Frequently Asked Questions (FAQ)
Which drugs can be prescribed in Lincolnshire?
Any drug listed in the drug tariff is available to prescribe on the NHS. However, the government mandate that each ICB needs to have their own local formulary. Most drugs in the formulary have been assessed by the Lincolnshire Joint Formulary Group and ratified by PACEF for their inclusion. The formulary classifications take into account NICE guidance, local guidance, quality & safety, and cost.
The formulary, Lincolnshire Formulary (lincolnshirejointformulary.nhs.uk) is divided into a “traffic light” system.
GREEN Drugs – are medicines approved for use in both primary and secondary care within the licensed indications. Specialist initiation and shared care guidelines are not considered necessary.
AMBER 2 Drugs – are medicines suitable to be prescribed in primary care after specialist recommendation or initiation.
AMBER 1 Drugs - are medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol. Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred.
RED Drugs – are medicines approved for use in secondary and tertiary care and should not be prescribed in primary care.
RED RED Drugs – are medicines not recommended for prescribing in either primary or secondary care. NB, any drug awaiting assessment by PACEF is classified as RED RED.
GREY Drugs – are medicines which are restricted for use in those patients under the care of external trusts i.e - Peterborough and Stamford Hospitals NHS Foundation Trust or the Northern Lincolnshire and Goole NHS Foundation Trust and can be continued if initiated by them.
What do I do if the drug is not in the formulary?
Occasionally you might find an area, or a particular drug or appliance, where there is no guidance in the formulary or in PACEF bulletins. The formulary is continuously being updated and this particular area or drug may never have been requested for review. Please ask the initiating prescriber to complete a New Drug Request form and forward to the Medicines Optimisation inbox at licb.mo@nhs.net.
I have been asked to prescribe a RED drug, what should I do?
RED drugs should be referred back to the hospital consultant to prescribe and supply.
A new patient has joined my practice and their prescription includes a RED RED drug on the Lincolnshire formulary, what should I do?
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First look in the patient’s records to see if the formulary alternatives have been tried. If not, please consider switching to a formulary medication.
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If other formulary alternatives are not suitable, i.e. tried in the past and not worked or not been tolerated, then in the best interests of the patient the drug may continue to be prescribed. Please document the rationale for prescribing and the reason why formulary alternatives were not suitable in the patient’s record.
I have been asked to prescribe a RED RED drug by a Lincolnshire hospital specialist, what should I do?
The practice should ensure that the specialist has folllowed steps 1 & 2 as above.
Can a drug be prescribed if it has been initiated by an out of area specialist?
Yes, it can be prescribed if it fulfils one of the following criteria:
- it is listed as GREEN in the Lincolnshire formulary
- it is listed as AMBER 1 in the Lincolnshire formulary, a shared care agreement has been signed by the GP and appropriate specialist, and this is saved in the patient’s records. For treatments being initiated by specialists outside of Lincolnshire, shared care agreements produced by that area should be provided by the specialist initiating treatment.
- it is AMBER 2 in the Lincolnshire formulary and has been initiated by the appropriate specialist.
If the product is non-formulary in both Lincolnshire and the specialist’s ICB, this should be referred back to the out of area specialist.
For privately practicing specialists, GPs should be satisfied these are from genuine prescribers in their relevant field.
What is a shared care agreement?
A shared care agreement is a written agreement, signed by both the initiating specialist and the patient’s GP, to allow the prescribing of amber 1 drugs on Lincolnshire formulary. It states who is responsible for which part of the patient’s care and includes baseline & further monitoring, blood tests, doses of medications, side effects and what to do if the patient’s condition deteriorates. Prescribing of medication is only taken over by the GP when the patient is stable on treatment. Often the consultant will continue annual review and assessment of the patient’s condition. Both specialist and GP sign and date the protocol if they are in agreement. A copy of this should be saved by the practice in the patient’s records. For treatments being initiated by specialists outside of Lincolnshire, shared care agreements produced by that area should be provided by the specialist initiating treatment.
Do I need a new shared care agreement if the dose has been changed after initial titration and stabilisation?
A new shared care agreement is not needed for dose changes, but the GP should contact the consultant to inform him/her of any deterioration in the patient’s condition and doses should only be adjusted as per specialist advice or agreed plan.
See the following link for further details: https://lincolnshire-pacef.nhs.uk/shared-care-agreements.
Which providers are commissioned to provide ADHD service to adult patients?
Lincolnshire ICB does not have a fully commissioned service for adults with ADHD however it uses the services of:
The ADHD 360 clinic
Dr Jajawi
Patients may be referred for NHS treatment through the OATS referral form to one of these providers.
