Specialist Medication: Shared Care + ADHD

General Approach to Specialist Request for Medication

We are required to prescribe in a consistent, safe and equitable way. Each medication request by any specialist will be considered and assessed in line with NHS GP best guidelines.

We prescribe when it is accordance with the medication license, NHS NICE (National Institute of Clinical Excellent) guidance and also the NCL (North Central London) JFC (Joint Formulary Committee) guidelines.

Specialists are able to prescribe a wide array of medicines- including some that we are unable to. When specialists see patients through the NHS they are obliged to prescribe in accordance with their hospital formulary which typically has the most cost-effective options as first line. When the same specialists see patients privately these restrictions are not in place and therefore the specialists often prescribe on the basis of personal preferance. Their desicison might not consider cost-effectiveness or other barriers, therefore they may initially prescribe options that, through the NHS, would be 4th or 5th line. We also appreciate why patients often do not want to privately pay for very expensive / less cost-effective medications. Equally, when more cost-effective options haven’t been tried first this does prevent us from prescribing the medication in question.

Patients are always free to follow the private specialist’s advice and recommendations but in some cases (when we are not able to prescribe the medication) this means obtaining the medication privately from the specialist on an ongoing basis or considering referral to an NHS specialist so they can recommend on an NHS approved treatment option.

The key considerations taken into account when we are requested to prescribe certain specialist medications are outlined in the NHS “Responsibility for prescribing between Primary & Secondary/Tertiary Care” guidance.

In summary these are:

The legal responsibility for prescribing lies with the doctor or health professional who signs the prescription and it is the responsibility of the individual prescriber to prescribe within their own level of competence. Further advice on this is contained within the General Medical Council’s (GMC) core guidance “Good Medical Practice” (GMP). A recommendation to prescribe a medicine by a specialist does not reduce the legal responsibility on the actual prescriber.
It is of the utmost importance that the GP feels clinically competent to prescribe the necessary medicines.
Shared care is a particular form of the transfer of clinical responsibility from a hospital or specialist service to general practice in which prescribing by the GP, or other primary care prescriber, is supported by a shared care agreement. The shared care agreement is designed to enable the primary care prescriber to feel able to prescribe however it also does not reduce the legal responsibility (for the drug and any consequences of it) which sit with the prescribing clinician.
When a specialist considers a patient’s condition to be stable or predictable, they may seek the agreement of the GP concerned (and the patient) to share their care. In proposing shared care agreements, a specialist should advise which medicines to prescribe, what monitoring will need to take place in primary care, how often medicines should be reviewed, and what actions should be taken in the event of difficulties.
Stable patients: A patient who has been prescribed the medication for at least 3 months and monitored to demonstrate the treatment has been optimised and the response is consistent.
When a shared care protocol exists and where the GP has confirmed willingness to accept the transfer of care, the hospital must initiate and abide by that agreement.
Referral to the GP should only take place once the GP has agreed to this in each individual case, and the hospital or specialist will continue to provide prescriptions until a successful transfer of responsibilities.
Patients should never be used as a conduit for informing the GP that prescribing is to be transferred. Any requests to enter into a shared care agreement should come directly from the specialist to GP.
People who are being treated on the advice of the secondary care team, but are no longer actively being seen in that setting, may still need review should problems arise. The appropriate level of care and/or advice should be available from the secondary care team in a timely manner without necessarily requiring a new referral.

ADHD Medications

Recently we have been receiving a large number of requests to prescribe ADHD medications in situations when it has not been possible to do so. Therefore we thought it might be helpful to have a section describing the general approach to specialist medicines.

There are many adults nationally with undiagnosed ADHD. Media and social media coverage of this has lead many patients to suspect they have ADHD and to come forward requesting referral for an assessment. We can appreciate why, for these patients, getting clarification and potentially a diagnosis of ADHD is important and potentially life-changing. Unfortunately, as a result of the huge increase in adults with suspected ADHD, the waiting times for assessments on the NHS has become very long (up to 5 years). Waiting times for children are fortunately much less but still significant.

Understandably some patients are reverting to self-funding private assessments. Often this results in a request for us to start prescribing stimulant ADHD medications. Unfortunately in the vast majority of cases this is not possible.

Stimulant ADHD medicines fall under the strictly regulated category of controlled drugs under both the Misuse of Drugs Act 1971 (MDA) and the Misuse of Drugs Regulations 2001 (MDR). They can also be associated with a list of significant side effects these include insomnia, weight loss, aggression, nausea, vomiting, dry mouth, abdominal pain, palpitations, ticks, raised blood pressure which can increase the risk of strokes and heart attacks. This is in addition to exacerbating underlying mental health conditions or leading to anxiety, depression, personality changes. For these reasons, this type of medication needs close initial monitoring followed by regular life long monitoring. For children this can affect their growth permanently so often requiring more frequent monitoring.

These specialist drug which can only be prescribed under an approved shared care agreement. Until a shared care agreement is in place all prescribing needs to occur in secondary care (within the specialist clinic). Once the patient is stable on medication the specialist/psychiatrist can write to the GP asking if they are able to enter into a shared care agreement through which (supported on an ongoing basis by the specialist) the practice can take over the prescribing.

Due to the long waiting lists on the NHS a large number of providers offering ADHD assessments and treatment have arisen. While many are offering appropriate care and appropriately detailed assessments there have been reports of patients being given an ADHD diagnosis and advised to commence treatment on the basis of inadequate assessments.

