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ˆ p Strategaeth Meddyginiaethau Cymru Gyfan
Prescribing
Dilemmas:
A Guide for
Prescribers
The resources for this guide have been taken from various Welsh & English
policies, including Abertawe Bro Morgannwg, Conwy & Denbighshire,
Anglesey & Gwynedd, Neath Port Talbot and Carmarthenshire
All Wales Medicines Strategy Group
Contents
Introduction
Clinical responsibility
Private referral
Patients who request to be referred privately Private prescriptions
Prescribing of medicines for an unlicenced use
Prescribing outside national guidance
Travel abroad
NHS patients travelling for three months or less NHS patients living or travelling abroad for more than three months of the year Controlled drugs: implications for patients Prescribing of borderline foods and dietary products
Complementary medicine and alternative therapies
Minor ailments
10.0 Fertility treatment
11.0 Treatment of erectile dysfunction
12.0 Doctors prescribing for themselves or their families
13.0 Visitors from overseas
14.0 Vaccines for occupational health purposes
References
Appendix 1: Vaccines and the GMS contract
Appendix 2: Hepatitis B vaccination
Prescribing Dilemmas: A Guide for Practitioners
Introduction
This document provides guidance for health professionals regarding prescribing situations not coveredby the NHS, including private care and private prescriptions, travel, foodstuffs, infertility treatment,minor ailments, homoeopathy, erectile dysfunction, prescribing for self and family, visitors fromoverseas, unlicensed medicines, and prescribing outside national guidance.
The information has been collated from various resources produced by former local health boards(LHBs) and trusts.
1.0 Clinical responsibility
Legal responsibility for prescribing lies with the prescriber who signs the prescription1,2. It is importantthat, as the prescriber, you understand the patient’s condition as well as the treatment prescribed, andcan recognise any adverse effects of the medicine should they occur3.
Independent prescribers may prescribe any licensed or unlicensed medicine (“licensed” meaning anyproduct with UK marketing authorisation) for any medical condition within their therapeutic area ofcompetence (with the exception of pharmacist-independent prescribers, who may not prescribecontrolled drugs)4.
Prescribing responsibility will be based on clinical responsibility, where it is good medical practice andin the best interests of the patient2,3. Systems should be in place to ensure such responsibility can beaccepted, with health boards (HBs) and local medical committees (LMCs) working together to identifydeficiencies in local arrangements and providing mutually acceptable solutions.
2.0 Private referral
A large number of patients opt to have some or all of their investigations and treatment privately.
Some use private health insurance, whilst others are willing to pay to be seen more quickly, or for theadded convenience or comfort of receiving their care in private facilities.
In addition to the increasing emphasis on patient choice within the NHS, it is also recognised thatpatients are entitled to choose whether they receive their treatment within the NHS or privately. Therehas been a blurring of the boundaries between NHS and private treatment, with patients switchingfreely between the two sectors.
Whilst administratively convenient but not always practical, treatment is defined by ‘episodes of care’,which may be either continuous or consist of a series of treatment and care episodes, some of whichmay be funded by the patient and some by the NHS.
2.1 Patients who request to be referred privately
Such patients are expected to pay the full cost of any treatment they receive in relation to the careprovided privately: consultation fees, drugs prescribed or treatment provided by a clinician in thecourse of a private consultation should be at the patient’s expense5. Patients should be informed of thisexpectation prior to referral.
All Wales Medicines Strategy Group
2.2 Top-up payments
There is no legal barrier to top-up payments for medicines not routinely funded for use in Wales;a letter was sent to HBs in March 2011 advising the adoption of the Improving the Availability ofMedicines for Patients in Wales – Top-up Payments Implementation Group Report recommendations5.
Top-up payment, where the patient typically pays to receive a medicine (for example a cancer drugwhich has not had National Institute for Health and Clinical Excellence [NICE] or All Wales MedicinesStrategy Group [AWMSG] approval) but then returns to NHS care, may be seen as different to privatecare, where the patient pays for all ongoing treatment. The principles of the report recommend thatpatients opting for top-up treatment should not lose their entitlement to NHS treatment and that HBshave the power to charge for associated monitoring and care (excluding unpredictable events). Thereare also recommendations relating to procedural issues that should be considered when top-uptreatment packages are introduced.
3.0 Private prescriptions
3.1 Following a private consultation
A consultant may see a patient privately in order to give an opinion to an NHS GP regarding diagnosisor further management. Alternatively, the consultant may treat a private patient for whom they willcontinue to have clinical responsibility and will personally determine the ongoing treatment for thatparticular condition. Until the consultant discharges the patient, this remains an episode of care. In thiscase, the consultant should prescribe privately for their private patient, and a GP may refuse toprescribe on the NHS in such a situation as they do not have the clinical responsibility for managingthat particular condition. The GP must, however, continue to provide NHS treatment and prescriptionsfor other conditions for which they retain clinical responsibility6.
