These recommendations aim to raise awareness and address some of the specific issues we have identified from our work during the last year.

We continually monitor progress and change to drive improvement in the safer management of controlled drugs.

For health and care services

Share information about concerns in relation to controlled drugs with the right organisations as soon as possible, including with NHS England controlled drugs local intelligence networks

This may include sharing appropriate information about persons of concern. One of the key findings of the Inquiry into the crimes of Harold Shipman was that failure to connect key pieces of intelligence meant that his actions were not identified earlier. This is why proactive membership of CDLINs is crucial. The Controlled Drugs (Supervision of management and use) Regulations 2013 emphasise the importance of sharing information. They also take account of data protection legislation. If you are concerned about whether it is appropriate to share information, your NHS England CDAO can support you with this.

For national bodies and government

Review the national system for prescribing identification numbers (PINs)

In its current form, the system has no expiry date for PINs and practitioners are only required to provide one main address of work. Any review should take account of increases in non-medical prescribing, and the fact that not all practitioners will be required to be registered with CQC to undertake their work, so they may not be subject to checks on the services they offer to people in future.

Address online prescribing of controlled drugs in Schedules 4 and 5 by services and prescribers outside of the United Kingdom

This issue remains a risk to people in England. Although there is no national dataset that quantifies this prescribing, we continue to hear about instances where this happens and results in harm to people. Relevant national stakeholders should work together to generate an accurate and current picture of these risks to determine the best way to manage this.

Review the impact of the 2018 legislation change to allow prescribing of cannabis-based products for medicinal use (CBPMs)

The intention for this change was to support treatment for individual patients for an unmet clinical need. We have since seen a significant increase in prescribing to treat a wide range of medical conditions, as well as changing models of care including those involving non-medical prescribers. It is important that accurate and up-to-date CBPM prescribing data is available to support any review and ongoing oversight of this sector. Prescription processing procedures should be reviewed to achieve this.

For police services

Consider whether controlled drugs liaison officers are adequately resourced

Controlled drugs liaison officers (CDLOs) are crucial partners and sources of support and advice for services that use controlled drugs. Resourcing for these important roles is inconsistent across different constabularies. Each constabulary should consider the resourcing needs for their specific area to ensure that health and care services are able to access CDLO expertise.