Terms of Reference

NHS-logo Pharmaceutical Aseptic Services Group

Founded 1992


1. Purpose:

  • To act as an expert and informed body on aseptic preparation; to promote good practice, to identify and resolve problems, to maximise the effectiveness and development of services, and to address all issues pertaining to this objective.

§ To act as a consultative resource for all matters relating to the aseptic preparation of injectable medication and other products.

§ To support NHS Trusts to ensure patients have access to safe injectable medicines, and equitable access to safe and effective pharmacy aseptic services.

2. Principal Functions & Objectives

2.1 To act as a nationally acknowledged expert group and communications network for the provision of advice on issues pertaining to aseptic preparation of injectable medication (including cytotoxics, parenteral nutrition) and all other aseptically prepared products.

2.2 To maintain effective links between the NHS PASG and local aseptic networking groups in order to disseminate information both to and from these local groups. In particular, this will enable awareness to be raised nationally about local issues and projects under development.

2.3 To evaluate, endorse and disseminate appropriate standards of best practice relating to medicines assurance, medication & patient safety and medicines optimisation within pharmacy aseptic services. Plus promote the efficient use of resources used in these services.

2.4 To compile such resource and management documents as necessary to promote best practice.

2.5 To develop appropriate relationships and communication with: the Medicines and Healthcare products Regulatory Agency (MHRA), Departments of Health, Royal Pharmaceutical Society (RPS), NHS England, Scotland, Wales and NI, the NHS Pharmaceutical Production Committee, UK Radiopharmacy Group, the NHS Pharmaceutical Quality Assurance Committee, NHS Technical Specialist Education and Training (TSET) , British Oncology Pharmacy Association (BOPA), British Pharmaceutical Nutrition Group (BPNG) and the pharmaceutical industry, to facilitate developments and initiatives of benefit to patients and hospital pharmacy aseptic services.

2.6 To provide a forum for the exchange of views, ideas, information and advice of special interest in the field of aseptic preparation services.

  1. To provide, support and encourage opportunities for education and training in issues relevant to the speciality.

2.8 To monitor, interpret and contribute to the development of relevant guidance or legislation, and to disseminate such information to interested parties.

2.9 To promote research and development in areas of need and to monitor and report on these activities.

2.10 To enable and encourage cooperative working.

2.11 To manage the National Aseptic Error Reporting Scheme (NAERS), analyse and trend

error data and disseminate information and shared learning.

2.12 To provide representation to working parties relevant to aseptic and technical services.

3. Minutes and Records

Minutes of meetings shall be taken and final approved minutes will be posted on the group website (www.pasg.nhs.uk), and also circulated to appropriate contacts in the following groups:

(i) NHS Pharmaceutical Production Committee

  1. NHS Pharmaceutical Quality Assurance Committee
  2. UK Radiopharmacy Group
  3. NHS Technical Services Education & Training (TSET)
  4. R&D Group
  5. Local Aseptic Services network groups (via committee members to their local groups)
  6. NHS Specialist Pharmacy Services (England) and equivalent (Scotland, Wales & Northern Ireland)

This is undertaken to promote communication and develop relationships.

4. Membership:

4.1 Membership of the NHS Pharmaceutical Aseptic Services Group will be by requested nomination only.

4.2 Members (pharmacists, pharmacy technicians or other specialist staff) will be nominated to ensure national representation, and where appropriate, will have been nominated by their local Aseptic Services network group. Specifically, the NHS PASG will consist of at least one, and preferably two, members from each of the following geographical areas:

North East

North West

West Midlands

South East Coast

South West

East of England

East Midlands


Thames Valley & Wessex

Yorkshire and Humber

together with one representative each from Scotland, Wales and Northern Ireland.

Members will also be nominated by and represent the NHS Pharmaceutical Quality Assurance Committee, R&D Group, NHS Pharmaceutical Production Committee, UKRG and NHS TSET on the PASG Committee. (See item 4.3(iii) below)

4.3 Members will reflect and be drawn from the following categories:

  1. Hospital Pharmacy staff with practical expertise in aseptic preparation services. This should include representatives from both licensed and unlicensed units, and those with specialist interests such as paediatrics and clinical trials.
  2. Quality Assurance Pharmacy staff with active responsibility for aseptic preparation services.
  3. Up to two representatives from each of the following committees:

NHS Pharmaceutical Production Committee

UK Radiopharmacy Group

NHS Pharmaceutical Quality Assurance Committee

NHS Technical Services Education & Training (TSET)

R&D group which is a sub-group of PASG as well as NHSPQA and the Production Committee

  1. In addition, representatives of academia and other bodies with an interest or expertise in aseptic services may be appointed by invitation of the Group e.g. RPS, Procurement Specialists & Clinical Trial Advisory Group. N.B. This list is not exhaustive.

5. Conduct and Management of the Group:

5.1 A nominated Chair, Vice Chair, Secretary and Treasurer, known as the Officers, shall administer the affairs of the NHS Pharmaceutical Aseptic Services Group.

