on Barnet CCG intranet

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CEPNConclude

Take home messages:

Knowing who to contact Who is your CCG pharmacist and how to contact them Where to find information: http://gp.barnetccg.nhs.uk https://www.ncl-mon.nhs.uk

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CEPNNext session- 6

Community pharmacist visit

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Please feel free to ask questions

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