PRESCRIBING OF NHS MEDICATION RECOMMENDED DURING OR AFTER A PRIVATE EPISODE OF CARE

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1 East Surrey CCG Guildford & Waverley CCG North West Surrey CCG Surrey Downs CCG Surrey Heath CCG PRESCRIBING OF NHS MEDICATION RECOMMENDED DURING OR AFTER A PRIVATE EPISODE OF CARE Version: 2.2 Name of originator/author: Sophie Bhandary / Clare Curran Name of approval committee: Medicines Commissioning Group Ratified by: Individual Clinical Commissioning Groups Date issued: March 2010 Last review date: October 2014 Next review date: October 2016

2 EQUALITY STATEMENT NHS Guildford and Waverley aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. We take into account the Human Rights Act 1998 and promote equal opportunities for all. This document has been assessed to ensure that no employee receives less favourable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. Members of staff, volunteers or members of the public may request assistance with this policy if they have particular needs. If the member of staff has language difficulties and difficulty in understanding this policy, the use of an interpreter will be considered. We embrace the four staff pledges in the NHS Constitution. This policy is consistent with these pledges. Version 2.2 October 2014 Page 2 of 14

3 EQUALITY IMPACT ASSESSMENT Stage One: Screening for Relevance to Equality Strands and Prioritising. To be completed and attached to any procedural document as part of main document sited between version control sheet and contents page. 1 Name of the strategy / policy / proposal / service function 2 Who is the strategy / policy /proposal / service function aimed at? Prescribing of NHS medication recommended during or after a private episode of care Primary care prescribing clinicians 3 What are the main aims and objectives? To provide guidance to manage the interface between NHS and private treatment at a practical level when private treatment is a substitute for treatment within the NHS 4 Identify the data / information you have regarding the use of the strategy / policy / proposal / service function by diverse groups? Use qualitative, quantitative and anecdotal information e.g. demographic data, results of consultations, research and surveys, local authority monitoring data, PALS, complaints, public enquiries, audits & reviews. N/A 5 Is the strategy / policy / proposal / service function relevant to any of the protected characteristics below? Please consider whether an impact if negative and positive. If YES please indicate if the relevance is low, medium or high. Low The policy may not be relevant to the Equality Duty as stated by law Little or no evidence is available that different groups may be affected differently Little or no concern raised by the communities or the public about the policy etc. when they are consulted (recorded opinions, not lack of interest) Medium The policy may be relevant to parts of the Equality Duty in the policy etc. regarding differential impact There may be some evidence suggesting different groups are affected differently There may be some concern by communities and the public about the policy High Equality strands There will be relevance to all or a major part of the Equality Duty in the policy regarding differential impact. There will be substantial evidence, data and information that there will be a significant impact on different groups There will be significant concern by the communities and relevant partners on the potential impact on implementation of the policy Will there be a positive or negative impact on this group? Yes/No Version 2.2 October 2014 Page 3 of 14 Low, Medium or High Patient, carer or family Age Yes Low Low Staff

4 Disability Yes Low Low Ethnicity / Race / Ethnic Groups Yes Low Low Gender Yes Low Low Gender reassignment Yes Low Low Religion and Beliefs Yes Low Low Marriage and Civil Partnership No Low Low Pregnancy and maternity Yes Low Low Sexual Orientation No Low Low 6 Are there barriers which could inhibit access to the benefits of the strategy / policy / proposal / service function? E.g. Communication / information, physical access, location, sensitivity etc. This policy is aimed at clarifying this issue for primary care prescribers which will ensure no-one is negatively impacted within our population; all will benefit via their prescriber being clearer on policy. The policy will be available on the CCG website and on the Surrey Prescribing Advisory Database. The CCG uses Google Interpreter so the policy can be read in different languages and the CCG will make the policy available in Braille and large print on request. 7 Does the strategy / policy / proposal / service function relate to an area where there are known inequalities? If so which and how? No 8 Please identify what evidence you have used / referred to in carrying out this assessment. Guidance based on NHS England documents and from the British Medical Association (BMA). 9 Identify any minor changes to the strategy / policy / proposal / service function which will reduce potential adverse impacts at this stage. None required 10 Please indicate if a Full Equality Impact Analysis is recommended (delete). NO YES 11 If you are not recommending a Full Impact assessment please explain why. The policy will improve equality of access to NHS medicines. 12 Signature of lead or Director Date completed 13/1/15 Names of people carrying out the assessment Rachel Mackay Name of lead Manager / Director Version 2.2 October 2014 Page 4 of 14