5.2 Officers will be elected for 2 year terms of office, and may be re-elected for further terms of office.

The Vice Chair will serve a period as Vice Chair, followed by a period as Chair and a further short period as Vice Chair for up to 6 months to support the new Chair and provide continuity. A new Vice Chair will then be elected who will follow the current Chair in due course.

5.3 The officers are appointed from within the membership of the group, and confirmed by the group. Details of the proposer & seconder of each nominee, and the result of each election will be recorded in the minutes of the meeting where the election is held.

5.4 Where an election is required for officers the nominees will be asked to leave the room and a show of hands taken for each nominee from the remaining members. If there are two nominees, the candidate with the most votes will be elected.

If there are more than two nominees standing for election, then:-

  1. If one candidate receives more than 50% of the votes they are elected.
  2. If no candidate receives more than 50% of the votes, then the candidate with the fewest votes is eliminated, and a second round of votes is held for the remaining candidates.

iii) The process from ii) is repeated until one candidate receives more than 50% of the votes and is elected.

The current Chair will conduct the election, and will only record a casting vote in the event of a draw to either decide the winner, or who should be eliminated from the next round of voting.

5.5 The Chair, Vice-Chair, other officer of the group or a member with a special interest, will represent the NHS PASG at other meetings and consultations where PASG has been invited to attend or send representation.

5.6 Meetings will be held four times a year.

5.7 A minimum of 10 members must be present for a meeting to be quorate, one of whom must be an officer of PASG.If less than 10 members are present the meeting may continue, but decisions must be deferred to a quorate meeting.

5.8 Where a conflict of interest may arise, members must declare their interest and be prepared to withdraw from the meeting of the NHS Pharmaceutical Aseptic Services Group when items of sensitivity are discussed, on the advice of the Chair (e.g. when commercial products or services, or related issues are raised).

  1. Finance

6.1 The NHS PASG Treasurer will manage the Group’s financial affairs.

6.2 The treasurer will be responsible for drawing up any business plans required for the financial affairs of the Group.

6.3 A bank account is held in the name of NHS Pharmaceutical Aseptic Services Group and is administered by the treasurer. This account requires two signatures from the officers of the Group namely the Chair, Vice Chair, Secretary or Treasurer on any correspondence or cheque. Online accounts held by NHS PASG require two signatories as above for any payment transactions.

6.4 A balance sheet is held for each financial year and is updated whenever a transaction occurs. At financial year end, this balance sheet must be presented at the next group meeting and will be scrutinised by the group before being verified as correct by the Chair who holds ultimate responsibility for the Group’s business affairs. This will be recorded in the meeting minutes.

6.5 Any monies generated by the activities of the group are deemed to be held ‘in trust’ on behalf of the NHS. In the event of the closure of the group any monies will be distributed to the appropriate NHS body.

  1. Strategy:

The NHS Pharmaceutical Aseptic Services Group shall achieve its purpose by the following:

7.1 National Meetings organised periodically to address topical issues, disseminate information and to educate. Specific aims for national meetings are:

· To provide a forum for the exchange of views and information.

· To identify and disseminate examples of best practice.

· To increase awareness of relevant standards, legislation and topical issues.

· To provide education and training according to identified needs.

NHS PASG in collaboration with the NHS Pharmaceutical QA Committee will be actively involved in organising the NHS QA & Technical Services Symposium. The

NHS PQA committee is the parent committee for the symposium, and NHS PASG will nominate members to represent it on the symposium organising committee.

7.2 Publications e.g. CIVAS Handbook, and by contributing to the Quality Assurance of Aseptic Preparation Services standards book.

7.3 Collaboration and two-way communication with local aseptic services network groups. Discussion should be lead and stimulated by PASG committee members at their local meetings.

7.4 Development and maintenance of a website and associated discussion forum.

7.5 Other publications - produced to meet specified requests and needs e.g.

  • Special topics of relevance and current interest.
  • Position statements on particular areas of practice.
  • Quarterly newsletter for the NAERS.
  • Articles for the pharmaceutical press.

7.6 Questionnaires / Surveys: - Periodic assessment of current practices

- Surveys of needs / research / education.

8. Officers:


Vice Chairman



Richard Needle

1992 - 2006

David Lovett

2007- 2014

Richard Needle 1996 - 2006 with Tim Sizer 1996 -2006

Jeff Koundakjian


Peter Rhodes

2006 - 2014

Peter Rhodes

2014 - 2015

Lyndsay Raine

2006 - 2010

Lyndsay Raine

2002 - 2007

David Lovett

2014 - 2018

John Landers

2015 - 2018

Mary Taylor

2010- 2011

Charlotte Gibb

2007- 2012

John Landers


David Lovett


Fiona Rowling

2011 - 2018

Sue Renn

2012 -

Oonagh McGrath

2018 -

John Horncastle


Document History

Discussion document originally drawn up on 25 March 1996: Tim Sizer

2ndDraft prepared 13 December 1996: NCIVASG Approved June 1997

Revised June 1999, June 2002, Dec 2003, June 2005, June 2006, April 2010, February 2015, Apr 2017, Nov2018

Review date – November 2020or earlier as required