Exceptions to this would be where the medication is specialised in nature and is not something GPswould generally prescribe (for example anti-TNF, interferon or fertility treatment), where themedication recommended is not clinically necessary, or where the medication is generally not providedwithin the NHS (e.g. a drug listed under part XVIIIA of the NHS drug tariff7).
For a specific condition, where a private consultant recommends a medication that is more expensivewithout good evidence that they are more effective than that recommended by the NHS, LHBprescribing advice should be followed by the NHS GP. This advice should be explained to the patient,who will retain the option of purchasing the more expensive drug via the private consultant.
3.2 For NHS patients
A GP may issue a private prescription for any item that is not available on the NHS and for
drugs to treat indications not covered by the ’SLS’ conditions8. These circumstances are:
The product is blacklisted (Schedule 6, Part 3 of the NHS General Medical Services [GMS] Contracts The product is in Schedule 1 of the NHS GMS Contracts (Prescription of Drugs) (Wales) Regulations 2004, and its use is outside of that allowed for in Schedule 2 (see section 4.0).
Travel vaccines, e.g. Japanese encephalitis vaccine, yellow fever vaccine(if at a yellow fever vaccination centre).
The product is in connection with travel and is for an anticipated condition (e.g. antibiotics fortravellers’ diarrhoea, acetazolamide, or the oral cholera vaccine Dukoral®) as outlined underRegulation 24, Schedule 5.
Prescribing Dilemmas: A Guide for Practitioners
3.3 For a branded product
Where NHS policy recommends that a generic medicine is used and a patient requests the brandedequivalent, a private prescription cannot be issued if the patient is being treated within the NHS,unless the product cannot be prescribed on the NHS as specified above (“the blacklist”). This list ofproducts may be found in the Drug Tariff.
Whilst issuing an NHS prescription for patients who request a branded equivalent is not prohibited,practices should be aware that this could be considered an example of inappropriate or excessiveprescribing as stated in the GMS contract10.
4.0 Prescribing of medicines for an unlicenced use
Prescribing of medicines that are licensed but are being used outside of their licensed indication isnot generally recommended. However, it is recognised that some circumstances may necessitate aprescription.
Points for consideration:
Prescribers should be satisfied that an alternative, licensed medicine would not meet the patient’s needs.
Prescribers have a duty in common law to take reasonable care and to act ina way consistent with the practice of a responsible body of peers of similar professional standing.
The responsibility for prescribing falls to the practitioner who signs the prescription. It is thereforeimportant that the prescriber understands the patient’s condition as well as the treatment prescribed,can recognise adverse effects, and is able to monitor the prescribed drug completely (or can besatisfied that adequate monitoring is taking place)3,6.
In situations following a recommendation by a consultant, the prescriberis unlikely to be found negligent if they can convincingly demonstrate that they acted in accordancewith a responsible body of relevant professional opinion11.
When unlicensed use of a medicine is prescribed, the prescriber is professionally accountable for theirjudgement in doing so, and may be called upon to justify their actions11.
Prescribers must give patients (or their carers) sufficient information about the proposed course oftreatment, any common side effects, and the reasons for prescribing an unlicensed medicine (or theoff-label use of a medicine) to enable the patient (or carer) to make an informed decision3.
An example of where an unlicensed or off-label medicine is prescribed may be a medicine that islicensed for use in adults, but there is a clinical need for prescribing in paediatrics.
All Wales Medicines Strategy Group
5.0 Prescribing outside national guidance
National and local guidance will often clarify what GPs should do for identified individuals, e.g. who toimmunise against influenza or human papillomavirus (HPV). Whilst issuing a WP10 for patients who falloutside of these recommendations is not prohibited, practices should be aware that this could beconsidered an example of inappropriate or excessive prescribing as stated in the GMS contract10.
5.1 Human papillomavirus
A national immunisation programme has been developed by the Joint Committee on Vaccination andImmunisation12. They have established the most cost-effective way of immunising against HPV andprotecting against cervical cancer.
Prescribers may make a decision, on a case-by-case basis, to prescribe HPV vaccine outside the nationalprogramme if there is a compelling clinical reason to do so. It is important to recognise that the rate ofHPV infection increases with a history of two or more sexual partners, and that once a patient isinfected with HPV (types 16 or 18), vaccination is not effective.
