Health Articles

Medicines management guide to prescribing

MEDICINES MANAGEMENT GUIDE TO PRESCRIBING
Medicines Management Team
APPROVED BY:
The Clinical Executive Team
DATE OF ISSUE:
July 2014
VERSION:

Amendments for East Surrey – Jay Voralia

Page 1 of 45
MEDICINES MANAGEMENT GUIDE TO PRESCRIBING
Foreword
This document aims to support the delivery of consistent prescribing advice to practitioners
prescribing on behalf of the CCG with a purpose of:
 Improving the quality and consistency of patient care  Improving patient access to healthcare services  Utilising limited resources as effectively as possible  Patients being fully informed of the reasons why a medicine has or has not been  Achieving good patient concordance or compliance with their prescribed treatment  Increasing the appropriateness and cost-effectiveness of prescribed treatments  Improving care between the primary, secondary and tertiary care interface.
The document was approved for use by The Clinical Executive Team for East Surrey CCG.
The intention is that the document is updated when required to provide up-to-date information
on changes to advice or legislation.
Implementation and Monitoring
The information in this guide is advisory in nature and should be regarded as good practice.
Prescribing in the CCG is monitored routinely through analysis of ePACT.net data, clinical audits
within GP practices and the analysis of acceptance/rejection of ScriptSwitch recommendations
(ScriptSwitch is a piece of software that links with GP clinical systems). Information messages in
ScriptSwitch are set up to support the advice and recommendations contained within this
document. All GP practices in the CCG have allocated pharmacy support on a regular basis.
Instances where a practitioner acts outside their terms of service or in contravention of legislation
are addressed through appropriate channels within the organisation.
Training
Many aspects of this document are self-explanatory and require little or no additional training.
When requested, the Medicines Management team are able to offer one to one support or group
sessions.
Kevin Solomons
Head of Medicines Management

East Surrey CCGmaterials may be downloaded / copied freely by people employed by the NHS in England for purposes that support NHS activities in
England. Any person who is not employed by the NHS in England and who wishes to download / copy East Surrey CCGmaterials, or who works for
the NHS in England and who wishes to download / copy materials for their own use and not in connection with NHS England activities, should first
seek the permission of East Surrey CCG.
Email: [email protected]
Medicines Management Team, Jay Voralia (Lead Primary Care Pharmacist
Telephone: 01372 201817
Page 2 of 45
CONTENTS
Document Purpose
Prescribing Responsibilities: Primary/Secondary Care Interface
General points to consider Traffic Light System Requests for GPs to prescribe Red/Hospital Only Drugs Payment by Results (PbR) Excluded Drugs/Funding Requests Prescribing New Products
Unlicensed Medicines
Prescribing Situations Not Covered By The NHS
Private Referral Infertility Treatment Private Service for Travel Vaccination Malaria Prophylaxis Emergency Travel Kits Clinical Trials / Research Vaccines
Global Sum Vaccines Prescribing Issues
Quantities - Acute Prescriptions Quantities - Repeat Prescriptions Reviewing prescribing Excessive and Inappropriate Prescribing Repeat Dispensing Electronic Prescription Service (EPS) Patients Travelling or Moving Abroad Temporary Residents/Eligibility to Free NHS Healthcare for Visitors to the UK Prescribing for yourself or those close to you Private scripts for NHS patients Monitored Dosage Systems (MDS) / Auxiliary Aids Prescribing for Nursing and Residential Home Patients Remote Prescribing Prescribing decision aids, tools and information
Prescribing Advisory Database Prescribing for the Management of Anxiety Spectrum Disorders and Depression Prescribing of Borderline Substances Prescribing Gluten Free Foods Non Medical Prescribing
Patient Specific Directions / Patient Group Directions
Medicines Management Committees
Medicinal Waste Management
Controlled Drugs Drug Donations to Other Countries BNF Availability
Diabetes and the DVLA
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This guidance is offered to all practitioners working for or on behalf of East Surrey CCG
2. DOCUMENT PURPOSE
This document aims to support the delivery of consistent prescribing advice to practitioners prescribing on behalf of the CCG with a purpose of:  Improving the quality and consistency of patient care  Improving patient access to healthcare services  Utilising limited resources as effectively as possible  Patients being fully informed of the reasons why a medicine has or has not been prescribed  Achieving good patient concordance with their prescribed treatment  Increasing the appropriateness and cost-effectiveness of prescribed treatments  Improving care between the primary, secondary and tertiary care interface
It is anticipated that this document will be under regular review and updated to reflect changes
relating to medicines management both nationally and within East Surrey CCG
The Medicines Management Team structure and a full list of contact details are available on
request from the East Surrey CCG offices
 The CCG has commissioned the Medicines Management Services which is hosted by Surrey
Downs CCG.

Job Title
Name and Contact Details
Lead Primary Care Pharmacist Primary Care Support Pharmacist Primary Care Support Pharmacist Elisabeth Durodie Primary Care Support Pharmacist Senior Pharmacy Technician Page 4 of 45
GUIDANCE
3. PRESCRIBING RESPONSIBILITIES: PRIMARY/SECONDARY CARE INTERFACE
East Surrey CCG interface with the following Acute Trusts  Surrey & Sussex Hospitals NHS Trust  Surrey & Borders Partnership NHS Mental HealthTrust The Medicines Management team interface with these Trusts at the following forums:
 The Prescribing Clinical Network (PCN)
 Ashford & St Peters - Drugs & Therapeutics Committee (D&TC)
 Frimley Park Hospital – D&TC and Primary/Secondary care Interface Prescribing Forum
 Royal Surrey County Hospital – D&TC
 Surrey & Sussex Hospitals – Area Prescribing Committee (APC)
 Epsom & St Helier University Hospitals - New Drug Appraisal & Interface Group (NDAIG)
 Surrey & Borders Partnership – Medicines Management Committee
 Kingston Hospital NHS Trust – D&TC and Interface Group

3.1
General points to consider
The GMC's Good Medical Practice guidelines state that you must:  Make the care of your patient your first concern  Recognise and work within the limits of your professional competence The doctor who has clinical responsibility for the patient should undertake the prescribing (EL
(91)127)
Prescribing at the primary/secondary care interface presents a number of potential difficulties:  The medicine may be outside of the GP's current experience  The GP may have been given inadequate information about the medication and its  The GP may not be in control of the monitoring and/or does not receive results of such  The treatment may be outside of the licensed indications  The dosage may be outside of the licensed range  Local Policy and/or the BNF recommends specialist supervision  The treatment may not be obtainable from community pharmacy Formal "Shared Care" arrangements may be an appropriate way of overcoming some of these
issues
3.2
Traffic Light System
The CCG and local Acute Trusts have developed drug formularies and a traffic light system that provides a framework for defining where clinical and, therefore, prescribing responsibility should lie through the categorisation of individual drugs. For details of the traffic light status for the individual drugs and where applicable the relevant amber shared care protocol or amber* information sheet please access the Prescribing Advisory Database (PAD). Click icon to enter the PAD: http://pad.res360.net/ Page 5 of 45
The system is only advisory but is intended to clarify expectations of prescribing responsibility. See section 9.1 for further details For specialist use in secondary/tertiary care on the grounds of one or more RED DRUGS / HOSPITAL ONLY of the following: 1. Only available in hospital 2. New classes of drugs (usually a minimum of 6 months since its launch) and new indications for older drugs: where clinical experience is limited in general practice 3. Clinical trial drugs that are being used in the hospital 4. Complex monitoring requirements and specialist drugs 5. Drugs being used outside licensed indications that are not in common usage and / or doses 6. Unlicensed drugs in certain situations Medicines that require preparation by the hospital pharmacy: unless an acceptable procedure for supply through a community pharmacy can be arranged. Prescribing initiated in secondary care with the potential to transfer to primary care when: 1. An individual GP has agreed to accept clinical responsibility for an individual patient 2. Agreed shared care arrangements have been established and the GP is willing to take over shared care 3. The patient's condition and / or treatment has been stabilised 4. In one off situations, a specific GP can agree to enter into a ‘shared arrangement' without a formal shared care guideline providing a letter is sent to the GP giving appropriate advice and guidance 5. The GP is provided with information and given the opportunity to accept prescribing responsibility before the transfer takes place 6. Under a shared care arrangement the prescriber must be able to: receive monitoring results promptly and be able to interpret them, have consultant / specialist support, ensure that the local pharmacy can dispense the drug to ensure continuity of supply Where a shared-care protocol has been developed and agreed it will be made available on the Prescribing Advisory Database (PAD) See section 9.1 for more details. Due to widespread GP experience these amber drugs are often prescribed in Primary Care following specialist advice and initiation in secondary care,  without the need for formal shared care If the GP feels unable to accept prescribing responsibility for a drug in the amber category then clinical responsibility for prescribing that drug rests with the initiating clinician Can be initiated and continued in primary, secondary or tertiary care If the GP has any concerns on either the treatment or the indication for use then it is suggested they contact a member of the CCG Medicines Management team for clarification. Page 6 of 45
Requests for GPs to prescribe Red/ hospital only drugs

GPs should not be asked to accept prescribing responsibility for Red or Black drugs from our local
Acute Trusts. If this occurs, the GP should contact a member of the Medicines Management
Commissioning team:
Pharmaceutical Commissioning East Surrey/Crawley/Horsham & Alternatively, contact the pharmaceutical commissioning team Head of Strategic Pharmaceutical Victoria Overland There may be some occasions where requests from tertiary centres are in conflict with the local Traffic Light System. In these instances the GP should:  Consider whether they have the confidence and knowledge/experience to accept the clinical responsibility associated with prescribing the drug  Decide whether they have been given sufficient information from the tertiary centre or if there is a shared care protocol available from the tertiary centre  Contact a member of the CCG Medicines Management team for further advice if necessary If a GP is unwilling to accept responsibility, it should be possible for prescriptions to be issued by a
hospital doctor and posted to a patient who lives at a distance from the hospital.

3.4 Payment by Results (PbR) excluded drugs and devices / funding requests to the CCG from
acute Trusts for high cost drugs
A number of high cost drugs, devices, procedures and products have been excluded for the scope
of the national tariff of PbR. PbR excluded drugs are not included within the national tariff prices
that are paid for routine packages of care.

