The safer management of controlled drugs: Annual update 2024

Register of controlled drugs accountable officers

Where relevant, the 2013 Regulations (as amended) require organisations that are registered with us to have a controlled drugs accountable officer (CDAO). These organisations are defined as ‘designated bodies’ under the regulations and are required to notify CQC of their CDAO appointment. We publish an online register of controlled drugs accountable officers (CDAOs) across England, which we update monthly.

At the end of 2024, there were approximately 1,000 CDAOs listed. We approved 16 requests to be exempt from the requirement during the year.

We remind all designated bodies that it is a legal requirement to tell us about any changes to the contact details for your CDAO so they are up-to-date on our published register. Designated bodies also need to notify us where a temporary CDAO is going to be in post for longer than 6 weeks. See more information for CDAOs

NHS England regional teams and controlled drug local intelligence networks

Under the 2013 controlled drugs regulations, NHS England controlled drugs accountable officers (CDAOs) are the assigned lead for establishing local intelligence networks (LINs) in their geographical areas in England.

NHS England’s National Medical Director is the Senior Responsible Officer for the CDAO function. In 2024, NHS England CDAOs worked effectively and collaboratively. They held regular national and local meetings for members of local intelligence networks.

Led by NHS England CDAOs, each network held at least 2 online meetings in the year. Several regions also held in-person or hybrid meetings. As well as sharing details about controlled drugs incidents, most LIN meetings also discuss how the learning can help to improve local management of controlled drugs.

NHS England CDAOs provide a regular reminder to attendees at local intelligence network meetings about the importance of sharing information of concern. This enables members to connect key pieces of intelligence to identify issues at the earliest stage. They explain what information can be shared appropriately, and within data protection legislation, where it relates to concerns over individual people or services.

Other initiatives from NHS England CDAOs included 2 national learning events for all local intelligence network members across the country. Regional CDAO teams also produced newsletters to share information and maintain contact with LIN members between the network meetings.

Key issues discussed at local intelligence network meetings

• Lack of governance processes, although more organisations reported that they are now carrying out regular audit and monitoring checks.
• Increasingly complex commissioning of services, and the need to ensure that all organisations involved consider controlled drugs appropriately.
• The challenge of ensuring adequate controlled drugs governance in relation to paramedics and independent ambulance services.
• Home Office controlled drugs licences, including those that have lapsed, or need to be progressed.
• Prescribing of cannabis-based products for medicinal use (CBPMs), support for people who have been prescribed CBPMs, and the governance arrangements needed.
• Diversion of controlled drugs:
  • by health and care professionals and support staff
  • in the lower schedules
  • through using electronic systems to conceal the theft.
• Ongoing fraud with private prescriptions, and as in previous years, often for controlled drugs in lower schedules.
• The increasing use of electronic controlled drugs registers and electronic medicines storage, and the benefits and issues associated with implementing electronic systems.

Artificial intelligence and online LIN meetings

Artificial intelligence (AI) is rapidly becoming part of everyday life, offering many benefits. We’re aware that some companies subscribe to AI programmes that are able to record and take minutes in meetings, even when the participant is not attending.

We remind all LIN participants that this software is not suitable for use at LIN meetings. This is because LINs must remain a safe space for participants to speak freely about concerns, incidents and learning from their practice. All NHS England CDAOs provide minutes for each of their LIN meetings for those who cannot attend, or who wish to use the information for future reference.

Controlled drugs reporting tool

The NHS England Controlled drug reporting tool provides a standard platform for regional CDAOs to receive reports of incidents and concerns, and carry out other related functions. It was updated to include a suite of short learning videos on controlled drug governance topics.

Controlled Drugs National Group

CQC leads the Controlled Drugs National Group, which met in March, June and November 2024. Membership comprises government departments, key regulators and agencies with a controlled drugs remit in England, Scotland, Wales, Northern Ireland, Ireland, Isle of Man and the Channel Islands.

A separate summary of activity from the past year shows how member organisations contributed to the overall safer management of controlled drugs. If you would like a copy of this summary, email medicines.enquiries@cqc.org.uk.

Operational sub-group

The operational sub-group to the National Group also met twice in 2024. Membership comprised:

• NHS England lead CDAOs
• specialist pharmacists and medication safety officers
• NHS Business Services Authority
• chief pharmacists
• integrated care system (ICS) prescribing leads
• other government bodies.

Going forward, this group will be re-structured and future meetings based around themed issues and concerns in relation to controlled drugs. We are also keen to include a wider range of organisations from across the NHS and independent sectors, dental and online providers, as well as social care.

If you wish to be involved in this group, or have concerns to propose for discussions, please get in touch at medicines.enquiries@cqc.org.uk