Prescribing -Clinical Commissioning Groups - CCG -Prescribing teams -epact data -APC & Joint Formulary -Traffic lights and shared care protocols -Medication review -Unlicensed meds / Specials
Primary Care Prescribing Team. Part of the prescribing and medicine management team Prescribing advisors - Alison Hale for Mansfield & Ashfield CCG Primary Care Pharmacist & Prescribing Support Technician allocated to each practice
What do we do? Monitor prescribing and budgets Annual prescribing visit Help practices work on their prescribing areas Cost effective, evidence based prescribing NICE and APC implementation Clinics & Audits Training Medicine queries & MHRA alerts
How is prescribing monitored? All NHS prescriptions sent for payment to the Prescription Pricing Division (PPD). Recorded against prescriber number Analysis available after approx. 2-3mths Forms epact data and reports
NSAID prescribing across the CCG
Range of NSAIDs in one practice
Prescribing of diclofenac drilled down to prescriber within one practice Prescriber Name BNF Name Total Items Dr 1 Diclofenac Sod_Tab E/C 50mg 11 Dr 2 Diclofenac Sod_Tab E/C 50mg 1 Dr 3 Diclofenac Sod_Tab E/C 50mg 1 Dr 4 Diclofenac Sod_Tab E/C 50mg 1 Nurse 1 Diclofenac Sod_Tab E/C 50mg 1
Prescribing responsibility It is the prescriber who signs the prescription who carries legal responsibility, not the person who may suggest it!
Prescribing guides Mrs LE has seen Dr Millard a dermatology consultant at QMC about her discoid lupus erythematosus. He would like you to prescribe Chloroquine to treat the condition dose = chloroquine (as base) 150mg daily. - You check the dose in the BNF and the indication and dose are correct do you prescribe??
Checking a new medicine Is the indication and the dose reasonable? Is the dose licensed? Has it been given a traffic light? Does any monitoring need to be arranged As a prescriber do I have enough knowledge to prescribe?
APC & Traffic lights - 1 Area Prescribing Committee APC website http://www.nottspct.nhs.uk/my-pct/napc.html Drugs are considered for classification at APC Shared care guidelines / clinical guidelines Formularies / position statements
APC & Traffic lights - 2 Joint formulary website http://www.nottinghamshireformulary.nhs.uk/ Is it on M&A Preferred Prescribing List (PPL)? The website is a guide and GPs can choose not to follow it if they believe they have reason, but the reason should be documented.
What do the traffic lights mean? Red specialist secondary care only Amber 1 initiated by specialist, shared care once stable (with a protocol) Amber 2 primary care prescribing after specialist recommendation Amber 3 Primary care / non specialist may initiate under APC guideline Green routine use Grey not recommended at the present as limited clinical/cost effective data
Prescribing guides Mrs LE has seen Dr Millard a dermatology consultant at QMC about her discoid lupus erythematosus. He would like you to prescribe Chloroquine to treat the condition dose = chloroquine (as base) 150mg daily. - You check the dose in the BNF and the indication and dose are correct do you prescribe??
JF traffic lights suggests
What about MRS LE? The dose prescribed would be reasonable The traffic light list states chloroquine is red for dermatology in this condition. Refer back to consultant and ask that they retain prescribing responsibility
Scenario 2 MR HT has had a heart transplant at Newcastle Hospital in 2001 and is stable on his anti-rejection medication including tacrolimus and azathioprine. He has recently moved to the area from Durham and wants you to prescribe these as his last GP did. He only has one week supply left Do you prescribe?
Mr HT Both medications are traffic lighted as RED in Nottinghamshire No local heart transplant specialist Contact the specialist at Tertiary centre Request consultant takes back the prescribing Confirm the dosages needed and supply enough until the prescribing can be passed back Consultant will prescribe and CCG will be charged for the cost of this medicine.
Mrs T (Part one) Has RA Started oral methotrexate by hospital now on 20mg weekly Consultant writes to ask you to prescribe Do you agree to prescribe?
Shared care protocol Shared clinical responsibility outlined in a standard agreement Passed by APC Only for stable patients For the stated clinical diagnosis only
Prescribing methotrexate Always 2.5mg tablets Take.. tablets ONCE A WEEK on a SATURDAY
Mrs T (Part 2) Mrs T visits the consultant on a routine appointment Consultant now asking you to prescribe methotrexate 10mg twice weekly as nausea with once weekly dosage Do you prescribe?
Practice prescribing meeting. Yearly meeting 3 action points & audit as part of Prescribing Incentive Scheme Large report covering therapeutic areas Evidence of completion needed to obtain the money.
Controlled drugs
CD requirements Appropriate dosage? to be taken as directed not sufficient One to be taken as directed 15mg to be taken when required How long is it valid for? 28 days Treatment length Good practice for a maximum of 30 days. Need good reason documenting for any longer
If anyone collects a CD for a patient from the pharmacy they will need to: Sign the back of the prescription State their relationship with the patient Provide proof of identification Give their address for the pharmacy CD register
Can CD s be destroyed? A GP practice can take back a patients unused CD s and destroy them NO A GP can destroy any out of date CD s in the doctors bag with the witness of another GP NO
Other CD info All private prescriptions for schedule 2 and 3 CD s need to be on a FP10PCD All CD s in a surgery or doctors bag need to be recorded in a CD register and monitored
Specials - Unlicensed / off label Unlicensed medication is no UK licence on the product e.g. melatonin Unlicensed indication/off label used for a UK licensed medication being used for an unlicensed indication e.g. in children
Considerations before using a Special 1. Is the medication still needed at all? 2. Can the patient have a licensed product in a different form e.g. dispersible or liquid? 3. Could you change to a different drug within the same class? 4. Consider using a licensed drug in an unlicensed manner e.g. by dispersing in water or crushing. 1. Not MR / SR as it destroys the release mechanism 2. Not cytotoxic or EC 5. Prescribe the special documenting the reasons for doing so. NB: Patient / carer must be aware that medicine is unlicensed