National Health Service (NHS) and private health care providers in England have taken positive steps to improve the monitoring and management of controlled drugs following the Shipman Inquiry, but more work is necessary to ensure that all concerns are picked up, investigated and, where appropriate, action is taken, says England’s health care watchdog the Healthcare Commission.

In a new report, the Commission outlines the steps taken to improve monitoring of controlled drugs since the Controlled Drugs (Supervision of Management and Use) Regulations took effect in England on January 1, 2007, after the fourth Shipman Inquiry report, The Regulation of Controlled Drugs in the Community, was published.

The Commission reports that, since the regulations came into force:
- almost all NHS Trusts and private hospitals have appointed an accountable officer responsible for monitoring the use of controlled drugs – 1,034 such officers are now in post;
- 89 local intelligence networks covering 138 Primary Care Trusts (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 regulators and the police. Network members have started to share information to identify concerns;
- health care providers have put better mechanisms in place for the management of controlled drugs, including improved documentation and procedures; and
- a national group of regulatory bodies and agencies, responsible for differing aspects concerning the use of controlled drugs, has been set up by the Healthcare Commission.

However, the agency believes that more work is needed and, specifically, that:
- 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;
- leadership and lines of accountability should be clearly identified in local intelligence networks that serve more than one PCT;
- health care professionals who prescribe or administer drugs to patients within care homes must ensure that the home has a written record of the drugs prescribed and administered, in addition to their own records. The Commission for Social Care Inspection (CSCI) has reported that this does not happen consistently;
- doctors, including general practitioners (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 (RPSGB) reports that some prescribers remain unaware of the new requirements and the need to use the standardised form; and
- 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.

The health care services have taken the first steps in minimizing the risk of “another Shipman” but “much work is still necessary,” said Healthcare Commission chief executive Anna Walker. “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,” she noted, adding: “we owe it to Shipman’s victims and their relatives to be vigilant in ensuring that controlled drugs are managed safely and effectively.”

- In 2000, Dr Harold Shipman was convicted of the murder of 15 patients, but a subsequent public inquest found evidence to suggest that he had probably killed over 250 people. He is the only doctor in the UK ever to have been found guilty of killing patients.