South East London Interface Prescribing Policy including the NHS and Private Interface Prescribing Guide 1. Introduction 1.1 This policy has been developed by the South East London Clinical Commissioning Group (CCG) Medicines Management leads. It has undergone consultation with the Medicines Management/Drug and Therapeutics Committees for Acute and Mental Health Trusts, CCGs in South East London (SEL). The policy has been approved by the SEL Area Prescribing Committee (SEL APC). 1.2 The policy clarifies the role of GPs, Acute Hospital clinicians, Mental Health clinicians, community consultants and aims to facilitate consistent prescribing across SEL through better communication between clinicians. 1.3 All prescribing decisions must consider safety and cost-effectiveness to the patient. 2. General Principles 1.1 Legal responsibility for prescribing lies with the doctor/independent prescriber who signs the prescription. 1.2 All patients should continue to receive the most appropriate drug therapy when necessary and in the most appropriate setting. 1.3 Prescribing responsibility must be based on clinical responsibility. Responsibility for prescribing lies with the clinician who, at the time, has clinical responsibility for a patient and is able to monitor treatment and adjust dose as necessary. This is in the best interest of patients. 1.4 Clinicians must recommend treatment by drug class except where it is clinically inappropriate. Pharmacists must dispense and label by generic name unless clinically appropriate to use the brand name. 1.5 The hospital will dispense medicines routinely as patient packs unless there are clinical reasons not to, in order to comply with European Community directive 92/27/EEC on pharmaceutical labelling, and the provision of information to patients. 1.6 CCGs expect providers to adhere to the guidance contained within the following circulars EL(91)127 Responsibility for prescribing between hospitals and GPs EL(94)72 Purchasing and Prescribing EL(95)5 Purchasing high-tech health care for patients at home Commercial sponsorship in the NHS, Dept of Health Nov 2000. This list is not exhaustive and compliance with all relevant circulars and guidance is required. 1.7 Trusts should have a discharge policy in place that includes arrangements for the transfer of prescribing information to GPs including standards of 6.2 of this policy.
1.8 Trusts to carry out medicines reconciliation as set out in the NICE guideline NG5 Medicines optimisation 1.9 GP prescribing under a shared care arrangement should only be considered when the patient s condition is stable, prior agreement of the GP has been sought, and the GP has sufficient information to safely prescribe for the patient. CCGs may require Trusts to work within locally agreed Shared Care Guidelines although this may not be necessary for all drugs and an individual management plan may suffice. (See section 7) 1.10 The South East London Area Prescribing Committee and the South East London Joint Medicines Formulary Committee should develop an up-to-date formulary/prescribing guidelines with the involvement of GPs and CCG Prescribing Advisers. 1.11 Where a joint primary secondary formulary is not in operation, hospital clinicians should be encouraged to recommend a class of drug for GPs to prescribe, rather than a specific drug. 1.12 The majority of prescribing by hospital clinicians should be in line with the Joint Medicines Formulary, or prescribing guidelines. Where, exceptionally, a patient s treatment necessitates the prescribing of a non-formulary drug, the hospital clinician should discuss the choice of drugs and reasons for prescribing outside the formulary with the individual GP. 2. In-patients (person admitted to hospital for the purpose of observation, care, diagnosis and treatment) 2.1 All drugs, enteral nutrition and dressings prescribed for administration while an in-patient are the responsibility of the consultant concerned. All necessary drugs and dressings will be supplied by the Hospital Trust (subject to paragraph 2.2). 2.2 Patients own drugs remain their own property and should be returned to them on discharge from hospital, providing such therapy is still appropriate. Patients own drugs, with the agreement of the patient, may be used while the patient is in hospital until a supply is made by the hospital pharmacy or where a policy exists regarding the use of patient s own drugs. They may be used to fulfil discharge medicine requirements. 2.3 When a patient is discharged from hospital, a minimum of 14 days of drugs, supplied in the form of a patient pack wherever possible or in compliance aids where appropriate, or via FP10HP to community pharmacy for compliance aids where appropriate, or 5 days of dressings should be supplied (subject to paragraph 2.2) unless the full course of treatment calls for a shorter supply. The amount should be sufficient to ensure safe continuation of treatment prior to GPs taking over prescribing responsibility. Where there is an agreed national tariff charge such that the tariff paid from an inpatient episode includes that the Trust retain responsibility for patients for a period of rehabilitation (which may be less or more than 30 days post discharge), then in accordance with guidance, provision of drug therapy for this period will be part of the Trust responsibility. 2.4 A policy should be in place for use of Patients Own Drugs, Self Administration of Medication, Dispensing Medicines for Discharge, and the use of Compliance aids (including monitored dosage systems), this should include liaison between primary and secondary care and appropriate arrangements for continuity of care after discharge.
