1. Does your Trust have a policy on the use of unlicensed medicines? Please answer Yes or No.  If yes, please provide a copy of the policy and all other relevant documentation Yes. However, this is currently under review.

2. Does your Trust have a policy or protocol on obtaining informed consent from patients when an unlicensed medicine is used?  Please answer Yes or No. If yes, please provide copies of all relevant documentation, including copies of template informed consent materials, used to consent patients where an unlicensed medicine is to be administered. Please see leaflet below. To be given to patients on the wards and on discharge / from outpatients, which will be used in conjunction with the Unlicensed Medicines Policy, once finalised.


Unlicensed_Medicines (PIN1423) leaflet


3. Please state which Board level job role(s) is (are) responsible for patient safety and consenting
Patient safety: Jo Mountjoy – Chief Nurse & Marianne Ilsley – Medical Director
Consenting: Niall Quinney – Deputy Medical Director

a. If no Board level job role(s) is (are) responsible for patient safety and consenting, please state which job role in the organisation is responsible for this N/A.

4. Does your Trust have, or intend to introduce, a policy that makes compounded bevacizumab routinely available to treat wet age-related macular degeneration? If Yes, please supply a copy of your policy The Trust is considering offering compounded bevacizumab as choice for patients with wet AMD who meet NICE criteria. This policy is in the final stages of review and will be considered at the September DTC – adoption of the Surrey Area Prescribing Committee policy.

5. Over the past two years has your Trust, on more than one occasion, used compounded Avastin (bevacizumab) for the treatment of wet age-related macular degeneration? Please answer Yes or No Yes.

If yes to 5:

6. Was the compounded Avastin (bevacizumab) for the treatment of age-related macular degeneration produced within an aseptic department owned/run by the Trust? Please answer Yes or No No.

If yes to 6:

7. Does the Trust’s aseptic department, referred to above, currently hold an MHRA license for the manufacture of specials? Please answer Yes or No N/A.

8. When was the Trust’s aseptic department, referred to above, in answer to Q5 last inspected by the CQC? N/A.

If you answered no to question 5, but yes to question 4:

9. Please provide information regarding from whom your Trust has obtained/purchased compounded Avastin (bevacizumab). If you cannot provide the name of any commercial supplier, please provide as much information as possible
This information is being withheld on the basis of the exemption contained within section 43(2) of the Freedom of Information Act (Commercial Interests). The Trust accepts that there is a public interest in how public money is spent; however there is also a need to withhold information that would prejudice the commercial interests of the Trust and/or third parties. In assessing the public interest, the Trust takes the view that this would be the case in this instance because disclosing our supplier may inadvertently lead to the disclosure of commercially sensitive pricing information.

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