If the case is made to immunise against HPV outside of the national programme, this is a GMS service.
GPs should not offer their patients a private service. The HPV vaccine Cervarix®13 should be prescribedif a clinical decision is taken to immunise a patient outside the national programme. The WelshAssembly Government have advised that the vaccine Gardasil®14 is to be administered by practicesonly after consideration has been given to the strong clinical case that would justify this (for example alatex allergy) and subject to the usual checks for contraindications15.
Both vaccines are black triangle medicines: all adverse effects should be reported to the MHRA usingthe Yellow Card reporting system. Extensive safety data is being collected for Cervarix® across the UK.
Further information on the HPV programme can be found on the Public Health Wales website16.
6.0 Travel abroad
6.1 NHS patients travelling for three months or less
Under NHS legislation, the NHS ceases to have responsibility for people when they leave the UK.
However, to ensure good patient care the following guidance is offered.
People travelling within Europe should be advised to carry the European Health Insurance Card (EHIC)at all times; this gives entitlement to local health care arrangements. Patients are advised to checkspecific entitlements and appropriate health advice prior to travel and obtain adequate holidayinsurance cover17,18.
Medication required for a pre-existing condition should be provided in sufficient quantity to cover thejourney and to allow the patient to obtain medical attention abroad. If the patient is returning withinthe timescale of a normal prescription (usually one and no more than three months) then this shouldbe issued, providing it is clinically appropriate. Patients carrying prescribed controlled drugs abroad fortheir own personal use may require a personal license17.
GPs are not required to provide prescriptions for medication which is requested solely in anticipationof the onset of an ailment whilst outside the UK, but for which treatment is not required at the time ofprescribing (e.g. travel sickness, diarrhoea). Patients should be advised to purchase these items locallyprior to travel; advice is available from community pharmacists if required. A private prescription maybe provided for any prescription-only medicines, such as ciprofloxacin for traveller’s diarrhoea. Forconditions unresponsive to self-medication, the patient should normally seek medical attention abroad17.
Prescribing Dilemmas: A Guide for Practitioners
Emergency travel kits are available in two forms, neither of which is available on the NHS. The ‘basic’kit contains items such as disposable needles and syringes, IV cannulae, sutures and dressings. The‘POM’ kit contains additional items such as plasma substitutes and medicines. A private prescription isrequired for the latter. The kits, or a list of suppliers, are available through travel clinics or communitypharmacies17.
Patients (including those not on a GP’s list), may be charged privately for travel vaccines notreimbursable on the NHS through the global sum. Guidance for prescribers on risk assessment fortravellers and appropriate advice is contained in the document Health Information for Overseas Travel17.
Travel vaccines that are available via the NHS for which reimbursement is received include:
polio (as combined diphtheria, tetanus and polio vaccine) For vaccines where no reimbursement is included through the global sum, and where use
is in relation to travel, a private script can be issued and practices may charge for both the
prescription and administration at their discretion. These vaccines include:
No charge should be made to any NHS patient of the practice for providing advice.
6.2 NHS patients living or travelling abroad for more than three months of the year
For longer visits abroad, the patient should be advised to register with a local doctor for continuingmedication; this may need to be paid for by the patient. It is wise for the patient to check with themanufacturer that medicines required are available in the country being visited. It is also worthadvising that medicines can be purchased without a prescription from pharmacies in some countries6.
Medication required for a pre-existing condition should be provided in sufficient quantity to cover thejourney and to allow the patient to obtain medical attention abroad17.
6.3 Immunisation for travel abroad
Guidance for GPs on risk assessment for travellers and appropriate advice is contained in the documentHealth Information for Overseas Travel17.
Immunisations which are available for reimbursement under the new GMS contract are provided free ofcharge to patients who require them (e.g. hepatitis A, polio and typhoid)17. In the case of immunisationfor conditions for which there are no arrangements for reimbursement (e.g. meningococcal A, C, W135and Y conjugate vaccine, hepatitis B and rabies), GPs may charge patients directly if use is in relation totravel abroad (see Schedule 5, Regulation 24 of the NHS GMS regulations 2004)9. This is an exceptionto the rule precluding GPs from charging patients for treatment under the NHS.
Newer (and more expensive) vaccines should normally be provided at NHS expense only if they aredemonstrated to be of improved efficacy or when there is other compelling clinical advantage. Advicewill be issued as new products arise.
All Wales Medicines Strategy Group
6.4 Malaria prophylaxis
In 1995, the Welsh Office issued guidance that medication for malaria prophylaxis may not bereimbursed under the NHS19. Instead, prescription-only medicines for malaria prophylaxis should beprescribed privately. The GP may also make a charge for the consultation and supplying theprescription if they wish. Some practices stock these items and dispense them from a privateprescription for a fee. Local community pharmacists also have access to up to date advice regardingappropriate prophylactic regimes and can advise travellers accordingly.