Should I sign a shared care agreement from a private company?
There are no shared care agreements written by Lincolnshire ICB for adult ADHD medicines. In the absence of adult services in Lincolnshire patients have looked for private providers. It is the GP’s decision whether to take over prescribing of ADHD drugs from the private provider and should only sign the shared care agreement if happy with the conditions within it.
Who should I contact regarding any queries about ADHD services?
There is a generic inbox for all ADHD queries:
What Gluten Free products can I prescribe?
Lincolnshire follows the national guidance for England. The only gluten free products which are allowed on prescription are bread, bread mixes and flour mixes.
The drug tariff, section XV borderline substances under gluten free, has been updated to reflect this and so if a product is listed in the drug tariff our guidance allows it to be prescribed.
The list from Coeliac UK lists more types of food than are available on prescription eg crispbreads, crackers and pizza bases. These are available to buy.
How many units of Gluten Free food should be prescribed?
The number of units that can be prescribed per month varies depends on the individual patient eg age, gender, pregnancy, breast feeding. The following the link provides Coeliac UK recommended units www.coeliac.org.uk, please follow this unless a dietician has advised otherwise.
For information:
400g bread = 1 unit
500g flour = 2 units
Due to the ongoing challenges around HRT, the ICB team are recommending the use of Special Pharmacy Services 'prescribing available HRT products' webpage here. Along with a 'HRT preparations and equivalent alternatives' guide issued by The British Menopause Society here.
These resources are updated frequently and will be the most accurate source of information for prescibers.
Please note this is for health professionals only and does require clinicians to register for an account (free to nhs.net email addresses).
Does Lincolnshire have guidelines on the use of Melatonin?
Before recommending medication to adults, there is a lot of guidance on the NHS website re sleep aid apps. Also consider giving sleep hygiene advice see Scenario: Managing short-term insomnia (< 3 months) | Management | Insomnia | CKS | NICE or for patients with long term insomnia check the following guidance Scenario: Managing long-term insomnia (> 3 months) | Management | Insomnia | CKS | NICE
2mg MR tablets are approved for use on the formulary within their licensed indication; monotherapy for short term treatment (13 weeks) of primary insomnia, characterised by poor quality of sleep in patients who are aged 55 or over.
There is a shared care agreement in place to support the use of melatonin in children and adolescents up to the age of 18 years, but no shared care guidance to support use in adults.
Can Melatonin be used for jetlag?
No, Melatonin is not recommended for use in jet lag on the NHS in Lincolnshire.
What licensed melatonin products are included in the formulary?
The current licensed products listed in the Lincolnshire Joint Formulary are:
2mg MR tablets are licensed for the short term treatment (13 weeks) of primary insomnia, in adults aged 55 or over.
Slenyto® MR 1mg and 5mg tablets licensed for the treatment of insomnia in children and adolescents aged 2 to 18 years with Autism Spectrum Disorder (ASD) and/or Smith-Magenis syndrome, where sleep hygiene measures have been insufficient. This will be under a SCA.
Adaflex® 1mg, 2mg, 3mg, 4mg and 5mg tablets licensed for the treatment of insomnia in children and adolescents aged 6-17 years with ADHD, where sleep hygiene measures have been insufficient. This will be under a SCA.
Ceyesto 1 mg/ml Oral Solution licensed for the treatment of insomnia in children and adolescents aged 6-17 years with ADHD, where sleep hygiene measures have been insufficient This will under a SCA.
What formulations of melatonin can be prescribed for children/adolescents that have difficulty swallowing tablets?
See copy of the shared care agreement for sleep disorders in children here.
- At the discretion of the clinician Circadin® can be crushed and dispersed in water if an immediate release profile is desired, (halving it with a tablet cutter will preserve some of it modified release properties). The use of this is “off-label” in children.
- Prescribe unlicensed “Melatonin 10mg/5ml oral suspension (Alcohol and Sugar Free)” if the indication does not meet Slenyto® licensed indication and dose or the patient cannot take tablets. Please add “Alcohol and Sugar Free” to the dose (e.g. 2.5ml ON, alcohol and sugar free). This is an unlicensed use.
Also see a leaflet regarding information for parents and carers on helping children to swallow tablets should this be an issue.
Liraglutide (Saxenda) for weight management is classed as RED-RED in Lincolnshire. This is because ULHT is not a tier 3 centre. See Lincolnshire formulary for information here.