East Surrey CCG has agreed specific commissioning arrangements for PbR excluded drugs with the
providers from which it commissions services. The commissioning intentions document details
East Surrey CCG's criteria and specific funding arrangements for each of the PbR excluded drugs; it
cannot be assumed that East Surrey CCG will automatically fund these drugs.
The Pharmaceutical Commissioning Team has developed a series of standard forms (‘tick box' or
individual funding request form) in line with CCG PBR excluded drug commissioning intentions.
Acute trusts must use these forms for either prior approval or notification as applicable. Forms
must be submitted electronically via the web-based database The patient must meet ALL pre-determined criteria for funding to be approved.
An individual funding request (IFR) should be submitted where a request for a PBRe drug is made
for use outside of the commissioning intentions or when the commissioning intentions specify that
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an IFR must be submitted for that particular drug and indication. If the IFR clinical triage panel agrees that the case is eligible for consideration as an IFR, it will be discussed at the next available IFR panel. IFR panels are held on the 4th Wednesday of each calendar month. This process considers funding requests for PbR excluded drugs and other high cost drugs that require continued prescribing by the acute Trusts (e.g. Red drugs and a small number of Amber drugs in East Surrey CCG's traffic light system). Although the majority of the PbR excluded drugs are Red drugs on East Surrey CCG's traffic light system (prescribing to be retained in secondary / tertiary care) detailed guidance on the use /prescribing of these drugs across the interface can be found in the Prescribing Advisory Database (section 9.1) NB: Where a Red drug is prescribed by a practice the financial impact should be considered. An adjustment to the practice prescribing allocation is unlikely to be made to cover the cost of prescribing. PRESCRIBING NEW PRODUCTS
(Acknowledgement to MeReC Bulletin 1998; 9:21-24) The principles outlined in this section of the document apply equally to the prescribing of medicines, dressings, stoma and continence products. If the GP does not feel confident to prescribe a new treatment they should discuss the implications with the CCG Medicines Management Team or their Defence Organisation before prescribing. Some new medicines may offer distinct advantages over current therapies. However there is often a lack of good quality demonstrable evidence at the time of launch to be able to define their place in therapy. In addition the safety profile of a new drug cannot be fully assessed as only a few thousand patients may have been exposed to it by the time it is licensed. Drugs that are newly licensed and are being monitored intensively by the Medicines & Healthcare products Regulatory Agency (MHRA) can be identified in the BNF by the black triangle symbol ▼ In order to avoid exposing patients to an unknown risk of adverse events, GPs need to have a careful, critical approach to the use of new drugs in order to ensure their use is appropriate. Extreme vigilance is needed to detect and report possible adverse effects; thereby ensuring patients are not exposed to unnecessary risks. Adverse Drug Reactions (ADR) – Yellow Card Scheme
An adverse drug reaction (ADR) can be reported online using the Yellow Card Scheme at Additional information about the Yellow Card Scheme and the reporting of ADRs can be found at Before prescribing any new innovative treatments, it is suggested that the GPs discusses this with a member of the CCG Medicines Management team to make sure that they have access to all available evidence on safety and effectiveness. The transfer of prescribing for new drugs, initiated by hospital consultants, should only be considered in cases where the drug has been added to the hospital formulary through due process, i.e. ratification by the Drugs and Therapeutics Committee. Consultants should not refer Page 8 of 45
the prescribing of these drugs to primary care as a means of bypassing their approved hospital formulary. The Prescribing Clinical Network (PCN) and the Medicines Commissioning Group (MCG) will keep abreast of developments nationally and locally e.g. NICE, NSFs, good practice guidelines, local priorities, Trust DTC decisions and identified problem areas. In doing this they will consider the implications of, and make recommendations for the managed entry of new drugs (Further information about the role of the PCN / MCG can be found in section 13). Before prescribing a new drug/product, there are a few things to consider:
 Is it a truly new medicine, or merely an attempt at patent extension e.g. a novel formulation or isomer
of a former medicine?  Does this medicine provide evidence-based, demonstrable benefits to patients?  Can pharmaceutical company claims be substantiated?  When this medicine should be used in preference to current treatment decisions and will it give better  What are the licensed indications?  Is it a specialist treatment?  Are there any published comparative safety data and has it been widely used?  Are there any monitoring requirements?  Are there any clinically important drug interactions?  Are there particular groups of patients in which this medicine should not be used or used with care?  Is there any independent guidance from the CCG Medicines Management team, the PCN / Medicines Commissioning Group  Is there good quality, demonstrable evidence that it is more cost-effective than existing treatments?  What impact would prescribing this medicine have on the whole health economy?
5. UNLICENSED MEDICINES

Medicines should be licensed for the indication for which they are intended.
When a GP chooses to prescribe a product outside the terms of its licensing agreement, the product liability passes to the GP. Before prescribing outside the licensed indications the GP should be confident that a reasonable body of medical opinion would support the use of the product in that way (Bolam principle). However, recent court judgements and Human Rights legislation may mean that the ‘Bolam test' may not always be a suitable defence. If in doubt, prescribers are advised to seek guidance from the CCG Medicines Management team or their defence organisation, if appropriate. All GPs are advised not to prescribe an unlicensed product if requested to do so by secondary care unless they have full clinical knowledge and understanding of the products efficacy and safety and are prepared to accept clinical responsibility for the use of the product in each patient. Under these circumstances a shared care agreement may be appropriate. For specific shared care information please access the Prescribing Advisory Database Many medicines initiated by the paediatricians in secondary care are unlicensed but their use is medically accepted practice. Providing that the drug, indication and dose is included in the Children's BNF then a shared care protocol is not required in order for the transfer across to primary care to take place. GPs are advised to seek advice from the CCG Medicines Management team and their medical defence organisation (on each occasion), as appropriate. Page 9 of 45
For further information see:
East Surrey CCG Recommendations to prescribers on the use of unlicensed medicines and licensed medicines for unlicensed indications" Click icon to enter the PAD: http://pad.res360.net/ Prescribing Situations Not Covered By the NHS
Private Referral
 The responsibility for prescribing rests with the doctor who has clinical responsibility for a particular aspect of the patient's care (EL (91)127).  Where an NHS GP refers a patient (privately or otherwise) to a Consultant for advice but retains clinical responsibility for the patient, then the GP should issue the necessary prescriptions at NHS expense.  In the situation where the Consultant retains clinical responsibility, for example, where he continues to administer any treatment or the treatment is recognised to be specialist in nature, then, it is the Consultant who should issue the prescriptions.  Where patients opt to be referred privately (i.e. outside of the NHS) then they would be expected to pay the full cost of any treatment they receive in relation to the referral, including that of any drugs and appliances until the Consultant has discharged the patient and the GP has accepted Clinical Responsibility. There are certain circumstances where this does not apply, as highlighted within "Guidance on NHS patients who wish to pay for additional private care"  Policies for Cancer "top-ups" should be available from local acute trust organisations.  In cases where the Consultant continues to have clinical responsibility for treating a particular condition, the consultant should continue to prescribe privately.  Following a private consultation, there is no obligation for the GP to prescribe the recommended treatment if the GP does not feel clinically competent to do this and it is contrary to his/her normal clinical practice For further information see:
"Prescribing of NHS Medication recommended during or after a private Episode of Care"
This is accessible on the Prescribing Advisory Database Click icon to enter the PAD: http://pad.res360.net/ Page 10 of 45
Infertility Treatment
IVF and other similar assisted conception methods are specialist services and access will normally be on the recommendation of a local NHS Consultant Gynaecologist and on some occasions from local NHS Consultant Urologist. East Surrey CCG believes that such treatment should not be undertaken in primary care and have alternative funded arrangements in place. Drug treatments are included in the cost of the package and will not be funded as separate elements by Primary Care clinicians. In essence, we would advise that you do not prescribe fertility drugs, not only due to clinical concerns but also to prevent inequalities across the CCG. Where a patient wishes to change from private to NHS status, the following principles apply:  A patient cannot be both a private and a NHS patient for the treatment of one condition during a single visit to a NHS organisation  Any patient seen privately is entitled to subsequently change his or her status and seek treatment as a NHS patient  Any patient changing their status after having been provided with private services should not receive an unfair advantage over other patients As a matter of principle a patient must never be treated on a different basis to another NHS
patient simply because they previously held private status.
For further information see:
East Surrey CCG Assisted Conception Commissioning Policy, Criteria for Access to Treatment and
the NICE Pathway for Fertility Treatment:
Further information can be found on the NICE website:

6.3
Private Service for travel vaccination
Immunisations for conditions for which there are no reimbursement arrangements (e.g. Hepatitis B, Rabies), GPs may levy a charge directly to the patient under Schedule 5 Fees and Charges of The National Health Service (General Medical Services Contracts) Regulations 2004 – see appendix 2 for additional information. Patients can be charged directly for some vaccinations but note:  You CANNOT charge for advice  You CANNOT charge if the service is available on the NHS  You CANNOT mix NHS and non-NHS  You can write a private prescription or charge patients for the stock and the administration  The level of charge is for the practice to determine. It is advisable for practices to develop a protocol which is available to patients or included in the practice leaflet. Malaria Prophylaxis
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Anti-malarial drugs, for the prophylaxis of malaria, may not be prescribed on the NHS.
The Department of Health issued guidance in 1995 (FHSL(95)7) suggesting that medication for malaria prophylaxis should be provided on a private prescription. This was supported by a change in the GMS Regulations to permit GPs to charge for such prescribing. However the guidance does not apply to the treatment of malaria or the use of the treatments specified below for any other indications. For the prevention of malaria doxycycline, proguanil with atovaquone (Malarone®), pyrimethamine with sulfadoxine (Fansidar®) and mefloquine (Lariam®) may be prescribed on private prescription as they are Prescription Only Medicines. Other medicines for the prevention of malaria are available for purchase "over the counter" at community pharmacies. Advice in relation to recommended malaria prophylaxis can be accessed on the NaTHNaC website and the TRAVAX website Other useful advice can be found by clicking the link to the Health Protection Agency website below. Patients should be advised to purchase sufficient prophylactic medicines to cover the period of their travel, please refer to up-to-date information in the BNF. Please note that due to the side effects with Mefloqine, patients should be advised to commence
therapy two and a half weeks prior to travel in case of adverse reactions.The importance of
prevention, e.g. through the use of mosquito nets, suitable clothing and insect repellents to
protect against being bitten, should be stressed.
Remember the four steps (ABCD) to prevent suffering from malaria in UK travellers
 Awareness: know about the risk of malaria
 Bites by mosquitoes: prevent or avoid
 Compliance with appropriate chemoprophylaxis
 Diagnose breakthrough malaria swiftly and obtain treatment promptly
6.5
Emergency travel kits
Emergency travel kits are available in two forms:  The "basic kit" contains items such as disposable needles and syringes, IV cannulae, sutures  The "POM" kit contains additional items such as plasma substitutes and medicines. A private prescription is required for the latter Neither kit is available on the NHS but the kits are available through community pharmacies
6.6
Clinical Trials / research
All trials of medicines within East Surrey CCG should have gained Research Ethics approval and meet research governance criteria where appropriate. NHS staff should have evidence that the research protocol has the ethical and regulatory approval it needs. Research governance for East Surrey CCG is managed by Sussex Research Consortium contact details are below: Page 12 of 45
Mrs. Helen Vaughan Senior Research Governance Officer Sussex NHS Research Consortium Research Department Worthing Hospital Lyndhurst Road Worthing, West Sussex, BN11 2DH Tel: 01903 285222 ext 4190 Fax: 01903 209884 E-mail: [email protected] For more detailed information on Research Governance please refer to the East Surrey CCG
Research Policy or contact Glynis John Quality & Clinical Governance Facilitator,
Tel: 07775 560105

