Microsoft word - pharm-0023-v1 safe prescribing transfer guidance review final quac nov 13

Guidance for safe transfer of prescribing
Background information
The majority of medicines prescribed to treat mental health illnesses are covered by NICE guidance.
Where prescribing follows NICE recommendations it is expected that prescribing responsibilities can be
transferred from secondary to primary care services once patients are stabilised on treatment. This allows
secondary care services to concentrate on the provision of specialist support and increases access to
services. It also offers a much more convenient system for patients obtaining their medicines and allows
primary care to provide comprehensive management of all of a patient’s medication.
Following a number of serious safety incidents it is recognised that it is increasingly important that
prescribing responsibilities are clearly defined and that prescribing and monitoring responsibilities are not
split. This follows recommendations made by the General Medical Council (GMC).

All the drugs in Chapter 4 of the BNF which are prescribed by the Trust have been classified into
categories which determine their prescribing status. The full list of drug classifications is provided in
Appendix1.
Initiation and continuation in secondary care. These are drugs which must be initiated by the specialist, but with the potential to transfer to primary care within written and agreed shared care protocols and according to the agreed process for transfer of care. The patient’s condition and/or treatment should normally be stabilised before the GP should be asked to participate in shared care. This time period can be variable dependent on the condition being treated and the individual patient’s response to the treatment. A minimum of one month’s stabilised dose would be expected to be provided by the specialist prescriber before considering transfer of prescribing. Shared care guidelines are available or are being developed for most amber drugs. If no shared care guideline is available, the specialist should provide the GP with sufficient information and support to allow treatment to be continued and managed safely in primary care. Criteria for an Amber drug are as follows: A specialist is required to start the medication. Both the specialist and GP have a shared responsibility in maintaining the patient’s progress and prescribing (details will be defined in a Shared Care Protocol). Both the specialist and GP share the responsibility for stopping the medication and this must be clearly defined in the shared care protocol. It is accepted that some drugs should be initiated by a specialist and may require annual/regular review but can be safely maintained in primary care without on-going
specialist monitoring and will be classified as GREEN+ rather than AMBER.
GREEN+ drugs will have stipulated criteria specified for transferring prescribing.
Information leaflets will be developed for some GREEN+ drugs where this assists
GPs continue treatment.
A minimum of one month’s supply will be given to patients before transferring
responsibility to primary care. If a patient uses compliance aids, consider the best
interests of the patient when deciding the length of the first supply.
These are defined as new and established drugs, which may be prescribed, initiated, changed or maintained on by the GP and if appropriate discontinued without Tees, Esk and Wear Valleys NHS Foundation Trust Guidance for safe transfer of prescribing v5 Transfer of prescribing procedure
Transfer of prescribing responsibility may be considered when: -
The patient’s mental state has been stabilised* The patient’s dosage has been stabilised* and treatment is approved for transfer of prescribing. Prescribing is within NICE recommendations. Drugs prescribed at doses above BNF limits, in combinations or for unlicensed indications not recommended by NICE cannot be transferred using this process. The stipulations related to specific drugs are met. The Transferring Prescribing template (see Appendix 2) specifies all the information required by primary
care to take over prescribing responsibility of a green/green plus classified drug. This information must be provided to the GP. *Patients are regarded as stabilised for the purpose of transfer of prescribing responsibility once they have completed their
response to medication and there are no recognised problems with compliance or significant acute risks of harm to themselves or
to others. They will usually have completed at least one month of treatment and be suitable for 28 day prescriptions.
Suspension of primary care prescribing arrangements
Prescribing in primary care should be suspended and revert back to secondary care when:
Patients default from attending secondary care reviews Patients are being seen intensively by secondary care Triggers for referral back to secondary care services or need for specialist advice
These include:
Any spontaneous deterioration in mental state that cannot be managed by the GP Patient intolerance of adverse side effects including the development of extra pyramidal side effects Specific prescribing circumstances e.g. pregnancy, breast feeding, initiation of concomitant therapy that may interact with the patient’s therapy or mental state Increase in smoking, alcohol or drug use or a deterioration in sleep pattern Deterioration or abnormalities in monitoring results
Access to services and specialist advice
The prescribing transfer form provides contact details for rapid access to services and advice.
Discharge of patients
The majority of patients taking antipsychotic or antimanic medication will remain within secondary care
services. However consideration may be given to discharging the patient from secondary care services where no
active treatment is being provided by specialist services and the patient has:
• had at least one annual review by secondary care services and
• been stable on and concordant with treatment for a minimum of 6 months and
• is not receiving aftercare under Section 117 and
• no other co-morbidity requiring consultant psychiatrist input
• explicit agreement from the GP and
• a formalised written agreement between secondary care and primary care and
• after discussion with the patient.
It is advised that the discharge care planning arrangements specifically highlight requirements for on-going physical
health monitoring.
For patients who may not require life long treatment an indication of longer term review arrangements where
discontinuation or review of treatment may be considered should be specified.
If after discharge a patient becomes mentally unstable or a slow deterioration in mental health is observed a referral
from primary care would result in prompt action by secondary care. The means of access to secondary care for
acutely ill patients would usually be via the single point of access for Adult Mental Health Services; referral of patients
to Older Peoples Services will be via the usual route.
Patients prescribed drugs for dementia, attention deficit hyperactivity disorder or lithium will not be
discharged from secondary care services.