Patients should be advised to purchase sufficient prophylactic medicines to cover the period of theirtravel, commencing at least one week before departure for most drugs. Exceptions are mefloquine(Lariam®)20, for which prophylaxis should be started 2–3 weeks before travel so that if adverse eventsoccur there will be time to switch to an alternative, and proguanil/atovaquone (Malarone®)prophylaxis which should be started 1–2 days before travel21. Treatment should be continued for atleast four weeks on return, except for Malarone® which should be stopped one week after returning21.
The importance of mosquito nets, suitable clothing and insect repellents to protect against beingbitten should be stressed. Travellers should be directed to the Health Protection Agency (HPA)document: Guidelines for malaria prevention in travellers from the United Kingdom 200722.
Remember the Public Health Laboratory Service Malaria Reference Unit four steps 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 Controlled drugs: implications for patients
Department of Health guidance recommends that, in general, prescriptions for controlled drugsshould be limited to a supply of up to 30 days treatment. Exceptionally (to cover a justifiable clinicalneed and after consideration of any risk) a prescription can be issued for a longer period, but thereasons for the decision should be recorded in the patient’s notes23.
Patients who are carrying certain controlled drugs abroad (or in the case of an import licence,
into the UK) for less than three months for their own personal use do not need a personal export
or import licence. They should carry a letter from the prescribing doctor with the following
details24:
Patient’s name, address and date of birth.
The outward and return dates of travel.
The country the patient is visiting.
A list of the drugs the patient will be carrying, including dosages and total amounts.
Additionally, it is always advisable to contact the Embassy, Consulate or High Commission of thecountry to be visited regarding their policy on the import of controlled drugs, as the legal status ofcontrolled drugs varies between countries.
Prescribing Dilemmas: A Guide for Practitioners
Controlled drugs should be:
carried in hand luggage (airline regulations permitting); carried with a valid personal import/export licence (if necessary; see below).
Persons travelling abroad (or visitors travelling to the UK) in excess of three months and carryingcontrolled drugs will require a personal export or import licence25. A personal licence has no legalstanding outside the UK and is intended to assist travellers passing through UK customs controls withtheir prescribed controlled drugs. Travellers are advised to contact the Embassy, Consulate or HighCommission of the country of destination (or any country through which they may be travelling)regarding the legal status and local policy on the importation of controlled drugs26.
Anyone staying outside of their home country for longer than three months should register with adoctor in the country they are visiting for the purpose of receiving further prescriptions. There is noallowance in the GMS contract to reimburse GPs for providing this service. It would be up to thediscretion of the GP practice whether to charge patients in these circumstances.
7.0 Prescribing of borderline foods and dietary
products
Prescribing of borderline foods and dietary products should comply with the recommendations of theAdvisory Committee on Borderline Substances: “Prescriptions for such products on WP10s areregarded as drugs for the treatment of specified conditions. Prescribers should satisfy themselves thatthe products can safely be prescribed, that patients are adequately monitored and that, wherenecessary, expert hospital supervision is available.” A complete list of conditions can be found in the British National Formulary23 or Drug Tariff27.
Most conditions can be included in the following categories:
There are several areas where prescriptions for dietary products do not comply with the aboverecommendations, and the responsibility lies with individual GPs who may use their judgement to makeexceptions to the above recommendations. This may occur following recommendations from a dietician,or for a medical condition requiring nutritional support for a defined period of time. An example of thelatter would be a patient having had maxillofacial surgery, being discharged from hospital with a wiredjaw and requiring nutritional support for six to eight weeks post-operation. Such a patient would beunlikely to receive adequate nutrition from a manageable volume of liquidised foodstuffs.
GPs are strongly advised not to prescribe dietary products for patients (including in nursing orresidential homes) outside the above uses, and using them as an alternative to liquidising/purchasingappropriate food.
All Wales Medicines Strategy Group
8.0 Complementary medicine and alternative
therapies
Evidence suggests that there are large numbers of complementary medicines and alternative therapiesavailable that have not been subject to the type of trials used to establish the effectiveness ofconventional clinical treatments. The evidence base is developing and up to date evidence oncomplementary therapies and alternative treatments can be obtained from the Cochrane library28 andspecialist evidence of NHS Library29.