3. Accident and Emergency, Urgent Care Centres 3.1 A minimum 5 days supply of drugs and/or dressings needed should be given unless the full course of treatment requires for a shorter supply. A minimum of 48 hours of analgesia at recommended doses should be supplied. 3.2 Patients own drugs should remain with the patient during the time of their assessment (unless unsafe to do so when e.g. safe storage of medicines is unavailable) and transferred with them if they are admitted or sent home, unless clinically inappropriate. 4. Outpatients (A person who is not an inpatient, not hospitalised) 4.1 Drugs and dressings prescribed for administration during a hospital outpatient consultation should be provided by the Trust. 4.2 If immediate treatment is required following an outpatient consultation, a minimum of 14 days of drugs (supplied in the form of a patient pack wherever possible) and a minimum of 5 days of dressings should be supplied by the hospital, unless the full course of treatment requires a shorter supply. Patients to be advised on the importance of a hospital supply for urgent treatment rather than a delayed supply from their GP. A separate policy exists for the supply of medicines for end of life care. 4.3 When the patient does not require an immediate supply, the patient should be informed that their treatment is not urgent. The clinician must fill out all relevant sections of the Out-Patient Referral form and tick the Non-Urgent box. Patients should be asked to contact their GP practice within 14 days to discuss initiation of treatment and to arrange a prescription on FP10 within 3 working days of the Out-Patient referral form reaching the GP. All relevant information enabling the GP to prescribe, should reach the practice within 10 working days. 4.4 There may be instances where the patient may not require an immediate supply of medication but the drug being recommended requires specialist initiation. In these instances the initial supply should be made by the hospital and the shared care process outlined in section 7 of this document should be implemented. 5. Day Case Patients (a person that requires an intervention to be performed in hospital but doesn t need to stay overnight) 5.1 Drugs and dressings prescribed for administration during day case treatments are the responsibility of the consultant concerned (subject to paragraph 2.2). All necessary drugs and dressings for administration as a day case will be supplied by the Trust (subject to paragraph 2.2). 5.2 Discharge medication for day case patients are subject to prescription charges as per out-patients. A minimum of 14 days of drugs (supplied in the form of a patient pack wherever possible) and a minimum of 5 days of dressings should be supplied, unless the full course of treatment requires a shorter supply. 6. Transfer of Information
6.1 On referral to a hospital consultant it is the responsibility of the GP to give comprehensive details of a patient s medical history, drug treatment, previous adverse reactions, allergies and any use of compliance aids 6.2 On discharge from hospital or the community, clinicians must provide the patients GP with information on diagnosis and reason for admission, patient s medication on discharge, including whether to continue or stop, any medication changes and reasons for the changes. In addition any relevant clinical or biochemical monitoring parameters should be communicated highlighting further monitoring to be undertaken by the GP. The information provided should include the recommended core content of records for medicines when patients transfer care providers as outlines in the RPS guidance keeping patients safe when they transfer between care providers- getting the medicines right and NICE guideline NG5 Medicines optimisation. This information must be made available to the patient s GP within 7days of discharge to allow ongoing treatment to be maintained. If this cannot be guaranteed, then the hospital should prescribe for as long a period as necessary. 7. Shared Care 7.1 Therapy initiated in hospital or Mental Health Trust which requires specialist knowledge, training and/or has complex monitoring schedules would not normally be prescribed in primary care. However it is possible that the GP and hospital/mh clinician can agree shared care for a named patient with a named drug once the patient s condition is stable. 7.2 The most appropriate method of ensuring adequate exchange of information is by development of local Shared Care Guidelines. CCG Prescribing Advisors are able to facilitate this process. Shared Care Guidelines should be developed collaboratively between secondary and primary care clinicians within a locally agreed process that involves local prescribing committees. However this does not preclude arrangements being made between primary and secondary care for individual patients where it is in the best interests of the patient to receive supply from their GP. As of January 2014, the process of developing shared care guidelines is managed through the SEL APC on a sector wide basis. The process will be facilitated by named lead CCG Medicines Optimisation teams for individual shared care guidelines. 7.3 In the development of shared care guidelines, the following criteria must be met; Prior agreement to shared care is reached between the prescriber and the hospital clinician The patient s condition is stable The GP is given sufficient information to monitor and prescribe treatment safely. The roles and responsibilities of both the GP and the hospital clinician are clearly defined. 7.4 The process for agreeing shared care guidelines in SEL and shared care guidelines approved by the SEL APC can be found at the Committee s website. 8. Special considerations 8.1 Responsibility for prescribing will remain with the hospital consultant where;
