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The safer management of controlled drugs

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We are responsible for making sure that health and social care providers, and other regulators, maintain a safe environment for managing controlled drugs in England.

Our annual update report for 2019 makes three recommendations for improvement based on our analysis of the data on prescribing in NHS primary care services, issues raised at controlled drug local intelligence networks (CDLINs), and CQC’s wider inspection and regulatory work:

1. The level of controlled drug prescribing continues to increase year on year. In light of this:

  • prescribers should regularly review patients’ clinical needs before prescribing and consider the quantity prescribed, particularly when issuing repeat prescriptions.
  • we encourage healthcare professionals to fully explain patients’ medicines at the point of prescribing and supply. This should include giving guidance and warnings of the potential for dependence and actions to take, appropriate to the patient’s needs.

2. The coronavirus (COVID-19) pandemic has highlighted the need to be able to access controlled drugs rapidly to manage care for people at the end of life, but we must now learn from this for the future. To achieve this:

  • CCGs should consider putting in place local arrangements to enable rapid mobilisation of medicines needed for end of life care in readiness for any future situation where the health and care system may come under similarly significant pressure.

3. The failings at Gosport War Memorial Hospital were the result of a blanket approach to prescribing end of life medicines irrespective of the circumstances of individual patients. To continue to learn from this, and our experiences during the peak of the COVID-19 pandemic:

  • all healthcare professionals should consider the needs and wishes of patients and carers on an individual basis, particularly at the end of their life.

The accompanying report highlights activity in 2019 from member organisations in the Controlled Drugs National Group and Cross-Border Group.

Previous safer management of controlled drugs reports

The safer management of controlled drugs 2018

The safer management of controlled drugs 2017

The safer management of controlled drugs 2016

The safer management of controlled drugs 2015

The safer management of controlled drugs 2014

You can find our earlier reports on the safer management of controlled drugs on the National Archives.

Last updated:
22 July 2020