In order for the Practice to be able to enter into a Shared Care Agreement the following criteria will need to be met

1. The diagnosis has been made by an appropriate specialist/psychiatrist specialising in ADHD and in accordance with UK criteria (the diagnostic criteria in some countries is different) and that we can be confident that the assessment has been a full / detailed one.

In line with NICE and national Psychiatry guidelines, the specialist should be trained in excluding other causes, such as general or specific learning difficulties; anxiety disorders; depressive disorder; autistic spectrum disorder, personality disorder, conduct disorder, abuse, trauma, oppositional defiant disorder, other neurodevelopments disorders, neurocognitive disorder, disruptive mood disorder, bipolar disorder, reactive detachment disorder, disruptive mood dysregulation disorder or rarely, medical conditions, such as unsuspected hearing problems or epilepsy.

In practice, the most appropriately qualified specialist to exclude the above listed alternative conditions with overlapping symptoms (and in doing so confirm the ADHD diagnosis) is someone with the level of experience of a consultant psychiatrist specialising also in ADHD. We are finding increasingly, privately and in the NHS, that clinicians are diagnosing and managing ADHD, who are not ADHD specialist psychiatrists, often not psychiatrists, often heathcare professionals other than doctors who are not even supported by a psychiatrist. These health care professionals that may undertake only a 1-2 days formative course/training for ADHD are now making the diagnosis. The diagnosis is essential and without the appropriately qualified specialist having deep knowledge of the above listed conditions needed to be excluded we cannot have confidence in the diagnosis.

There are a number of providers (NHS & Private) who do not use appropriately qualified pyschiatric specialists able to diagnose, manage or exclude the above lists of diagnosis, and for such providers we will not be able enter into a shared care agreement. For these reasons it may not of benefit to be assessed by such a service if this leads to an expectation that we would be required to prescribe such controlled medication that may exacerbate any underlying condition.

2. The request to enter into a shared care agreement needs to come directly from the specialist. The specialist must be readily available for both the patient and GP should any issues or queries arise.

Patients should never be used as a conduit for informing the GP that prescribing is to be transferred. Any requests to enter into a shared care agreement should come directly from the specialist to GP.

3. The patient is going to remain under the care of that psychiatrist for the entire period treatment is occurring and that this continuity is not dependent on the patient being able to self-fund or private insurance (which sometimes patient lose access to if a work-scheme and sometimes insurance companies refuse to cover ongoing care). It is obviously not possible to enter into a “shared care” agreement when continuity of care by the specialist is not guaranteed.

4. The specialist is recommending a treatment course in line with the local protocols and is happy sign the local shared-care agreement (which many private specialists are not).

We will obviously consider any request to take on prescribing responsibility. In practice, however, these requirements mean that for the vast majority of cases, it will only be possible to routinely enter into (and prescribe under) a shared-care agreement when a patient is under the care of an NHS specialist ADHD team. In a situation in which the four points above are not met it is highly unlikely that it will be able to take over prescribing.

In many cases previously what was portrayed as “shared care” has in fact been a complete transfer of care into primary care, leaving patients unwell and unsupported on potent medications and the practice unsupported and prescribing contrary to local guidelines and, potentially, the best interests of the patient.

Patients are free to obtain a private assessment. Private assessments tend to lean towards over-diagnosis and therefore if the provider feels ADHD is unlikely patients may feel it is not worth waiting on the NHS for an assessment. If, however, a provider feels a diagnosis of ADHD is indicated then it may well be worth waiting for a confirmatory assessment / diagnosis via a recognised specialist in ADHD on the NHS (as per above). Once the confirmatory assessment through the NHS the specialist ADHD service has occurred we may well be able to enter into a shared-care agreement under which we can prescribe. Until we can take on prescribing, however, it would need to be done by the provider.

Controlled drugs are typically only prescribed a month at a time and this may require multiple consultations with the private provider. Therefore patients that opt to pay for a private ADHD assessment and opt to commence treatment privately need to be aware (and accept) that prescribing through their NHS GP will usually only be possible once they are similarly under the care of a NHS ADHD specialist team. Prior prescribing would need to occur privately - either with the provider that made the initial diagnosis or an alternative private provider. Stimulant medicines used for ADHD are moderately expensive and the private provider may state that a consultation (and associated fee) is required for each prescription. This therefore amounts to a not insignificant financial commitment. For many patients, it is not a viable option and we therefore strongly encourage our patients to view a private assessment as a screening process rather than something that will expedite treatment.

For the same reasons patients that have had assessments abroad (whether private or through the relevant state healthcare system) will likely need to have been seen through a NHS ADHD service with ongoing input before it will be possible to enter into a shared-care agreement and prescribe medication through the NHS. As above we will consider any request to take over prescribing however the four criteria stated above still need to be met and we therefore recommend patients registering whose care has been abroad to ensure they have adequate supplies of their medication (or a mechanism to obtain more medication) pending transfer into a NHS ADHD specialist clinic. This includes that the diagnosis has been made by a psychiatrist specialising in ADHD and in accordance with UK criteria (the diagnostic criteria in some countries is different) and that we can be confident that the assessment has been a full / detailed one.

As mentioned, we have taken this position after careful consideration to have a clear and consistent approach that is based on quality, safety and equity.