The safer management of controlled drugs: Annual update 2022

Register of controlled drugs accountable officers

We maintain and publish an online register of controlled drugs accountable officers (CDAOs) across England. This covers those organisations that are registered with us and are required under the 2013 Regulations as amended to have one. The regulations define these organisations as designated bodies and require them to notify CQC of their CDAO appointment.

We update this register monthly. At the end of 2022, there were over 1,000 CDAOs listed. We approved 6 requests to be exempt from the need for a CDAO during the year.

Updating details for controlled drug accountable officers

Over the last year, more organisations needed to appoint temporary CDAOs to cover circumstances such as extended leave and recruitment gaps. If your organisation needs to have a CDAO, it is important to ensure you tell us when the details about the person change. This is a legal requirement.

Where a temporary CDAO is in post for longer than 6 weeks, it is important that you notify us about this so we can include these current details on our CDAO register.

We provide resources and helpful information for CDAOs.

NHS England regional teams and controlled drug local intelligence networks

NHS England controlled drugs accountable officers (CDAOs) worked effectively and collaboratively during 2022. They held regular meetings that resulted in more consistent messaging to members of local intelligence networks (LINs) – both nationally and regionally.

There were 83 local intelligence network meetings across England in 2022. Each network met online at least twice, and several regions held a dedicated controlled drug learning event, as well as 2 nationally-organised learning events. We attended 75 network meetings along with other designated bodies and responsible bodies.

Local intelligence network meetings are an effective way to raise concerns and share intelligence and learning, as well as providing valuable networking opportunities for members.

Key concerns discussed at local intelligence network meetings

• Ineffective governance arrangements in services. Workload pressures sometimes mean that staff are unable to carry out audits regularly or in as much detail as needed.
• The diversion of controlled drugs in lower schedules. This can be a particular challenge to identify for organisations that use them in larger volumes.
• Failure to report losses of controlled drugs, either through diversion or accidental losses.
• Diversion of controlled drugs by health and care professionals.
• No communication about changes to people's medicines. For example, when a GP or hospital changes the directions for a person's medicines, and this is not passed on to those who are caring for them.
• Ongoing fraud with private prescriptions, often for controlled drugs in lower schedules.
• Care homes not using the reporting tool to report incidents to NHS England CDAOs.
• Arrangements for using oral liquids safely – including balance checking, and how to better educate patients on the dangers of inaccurate dosing.
• Controlled drug patches, such as those containing fentanyl and buprenorphine. This includes inappropriate prescribing, where people don't need constant pain relief, as well as problems with administration.
• Loss of prescriptions in either postal or courier services. This is a particular issue for services who treat people for substance misuse.

Most NHS England regional CDAO teams published newsletters as an effective way of sharing information and maintaining contact with members between the network meetings.

We have had positive feedback from network members across all regions in relation to national learning events. During the year we had conversations with CDAOs in NHS trusts, some of whom provided feedback on their experience of local intelligence networks. We will share this feedback with NHS England CDAOs to consider for future meetings.

Controlled drug reporting tool

NHS England updated this tool in December 2022. The new design has improved how users report concerns and incidents and has streamlined other controlled drug functions.

The update has also helped to further standardise processes across regions. You can read full information on all of the upgrades to the tool, including contacts for technical assistance, on NHS England's website. The tool also now includes helpful training modules.

Controlled Drugs National Group

CQC leads the Controlled Drugs National Group, which met in March, June and November 2022. Membership comprises government departments, key regulators and agencies with a controlled drug remit in England, Scotland, Wales, Northern Ireland, Ireland and the Channel Islands.

Key discussion topics and issues of shared interest between our cross-border members included:

• controlled drug governance
• non-medical prescribing
• cannabis-based products for medicinal use (CBPMs).
• controlled drugs and medication safety
• Home Office licences.

A separate summary of activity from the past year shows how member organisations contributed to the overall safer management of controlled drugs. If you would like a copy of this summary, email medicines.enquiries@cqc.org.uk.

Operational Sub-group

The operational sub-group to the National Group also met regularly in 2022. Membership comprised:

• NHS England lead CDAOs
• specialist pharmacists and medication safety officers
• NHS Business Services Authority
• chief pharmacists
• Integrated care system (ICS) prescribing leads
• other government bodies.

Where appropriate, we also invited other healthcare professionals with relevant expertise to contribute.