Physical healthcare
The introduction in 2004 of the General Medical Services contract provides opportunities for primary care services to
offer improved physical healthcare for patients with severe long term mental health problems. This group of patients
tends to neglect general health issues. The GMS Quality and Outcomes Framework include clinical indicators which
require regular reviews offering routine health promotion and prevention advice appropriate to their age gender and
health status. Secondary care should be notified of patients who persistently fail to attend for physical health
reviews.
Tees, Esk and Wear Valleys NHS Foundation Trust Guidance for safe transfer of prescribing v5 APPENDIX 1
Classification of drugs prescribed in TEWV, suitable for transferring prescribing

responsibility, agreed with commissioning CCGs
Initiation and continuation in secondary care only
Shared care - initiation in secondary care suitable for transfer of
prescribing when stable, patients should not be discharged from service
G REEN PLUS
Initiation in secondary care suitable for transfer of prescribing when stable
Initiation and prescribed in all care settings. First choices Alternative
Detailed prescribing guidance can be found in the central nervous
system chapter of the Formulary
GREEN PLUS
4.1.1 Hypnotics
Temazepam
4.1.2 Anxiolytics
Initiation by specialist; Prescribing follows NICE CG 113 Anxiety (only if SSRIs or SNRIs not tolerated);
Stabilised on treatment; Minimum of one month’s supply on transfer
Diazepam
4.2.1 First generation antipsychotics
Initiation by specialist; Prescribing follows Psychosis Care Pathway; Baseline monitoring completed;
Stabilised on treatment; Minimum of one month’s supply on transfer; Annual review of medication by
specialist services whilst actively involved in providing treatment
Haloperidol
4.2.1 Second generation antipsychotics
Initiation by specialist; Prescribing follows Psychosis Care Pathway; Baseline monitoring completed;
Stabilised on treatment; Minimum of one month’s supply on transfer; Annual review of medication by
specialist services whilst actively involved in providing treatment

(specify clinical indication for orodispersible preparations) (specify clinical indication for MR preparations) (specify clinical indication for orodispersible preparations) Tees, Esk and Wear Valleys NHS Foundation Trust Guidance for safe transfer of prescribing v5 GREEN PLUS
4.2.2 Antipsychotic depots (Responsibility for prescribing & administration not split)
Initiation by specialist; Prescribing follows Psychosis Care Pathway; Baseline monitoring completed;
Stabilised on treatment; GP practice agreement to administer depots; Annual review of medication by
specialist services whilst actively involved in providing treatment
4.2.3 Antimanic drugs
Initiation by specialist; Prescribing follows Bipolar Care Pathway; Baseline monitoring completed;
Stabilised on treatment; Minimum of one month’s supply on transfer; Annual review of medication by
specialist services whilst actively involved in providing treatment
Follow shared care protocol when transferring prescribing
(specify clinical indication for orodispersible preparations) 4.3.1 Tricyclic and related antidepressants
Amitriptyline
4.3.2 Monoamine-oxidase inhibitors
Initiation by specialist; Prescribing follows Depression Care Pathway; Stabilised on treatment;
Minimum of one month’s supply on transfer
4.3.3 Selective serotonin re-uptake inhibitors
Initiation by specialist; Prescribing follows Depression Care Pathway; Stabilised on treatment;
Minimum of one month’s supply on transfer
Citalopram
4.3.4 Other antidepressants
Initiation by a specialist; Prescribing follows Depression Care Pathway; Stabilised on treatment;
Minimum of one month’s supply on transfer;
Mirtazapine
Tees, Esk and Wear Valleys NHS Foundation Trust Guidance for safe transfer of prescribing v5 GREEN PLUS
4.4 CNS Stimulants & drugs used for ADHD
Follow shared care protocol when transferring prescribing
4.8.1 Antiepileptics
Initiation by specialist; Prescribing follows NICE CG 137 Epilepsy ; Stabilised on treatment; Minimum of
one month’s supply on transfer
Carbamazepine
4.8.2 Drugs used in status epilepticus
Diazepam
4.10.1 Alcohol dependence -.
Initiation and continuation by specialist commissioned service; Prescribing follows NICE CG115 alcohol
dependence and harmful alcohol use;
4.10.2 Nicotine dependence
Bupropion
4.10.3 Opioid dependence
Initiation and continuation by specialist commissioned service
4.11 Drugs for dementia (Monotherapy only)
Initiation by a specialist; Prescribing follows Dementia Care Pathway; Stabilised on treatment; Indications
within NICE guidance for cognitive and non-cognitive symptoms of Alzheimer’s disease; Minimum of one
month’s supply on transfer; six monthly review of cognitive symptoms, global, functional and behavioural
assessment by specialist services.
(specify clinical indication for orodispersible preparations) Tees, Esk and Wear Valleys NHS Foundation Trust Guidance for safe transfer of prescribing v5 (specify clinical indication for patches) Tees, Esk and Wear Valleys NHS Foundation Trust Guidance for safe transfer of prescribing v5 TRANSFERRING PRESCRIBING
Appendix 2

Information required when transferring prescribing which is in accordance with NICE
guidance from secondary care prescriber to GP

GP details:

Patient details (name/address/DOB/NHS number):
Diagnosis:

Medication details (full list of current medicines for mental health conditions detailing drug, dose,
frequency and specifying clinical indications for non-standard formulations) :
Discontinued medication (details of drug, dose and frequency):
Prescription issued (details of date and length of supply):
Monitoring results:

Review frequency:

Actions requested of GP: We would be grateful if you would

Secondary care contacts:
Contact details (address/telephone no):

Signature & date:

Tees, Esk and Wear Valleys NHS Foundation Trust Guidance for safe transfer of prescribing v5

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