Whenever we prescribe medication, we have to ask "is it safe for us to prescribe this medication for this patient"?
Medications are divided into 4 categories:
- Green - suitable for non-specialists to prescribe
- Green Plus - suitable for non-specialists to prescribe on the advice of a specialist
- Amber - only specialists can prescribe, but prescriptions could be issued by non-specialist if a shared care agreement is in place
- Red - only specialists can prescribe. Under only very exceptional circumstances could a non-specialist issue a prescription for these.
All doctors are specialists in their own field. GPs are considered to be experts in general medicine but don't have the indepth knowledge that a hospital consultant will do in their own specialism. When doctors prescribe medication they are required to do so within their area of expertise. This does mean that there are some medications that only a specialist in that field would have the necessary training to prescribe. Examples of this might include methotrexate which a rheumatologist might have training in but, say, a gynaecologist wouldn't, or cancer treatment drugs which an oncologist could use but a cardiologist couldn't.
Some of these specialist drugs are considered to be fine for a GP to issue on behalf of a consultant so long as there are robust safeguards in place - this is called a "shared care agreement". GPs are under no obligation to enter into a shared care agreement nor to issue drugs that are on the "amber list".
As a practice, we understand that getting prescriptions from a local pharmacist is far more convenient, particularly since hospital computer systems are still unable to send prescriptions electronically to a patients nominated pharmacist in the same way GPs can. When we do so, though we need to ask if it is safe to do so and this depends on a couple of things:
- Do we have the capacity to take on a shared care prescription (since it takes time to set up, check prescriptions for any monitoring before issuing and liaise with specialsits)
- Are there safe monitoring processes in place with the specialist, which includes withdrawing medication if monitoring is missed by the patient?
There are some locally funded initiatives for common shared care drugs such as those used for rheumatoid arthritis or prostate cancer treatment. There are robust safety systems in place with ongoing regular reviews by both the hospital and ourselves.
However, a lot of requests we receive are not funded and do not have the same safe systems in place. These we consider on a case by case basis, but generally we will not issue for the sake of patient safety. It can be confusing because there may be different "rules" for different units.
ADHD medication
A common example currently is requests from private providers to prescribe ADHD medication on behalf of their specialists.
Shared care agreements for ADHD medication, even with CNTW and locally commissioned non-NHS providers (currently only Psychiatry UK is locally recognised), are unfunded. Where we have capacity, we may, at our discretion, agree to enter into a shared care agreement with the locally commissioned services (CNTW and Psychiatry UK). Generally speaking though we will not enter into a shared care agreement with any other provider, even if they are NHS commissioned.
We understand that there is an unprecedented waiting time to access mental health services and as such patients are exercising their right to request referral to a private or third party Right to Choose provider. We cannot vet all of these providers or even confirm that they do indeed have a safe prescribing systems. Some we have been asked to support a referral to are not even UK based, with health information being kept in non-EU countries. Many of these providers make a diagnosis and recommend prescriptions and then discharge back to the GP even after apparently setting up a shared care agreement - which puts patients in an even worse position of starting a medication but then being left without it. In line with best practice, therefore, we cannot enter into a working relationship with these private providers long term.
In short, us supporting a referral to a private provider at the request of a patient should not be taken to constitute an agreement that we will agree to prescribe any recommended medication.