Lincolnshire patients are managed through the regional Derbyshire Tier 3 centre as an NHS service. We understand that GPs can make a direct referral.
Where prescription forms are lost (whether or not theft is suspected), this must be reported immediately to the practice manager.
The practice manager should immediately inform:
1. The police
2. The controlled drugs accountable officer 07730 381119 or England.centralmidlands-cd@nhs.net
3. The NHS England Contracting Team at Lincoln 0113 8248642 or england.eastmidlandspharmacy@nhs.net
Any report of loss of prescription forms should as a minimum include: date and time of loss / place where loss occurred / type and quantity of prescription stationery / serial numbers / details of to whom the incident has been reported.
Practice staff must complete an incident reporting form in accordance with their own incident reporting policy.
For all non-medical prescribers working within a GP practice, registration is completed by the Medicines Optimisation following the process outlined below. Please read the Non-Medical Prescribing Policy for more details.
On joining a GP Practice(s) the non-medical prescriber is required to complete a registration form. This form should be completed and emailed to the Medicines Optimisation generic inbox licb.mo@nhs.net. It is a requirement that this form is signed by the prescriber as the ICB has to keep a record of all non-medical prescriber’s signatures.
As part of the registration process, Medicines Optimisation will confirm the non-medical prescriber’s eligibility to prescribe with their relevant professional registration body and then consequently fill in the necessary paperwork to send to NHS BSA to complete the registration. This information is stored on an ICB database.
The NHS BSA do not usually acknowledge the registration and only get in contact with Medicines Optimisation if there is a problem. The NHS BSA complete applications quite quickly and if there has been no contact it can be assumed that registration has been completed after 2-3 working days.
If starting at a GP practice, having changed jobs from another organisation eg LCHS or another Trust, it is important that the NMP informs the organisation they have left so they can be de-registered from those services.
If prescription pads are required, these are obtained through Primary Care Services England by the Practice. If working across multiple practices, NMPs can use one prescription pad but must add the relevant practice code number for each patient for whom they prescribe.
When a NMP leaves a practice any remaining prescription pads must be destroyed at this point e.g., by shredding and access to practice computer systems removed.
Any prescriber who works for more than one employer or in more than one setting must have a separate prescription pad for each organisation.
No, the Medicines Optimisation team are not responsible for registering GPs.
The registration is done by Primary Care Services England, and can be found here.
New GPs can register for their PPA number and existing GPs can amend their practice location details. Practice managers will also have access to this site.
If pharmacies have difficulty obtaining supplies of drugs and their wholesaler responds with an “out of stock “ message, they should first check the SPS drug shortage tracker for updates; Medicines Supply Tool – SPS - Specialist Pharmacy Service – The first stop for professional medicines advice. If no shortage is noted on the SPS tracker, then check directly with the manufacturer of the generics you routinely order to find out if there are any issues with the supply. If there is no manufacturing issue causing a delay, then contact your wholesaler and prompt them to reorder stock. If this is an ongoing issue then raise this with the area manager or customer services team at the wholesaler, so they can review their stock ordering process.
Please see the Good Practice for Managing Medicines Stock Shortages document here.
Lincolnshire ICB supports the NHS view that a 28-day repeat prescribing interval makes the best balance between patient convenience, good medical practice, and minimal drug wastage.
The British Medical Association notes that “Prescribing intervals should be in line with the medically appropriate needs of the patient, considering the need to safeguard NHS resources, patient convenience, and the dangers of excess drugs in the home.”
There are several benefits to monthly prescribing intervals, including the following:
- Reducing the amount of medicine which is currently wasted when your doctor stops or changes your medicine.
- Reducing the potential for error when your medication is changed in the middle of supply.
- Increased safety as you will not have multiple containers of the same medicine meaning it is likely to reduce the number of mistakes made by, for example, elderly patients, and it will also reduce the risk of potential poisoning of young children.
- Financial losses due to medicines waste represent a direct loss to patient care. Since 28-day prescribing reduces medicines waste, this in turn has a positive impact on patient care.
See the attached Guidance for Patients
- In order to answer your query, please provide:
- Your name and profession
- Place of work and contact details
- Include relevant GP details if applicable
- For specialist, hospital or out of area prescribing queries, in addition, please provide the following:
- The specialists name and profession / speciality
- Indication for treatment
- Place of work
- Patient’s GP (further patient details maybe requested if necessary)
To allow your query to be answered efficiently, please provide a brief summary of your query and all relevant detail relating to it, such as other medicines that have been tried if looking for an alternative. If this is in relation to a paediatric patient, include the age.
We may request further information if required.