5 CONTENTS EQUALITY IMPACT ASSESSMENT TOOL PRINCIPLES PURPOSE AND SCOPE DUTIES AND RESPONSIBILITIES CLINICAL GOVERNANCE AND COMMUNICATION RATIFICATION AND REVIEW PROCESS... 9 Appendix A - Case Studies for Illustrative Purposes Appendix B Information for Patients Appendix C Advice to Primary Care Prescribers References Version 2.2 October 2014 Page 5 of 14

6 1 PRINCIPLES This policy acknowledges the following founding NHS principles from the NHS Constitution: 1 the NHS provides a comprehensive service, available to all access to NHS services is based on clinical need, not an individual's ability to pay public funds for healthcare will be devoted solely to the benefit of the people that the NHS serves. 1 As emphasis on patient choice within the NHS grows, it is recognised that patients are entitled to choose between NHS and private treatment. When considering patient transfer from private care to NHS care, the general principles are: The NHS should never subsidise private care with public money; this would breach core NHS principles. 2 Patients should never be charged for their NHS care, or be allowed to pay towards an NHS service (except where specific legislation is in place to allow this) as this would contravene the founding principles and legislation of the NHS. 2 Patients who choose to be treated privately are entitled to NHS services on exactly the same basis of clinical need as any other patient 3 and should not be put at any advantage or disadvantage in relation to the NHS care they receive. Patients entitled to NHS treatment may opt into or out of NHS care at any stage. 4 The transfer between private and NHS care should be carried out in a way which avoids putting the patient at any unnecessary risk. Therefore existing procedures for shared care, including proper communication, should be followed. 4 To avoid these risks, there should be as clear a separation as possible between private and NHS care. 2 It is not normally appropriate for patients to move repeatedly between the NHS and private sector for clinical management of the same condition. The Surrey Interface Prescribing Policy (Appendix to Service Level Agreements) forms part of the contractual requirements for provider organisations. Any request for a GP to prescribe should be in line with this policy whether this originates from a private or a NHS consultant. 5 2 PURPOSE AND SCOPE GPs are often requested by a private consultant to prescribe medication on the NHS as a recommendation following a private treatment episode. Even if a NHS patient opts for private treatment, they are still entitled to NHS services. This policy will assist in decision making about requests to prescribe when a patient returns to the NHS after a private episode of care. It provides guidance to manage the interface between NHS and private treatment at a practical level where private treatment is a substitute for treatment within the NHS. The policy does not cover situations when private treatment is delivered in addition to NHS care, where single episodes of NHS care are supplemented with privately purchased treatments, also referred to as top up payments. 4 Version 2.2 October 2014 Page 6 of 14