Drugs are undergoing or included in a hospital based clinical trial or for compassionate use The consultant considers that only they are able to monitor the patient s response to medication because, for example, of the need for specialised investigations A drug or appliance is not available on a FP10 or is only available through the hospital Drugs subject to High-tech Hospital at Home guidance, EL(95)5 GP does not feel confident taking on clinical responsibility for prescribing of specialist drugs. Where agreements have been made at medicines management/dtc meetings, GPs should be encouraged to prescribe in line with these.(disagreements should be resolved at the local Interface meetings) Red drug from RAG list of drugs 8.2 Unlicensed drugs remain the responsibility of the hospital consultant except where; a substantial body of evidence exists to support the use of an unlicensed medicine or a licensed medicine outside its licensed indications e.g. paediatrics, the GP may be asked to prescribe. 8.3 Where a treatment is not licensed for a particular indication, the GP must be informed and the consultant should give full justification for the use of the drug to the GP and patient before agreeing to transfer to primary care. 9. New Drugs and Clinical Trials 9.1 The process for managing the entry of new drugs must consider clinical and costeffectiveness and the impact on Primary Care prescribing. In South East London, the process for managing the entry of new drugs is through the SEL APC. Submissions will be considered either through the New Drugs Panel (primary care/ccg commissioned medicines) or the Joint Formulary Committee (hospital only, in-tariff medicines). 9.2 Clinicians should refer to the Terms of Reference for the SEL APC for detail on how New Drug applications should be submitted; these can be accessed via the Committee s website. 9.3 Individual CCGs will need to ensure that a process is in place by which GPs are informed of decisions for new drugs, approved or rejected, by the SEL APC. 9.4 All clinical trials must have been subject to Ethical Committee approval. The hospital clinician is responsible for informing the GP if a patient is participating in a clinical trial. 9.5 Prescribing and supply of clinical trial material is the responsibility of the Hospital Trust 9.6 Patients should be made aware that funding for clinical trial medication may not be available once the trial comes to an end. 9.7 Trusts must discuss on-going treatment with appropriate commissioners. Developed by SE London Chief Pharmacist Group. Please contact Heads of Medicines Management in Bexley, Bromley, Greenwich, Lambeth, Lewisham or Southwark CCGs for further information
Appendix 1 NHS and Private Interface Prescribing Guide 1 Background 1.1 The following guide has been developed to assist General Practitioners (GPs) in dealing with requests to prescribe by registered patients following a private consultation. The decision whether to prescribe or not remains at all times with the individual GP. 1.2 Patients are utilising private health care provisions for diagnosis and/or treatment, often combining this with NHS care. Private consultants often choose to recommend a specific medication and ask the GP to prescribe it, rather than getting the patient to pay for it privately. 1.3 This guide is based on information from the BMA document The interface between NHS and private treatment: a practical guide for doctors in England, Wales and Northern Ireland. Guidance from the BMA Medical Ethics Department. May 2009. Further details may be found in the full text. 2 General principles o Private and NHS care should be kept separate. o We have a responsibility to make rational decisions when deciding how resources will be allocated. We must act fairly between patients. o Patients may opt into or out of NHS care at any stage. o Patients should be neither advantaged nor disadvantaged for seeking private health care. o Patients may pay for additional, private health care while continuing to receive care from the NHS. o Patients who have had a private consultation for investigations and diagnosis may transfer to the NHS for any subsequent treatment, but must be treated according to NHS protocols. o All doctors have a duty to share information with others providing care and treatment for their patients.
3 Recommendations to GPs on request to prescribe by private consultant 3.1 The South East London (SEL) Interface Prescribing Policy gives guidance on the transfer of care between primary care and secondary care, special considerations and information on shared care guidelines. The principles forming the basis of the SEL Interface Prescribing Policy should be applied to any request to prescribe received following a private consultation. 3.2 GPs are recommended to provide patients with clear information about what services can and cannot be provided by the practice following referral to a private consultant. This includes advising patients that it may not be possible or appropriate for any drug(s) recommended at the consultation to be prescribed by the GP and that they may be required to obtain prescriptions directly from their specialist. 3.3 A request to prescribe a new medication should not automatically be accepted. 3.4 Review an individual s medical records to ascertain medical history and assess the individual before any prescribing is undertaken. 3.5 Assess the clinical need for the prescription. The clinical and legal responsibility for prescribing remains with the person who writes the prescription. 3.6 Ensure familiarity with the drug to be prescribed, including the side effect profile and the requirement for monitoring. 3.7 Where the drug is not routinely offered as part of NHS services or the patient would not be eligible for the NHS service, there is no obligation to prescribe. 3.8 Medication recommended by a private consultant may be less clinically or cost effective than the NHS-recommended option for the same clinical condition. In these circumstances the drug prescribed should be as recommended in the applicable local guideline or advice should be sought from the Medicines Management Team. 3.9 Where the drug is listed in Schedule 1 to the National Health Service (General Medical Services Contracts) (Prescription of Drugs etc.) Regulations 2004 [ Black list ], the GP must not prescribe. 3.10 As with requests from NHS Consultants, GPs should not take on prescribing for drugs if there is a need for specialist knowledge or monitoring, unless there are shared-care arrangements in place.
