You are here

Report warns of need for continued vigilance and monitoring of controlled drugs

13 August 2013
  • Media

13 August 2013

The health and care regulator the Care Quality Commission (CQC) today (Tuesday 13 August) publishes the sixth annual report into the management of controlled drugs. The report covers all schedules of controlled drugs, including narcotics, amphetamines and anabolic steroids. The report covers the year ending 31 December 2012.

In 2013, changes were made to the regulations governing controlled drugs to align them with the new NHS architecture. This is therefore the last report under the 2006 regulations.

The report warns that whilst the arrangements for monitoring controlled drugs have worked well over the past six years, continued vigilance is needed to make sure this good practice continues.

The report details the progress made in implementing regulations introduced in response to the Shipman Inquiry which found ineffective monitoring had allowed Dr Harold Shipman to divert supplies of diamorphine to kill at least 15 and possibly up to 200 patients without detection.

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.

CQC Chief Executive, David Behan, said:

“As new systems and processes bed in across the NHS it is vital that vigilance is maintained to ensure the safety of patients.

“We’re greatly encouraged by the progress made over the last six years by provider organisations in improving and embedding the systems and processes necessary to ensure controlled drugs are managed safely.

“It is important and absolutely correct that CQC looks at the governance arrangements for controlled drugs in primary medical services now we are the regulator for these services.”

Trends within prescribing of controlled drugs

  • In 2012, the total number of controlled drugs items prescribed in NHS primary care was 47,308,286, which is an increase of 1% compared with 2011.
  • The cost of this was £452,763,739 representing an increase of 2% compared to £443,380,585 in 2011.
  • The use of temazepam –, a benzodiazepine hypnotic (sleeping agent) has continued to fall steadily since 2007.
  • At the same time (since 2007) there have been increases in prescribing of buprenorphine, morphine sulphate, oxycodone, fentanyl, methylphenidate, midazolam and diamorphine.
  • Private prescribing of controlled drugs decreased by 10% in 2012 (39,432 items) compared with 2011 (43,640 items).Private prescribing accounts for about 0.1% of overall controlled drug prescribing.
  • Over the six-year period, the volume of private prescribing of controlled drugs has decreased by 24%.
  • The profile of private prescribing continued to differ from NHS primary care prescribing, with dexamfetamine (central nervous stimulant) appearing as the second most commonly prescribed item. Dexamfetamine does not appear at all in the top 10 Schedule 2 controlled drugs prescribed in primary care.

The report made the following five recommendations...

  • Health and social care professionals must ensure they know how to contact their local controlled drugs accountable officer (CDAO) and know the mechanism for reporting controlled drug concerns.
  • CDAOs need to ensure they are following the guidance on CQC’s website to update contact details promptly to ensure the CDAO register is accurate.
  • Effective systems developed at the local level for secure gathering, sharing and recording of intelligence relating to concerns about safe management of controlled drugs should be preserved and transferred into the new NHS structure.
  • CDAOs, clinical commissioning groups and controlled drugs leads must be mindful of their continuing responsibilities for good governance and safe use of controlled drugs to ensure on-going monitoring and vigilance.
  • Looking forward to 2013, CQC must incorporate providers’ governance arrangements for controlled drugs into its inspection model for primary medical services.


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

Notes to editors

  1. The Controlled Drugs (Supervision of Management and Use) Regulations 2006 were introduced in 2007 and have now been superseded by the 2013 regulations which came into force on 1st April 2013 to reflect the NHS structure changes.
  2. 2012 was the last full year in which primary care trusts held responsibility for assessing the governance arrangements for controlled drugs within primary medical services. From April 2013, CQC will regulate this sector.
Last updated:
30 May 2017