7 3 DUTIES AND RESPONSIBILITIES When writing a private referral letter, the GP should make the specialist aware that there may sometimes be circumstances when the request to prescribe will be refused. See Appendix C for a statement to be included in private referral letters. When a patient undergoes private specialist treatment, the private consultant may prescribe any necessary medication. However the private consultant may request the patient s GP to issue a NHS prescription for the medication so the patient will not have to pay for it privately. Even if patients chose private treatment or assessment, they are still entitled to NHS services. 4 Where the GP (i) considers the medication recommended is clinically necessary and (ii) is happy to accept clinical responsibility, he or she would be required under the NHS terms of service to prescribe that medication within the NHS (subject to the considerations outlined in Appendix A), even if the recommendation comes from the private sector. The issues arising are similar to those when a NHS consultant asks a GP to prescribe. As always, there should be proper communication between the consultant and GP about the diagnosis, treatment plan and a proposed medication. However there may be occasions when the GP is requested by a private consultant to prescribe medication they would not usually prescribe: Specialist medication If the medication is specialist in nature and is not something GPs would generally prescribe, it is for the individual GP to decide whether to accept clinical responsibility for the prescribing decision recommended by another doctor. This may be appropriate when the request to prescribe medication is outside their usual expertise and experience or if it is not one usually recommended by locally agreed policy or national guidance. Medication considered as not suitable for routine prescribing The private consultant may request the GP to issue a NHS prescription for medication that has been considered as not suitable for routine prescribing locally. This status is designated following a decision by the Prescribing Clinical Network and the drug is shown as BLACK on the Surrey Prescribing Advisory Database: For drugs considered as not suitable for routine prescribing locally but which can be prescribed on the NHS, the GP may offer the patient a clinically suitable alternative. For example, the private consultant requests the GP to prescribe solifenacin (not locally recommended) and the patient is not prepared to accept a clinically suitable alternative (an alternative antimuscarinic for the treatment of overactive bladder). In this situation, a GP would be breaking their terms of service if they issue a private prescription for solifenacin for their NHS patient. If the patient requests solifenacin is supplied privately they should be referred to an appropriate clinician. If the initial recommendation was from a private consultant, it would be reasonable to ask this clinician to continue to prescribe. Alternatively, it may be acceptable to refer a patient privately to a GP in another practice. See Appendix A for case studies for illustrative purposes. Note: For drugs not available on the NHS, a GP may issue a private prescription for their NHS patient if they feel it is clinically appropriate and they are happy to take responsibility for prescribing. The GP may not charge their NHS patient (registered with them or another GP in the same practice) for writing this private prescription. The only exceptions to this rule are Version 2.2 October 2014 Page 7 of 14

8 when a GP issues a private prescription for the prevention of malaria or for a drug requested by the patient just in case of the onset of illness while outside the UK. Following approval by the Medicines Commissioning Group, this policy will be ratified by individual Clinical Commissioning Groups who will then consider appropriate measures for implementation. 4 CLINICAL GOVERNANCE AND COMMUNICATION Transferring between private and NHS care should be carried out in a way which avoids putting patients at any unnecessary risk. The NHS and the private provider should work collaboratively to put in place protocols to ensure effective risk management, timely sharing of information, continuity of care and coordination between NHS and private care at all times. If different clinicians are involved in each element of care, these protocols should include arrangements for the safe and effective handover of the patient between the clinician in charge of the NHS care, and the clinician in charge of the private care. 2 It should always be clear which clinician and which organisation are responsible for the assessment of the patient, the delivery of any care and the delivery of any follow up care. 2 GPs are advised to contact private prescribers directly if they have an issue of concern or which requires clarification to reach a position where all parties are content. 4 Concerns often felt by GPs when requested to prescribe may include: being placed in a position of appearing unsupportive of their patients being asked to accept legal, financial and ethical responsibility for medication they have not initiated or which they may not consider clinically necessary having insufficient expertise for prescribing a specialist medication. Private clinicians requesting GPs to take over prescribing should be sensitive to these points when discussing the matter with patients. See Appendix B for explanatory information for patients. Many of the problems and concerns that arise in relation to prescribing shared between the private sector and the NHS could be avoided by improved communication between the parties concerned. It is well established that effective communication is important for safe and effective patient care and is likely to reduce errors. 2,4 All consultants are advised to 4 : Avoid simply informing patients that their GP will prescribe the recommended medication. Any changes made to the patient s prescription should be documented and dated, ready to be communicated to the person to whom the patient s care is being transferred. Recommend patients ask their GP if he or she is happy to prescribe, being sensitive to the objections the GP may have. Communicate directly with the GP themselves. Ensure that any patient information regarding the availability of NHS services provided by them is accurate and up-to-date and conforms to any local guidelines. 3 Version 2.2 October 2014 Page 8 of 14