7
VACCINES
Guidance for GPs on risk assessment for travellers, advised vaccinations, antimalarials and other appropriate advice is available by logging on to the TRAVAX website TRAVAX aims to give 'evidence based' and practical information and to this end undertakes continual monitoring of travel related health risks and the available preventive measures. Quality is also regulated by the clinical governance procedures in place in Health Protection Scotland. TRAVAX carry out literature searches and specific research as required guided by the TRAVAX Advisory Board. Global sum vaccinations
A number of vaccinations are available on the NHS for specific indications/circumstances – see Appendix 1 No charge can be made to patients for these vaccines and immunisations. The global sum vaccines can be obtained in bulk by the practice and charged to the PPA on FP10 (or FP34D for specific vaccines). The payment for the administration service provided by practices is paid for from the Global Sum (GMS) or built into the baseline funding for PMS practices. The following services are managed by NHS England (Public Health team). Some are subject to additional payments that can be claimed through an Enhanced Service:  Influenza & Pneumococcal programme over 65 years and at risk patients = £7.64 per  Influenza – Children 2 & 3 year olds only - £7.64 per completed course  Influenza Housebound – recently launched a programme to monitor and vaccinate those housebound patients for flu. Payment will be split into 2 payments 1 when signing up to the scheme and the other when activity is returned at the end of the year showing outcomes and patients vaccinated. This payment is based on practice list size.  Childhood Immunisation programme – payment via vaccinations and immunisations as part of the core contract. However a payment will be made if practices reach a certain target of patients vaccinated. (price depends on the level reached and is calculated by the PCSS.)  Men C has been added to the childhood immunisation programme this year. Page 13 of 45
 Shingles patients aged 70 years and a catch up programme for patients aged 79 years. Payment per vaccine of £7.64  Rotavirus vaccines provided when patients are 2 & 3 month olds £7.64 per completed o Part 1 - Identifying patients and offering a written call and recall programme - £1.50 per qualifying child o Part 2 – Provide one or two doses as required to the patient aged 16 or over - £7.64 o Patients under 16 years would be included in the vaccinations & immunisations payment within the core contract.  HPV – Most of the HPV vaccines are administered by the school nursing programme but GPs pick up those patients who fall through. £7.64 per vaccine administered.  Hep B Babies – Patients deemed at risk where a hospital has initiated the treatment. Continued vaccination programme - £7.64 per vaccine. HPV and other vaccines that are part of the National Childhood Immunisation Programme cannot
be claimed on FP34D as they are supplied free of charge to practices.

8
PRESCRIBING ISSUES
8.1.1 Quantities – Acute Prescriptions

Prescriptions for medicines which have never been supplied to the patient before should be the
minimum quantity necessary to assess the response and for no longer than the next review date
(to a maximum of 28 days). It is worth remembering that most acute side effects occur within the
first 7 to 14 days.
Quantities of medicines which are ‘when required' should reflect the anticipated need of this
course of treatment or review period.
8.1.2 Quantities - Repeat Prescriptions
The decision to delegate a medicine as suitable for inclusion on the repeat medication list should be taken in accordance with the practice repeat prescribing policy. The Department of Health takes the view that prescribing intervals should be in line with the medically appropriate needs of the patient, taking into account the need to safeguard NHS resources, patient convenience, and the dangers of excess drugs in the home. East Surrey CCGwould suggest that if a medicine is to be issued as a repeat item, the quantity should usually be for 28 days (with the exception of HRT, oral contraceptives, levothyroxine and preparations supplied in original packs that cannot be broken down, e.g. certain creams, Didronel PMO® etc). A maximum of 28 day supply is particularly recommended for medicines such as:  Benzodiazepines & other hypnotic agents (based on CSM advice)  Anti-depressants (particularly where there is potential for overdose) Page 14 of 45
 High cost drugs i.e. those costing £2,500 per patient per annum  New drugs (whilst you establish benefit versus adverse effects) It is estimated that between 5-10% of all prescription medicines are wasted (£8 -£15 million across Surrey based on 2009-10 spend. The majority of wastage is due to changes in medication resulting in destruction of previously dispensed medicines. Consideration of quantities prescribed will have a beneficial effect on this level of wastage. Special consideration should be given when prescribing for patients over 60 years of age.This age group is more vulnerable to the adverse effects of medicines and their general health varies greatly. This increases the likelihood that prescriptions will alter more frequently. Consequently, longer supplies often equate to more waste. If a longer period is prescribed, consideration should be given to the likelihood of any adverse events, which may go unnoticed or alterations in therapy which will result in wastage. All repeat medicines should be reviewed regularly to assess effectiveness and side-effects. With the development of repeat dispensing and Electronic Transfer of Prescriptions, it is likely that prescription intervals of 28 days will become the norm – see below for further information about Repeat Dispensing and the Electronic Prescription Service. Pre-payment certificates
Up to 80% of people do not pay for their prescriptions but for those who do, a pre-payment certificate may be a cost effective option where they regularly have 4 or more prescription items in 3 months or 14 items in 12 months. These can be paid by direct debit – see NHSBSA website for details There are 3 ways to apply for a pre payment certificate:  Over the internet at Over the telephone on 0300 330 1341  Send an application form (Available from GP surgeries and community pharmacies (form FP95) NHS Help with Health Costs
PPC Issue Office
152 Pilgrim Street
Newcastle Upon Tyne
NE1 6SN

8.1.3 Reviewing prescribing1

You must make sure that suitable arrangements are in place for regular monitoring, follow-up and
review, taking account of the patients' needs and any risks arising from their medicines. When you
review a patient's medicines, you should re-assess the patient's need for unlicensed medicines for
example antipsychotics used for the treatment of behavioural and psychological symptoms in
dementia.
Reviewing medicines will be particularly important where:
 patients may be at risk, for example, patients who are frail or have multiple illnesses  medicines have potentially serious or common side effects 1 GMC Good Practice in Prescribing and Managing Medicines and Devices; February 2013 Page 15 of 45
 the patient is prescribed a controlled drug or other medicines that are commonly abused  the BNF or other authoritative clinical guidance recommends blood tests or other monitoring at regular intervals  continued usage may not be necessary or appropriate Pharmacists can help improve safety, efficacy and adherence in medicines use, for example by advising patients about their medicines and carrying out medicines reviews. This does not relieve you of your clinical responsibility and duty to ensure that your prescribing and medicines management is appropriate. You should consider and take appropriate action on information and advice from pharmacists and other healthcare professionals who have reviewed patients' use of medicines, especially following changes to their medicines or if they report problems with tolerance, side effects or with taking medicines as directed.
8.1.4 Excessive and Inappropriate Prescribing
A policy has been produced to support best prescribing practice and is intended to inform all
prescribers in relation to prescribing behaviour that could be considered excessive or
inappropriate. This policy refers to Annex 8 of the GMS contract but the principles will be applied
to any prescriber working for or on behalf of a practice.
Add local link
8.2
Repeat Dispensing
Repeat dispensing is the process by which patients can obtain supplies of their repeat medicines over a defined period of time, without the need to contact their GP practice on each occasion a new supply is required. Under the repeat dispensing system, the prescriber produces a ‘repeatable' prescription on a standard FP10 prescription form for the patient's repeat medicines. This must be annotated to distinguish it from a standard prescription form. A series of accompanying ‘batch issues' (also printed on FP10 forms) enable the pharmacist to continue to dispense the medicines by instalments for the duration of the original repeatable prescription. This can be up to 12 months. Repeat Dispensing makes it easier for patients to obtain repeat supplies of their medication in instalments at the community pharmacy, speeding up services and relieving pressure on GP surgeries. Repeat Dispensing offers an opportunity to streamline the process, improve services for patients, reduce wastage and enhance the role of community pharmacists. Practices must notify the Contracts Team at their local NHS England Area Team of their intention
to provide repeat dispensing services. This notification should:
 Provide the names of the GPs who will be providing services
 Specify a start date. This should provide at least one week's notice to allow the Contracts
Team at their local NHS England Area Team to amend the list of doctors providing repeat dispensing services2 2 The National Health Service (General Medical Services Contracts) Regulations 2004 Page 16 of 45
Repeat dispensing is specified as an essential service under the new Community Pharmacy Contractual Framework. As of 1st October 2005 therefore, all pharmacies must be in a position to dispense a repeatable prescription if presented with one. There is a requirement for community pharmacists to undertake appropriate training before providing repeat dispensing services. Training requirements are set out in paragraph 3.2 of part VIA of the drug tariff. Prior to each dispensing episode the pharmacist will ensure that the patient is taking or using, and is likely to continue to take or use, the medicines or appliances appropriately, and that the patient is not suffering any side effects from the treatment which may suggest the need for a review of treatment. The pharmacist will also check whether the patient's medication regimen has been altered since the prescriber authorised the repeatable medication and whether there have been any other changes in the patient's health since that time, which may indicate that the treatment needs to be reviewed by the prescriber.3 The selection of appropriate patients is vital for the success of the repeat dispensing process. For
more information about this and other elements of Repeat Dispensing please contact a member of
the Medicines Management Team.
8.3
Electronic Prescription Service (EPS)

The Electronic Prescription Service (EPS) enables prescribers - such as GPs and practice nurses - to
send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice. This
makes the prescribing and dispensing process more efficient and convenient for patients and staff.
EPS will bring gains in both efficiency and safety for both patients and health professionals. Once fully operational, EPS will:  Improve patient safety by reducing the likelihood of dispensing errors due to unclear or illegible prescriptions  Allow the instant cancellation of prescriptions thought no longer clinically appropriate  Prevent the loss of prescription forms  Reduce the number of fraudulent prescriptions  Allow preparation of prescriptions in advance of collection, saving patient time at the dispensary, and making workflow and stock control easier for pharmacists to manage  Relieve patients of the need to collect prescriptions from the prescriber  Eliminate the need for pharmacists to re-enter prescription information, thereby saving time and increasing dispensing accuracy  Allow faster and more accurate processing of prescriptions by the BSA (Business Services
For further information visit:

Or visitto request information / raise queries with the
information centre:
Your local contact is the EPS project sponsor at the Area Team:
Mike Hedley [email protected]
3 Service Specification ES2 (version 1 10-10-04) Page 17 of 45
Patients travelling or moving abroad - access to NHS care

NHS funding and healthcare abroad, in other European countries, including emergency care, is
now the responsibility of NHS England. For further information contact
from the Surrey & Sussex Area Team.
Under NHS legislation, the NHS ceases to have responsibility for people when they leave the U.K. However, to ensure good patient care the following guidance is offered: People travelling to a European Economic Area (EEA) country or Switzerland should make sure they obtain a European Health Insurance Card (EHIC) as well as private health insurance. The card entitles you to reduced cost, sometimes free, medical treatment in most European countries. The EHIC is issued by the NHS Business Services Authority (NHSBSA) and is free of charge. You can apply for an EHIC for your spouse/partner and any children up to the age of 16 (or 19 if they are in full-time education) at the same time as applying for your own. If you are a foster parent or guardian (including boarding school teaching staff), you can apply on behalf of any children you are looking after. You must be over 16 to apply as a main applicant. Apply for an EHIC:  Online at The card will be delivered within 7 days.
 By phone on 0300 3301350. The card will be delivered within 10 days.
 By post - pick up a form from the Post Office. The card will be delivered within 21 days.
Beware! Unofficial websites offering EHIC's
An internet search will produce a number of unofficial sites offering to process your EHIC application or a fast-track service. These sites often ask for a processing or service charge. ALWAYS use the official sto get your free EHIC Patients travelling abroad should always have clear information about any existing medical conditions & medications and should keep a written record. This may be required in order to export their medication or to bring it back into the UK. The generic names, as well as the trade names, may be required in order to accurately identify any medicines. Medication required for a pre-existing condition should be provided in sufficient quantity to cover the journey. If the patient is returning within the timescale of a normal prescription then this should be issued. For longer visits abroad, the patient should be advised to register with a local doctor for continuing medication (this may need to be paid for by the patient). NB. It is wise to check with the manufacturer that medicines required are available in the country being visited. Persons who have left the UK, or who are intending to leave the UK for more than 3 months are
not normally allowed to continue to be registered with a practice
GPs are advised not to provide prophylactic treatment on NHS prescriptions for conditions that may arise while travelling e.g. travel sickness, diarrhoea. Patients should be advised to purchase these items prior to travel. Advice is available from community pharmacists if required. Patients Page 18 of 45
should be advised to seek medical attention abroad for conditions that arise at that time and are
unresponsive to self medication.
8.5
Temporary Residents / visitors to the UK

Entitlement to free NHS services is a complex matter and depends on many factors. The
regulations concerning entitlement to NHS treatment in England and additional advice concerning
overseas visitors can be found on the NHS Choices website
A GP remains clinically responsible for the duration of the treatment that they prescribe. It is
therefore advised that prescribing for Temporary Residents should reflect the time the patient is
under the temporary care of the GP. Thus if a patient is registered for 14 days any prescription
should be for a very limited period. However, some flexibility may be needed to support patients
in seeking further medical advice, e.g. from their own GP on their return home. In general, such
prescriptions should not exceed 28 days, and it will often be appropriate for them to be shorter.

