General Approach to Specialist Request for Medication
We are required to prescribe in a consistent, safe and equitable way. Each medication request by any specialist will be considered and assessed in line with NHS GP best practice guidelines.
We prescribe when it is accordance with the medication license, NHS NICE (National Institute of Clinical Excellent) guidance and also our ICB (Integrated Care Board) and JFC (Joint Formulary Committee) guidelines.
Specialists are able to prescribe a wide array of medicines- including some that we are unable to. When specialists see patients through the NHS they are obliged to prescribe in accordance with the hospital formulary which typically has the most cost-effective options as first line. When the same specialists see patients privately these restrictions are not in place and therefore the Specialists often prescribe on the basis of effectiveness rather than cost-effectiveness and therefore go straight for options that, through the NHS, would be 4th or 5th (and only prescribed if more cost-effective options had not worked). We appreciate why specialists often focus on ultimate effectiveness. We also appreciate why patients often do not want to privately pay for very expensive / less cost-effective medications. Equally, when more cost-effective options haven’t been tried first this does prevent us from prescribing the medication in question.
Patients are always free to follow the private specialist’s advice and recommendations but in some cases (when we are not able to prescribe the medication) this means obtaining the medication privately from the specialist on an ongoing basis or considering referral to an NHS specialist so they can recommend on an NHS approved treatment option.
The key considerations taken into account when we are requested to prescribe certain specialist medications are outlined in the NHS “Responsibility for prescribing between Primary & Secondary/Tertiary Care” guidance.
In summary these are:
- The Legal responsibility for prescribing lies with the doctor or health professional who signs the prescription and it is the responsibility of the individual prescriber to prescribe within their own level of competence. Further advice on this is contained within the General Medical Council’s (GMC) core guidance “Good Medical Practice” (GMP). A recommendation to prescribe a medicine by a specialist does not reduce the legal responsibility on the actual prescriber.
- It is of the utmost importance that the GP feels clinically competent to prescribe the necessary medicines.
- Shared care is a particular form of the transfer of clinical responsibility from a hospital or specialist service to general practice in which prescribing by the GP, or other primary care prescriber, is supported by a shared care agreement. The shared care agreement is designed to enable the primary care prescriber to feel able to prescribe however it also does not reduce the legal responsibility (for the drug and any consequences of it) which sit with the prescribing clinician.
- When a specialist considers a patient’s condition to be stable or predictable, they may seek the agreement of the GP concerned (and the patient) to share their care. In proposing shared care agreements, a specialist should advise which medicines to prescribe, what monitoring will need to take place in primary care, how often medicines should be reviewed, and what actions should be taken in the event of difficulties.
- Stable Patients: A patient who has been prescribed the medication for at least 3 months and monitored to demonstrate the treatment has been optimised and the response is consistent
- When a shared care protocol exists and where the GP has confirmed willingness to accept the transfer of care, the hospital must initiate and abide by that agreement.
- Referral to the GP should only take place once the GP has agreed to this in each individual case, and the hospital or specialist will continue to provide prescriptions until a successful transfer of responsibilities.
- Patients should never be used as a conduit for informing the GP that prescribing is to be transferred. Any requests to enter into a shared care agreement should come directly from the specialist to GP.
- People who are being treated on the advice of the secondary care team, but are no longer actively being seen in that setting, may still need review should problems arise. The appropriate level of care and/or advice should be available from the secondary care team in a timely manner without necessarily requiring a new referral.