9 If any primary care prescriber requires further advice and guidance about a prescribing issue, they should contact the Clinical Commissioning Group Medicines Management Team. If a patient wishes to complain, this should be addressed as far as possible by the practice. If it is not possible to resolve the matter in this way, the Patient Advice and Liaison Service (PALS) may be able to assist. 5 RATIFICATION AND REVIEW PROCESS This policy will be presented to the Medicines Commissioning Group for approval and the policy will be ratified by individual Clinical Commissioning Groups who will then consider appropriate measures for implementation. Once ratified this policy will be available on the Surrey Prescribing Advisory Database: The policy will be reviewed every two years. If there are any further queries regarding this policy, please contact the Medicines Management Team of the relevant Clinical Commissioning Group. Version 2.2 October 2014 Page 9 of 14

10 APPENDIX A CASE STUDIES FOR ILLUSTRATIVE PURPOSES Scenario - Private recommendation does not follow evidence base and latest national /local guidance 1. Patient A has opted for a private health assessment which results in rosuvastatin being initiated for primary prevention of cardiovascular disease. The patient returns to their NHS GP and requests a prescription for rosuvastatin. The drug recommended by private practice is more expensive, but without good evidence that it is more effective when compared to drugs locally prescribed for the same condition in the NHS. The GP is being asked to accept the legal, financial and ethical responsibility for this medication when local and national policy does not recommend rosuvastatin for primary prevention. The obligation to prescribe does not arise if the medication is not clinically necessary or if the medication is generally not provided within the NHS. Local prescribing advice may be requested and the NHS GP should explain the situation to the patient. The patient retains the option of obtaining the more expensive drug via the private consultant or via a GP in another practice. 2. A private healthcare consultant recommends fulvestrant for patient B for metastatic breast cancer and requests continuation of treatment. The NHS GP may not have the expertise to accept responsibility for the prescription, particularly as the drug is not normally prescribed by primary care prescribers. Fulvestrant is listed as a red drug (for specialist use in secondary / tertiary care prescribing to be initiated and continued by the specialist). The Surrey Prescribing Advisory Database (PAD) provides guidance 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 through categorisation of individual drugs:

11 Scenario - Treatment remains a package of care 3. Patient C has sought IVF treatment in the private sector and asks their GP to issue NHS prescriptions for the drugs recommended by the private consultant. IVF treatment is a specialised treatment requiring a package of care including interventions such as embryo transfer as well as drugs. Therefore drug treatments are included in the cost of the package and are not funded as a separate element by primary care clinicians. 4. Patient D needs to use low-molecular weight heparins (LMWH) instead of warfarin pre-operatively. The private surgeon has requested the GP to prescribe on the NHS for this patient. Low molecular weight heparins are commonly prescribed prior to surgery but treatment is regarded as a package of care within the NHS so should be prescribed by the acute trust. Private patients should not receive care that is different to that of NHS patients and, on that principle, the pre-operative LMWH should form part of that patient s private care. Scenario- Treatment is unlicensed 5. For recurrent aphthous ulceration a private consultant recommends, doxycycline application whereby 100mg doxycycline is stirred into water and patient advised to rinse around the mouth for 2-3 minutes 4 times daily for 3 days. This scenario would need questioning regarding any previous treatment. Unlicensed use of medicines becomes necessary if the clinical need cannot be met by licensed medicines; such use should be supported by appropriate evidence and experience. Professional guidance for prescribers on the use of unlicensed medicines and licensed medicines for unlicensed indications should be considered: Scenario- Defined criteria to be satisfied 6. Patient E has been diagnosed with Alzheimer s disease after private consultation and recommended treatment. If donepezil, galantamine, rivastigmine or memantine is recommended through a private consultation, it may be acceptable for the patient to transfer back to the NHS if sufficient information is provided and the patient meets local criteria for shared care, in line with NICE guidance, including arrangements for subsequent monitoring. Shared care protocols are available for each of these medications: Version 2.2 October 2014 Page 11 of 14