8.5.1 Asylum seekers
Asylum seekers and refugees who are given leave to remain in the UK, or who are awaiting the results of an application to remain or an appeal, are entitled to register with a GP practice and receive free NHS primary medical services. If an asylum seeker loses their claim to asylum and all appeal processes have been exhausted, they become ineligible for routine NHS primary care treatment from the date their asylum claim failed. A practice can then charge the individual concerned as a private patient for any treatment which it provides, unless the treatment is emergency or immediately necessary – further information and advice from NHS England can be found on the NHS Choices website
8.5.2 Emergency or Immediately Necessary treatment
A practice is required to offer free NHS treatment to anyone who requests it if, in the opinion of a clinician, it is immediately necessary. This is essential treatment, which in the clinical judgement of a healthcare professional cannot be delayed or avoided. A practice is also required to offer free emergency or immediately necessary treatment to a person who:  Has been refused acceptance onto the practice list for up to 14 days from the date of refusal or until registered elsewhere (whichever is sooner)  Has been refused by the practice as a Temporary Resident for up to 14 days from the date of refusal or until accepted elsewhere (whichever is sooner)  Is in an area for less than 24 hours A patient might require necessary drugs or dressings following immediately necessary treatment. These are supplied and prescribed in the same was as for UK residents. Prescription charges might also be applicable. Immediately necessary treatment also includes treatment that, in the clinical judgement of a health care professional, is required to treat a pre-existing condition that has become exacerbated during the period of a person's stay in the UK. Page 19 of 45
Prescribing for yourself or those close to you
Wherever possible you must avoid prescribing for yourself or anyone with whom you have a close
personal relationship.

Controlled medicines present particular dangers, occasionally associated with drug misuse,
addiction and misconduct. You must not prescribe a controlled medicine for yourself or someone
close to you unless:
 no other person with the legal right to prescribe is available to assess and prescribe without a delay which would put your, or the patient's, life or health at risk or cause unacceptable pain or distress, and  the treatment is immediately necessary to: o save a life o avoid serious deterioration in health, or o alleviate otherwise uncontrollable pain or distress. If you prescribe for yourself or someone close to you, you must:  make a clear record at the same time or as soon as possible afterwards. The record should include your relationship to the patient (where relevant) and the reason it was necessary for you to prescribe  tell your own or the patient's general practitioner (and others treating you or the patient, where relevant) what medicines you have prescribed and any other information necessary for continuing care, unless (in the case of prescribing for somebody close to you) they object Private scripts for NHS patients
A private prescription may be issued under a number of circumstances, for example where an item
is not available on the NHS (drugs and preparations listed in Part XVIIIA of the Tariff), for drugs to
treat indications not covered by the 'SLS' conditions, vaccinations/antimalarials for travellers or
drugs prescribed in anticipation of an ailment for patients travelling abroad (i.e. there is no clinical
need at the point of prescribing). Under these circumstances a charge could be levied for the issue
of a private prescription.
8.7.1 Private scripts for a branded product
The GP NHS terms of service require that a patient receives an NHS prescription where a treatment is clinically necessary. If a patient requests a particular branded product, despite local NHS policy to prescribe generically, the GP may issue a private prescription but must note the following:  An NHS prescription must be offered. The view of the MCG is that the NHS prescription should be generically prescribed  The patient can choose whether to accept the NHS or private prescription. If the private prescription is chosen then this should be clearly documented in the patients notes  The private prescription can be written generically and the patient should be informed to request the branded equivalent at the point of dispensing. This negates the need to enter the branded drug onto the patients clinical notes and thus avoid the risk of the branded product accidentally appearing on subsequent NHS prescriptions  The patient should be informed that the pharmacist will charge them accordingly Page 20 of 45
 The prescriber must NOT levy a charge for the issue of a private prescription under there
8.7.2 Private scripts to avoid NHS prescription charges
There are circumstances where the NHS prescription charge is greater than the cost of a private prescription (including dispensing on-costs applied by the pharmacy). Therefore, where a patient pays for their NHS prescriptions, it is possible that the patient may request a private prescription. Although this practice does not contravene any regulations, the implications and limited significant benefits render this inadvisable as a matter of routine. The view of the Local Medical Committee (LMC) is as follows:  The patient must also be offered an NHS prescription and choose which one to accept. There is a view that the patient should not be given both prescriptions as both may be obtained. However, this might cause difficulties at the point of dispensing if costs have changed and the private prescription is going to cost the patient more than the NHS prescription charge  Although this may be an attractive option, the practicalities and potential hazards make this difficult to work and therefore inadvisable  In circumstances where the purchase price of the drug is less than the NHS prescription charge, any significant cost benefit is often negated by the addition of the pharmacist's dispensing fee  It is thought that there are only a limited number of patients prescriptions for whom there would be a tangible benefit, and the time spent explaining the process may also make it an unrealistic option for most consultations  If this process were to be used for a number of circumstances, it would be advisable for all of the GPs within the practice to adopt a consistent approach and a patient explanatory letter developed. Monitored Dosage Systems (MDS) / auxiliary aids
An auxiliary aid may be more appropriate than a Monitored Dosage System (MDS).The decision rests with the pharmacist in conjunction with the patient and others involved in their care. Under the Disability Discrimination Act (DDA) pharmacies must provide the most appropriate auxiliary aid to disabled customers. Auxiliary aids include:  Tick charts / medication administration charts  Reminder cards  Wing tops  Large labels  Oversized bottles An MDS should not be used when Social Services care workers (not necessarily the case for other
care workers) are in attendance, because they can administer from a labelled container.
An MDS is not suitable where medications are "when required", dispersible, liquid or in a form with limited stability. Pharmacies can make a charge to cover the cost of providing an auxiliary aid if:  the patient does not meet the criteria of the DDA, or Page 21 of 45
 Another adjustment is deemed more appropriate, but the patient or their carer insists on a particular auxiliary aid. Where the intention is to dispense a 28-day supply, pharmacies can not request 7-day prescriptions. The following statement summarises the agreement between our LMC and LPC:  Community pharmacists will not directly request 7 day prescriptions from any GP  If as a result of a DDA assessment, or by other means, a patient is identified as needing an MDS unit, this will be initially discussed with the pharmacist: this may be with the patient, relative, community nursing staff, or carer  If the pharmacist agrees that they are willing to dispense via MDS, and other issues (such as how the prescription is received and collected/delivered) are resolved, then the patient or their representative will contact the GP to explain the above  The final decision as to the prescribing interval used is for the GP to make, bearing in mind such issues as the patient's clinical needs, safeguarding NHS resources, patient convenience, and the dangers of excess drugs in the home, need to be taken into account – these examples are all drawn from BMA advice. Prescribing for Nursing & Residential Homes – Homely remedies
By law an appropriately trained nurse can administer any P or GSL medication to a patient in their care without the need for a prescription. However, it is strongly recommended by the Nursing & Midwifery Council (NMC) that a robust protocol is in place with their employing organisation. A "homely remedy" protocol can be agreed between the care home and the GP providing the prescribing service, which allows nursing staff to administer specific non-emergency, non-prescription medicines that would otherwise require the GP or out-of-hours provider to be called, or the patient going without the medicine until the GP is able to visit. Examples of typical homely remedies include:  Gaviscon liquid  Paracetamol tablets  Senna tablets  Lactulose  Aqueous cream The medicines included in the homely remedy protocol can be obtained in one of two ways:  The care home can purchase these medicines to keep as stock  The GP can write a bulk prescription on an FP10 – however, this is not always possible (see A bulk FP10 prescription can be written4:  For any P or GSL medicines that is prescribable on FP10  For any 2 or more patients  Where the care home has at least 20 residents and the GP issuing the bulk prescription is responsible for at least 10 or more of those residents The prescription should bear the name of the institution and there are no charges for bulk prescriptions. 4 Drug Tariff March 2008; Part VIII paragraph 9 Page 22 of 45
8.10 Remote prescribing
The GMC Guide to Prescribing states that "before you prescribe in the absence of the patient (via
telephone, video-link, online) you must be satisfied that you have adequate knowledge of the
patient's health, can make an assessment of their needs and establish the appropriate patient
consent." This is particularly relevant when prescribing for children of for drugs that may be
subject to abuse for example, strong analgesia or controlled drugs.
The GMC continue to state that "you must consider the limitations through which you are
communicating with the patient for example, the need for a physical examination of the patient
and access to the patient's medical records.
Note: Products such as Botox, Dysport or Vistabel must only be prescribed after physical
examination of the patient and cannot be prescribed remotely
If prescribing for a patient in a care home, nursing home or hospice, you should communicate with
the patient (or carer) to make your assessment and provide the necessary information and advice.
Instructions for administration or monitoring must be clearly understood by the recipient and
written confirmation should be sent as soon as possible."
9
Prescribing decision aids, tools and information
Prescribing Advisory Database (PAD)

(Click icon to enter the PAD)
The Surrey Prescribing Advisory Database (‘PAD') is an innovative, web-based resource which can be accessed by healthcare professionals in primary and secondary care and by patients. The PAD provides guidance and key information on medicines use within Surrey. Information available on the PAD includes:  Recommendations, policy statements and submission papers from our Prescribing Clinical Network (PCN) and Medicines Commissioning Group (MCG)  Links to associated NICE Technology Appraisals  Relevant drug / safety alerts issued by the NPSA, EMEA and the MHRA  Local policies, procedures, protocols and guidelines relating to the use of medicines  Materials used in the course of optimising medicines use e.g. audit tools, letter templates Each drug entry on the PAD has been assigned which is a locally agreed colour-coded guidance system on the use of medicines across the interface between primary and secondary care. It provides a framework for defining where clinical and therefore prescribing responsibility should lie. The system is only advisory but is intended to clarify expectations of prescribing responsibility. The PAD is maintained by members of the Medicines Management Teams who provide services to the local Clinical Commissioning Groups. For comments or suggestions regarding the PAD please email Page 23 of 45
Prescribing for the Management of Anxiety Spectrum Disorders and Depression – The
Mood Hive
The Mood Hive is a web-based tool to help health care professionals recognise and manage
depression and anxiety spectrum disorders. The tool has been developed with East Surrey CCG
and Surrey and Borders Partnership NHS Trust. It has been designed to help with diagnosis of
depression and anxiety, management and treatment choices, the management of lack of efficacy
and / or tolerability issues and appropriateness of referrals to secondary care.