3.11 Where the drug being requested is to be used outside its product license ( offlabel ), is without a product license in the UK or is available only as a special, contact your local Medicines Management Team for further guidance. 3.12 Where there is a good clinical, legal or cost-effectiveness reason not to accept prescribing of the requested medicine, a discussion with the patient and consultant should be initiated. Where appropriate, the patient should be reminded that they reserve the right to obtain their medication using a private prescription from the specialist who originally recommended the treatment. 3.13 Where you do not feel able to accept clinical responsibility for the medication, consider seeking advice via email from an NHS consultant who can determine if the medication should be prescribed for the patient as part of NHS funded treatment. 3.14 Where a patient has seen a private specialist without referral from the GP, s/he should be informed of the NHS referral and prescribing arrangements. References 1. South East London Interface Prescribing Policy, June 2015 2. The interface between NHS and private treatment: a practical guide for doctors in England, Wales and Northern Ireland. Guidance from the BMA Medical Ethics Department. May 2009. 3. GP Prescribing Guide. Kensington and Chelsea Primary Care Trust. December 2005. 4. East Midlands Specialised Commissioning Group. Defining the boundaries between NHS and private healthcare. 2009. 5. West Midlands Strategic Commissioning Group. Commissioning Policy (WM/13) Defining the boundaries between NHS and Private Healthcare. April 2010. Medicines Management Team Contact Details Bexley CCG 020 8298 6000 (switchboard) bexley.mmt@nhs.net Bromley CCG 01689 866228 No email address Greenwich CCG 020 3049 9000 GRECCG.Pharmacy@nhs.net (switchboard) Lambeth CCG 020 3049 4197 lamccg.medicinesoptimisation@nhs.net Lewisham CCG 020 7206 3200 No email address (switchboard) Southwark CCG 020 7525 3253 souccg.medicines-optimisation@nhs.net South East London Area Prescribing Committee: A partnership between NHS organisations in South East London:
Appendix 1: Template Letter for Adaptation: Practice to Consultant <Add Practice Header> Dear Colleague RE: Private Treatment Practice Policy on Prescribing We have many NHS patients who see consultants privately. On occasions, we are requested to prescribe medication you recommend as an NHS script. We have a prescribing policy that applies to all NHS prescriptions and as long as the prescription request falls within these recommendations, we will usually be happy to prescribe it. This policy can be found on the South East London Area Prescribing Committee Website, http://www.lambethccg.nhs.uk/news-and-publications/meeting-papers/south-east-london-areaprescribing-committee/pages/default.aspx It may be helpful for you to be aware that: We prescribe generically except in the very specific cases associated with variations in bioavailability. We avoid using combined preparations and modified release preparations whenever possible. We follow local formulary committee (or Medicines Management Team) recommendations on prescribing. We do not routinely prescribe drugs out of protocol or for unlicensed indications. We prescribe from a limited range of medications in any therapeutic class and prescribe on an evidence base, selecting the most cost effective out of equivalent preparations. We would thus be grateful if you could, wherever possible, recommend a drug by therapeutic class rather than by name. Please also consider the cost effectiveness of any therapeutic intervention prior to prescription. Thank you for your cooperation and assistance in the management of our patients. Yours faithfully, (Insert Practice Name)
South East London Sector Interface Prescribing Policy Appendix 2: Template Letter for Adaptation: Practice to Patient <Add Practice Header> Private Treatment Practice Policy on Prescribing Dear Patient, You have been referred at your request to a private consultant. We have many NHS patients who request to see consultants privately. On occasions, we are requested to prescribe medication as an NHS prescription. In certain circumstances it may be appropriate to prescribe your medication as an NHS script, but the prescribing policy that is applied to all our NHS prescriptions will be followed. This prescribing policy can be found on the South East London Area Prescribing Committee Website, http://www.lambethccg.nhs.uk/news-and-publications/meetingpapers/south-east-london-area-prescribing-committee/pages/default.aspx If your consultant prescribes a medication that falls outside a licensed indication or is outside the local recommendations on prescribing, your consultant will need to provide you with a private prescription, which you will be able to take to any community pharmacy for dispensing. You will have to pay a charge for the drugs on this prescription even if you are normally exempt. This only happens on a few occasions, but it is in your interest that you are aware of this possibility before a consultation. Please be aware that two working days notice is needed for the practice to process NHS prescriptions. Thank you for your cooperation. (Insert Practice Name)