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But more work is necessary to ensure all concerns are picked up, investigated and, where appropriate, action is taken.

This is the main finding of a Healthcare Commission report published today (Friday).

The report outlines the steps that have been taken to improve monitoring of controlled drugs since the Controlled Drugs (Supervision of Management and Use) Regulations came into force in England on 1 January 2007.

The regulations followed the Government’s response to the fourth Shipman Inquiry report, The Regulation of Controlled Drugs in the Community (July 2004), and provide a new legislative structure for the safer management of
drugs that are liable to abuse, including narcotics such as diamorphine.

The regulations gave the Healthcare Commission an overarching responsibility to coordinate this work. They also require the appointment of “accountable officers” within all NHS trusts and private hospitals to be responsible for the safe and secure management of all aspects of controlled drugs within their organisation. This includes monitoring the prescription,
storage and administration of controlled drugs and checking that they are not diverted for inappropriate use or financial gain.

The regulations also introduce a new requirement to share information through local intelligence networks.


The report states that, since the regulations came into effect in January 2007:

• Almost all NHS trusts and private hospitals have appointed an accountable officer responsible for monitoring the use of controlled drugs – 1034 accountable officers are in post. The Healthcare Commission will follow up with organisations where an accountable officer is not in post.
• 89 local intelligence networks covering 138 PCTs have been established across England. Network members from across the health and social care community are required to report concerns about any aspect of controlled drugs handling to the group, whose membership includes Healthcare Commission assessors, other regulators and the police. Network members have started to share information to identify concerns.
• Healthcare providers have put better mechanisms in place for the management of controlled drugs,     including improved documentation and procedures.
• A national group of regulatory bodies and agencies responsible for differing aspects concerning the    use of controlled drugs has been established, set up by the Healthcare Commission.

However more work is needed in some areas to ensure that all concerns are picked up, investigated and, where necessary, acted upon. The Healthcare Commission’s recommendations include the following:

• Local intelligence networks must share information about controlled drug concerns, including concerns related to named individuals. The review found that individuals within the networks are not always confident to share information, including concerns about named healthcare professionals.

      The Healthcare Commission is working with the networks to ensure they understand how this can be addressed.


Leadership and lines of accountability should be clearly identified in local intelligence networks that serve more than one primary care trust.

Healthcare professionals who prescribe or administer drugs to patients within care homes must ensure that the care home has a written record of the drugs prescribed and administered, in addition to their own records. The Commission for Social Care Inspection have reported that this does not happen consistently.

• Doctors, including GPs and private doctors, must write private prescriptions for controlled drugs on     the appropriate form in order that the quantity and type of all schedule 2 and 3 controlled drugs being prescribed privately can be monitored. The Royal Pharmaceutical Society of Great Britain report that some prescribers remain unaware of the new requirements and the need to use the standardised form.
• Each NHS chief executive and board needs to know whether the trust is fulfilling its responsibility in    relation to controlled drugs, for example by receiving quarterly reports from the accountable officer.

Anna Walker, Chief Executive of the Healthcare Commission, said: “Healthcare services have taken the first steps in minimising the risk of another Shipman. This is important in improving patient safety and it is to be welcomed.

 “Much work is still necessary to embed the new networks and ensure that concerns about controlled drugs are picked up, investigated and, where necessary, acted upon. Healthcare managers need to ensure that the networks
are working effectively, staff feel able to raise concerns as appropriate and unusual patterns in the use of these drugs are investigated.

“We owe it to Shipman’s victims and their relatives to be vigilant in ensuring that controlled drugs are managed safely and effectively.”

In 2008, the Commission will continue to work with all involved to drive up standards of sharing and reviewing risks, to build on the good start that has already been made with the setting of new mechanisms and systems to do this. It will also monitor the performance of senior management in responsible bodies to ensure that they are engaged and have in place
mechanisms to ensure that they can review risks effectively.