9.3
ScriptSwitch® is a software solution which works alongside practice clinical IT systems to offer up-to-date prescribing recommendations at the point of prescribing. The advice offered by ScriptSwitch® is tailored by the CCG Medicines Management team to reflect local and national prescribing recommendations and offer both clinical and cost-effective prescribing advice. The prescriber is able to accept or reject the advice at the click of a button. Feedback on any ScriptSwitch® recommendations should be directed towards the CCG Medicines Management Team on 9.3.1 ScriptSwitch® Reports
Both the CCG and the practices are able to access ScriptSwitch® reports at Should you experience any difficulties in doing this, the Technical Support number at ScriptSwitch® is 02476 430 064 Practices are able to access their own reports to review the number of times each prescriber
accepts or rejects the ScriptSwitch® advice. This will allow practices to identify internal variation in
prescribing practice. The extent to which practices use this data is entirely up to them.
The CCG Medicines Management team are able to access reports of the number of times each
practice accepts or rejects the advice and the potential financial benefit for the CCG and practice.
This information is used to refine the messages and identify key areas of change and to evaluate
the cost effectiveness of the system.
9.3.2 Summary of advantages
ScriptSwitch® provides advice which:  Is up to date and relevant to local prescribing issues  Is delivered simply, quickly and safely at the point of prescribing  Supports practices in achieving financial balance  Supports achievement against national and local targets e.g. QIPP, Incentive schemes ScriptSwitch® allows the prescriber to make quick changes to patients' prescriptions with no extra effort. Prescribing of Borderline substances
In certain conditions some foods and toilet preparations have characteristics of drugs. The Advisory Committee on Borderline Substances (ACBS) advises as to the circumstances when such substances may be regarded as drugs and can be prescribed on the NHS. Page 24 of 45
When prescribed under these circumstances the prescription should be endorsed "ACBS".
Doctors should satisfy themselves that the products can safely be prescribed, that patients are
adequately monitored and that, where necessary, expert hospital supervision is available.
A list of these preparations and the specific conditions that they can be used to treat are listed in
part XV of the Drug Tariff.
Although this is a non-mandatory list, Nurse and Pharmacist Independent Prescribers should
normally restrict their prescribing of borderline substances to items on the ACBS approved list.
They should also work within the guidance of their employing organisation.
GPs may use their clinical judgement and take full responsibility when they choose to make
exceptions to the approved list.
This may occur following recommendations from a dietician or for a medical condition requiring
nutritional support for a defined period of time. For example a patient discharged from hospital
having had a wired jaw and requiring nutritional support for 6-8 weeks post-operation.
The CCG will support any doctor wishing to refuse prescriptions of dietary products for patients
(or nursing / residential homes) not complying with the above uses and using them as a
convenience rather than liquidising/ purchasing appropriate food.
GPs are often requested by patients to prescribe dietary supplements or herbal remedies that
might have medical value. Examples include St. John's Wort and co-enzyme Q10. As these are all
currently unlicensed, it is recommended that these are not prescribed and that the patient is
directed to purchase them from an appropriate outlet. Of course, if an illness such as depression is
diagnosed, then licensed medicines should be prescribed as appropriate. Please consult a member
of the Medicines Management team for further advice when necessary.

9.4.1 Drugs requiring Selected List Scheme "SLS" endorsement
The following drugs are only prescribable on the NHS for specific groups of patients with specific conditions - see Part XVIIIB of the Drug Tariff for list. Prescriptions should be endorsed with the reference "SLS":  Clobazam  Cyanocobalamin tablets  Locabiotal aerosol  Niferex elixir 30ml paediatric dropper bottle  Nizoral cream  Oseltamivir (Tamiflu)  Zanamivir (Relenza)  The following drugs for erectile dysfunction: o Alprostadil (Caverject, MUSE, Viridal) o Apomorphine hydrochloride (Uprima) o Moxisylyte hydrochloride (Erecnos) o *Sildenafil (Viagra) o *Tadalafil (Cialis) o Thymoxamine hydrochloride (Erecnos) o Vardenafil (Levitra)
*Note: there have been prescriptions for Sildenafil and Tadalafil, prescribed for pulmonary
hypertension with an SLS endorsement. This is against the GP terms of service. GPs should contact
the medicines management team if asked to prescribe these drugs for any indication other than
erectile dysfunction
Page 25 of 45
*Note: prescribing of these drugs for severe distress should only be carried out in specialist
centres using FP10(HP)s and endorsed SLS if they are to be dispensed in the community.

9.5
Prescribing gluten-free foods
To achieve a balanced diet, it is essential that patients include naturally gluten free carbohydrates in their diet. These include rice, potatoes, corn (maize), soy, buckwheat, millet, lentils, quinoa and amaranth. GPs can aid patient adherence to a gluten free diet by prescribing up to a maximum of eight items
of bread or flour per patient, per month.
Since March 2011 East Surrey CCG has recommended a restriction of gluten free foods to ensure
the cost effective use of NHS resources and the equity of the supply of dietary products.
Clickfor the list of bread, flour and bread mix agreed for funding by East Surrey CCG
10
Home Oxygen
The New Home Oxygen contract started on 26th March 2012 and the supplier for East Surrey CCG patients has changed from Air Liquide to Dolby Vivisol. The aim of the new contract is to improve patient access to a wider range of technologies, introduce a robust assessment process reflecting the Department of Health Home Oxygen Good Practice Guide for Assessment and Review (available for Long Term Oxygen Therapy (LTOT) and ambulatory oxygen. One of the major changes
to the new contract is that the prescriber chooses the equipment rather than the supplier.
Home Oxygen Consent form
A consent form must be completed for all patients receiving home oxygen for the first time,
available here
The Home Oxygen Consent Form (HOCF):  Must be signed by the patient to indicate that they agree to the sharing of their information with Dolby Vivisol  Should be completed in the presence of the patient
 Should be completed at the same time as the HOOF
 Should be copied (front page only) and filed in the patient's notes; copy given to the patient
Note: Once a patient has completed a consent form, they will not be required to complete
another, even if a new HOOF form is completed.
Prescribing Home Oxygen
Prescribing of home oxygen is done via the HOOF (Home Oxygen Order Form) – since the
introduction of the new contract, there are 2 types of HOOFs:
HOOF Part A: The HOOF Part A should be used where the request is made via non-specialist Healthcare Professionals, or for temporary supply pending a specialist review. Static concentrators (usually for LTOT) and static cylinders for short burst oxygen therapy (SBOT) can be ordered using this form. The HOOF part A is available here: Page 26 of 45
Training on how to complete the HOOF Part A is available on the Dolby Vivisol website here: HOOF Part B: The HOOF Part B is for specialist Healthcare Professionals trained in assessing and reviewing patient's home oxygen needs (e.g. respiratory specialist practitioners). The HOOF Part B gives access to a wider range of treatment modalities, including several options for ambulatory oxygen. Prescribing of oxygen should only routinely be done by respiratory specialists (exceptions include palliative care) oxygen for patients suffering from cluster headaches and paediatric patients should only be initiated under the recommendation of the relevant specialist. All HOOFs and consent forms should be faxed to Dolby Vivisol on: 0800 781 4610  A copy of the completed HOOF should be: o Filed in the patient's notes (original form) o Copied to the patient's GP (if you are not the GP!) On receipt of the HOOF Dolby Vivisol will:  confirm by automatic fax back that they have received the form  Fax a copy to the Commissioning Pharmacist/Oxygen Lead at Cedar Court (the patient signs a consent form (HOCF) for the sharing of this information to enable the CCG to check payments to the supplier)  activate the request and arrange delivery of the oxygen as specified  undertake any necessary installation and provide all the necessary equipment to the patient  ensure that the patient is trained in its use before informing the specialist team that the order has been completed  maintain regular contact with the patient to ensure that they have the necessary supplies and that their equipment is regularly maintained  It is extremely important that ALL section of the HOOF are completed for CCG records and auditing purposes – particularly Section 3.1 Clinical Code(s) on the HOOF Part A. A HOOF remains valid and Dolby Vivisol will continue to provide oxygen supplies until you either
notify them of a change in the patient's requirements by completing a new HOOF, or if you
terminate the supply by notifying them. It is recommended that patients should be reviewed
regularly to determine whether they still require oxygen or whether their oxygen requirements
have changed. If a patient dies or no longer requires Oxygen, Dolby Vivisol and the CCG must be
notified, so their Oxygen account can be closed, otherwise East Surrey CCG may continue to be
billed until notification.
Oxygen Therapies
 Short burst (SBOT) - Where oxygen therapy is only required on an as required basis for short
periods of time. Patients may require assessment for long term oxygen and need specialist referral  Long-term (LTOT) - Where a patient requires continuous oxygen for several hours a day and/or night (including where this is part of palliative care for patients being cared for at home) - this is usually delivered via a concentrator. Respiratory patients must be clinically stable for 5-6 weeks before assessment (including blood gases) for LTOT can be conducted – during this time they may be prescribed a trial of SBOT. Page 27 of 45
 Ambulatory - Where, following specialist assessment, it is considered that a patient has a clinical need (e.g. desaturation on exertion) or is on LTOT and requires the greater mobility provided by the use for portable or ambulatory oxygen (e.g. to continue to attend school or work).  Emergency oxygen - Where a GP or out of hours service decides oxygen is needed urgently in the home but the patient does not require hospital admission. Dolby Vivisol will deliver within four hours of receipt. Patients should then be referred to the relevant specialist team for assessment of ongoing need. Additional Emergency supplies
Holiday provision
 If patients require oxygen away from home using the same equipment they have at home, a Holiday HOOF is no longer required under the new contract. Instead, the patient can call
the Dolby Vivisol Customer Contact Centre on 0500 823 773 (Freephone) and arrange their
oxygen-away-from-home supply at least 3 weeks before departure.
 If a patient needs different or additional equipment (for instance portable oxygen) to travel within the UK, they need to advise their Healthcare Professional. Please allow enough time
for a new holiday order form (holiday HOOF) to be processed - at least 3 weeks before
required. Details, such as arrival and departure dates, contact details at the destination and
the address where the oxygen will be required should be completed on the HOOF.
This HOOF should then be faxed to Dolby Vivisol in the normal way and they will arrange the supply to the holiday address.
Emergency provision - Complete the HOOF in the normal way, identifying that this is an URGENT
request (Box 10.3 on the HOOF Part A). Oxygen will be provided within 4 hours of receipt of the
HOOF. Patients should then be referred to the relevant specialist team for assessment of ongoing
need. Note there is an additional cost for urgent delivery.
Specialist Assessment
Clinical good practice guidelines recommend that patients requiring LTOT or ambulatory oxygen
should be referred to a respiratory consultant/specialist practitioner for assessment
Specialist teams will assess the patient and order oxygen if appropriate when:  a GP has referred a patient for specialist assessment  a patient is discharged from hospital  a patient's needs are re-assessed as part of clinical follow up and review services After assessment, many patients will remain under the care of the specialist who should liaise
directly with Dolby Vivisol whilst also keeping the GP informed
Hospital discharge
Dolby Vivisol operates a dedicated advice service for clinical staff who may wish to discuss their
patient's needs and will also provide an office hours advice and support service for patients and
carers on the use and maintenance of equipment and a 24-hour emergency service for patients
experiencing problems with their equipment (see Dolby Vivisol contact details below).
Dolby Vivisol will provide oxygen services to a patient's home within 24 hours of notification of the patient's discharge (provided box 10.2 on the HOOF Part A is ticked to indicate next day delivery is required). The cut off point is 5pm on the day of order. Nursing/Residential Homes requesting oxygen
Page 28 of 45
Oxygen is a drug and should only be prescribed for patients following individual assessment (preferably by a specialist team with the exception of palliative care) or used by emergency services. Use of oxygen by an untrained person can have disastrous consequences. The private supply of oxygen to nursing/residential homes is not supported by East Surrey CCG and nursing/residential homes using oxygen in this manner do so at their own risk . Homes should be reminded that Dolby Vivisol can deliver emergency oxygen within 4 hours of receipt of a HOOF from a GP. Where oxygen is needed more urgently than this the ambulance service should be called.
Managing Oxygen Costs – Prescribing Advice
The tariff charged for oxygen was agreed nationally by the Department of Health and the
suppliers. Unlike the previous contract where the CCG was charged a daily tariff for oxygen
regardless of actual use, the CCG is now charged per delivery and per refill, and for equipment
rental, resulting in potential cost savings provided the cost of oxygen is not driven up by large
numbers of refills or deliveries. It is important that prescribers therefore order the right amount
and type of equipment – if assistance with this is required, contact the Dolby Vivisol dedicated
clinician support line (see below).
Where a GP feels it is appropriate for him/her to prescribe oxygen, patients should then be referred to specialist teams as soon as possible for further assessment. Patients requiring ambulatory oxygen should be referred for specialist assessment and considered for Pulmonary Rehabilitation. Dolby Vivisol Contact Information: Dedicated Clinician support line: 0844 381 4402  Free phone patient number, 24 hrs, 7 days a week: 0500823773  Healthcare professional's email: (should you need to send patient identifiable data please use Non- Medical Practitioners
Non medical prescribing is a generic term that covers independent and supplementary prescribing.
11.1 Independent Prescribing
Independent prescribing was introduced in May 2006 and is prescribing by a practitioner
responsible and accountable for the assessment of patients with undiagnosed or diagnosed
conditions and for decisions about the clinical management required, including prescribing.

