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Information sharing must increase to ensure controlled drugs safety, says Care Quality Commission

19 August 2014

The Care Quality Commission (CQC) publishes the seventh annual report into the management of controlled drugs, today (Tuesday 19 August). The report examines the governance arrangements for controlled drugs during 2013 and in particular the implementation of the revised regulations which came into being on 1 April 2013.

The report sets out that 2013 was a transitional year in which safe arrangements for controlled drugs were maintained despite changes in both legislation and the NHS.

Professor Steve Field, Chief Inspector of General Practice, said: “Significant progress has been made in order to improve the management of controlled drugs since the Shipman inquiry ten years ago.

“However, more needs to be done in terms of improving systems that can enable secure gathering, sharing and recording of intelligence about controlled drugs concerns.

“We are still seeing examples of a very small number of healthcare professionals taking controlled drugs without permission and supplying them to others illegally or taking them in order to misuse substances themselves. This is why the role of the controlled drugs accountable officers (CDAOs) and local intelligence networks is key.

“At CQC, we will continue to support the sharing of information more widely, by ensuring that relevant concerns around medicines management that arise as part of our inspections, as well as key information from relevant meetings, is flagged up with NHS England, CDAOs and intelligence networks.”

Clare Howard, Deputy Chief Pharmaceutical Officer and co-chair of the NHS England National Controlled Drugs Group said: “Controlled drug accountable officers have worked very hard over the last year to ensure that robust local systems are in place for the safer management and use of controlled drugs. We are confident that further progress will be made in the next year to ensure that arrangements across the country are working well and consistently.”

The support pledged by the regulator follows the recommendations made in its 2013 report which calls for adequate resources for NHS England controlled drug accountable officers and support from local CCGs to enable CDAOs to effectively carry out their duties.

The CQC is urging health and social care professionals to help build upon the progress being made in the detection of controlled drugs misuse, by ensuring that they raise any concerns promptly and share information more widely.

The latest CQC report comes during the ten year anniversary of an inquiry, which called for stricter controls around the use and possession of controlled drugs, following the shocking case of Dr Harold Shipman, who killed patients in his care due by deliberate misuse of drugs.

Following the inquiry, new governance arrangements were introduced in 2007, which included the appointment of controlled drugs accountable officers (CDAOs) within healthcare settings, who are responsible for monitoring controlled drugs across local communities. In addition, Controlled Drugs Local Intelligence Networks were set up specifically for the reporting of controlled drug concerns.

The health and social care regulator reminds professionals across health and social care to make sure that they know how to contact their local controlled drugs accountable officer (CDAO) and know the mechanism for reporting controlled drug concerns.

Prescribing trends for controlled drugs, include:

  • In 2013, the total number of controlled drugs items prescribed in NHS primary care was 47,044,814, which is a decrease of 1% compared with 2012. The cost of this was £498,942,743 representing an increase of 10% compared with £452,761,855 in 2012.
  • The prescribing of temazepam – a benzodiazepine hypnotic (sleeping agent) has continued to fall steadily since 2007. Between 2012 and 2013, prescriptions fell by 355,357.However, it is likely that the non-benzodiazepine hypnotics, zolpidem, zopiclone and zaleplon, are now being prescribed instead.
  • At the same time (since 2007) there have been increases in prescribing of morphine sulphate, oxycodone, fentanyl, methylphenidate and midazolam.
  • Private prescribing of controlled drugs decreased by 6% in 2013 (36,935 items), compared with 2012 (39,203 items). Private prescribing accounts for about 0.1% of overall controlled drug prescribing.
  • The use of drugs to provide relief for severe and long term pain management has increased, with use of Morphine up by 223,838 between 2012 to 2013 and use of Fentanyl up by 42,155 between from 2012 to 2013.
  • Attention Deficit Hyperactivity Disorder (ADHD) drug, methylphenidate continues to rise steadily in use from last year by 68,458. Private prescriptions for this drug increased by 7% in 2013.

To find out more controlled drugs and view the 2013 report in full, visit:

Health and social care professionals can check the details of their local CDAO on the CQC website, at:


For media enquiries, call the CQC press office on 0207 448 9401 during office hours, or for out of hours enquiries call on 07917 232 143. For general enquiries call 03000 616161.

Last updated:
30 May 2017

Notes to editors

The recommendations are:

Recommendation 1

NHS England controlled drug accountable officers must be adequately resourced to carry out their roles and responsibilities with regard to controlled drugs.

Recommendation 2

NHS England controlled drug accountable officers must be clear about their responsibilities for controlled drug governance arrangements and strengthen their relationships with clinical commissioning groups (CCGs) and commissioning support units (CSUs) so that these organisations are clear as to how they can support them.

Recommendation 3

NHS England controlled drug accountable officers should consider organising learning events for controlled drug accountable officer colleagues and controlled drug leads, to enable them to share learning and best practice.

Recommendation 4

NHS England controlled drug accountable officers should consider extending membership of the controlled drug local intelligence network to other relevant local organisations (such as social enterprise organisations or community interest companies) either on a permanent or ‘as required’ basis.

Recommendation 5

A formal process should be put in place by NHS England controlled drug accountable officers to ensure controlled drug concerns and good practice are shared nationally where appropriate.

Recommendation 6

Healthcare providers must determine whether they are required to appoint a controlled drug accountable officer or whether they meet the criteria for an exemption.

Recommendation 7

The Care Quality Commission should summarise the key messages from the Controlled Drugs National Group meetings and circulate them to NHS England controlled drug accountable officers to pass on to members of their controlled drug local intelligence networks.

  • The Controlled Drugs (Supervision and Management of Use) Regulations 2013 superseded the 2006 regulations which were introduced following the Shipman Inquiry.
  • Controlled drugs include opioids, such as morphine and diamorphine, which are used in relieving severe pain and treating drug dependence. Controlled drugs also include benzodiazepines (tranquillisers and sleeping tablets), anabolic steroids and growth hormones.
  • The report makes seven recommendations and sets out in particular the importance of national sharing of controlled drug concerns through the NHS England Controlled Drug Accountable Officers and the need to share good practice through learning events and ongoing communications so that harms from controlled drugs are minimised.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.