12 APPENDIX B INFORMATION FOR PATIENTS East Surrey CCG Guildford & Waverley CCG North West Surrey CCG Surrey Downs CCG Surrey Heath CCG NHS prescribing following private assessment or treatment in the private healthcare sector Your GP (family doctor) can provide some medicines on the NHS on advice from a clinician in the private sector. However, there are a number of circumstances when your GP may refuse the request, or offer to prescribe an alternative medicine. Your GP may decide not to prescribe if: 1) A full diagnosis, with appropriate test results, has not been provided by the consultant in the private sector 2) He or she feels the medicine is not clinically necessary 3) The medication is an unlicensed medicine 4) The medication is prescribed outside of its licensed indications 5) The medication needs special monitoring and he or she feels they do not have the expertise to do this 6) The use of a more cost effective medicine has been agreed locally If you have further queries or would like to discuss your options please return to your GP or health professional at your practice.

13 APPENDIX C ADVICE TO PRIMARY CARE PRESCRIBERS Letters for private referral East Surrey CCG Guildford & Waverley CCG North West Surrey CCG Surrey Downs CCG Surrey Heath CCG It is suggested that the statement below is included in all private referral letters. NHS primary care prescribing following a private referral: Any recommendation for primary care prescribing should be in line with the Surrey Interface Prescribing Policy (Appendix to Service Level Agreements): GPs and Non-Medical Prescribers prescribe in line with locally agreed prescribing guidance and drug choices based on published evidence and cost effectiveness of equivalent preparations. The Surrey Prescribing Advisory Database (PAD) provides guidance and information about medicines use in Surrey. It can be accessed by healthcare professionals in primary and secondary care and by patients: If the recommended medication does not follow local/national guidance, the GP may not agree to prescribe (in which case prescribing remains with the specialist) or the GP may substitute a clinically appropriate alternative. The specialist should be sensitive to this when discussing proposed treatment with the patient. Practices are welcome to use this or adapt as appropriate. Version 2.2 October 2014 Page 13 of 14

14 Primary Care Prescribers are reminded: To ensure that they only prescribe medicines where they are confident to take on the clinical responsibility. GPs are advised not to prescribe medicines that are generally regarded as RED (hospital only) or require specialist involvement/monitoring; or to prescribe outside of the manufacturer s product licence unless there is good evidence to support this. That safety is of paramount importance. A GP should only consider prescribing on receipt of a detailed clinical summary following patient assessment. To prescribe medicines in line with locally agreed prescribing guidance based on published evidence and cost effectiveness of equivalent preparations. Refer to the Surrey Prescribing Advisory Database (PAD): To prescribe generically, except in very specific cases usually associated with variations in bioavailability or magnitude of cost. REFERENCES 1 Department of Health. The NHS Constitution. 26 March 2013 Accessed online July onstitution.pdf 2 Department of Health. Guidance on NHS patients who wish to pay for additional private care Accessed online July m_dh/groups/dh_digitalassets/documents/digitalasset/dh_ pdf 3 Department of Health. A code of conduct for private practice January Accessed online July pdf 4 British Medical Association The interface between NHS and private treatment: a practical guide for doctors in England, Wales and Northern Ireland May Accessed online July Surrey Prescribing Advisory Database or contact the individual Clinical Commissioning Group for a copy of their policy. Version 2.2 October 2014 Page 14 of 14

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