The following healthcare professionals are able to act as independent prescribers following
successful completion of programmes approved by their professional body:
 Registered nurses (first  Registered specialist Community
Public Health Nurses  Registered midwives  Registered optometrists The DH Guide to Implementation and the NMC Standards of Proficiency for nurse and midwife prescribers state that nurses put forward for prescribing training must have at least three years Page 29 of 45
post-registration experience. Pharmacists should have at least two years experience following
their post-registration year.

11.1.2 What can they prescribe?
Nurse and pharmacist independent prescribers can prescribe any licensed medicine (i.e. products with a valid marketing authorisation/licence in the UK) in the British National Formulary, including schedule 2-5 controlled drugs, for any condition within their clinical competence. This does not apply to the prescribing of cocaine, diamorphine or dipipanone for the treatment of addiction (this is restricted to Home Office licensed doctors). Nurse and Pharmacist Independent Prescribers are permitted to prescribe unlicensed medicines (medicines without a UK marketing authorisation) and licensed medicines for uses outside their licensed indications/UK marketing authorisation (so called ‘off-licence' or ‘off-label'). They must however, accept professional, clinical and legal responsibility for that prescribing, and should only prescribe ‘off-label' where it is accepted clinical practice. Optometrist independent prescribers are able to prescribe any licensed medicine for ocular conditions affecting the eye, and the tissue surrounding the eye, within their recognised area of expertise and competence, except for controlled drugs or medicines for parenteral administration. Optometrist independent prescribers are not permitted to prescribe unlicensed medicines. Independent prescribers should also work within the guidance of their employing organisation and
take into account local formulary policies and the implications for primary care.
Further guidance on independent prescribing can be found in the Department of Health document
‘Improving patients' access to medicines: A guide to implementing nurse and pharmacist
independent prescribing within the NHS in England'.

11.1.3 What training is required?
Higher education institutions (HEIs) provide a specific programme of preparation and training for independent prescribing. These programmes are approved by the Nursing and Midwifery Council and the Royal Pharmaceutical Society of Great Britain (RPSGB). Pharmacists and nurses must register their prescribing qualification with their professional body http://www.pharmacyregulation.org/ andrespectively. The training for nurses and pharmacists is spread over a period of six months, and consists of at least 26 days training and 12 days learning in practice. All participants must pass the end of course assessments. A designated medical practitioner (DMP) is required to supervise the student during the in-practice learning and provide support. The DMP has a critical and highly responsible role in educating and assessing the non-medical prescriber and assuring competence in prescribing. Guidance entitled ‘Training non-medical prescribers in practice – A guide to help doctors prepare for and carry out the role of designated medical practitioner' is available on the National Prescribing Centre website at
11.2 Supplementary Prescribing
Page 30 of 45
Supplementary prescribing is a voluntary prescribing partnership between the independent prescriber (who must be a doctor or dentist) and supplementary prescriber, to implement an agreed patient-specific clinical management plan (CMP), with the patient's agreement. This mechanism of prescribing is helpful for nurse and pharmacist prescribers when they are newly qualified. It will also be appropriate in specific situations, for instance  - When working within a team where a doctor is accessible  - For specific long-term conditions  - For mental health and  - For situations involving Controlled Drugs
11.2.1 Who can be a supplementary prescriber?
Supplementary prescribing was introduced for nurses and pharmacists, and has been extended to include physiotherapists, chiropodists/podiatrists, radiographers and optometrists.
11.2.2 What can they prescribe?
The CMP (written or electronic) must:  be in place before supplementary prescribing can occur  be specific to a named patient/client and to that patient/client's specific condition(s) to be managed by the supplementary prescriber  include details of the illness or conditions that may be treated, the class or description of medical products that can be prescribed or administered, and the circumstances in which the supplementary prescriber should refer to, or seek advice from, the doctor/dentist Supplementary prescribers must have access to the same patient/client health records as the doctor/dentist. Following agreement of the CMP, the supplementary prescriber may prescribe any medicine for the patient that is referred to in the plan, until the next review by the independent prescriber. There is no formulary for supplementary prescribing, and no restrictions on the medical conditions that can be managed under these arrangements. Supplementary Prescribers can prescribe Controlled Drugs and unlicensed medicines in partnership with a doctor, where the doctor agrees within a patient's CMP. What training is required?
The training for supplementary prescribing is incorporated into Nurse and Pharmacist Independent Prescribing. Many Higher Education Institutions (HEIs) are offering the supplementary prescribing elements of the course as multi-disciplinary training for nurses, pharmacists, and Allied Health Professionals. The exception is optometrists, who follow a programme more specific to the eye. All professional groups must register their supplementary prescribing qualification with their regulatory body before beginning to prescribe.
12
Patient Specific Directions and Patient Group Directions

12.1 Patient Specific Directions (PSDs)
Page 31 of 45
A Patient Specific Direction is the traditional written instruction, from a doctor, dentist or independent prescriber (i.e. nurse or pharmacist independent prescriber), for medicines to be supplied or administered to a named patient or group of named patients. As it is individually tailored to the needs of patients, it should be used in preference to a Patient Group Direction (PGD) wherever appropriate. PSDs are used once a patient has been assessed by a prescriber and that prescriber (doctor, dentist or independent prescriber) instructs another healthcare professional in writing to supply or administer a medicine directly to that named patient or to several named patients. Examples of a PSD for a single named patient:  The usual method for the supply and administration of vaccines in the routine childhood immunisation programme could be via a PSD. The authorisation for this is usually the responsibility of the GP or an independent nurse prescriber at the six to eight-week check and is recorded as an instruction in the Personal Child Health Record (PCHR or Red Book). This agreement allows immunisations to be given in GP surgeries or clinics.  A prescriber (i.e. GP) could make an electronic written instruction for a patient to be administered a particular vaccine in a patients medical record. This written instruction from the prescriber would constitute a PSD. Example of a PSD for a group of named patients  As an example, a GP could print off a list of patients' names off the computer, write an instruction for them all to have a vaccination administered, then add the practice address and date it (the GP signature is also advisable). Where a PSD exists, there is no need for a PGD.
12.2
Patient Group Directions
A Patient Group Direction (PGD) is a written instruction for the supply or administration of a medicine where the patient may not be individually identified before presenting for treatment. The supply and administration of medicines under PGDs should be reserved for the limited number of situations where this offers an advantage for patient care (without compromising patient safety). PGDs can only be used by the following registered healthcare professionals, as named individuals:  optometrists  chiropodists/podiatrists  radiographers  health visitors  physiotherapists  occupational therapists  prosthetists  speech and language therapists PGDs are legal documents and must follow the guidance set out in HSC 2000/026. This includes
the requirements that:
 The PGD must be signed by a senior doctor and a senior pharmacist, both of whom should
have been involved in developing the direction  The PGD must be authorised by the CCG: 1. Patrick Kerr (Prescribing Lead for East Surrey CCG) 2. Karen Devanny (Director of Quality and Nursing for East Surrey CCG) Page 32 of 45
 PGDs should be drawn up and signed by a multi-disciplinary group involving a doctor, a pharmacist and a representative of any professional group expected to supply medicines under the PGD  A senior person in each profession should be designated with the responsibility to ensure that only fully competent, qualified and trained professionals operate within directions  All professions must act within their appropriate Code of Professional Conduct A PGD can include a flexible dose range so the healthcare professional can select the most appropriate dose for the patient. Medicines can be used outside the terms of their Summary of Product Characteristics (SPC) so called ‘off-license/off-label' use, provided such use is supported by best clinical practice. The PGD should state when the product is being used outside the terms of the SPC and why this is necessary. However, unlicensed products which do not have a marketing authorisation in the UK, cannot be authorised under a PGD. Black triangle () vaccines used in immunisation programmes may be included in PGDs, providing they are used in accordance with the recommendations of the Joint Committee on Vaccination and Immunisation (JCVI) (Health Service Circular, 2000/026). The PGD should state that a black triangle medicine is being included. Information which must be included in a PGD is subject to legislation which specifies that each PGD must contain the following information:  the name of the business to which the direction applies i.e. East Surrey CCG  the date the direction comes into force and the date it expires  a description of the medicine(s) to which the direction applies  class of health professional who may supply or administer the medicine  signature of a doctor or dentist, as appropriate, and a pharmacist  signature by an appropriate health organisation i.e. clinical governance lead  signature of a representative of the professional group expected to supply medicines under  the clinical condition or situation to which the direction applies  a description of those patients excluded from treatment under the direction  a description of the circumstances in which further advice should be sought from a doctor (or dentist, as appropriate) and arrangements for referral  details of appropriate dosage and maximum total dosage, quantity, pharmaceutical form and strength, route and frequency of administration, and minimum or maximum period over which the medicine should be administered  relevant warnings, including potential adverse reactions  details of any necessary follow-up action and the circumstances  a statement of the records to be kept for audit purposes 13 East Surrey CCG Medicines Management Committees

13.1 Medicines Commissioning Group (MCG)

The Surrey CCGs collaborate as a commissioning group to promote a consistent approach to
medicines management across Surrey. The group provides oversight, governance and assurance to
CCG Governing Bodies on the safe, effective and affordable use of medicines
Page 33 of 45
Commissioning Group Terms of Reference May 2013.pdf
13.2 Prescribing Clinical Network (PCN)

The PCN uses a collaborative approach with its constituent CCG and Acute Trust representatives to
promote equity and provide rational, safe and transparent recommendations on the use of
medicines across the local health economy.
Recommendations from the PCN are considered at the Medicines Advisory Group and ratified by
Karen Devanny and Patrick Kerr prior to acceptance and implementation within the CCG.
Prescribing Clinical Network Terms of Reference July 2013.pdf Medicinal Waste Management
Medicinal waste includes expired, unused, spilt, and contaminated pharmaceutical products, drugs, vaccines, and sera that are no longer required and need to be disposed of appropriately. The category also includes discarded items used in the handling of pharmaceuticals, such as packaging contaminated with residues, gloves, masks, connecting tubing, syringe bodies and drug vials. Medicinal waste is classified into two categories:  cytotoxic and cytostatic medicines  Medicines other than those classified as cytotoxic and cytostatic. Cytotoxic and cytostatic medicines are classified as hazardous waste and it is a legal requirement to segregate cytotoxic and cytostatic medicines from other medicines. Community Pharmacies are obliged to accept back unwanted medicines from patients. The pharmacy will sort them into solids (including ampoules & vials), liquids and aerosols if required by the waste contractor. No medicines that have been dispensed for a patient can be re-used for another patient and must be appropriately disposed of. Community pharmacies should not accept waste from Nursing Homes or Dual Registered Homes
as this is classified as industrial waste. In order to take waste from a nursing home, the pharmacy
would need to obtain a waste management license. Pharmacists contemplating dealing with waste
from a nursing home should contact their local Environment Agency for authoritative guidance5

5 Pharmaceutical Services Negotiating Committee (PSNC); FAQs Page 34 of 45
14.1 Controlled Drugs
Under the Regulations, all Schedule 1 and 2 stock controlled drugs can only be destroyed in the presence of a person authorised under those Regulations to witness destruction. The Accountable Officer role lies with the Area Team. Enquiries relating to Controlled Drugs should be directed to [email protected] When a stock controlled drug is destroyed, details of the drug must be entered into the controlled drugs register. This should include:  the name of the drug;  its form;  its strength and quantity;  the date it was destroyed  The signature of the authorised person who witnessed the destruction, and the person destroying it (that is, two signatures). Once issued/dispensed to a patient, the requirements for an authorised witness do not apply, however best practice recommends the use of a separate patients returns log where destruction of patient returns CDs are witnessed Ideally, a controlled drug denaturing kit should be used but, in all cases, the guidance issued by the RPSGB should be followed when denaturing controlled drugs – this applies to both stock and returned medicines
14.2 Sharps Waste

The duty to arrange collection of sharps on request by patients rests with the local authority, and
this remains the preferred method of disposal.
Please contact the local borough councils for more details of the sharps collection services. There is no obligation for a pharmacist to accept sharps for disposal but if they do so, pharmacy
contractors should ensure that accepting sharps, storing and arranging for their disposal is
undertaken with regard to the need to protect the environment and to protect workers and others
who might be affected by these activities.
14.3 Drug donations to other countries6

The World Health Organisation revised their Guidelines for Medicine Donations in 2010. One of
their core principals is that "There should be no double standard in quality. If the quality of an item
is unacceptable in the donor country, it is also unacceptable as a donation."

They go on to explain that "Donating returned medicines (unused medicines returned to a
pharmacy for safe disposal, or free samples given to health professionals) is an example of a
double standard because in most countries their use would not be permitted owing to regulations
on quality control. Such donations also frustrate management efforts to administer medicine
6 World Health Organisation; Guidelines for Drug Donations; Revised 2010 Page 35 of 45
stocks in a rational way. Prescribers are confronted with many different medicines and brands in
ever changing dosages, while patients on long-term treatment suffer because the same medicine
may not be available in future. For these reasons this type of donation is forbidden in an increasing
number of countries and is discouraged elsewhere."

15
British National Formulary - availability
The British National Formulary (BNF) is published every six months (in March and September). The BNF for Children (BNFC) is published annually in July. Download the free app for users of(Users will need to use their NHS Athens password. Technical support, email: [email protected]) In England, free copies of the BNFs are mailed individually to the following healthcare
professionals (see table below for order/registration contact details):
 NHS doctors  Dentists  Pharmacists  non-medical prescribers  community pharmacies How to obtain copies
Members of the public and healthcare organisations that Paper copies may be obtained through any bookseller are not part of the NHS Pharmaceutical Pressc/o Macmillan Distribution (MDL) Brunel Rd Houndmills Basingstoke RG21 6XS UK  Tel: +44 (0) 1256 302 699  Fax: +44 (0) 1256 812 521  Em GPs in GP practices Direct distribution Including Partners, salaried GPs and locums Please contact the DH Publications Order line: 0300 123 1002 to obtain a registration form. Community Pharmacies Direct distribution To obtain a copy for a new pharmacy, or an extra copy for Please contaa large pharmacy. Public Health/ Central distribution to organisation / Pharmaceutical or Medical Advisors in organisations Non-medical prescribers Direct distribution Please conta Page 36 of 45
Diabetes and the DVLA
Under certain circumstances it is necessary for patients with diabetes to inform The Driver and Vehicle Licensing Authority (DVLA). There are two groups of licence holders and the medical standards differ according to each group:  Group 1 includes motorcars and motorcycles.  Group 2 includes large lorries (category C) and buses (category D). The medical standards for Group 2 are much higher than those for Group 1 because of the size and
weight of the vehicle.
Driving large goods vehicles (LGVs) and passenger carrying vehicles (PCVs) – Group 2 licence
People whose diabetes are treated by diet alone or by tablets are normally allowed to hold Group 2 licenses, which includes LGVs and PCVs, provided they are otherwise in good health and have passed the relevant driving test. (Until 1991 these were known as heavy goods vehicles [HGV] and public service vehicles [PSV].)
Patients treated with medication that may cause hypoglycaemia:
If a patient with diabetes holds a Group 2 licence and are treated with a sulphonylurea or prandial glucose regulator they must notify the DVLA as these increase the risk of hypoglycaemia. If patients are on any other diabetes treatment, including non-insulin injections, it may not cause hypoglycaemia when taken on its own. But when used in combination with any of the tablets listed below, then the risk of hypoglycaemia is increased and so the DVLA must be informed: Medicine Group
Generic (proper) name
Brand (trade) name
Diamicron/ Diamicron MR Glibenese/Minodiab Prandial glucose regulator After being notified the DVLA would, with the patient's consent, seek further information from the patient's healthcare team. Therefore, each case will be considered individually. Note: the use of exenatide or gliptins on their own currently carries no specific driving restrictions
for Group 1 (car or motorcycle) licences.

Patients treated with insulin
From 15 November 2011, the DVLA have removed the ban for people on insulin driving Group 2 vehicles (larger vehicles, and some passenger-carrying vehicles). People with diabetes treated with insulin can now undergo individual independent medical assessment annually to assess their fitness to drive these vehicles. To apply for a licence for these larger vehicles the following criteria will need to be met:  No episode of hypoglycaemia requiring the assistance of another person has occurred in the preceding 12 months  Has full awareness of hypoglycaemia Page 37 of 45
 Regularly monitors blood glucose at least twice daily and at times relevant to driving  Must demonstrate an understanding of the risks of hypoglycaemia  There are no other debarring complications of diabetes such as a visual field defect The Diabetes UK website provides some useful information for patients around DVLA requirements: East Surrey CCG materials may be downloaded / copied freely by people employed by the NHS in England for purposes that support NHS activities in England. Any person who is not employed by the NHS in England and who wishes to download / copy East Surrey CCG materials, or who works for the NHS in England and who wishes to download / copy materials for their own use and not in connection with NHS England activities, should first seek the permission of East Surrey CCG. Email: [email protected] Medicines Management Team, Cedar Court, Guildford Road, Leatherhead, KT22 9AE Telephone: 01372 201500 Page 38 of 45

Appendix 1
GUIDANCE ON PAYMENTS FOR VACCINES

The Green Book ‘Immunisation against infectious diseases' gives Department of Health advice on the circumstances when patients should be offered vaccination. This does not
necessarily mean the vaccines should be offered under the NHS. The purpose of this document is to clarify situations where vaccines may be given free of charge under the NHS
(paid for under the global sum) and where patients should be charged (as a private service).

Vaccine name
Global sum
Method for claiming
Private service?
(Situations where vaccine should be offered free of charge under the NHS)
payment under
(Issue a private prescription or supply vaccine global sum
from stock and charge patient)  Persons at an identifiable risk, mainly those who come into contact with imported / Only the cost of the vaccine can be claimed infected animal products – see Green Book from the global sum. The cost of providing an occupational service is not covered. Practices should seek appropriate remuneration for providing such a service.  Aid workers assisting in disaster relief or refugee camps Travellers seeking vaccination that do not  Backpackers travelling to remote regions with limited access to medical care qualify for vaccination under the NHS. If charge  Individual risk assessment is essential, based on area of travel and any underlying is levied to patient, vaccine must not be health conditions, e.g. may be considered for at risk travellers with underlying claimed on FP10. gastrointestinal illness or immune suppression in whom cholera would have serious adverse consequences  Usually part of childhood immunisation for under 6 years
Only the cost of the vaccine can be claimed antigen diphtheria  Children aged 10 and over who have not had the basic course of immunisation from the global sum. The cost of providing an  Hospital staff considered at risk of infection – see Chapter 12 of Green Book FP10 if not part of
occupational service is not covered. Practices  Children aged 6 and over that have had basic course but require a reinforcing dose should seek appropriate remuneration for  For travellers visiting epidemic or endemic areas where diphtheria protection is
providing such a service. diphtheria vaccine required and the last dose was given more than 10 years ago (see Green Book and latest advice from CMO)  Adults and children over 10 years requiring either a primary course or a booster should supplied free to the containing other be given the low-dose vaccine NHS for childhood  Previously immunised travellers requiring a booster if they are to live or work with local residents and their primary immunisation was more than 10 years ago Page 39 of 45
Vaccine name
Global sum scenarios
Method for claiming
Private service?
(Situations where vaccine should be offered free of charge under the NHS)
payment under
(Issue a private prescription or supply vaccine global sum
from stock and charge patient) Haemophilus
 Usually part of childhood immunisation. Haemophilus influenza type b (Hib) vaccine is
FP10 if not part of
Influenza type b
given as part of the combined 5 disease vaccine. For childhood vaccination schedule see Green Book and latest advice from CMO.  Asplenic children and adults. Children and adults who have been fully immunised
with Hib as part of the routine programme who then develop splenic dysfunction supplied free to the should be offered an additional dose of Hib (usually as combined Hib/Men C vaccine). NHS for childhood Hepatitis A
 Patients with chronic liver disease  Occupational exposure (refer to employer  Haemophiliacs to undertake or refer to another practice)*  Persons in institutions who are exposed to a high risk of infection and for whom  Travellers seeking vaccination that do not vaccination is recommended by the Medical Officer of Environmental Health qualify for vaccination under the NHS. If  Parenteral drug users. Hepatitis A is recommended for injecting drug users and can be charge is levied to patient, vaccine must given at the same time as Hepatitis B as separate/combined vaccines. not be claimed on FP34D. Recommended for travellers to areas of poor sanitation and where the degree of exposure to infections is likely to be high. See Green Book and latest advice from CMO.  Persons (particularly those going to reside for 3 months or more and if infected might be less resistant due to pre-existing disease) travelling outside of Northern Europe, Australia or New Zealand to areas of poor sanitation, where degree of exposure is likely to be high Page 40 of 45
Vaccine name
Global sum scenarios
Method for claiming
Private service?
(Situations where vaccine should be offered free of charge under the NHS)
payment under
(Issue a private prescription or supply vaccine global sum
from stock and charge patient) Hepatitis B
 Babies born to mothers who are chronic carriers of hepatitis B virus or to mothers who Occupational exposure where worker is
have had acute hepatitis B during pregnancy involved in invasive procedures or caring for  Parenteral drug users drug misusers or patients with severe learning  Individuals who change sexual partners frequently difficulties - (refer to employer to undertake or  Close family contacts of a case or carrier refer to another practice)*  Families adopting children from countries with a high prevalence of hepatitis B Note: The risk for workers NOT involved in  All short term foster carers and their families who receive emergency placements and invasive procedures is no greater than the those accepting high risk foster children. population as a whole and for whose welfare  Haemophiliacs and their carers they are responsible e.g. prison, police,  Patients with chronic renal failure ambulance officers, morticians and embalmers  Patients with chronic liver disease  Persons in institutions who are exposed to a high risk of infection and for whom Travel vaccination. Those requiring
vaccination is recommended by the Consultant in Communicable Disease Control immunisation for travel as suggested in the (Health Protection Agency). Green Book should be charged privately. If  Children born outside the UK and who have received a primary dose in their country or charge is levied to patient, vaccine must not be origin and who are now domiciled in the UK should have their course of the vaccine claimed on FP34D. completed under GMS Hepatitis A and B
 In the few limited cases where hepatitis A & B is required the combined vaccine may combined
 Children under 16. Where combined Hepatitis A and B are indicated this may be given in the paediatric two dose combined vaccine (Ambirix) which reduces the number of injections still further from 5 to just two. These are given 6 months apart and so this is unsuitable for rapid immunisation. Hepatitis A and
 Advised where sanitation is primitive and where the degree of exposure to infection is Travellers seeking vaccination that do not Typhoid Combined
likely to be high. See Green Book and latest advice from CMO. qualify for vaccination under the NHS. If charge  Persons (particularly those going to reside for 3 months or more and if infected might is levied to patient, vaccine must not be be less resistant due to pre-existing disease) travelling outside of Northern Europe, claimed on FP34D. Australia or New Zealand to areas of poor sanitation, where degree of exposure is likely to be high Page 41 of 45
Vaccine name
Global sum scenarios
Method for claiming
Private service?
(Situations where vaccine should be offered free of charge under the NHS)
payment under global
(Issue a private prescription or supply vaccine from stock and charge patient)  Gardasil® vaccination is available to Year 8 girls (aged 12-13 years) as part of the NHS Vaccine supplied free Patients who fall outside the NHS programme vaccination programme (delivered via a school based programme). to NHS for eligible and request the vaccination should be referred  Catch-up vaccination may be offered to girls aged 13-18 (i.e. have completed year 9 to another practice since GP practices may not Use FP10 for those provide a private service for HPV vaccination  It is reasonable to complete the vaccination schedule if a female over 18 has started outside of the national and charge patients on their NHS list Influenza
 Immunisation offered under the NHS on an annual basis for those aged 65 years and  Patients who fall outside an at risk over or those aged under 65 years in a risk category category and request the vaccination as a private service may be directed to a facility offering that service e.g. private clinic, community pharmacy or another practice. GP practices may not provide a private service for influenza vaccination to patients on their NHS list.  Practices may offer a private service to patients who are not registered with the
practice. If charge is levied to patient,
vaccine must not be claimed on FP34D.
Japanese B
In connection with travel abroad. Vaccine not licensed in UK - available only on named patient basis. Measles, Mumps
 Usually part of childhood immunisation / catch-up campaign. For childhood
It is recommended that all NHS staff born after and Rubella (MMR)
vaccination schedule see Green Book and latest advice from CMO. Vaccine supplied free 1970 having regular contact with patients  May be recommended by the Consultant in Communicable Disease Control (Health to NHS for childhood should be immunised with MMR. This is an Protection Agency) for contacts of a case of measles.
occupational health issue and should be provided by the employing NHS organisation Meningococcal A,C, 
Not usually available under NHS for travel Travel vaccination. Those requiring FP34D or Vaccine  Asplenic children and adults, if travelling to a country where there is increased risk of immunisation for travel as suggested in the supplied free to NHS serogroup A, W135 or Y disease, should be given the vaccine under the NHS Green Book may be charged privately. If charge is levied to patient, vaccine must not be claimed on FP34D Page 42 of 45
Vaccine name
Global sum scenarios
Method for claiming
Private service?
(Situations where vaccine should be offered free of charge under the NHS)
payment under
(Issue a private prescription or supply vaccine global sum
from stock and charge patient) Meningococcal C
 Usually part of childhood immunisation or catch-up campaign (Hib/Men C). For childhood vaccination schedule see Green Book and latest advice from CMO. FP34D if not part of A catch-up booster of Men C is to be offered to children of 12 and 13 years  Travel vaccination. Those requiring Adults (under 25 years) entering university for the first time after August 2014 and immunisation for travel as suggested in the who did not receive the Meningococcal C vaccine at 13 – 15 years of age Green Book may be charged privately. If Asplenic patients (use Hib/Men C). Children and adults who have been fully immunised charge is levied to patient, vaccine must with Men C as part of the routine programme who then develop splenic dysfunction not be claimed on FP34D supplied free to the should be offered an additional dose of Men C (usually as combined Hib/Men C NHS for childhood May be recommended by the Consultant in Communicable Disease Control (Health Protection Agency) for contacts of a case of meningococcal disease  Part of the routine childhood vaccination schedule. See Green Book and latest advice Vaccine supplied free to NHS for childhood  Offered under the NHS for those aged 65 years and over or those aged under 65 years in a clinical risk category outlined in latest advice from CMO. Inactivated
 Offered to children under 10 as part of the national Childhood Immunisation FP10 if not part of
Poliomyelitis (only
Occupational exposure (refer to employer to available as
 For travellers visiting epidemic or endemic areas it is recommended that the
undertake or refer to another practice)* combined
combined D/T/P-IPV is given where a booster of any element is required. vaccines)
 Previously immunised but without receiving a reinforcing dose, it is recommended that the D/T/P-IPV is given where a booster of any element is required. Where supplied free to the immunisation history is incomplete or unknown as many doses as required to NHS for childhood complete a 5 dose schedule should be offered. Single dose vaccine is available where clinically appropriate  Travellers seeking vaccination  Occupational exposure (refer to employer to undertake or refer to another practice)* Rota Virus
 Part of the childhood immunisation programme Page 43 of 45
Vaccine name
Global sum scenarios
Method for claiming
Private service?
(Situations where vaccine should be offered free of charge under the NHS)
payment under
(Issue a private prescription or supply vaccine global sum
from stock and charge patient) Shingles
 Introduced on 1st September 2013 for patients aged 70  Catch-up campaign for those aged 79  Patients not included in the target groups may be vaccinated at the practice discretion when all eligible patients have been vaccinated and if stocks permit Tetanus (only
 Usually part of childhood immunisation. Tetanus vaccine is given in combination with
available as
diphtheria, pertussis, poliomyelitis and haemophilus influenza type b as a component combined
of the primary course of childhood immunisation. For childhood vaccination schedule vaccines (DTP)
see Green Book and latest advice from CMO  Children aged 15-19 who were not previously immunised  Individuals aged 10 years or over who have only had 3 doses of a tetanus containing vaccine, with the last dose at least 5 years ago, should receive the first tetanus booster combined with diphtheria and polio vaccines (Td/IPV)  As a second reinforcing/final school booster dose ideally given 10 years after the first reinforcing dose (or at least 5 years after the first reinforcing dose if previous doses have been delayed). Travellers requiring vaccination or booster. Additional doses may be required according to the destination and nature of travel (see DOH Yellow Book 2010 for further information). For travellers to areas where medical attention may not be accessible and where dose of tetanus containing vaccine was more than 10 years previously, a booster dose should be given prior to travelling. This is a precautionary measure in case immunoglobulin is not available to the individual should a tetanus prone injury occur (see Green Book and latest advice from CMO).  Reinforcing dose following a tetanus prone wound. Extra cover should not be
necessary if the patient is up to date with normal vaccination schedule. See Green book for detailed information. Tick-borne
Travellers requiring vaccination. Vaccine not licensed in UK - available only on named patient basis, see BNF for details  Travellers to countries where typhoid is endemic (e.g. South Asia, parts of South-East Travellers seeking vaccination that do not Asia, the Middle East, Central and South America, and Africa), especially if staying with qualify for vaccination under the NHS. If or visiting the local population charge is levied to patient, vaccine must not  travellers to endemic areas (see above) with frequent and/or prolonged exposure to be claimed on FP34D. conditions where sanitation and food hygiene are likely to be poor  Travel to countries where it is a condition of entry that visitors should have been Page 44 of 45
Vaccine name
Global sum scenarios
Method for claiming
Private service?
(Situations where vaccine should be offered free of charge under the NHS)
payment under
(Issue a private prescription or supply vaccine global sum
from stock and charge patient) Varicella
 Healthy susceptible close household contacts of immunocompromised patients (eg Occupational exposure for private siblings of a leukaemic child, or a child who is undergoing chemotherapy). organisations (refer to employer to undertake  Management of at-risk individuals following significant exposure to chicken pox or or refer to another practice)* varicella zoster (See Green Book for detailed information).  Frontline healthcare workers (through their occupational health departments) Yellow fever
Travellers seeking vaccination may only be offered as a private service via designated Yellow Fever Vaccination Centres.
*Occupational Health Services:
GPs cannot provide occupational health services to their own registered patients and charge the patient. The patient should be advised that it is not the responsibility of the practice
to provide this under the NHS. This includes the provision of Hep A or B vaccination for occupational purposes for medical or nursing students. The immunisation should ideally be
given under the employer's or university's private occupational health scheme. However, the employer may negotiate a private contract with a private clinic or GP practice to
undertake an occupational health programme, but the employer must be charged directly for this service and not the patient. In the absence of such a scheme, the patient should be
referred to another practice for a private service (practices may charge patients for occupational health services as long as they are not registered at that practice).
Patient Group Directions (PGDs):
GP practices with an NHS contract may use PGDs developed and approved by their CCG for vaccinations provided under the NHS. CCG PGDs may not be used for vaccinations given
privately. Practices may not use their own PGDs for these purposes. This means that for private vaccinations, Patient Specific Directions must be used.
Post-exposure immunisation:
Certain vaccinations may be recommended by the local Health Protection Unit for possible contacts of vaccine-preventable infectious diseases, and these should be offered free of
charge under the NHS.

Acknowledgements

Kent Local Medical Committee
GPC Focus on Vaccines & Immunisations – Guidance for GPs – November 2013
Page 45 of 45

Source: http://www.eastsurreyccg.nhs.uk/docsPolicies/Medicines%20Management%20Guide%20to%20Prescribing.pdf