Complementary and alternative therapies include, but are not limited to:
Complementary medicines or alternative therapies are generally not used by the NHS30. They areoccasionally used as part of a mainstream service care plan (e.g. as part of an integratedmultidisciplinary approach to symptom control by a hospital-based pain management team) and assuch will be used as part of an existing contract. On existing available evidence, the HB will notsupport referral outside of the NHS for these services. Prior approval is required on a case-by-case basisfor any requests outside the above criteria. The request for referral would need to be supported byevidence of the clinical effectiveness of the treatment, which should be provided by appropriatelytrained and qualified practitioners with recognised qualifications.
9.0 Minor ailments
From 1 April 2007, prescription charges for drugs and appliances no longer applied. However, theMinister for Health advised: “While free prescriptions will benefit everyone who currently pays for prescriptions in Wales, it shouldparticularly benefit those people on modest incomes or who have chronic illnesses who may not havepreviously been eligible for free prescriptions under the complicated exemption system. This is the simplestand most effective way of resolving health inequalities and those inconsistencies in prescribing. The moveremoves all the unfairness surrounding the present outdated 1968 exemption system where, for example,a diabetes patient automatically gets all prescriptions free but a cystic fibrosis sufferer doesn’t.” “It must be stressed though that the free prescription policy aims to provide medication for free that is onlyavailable with a prescription. Where patients already buy non-prescription medication over the counter theyshould continue to do so in the normal way. If patients change their behaviour radically this could have adetrimental impact on the NHS as a whole and indirectly on those patients who are in most need of the freeprescriptions.”31 The General Medical Council (GMC) advise that prescribers should only prescribe drugs to meet theidentified needs of patients and never for their own convenience or simply on patient demand3.
Declining patient requests from the outset may deter patients from making similar future demands(for example requests for simple analgesia or for antibiotics for viral infections).
Prescribing Dilemmas: A Guide for Practitioners
10.0 Fertility treatment
A revised referral pathway for specialist fertility treatment for Welsh residents was developed
by Health Commission Wales and approved in April 2009. The pathway includes three levels
of care:
Level 1. Initial investigation and management by the primary care team.
Level 2. Referred by GP to infertility clinics led by special interest consultants.
Level 3. Referred by consultant to tertiary centre for assisted conception cycle. Currently, new referralsare to be made to Cardiff, Shrewsbury or Liverpool.
As of April 2010, the Welsh Assembly Government decided that two cycles of in vitro fertilisation (IVF)or intracytoplasmic sperm injection treatment will be available on the NHS to those patients who meetthe specified criteria32.
The following access criteria apply for tertiary infertility treatment:
The cycle of treatment should start before the female patient’s 40th birthday.
The upper age limit of the female patient, at time of referral to the tertiary service, should be no morethan 38 years 6 months.
Any previous completed cycles of NHS IVF treatment by the female patient will exclude further NHS IVFtreatment.
Three or more IVF cycles by the female patient will exclude any further NHS IVF treatment.
Subfertility must be demonstrated before there can be access to NHS funded IVF treatment. Subfertilityfor heterosexual couples is defined as inability to conceive after two years of unprotected intercourse orfertility problem demonstrated at investigation. Subfertility for same sex couples/single women is definedas no live birth following insemination at or just prior to the known time of ovulation on at least ten nonstimulated cycles, or fertility problem demonstrated at investigation.
For couples: there are no children (biological or adopted) living with the couple and one of the partnershas never had a biological or adopted child. For single women: that the woman has never had abiological or adopted child.
Subfertility is not the result of a sterilisation procedure in either partner or the single woman. This doesnot include conditions where sterilisation occurs as a result of another medical problem.
The couple/single woman must have a body mass index of between at least 19 and up to and including30. Couples/single women outside this range will be added to the waiting list but must have achievedthis range at time of treatment.
Where either of the couple or the single woman smokes, only couples/single women who agree to takepart in a supported programme of smoking cessation will be accepted on the IVF treatment waiting listand must be non-smokers at the time of treatment.
Patients not conforming to the Human Fertilisation and Embryology Authority code of practice will beexcluded from having access to NHS funded assisted fertility treatment.
10.1 Prescribing implications
It would be reasonable to prescribe within levels 1 and 2 (i.e. Clomifene [Clomid®]33) under a sharedcare protocol but it is not expected that GPs will prescribe treatments for level 3 (see section 10.0).
All Wales Medicines Strategy Group
11.0 Treatment of erectile dysfunction
Alprostadil (Caverject®, MUSE®, Viridal®), moxisylyte hydrochloride (Opilon®), sildenafil (Viagra®),tadalafil (Cialis®), or vardenafil (Levitra®) can be prescribed on a WP10 (endorsed ‘SLS’) under thefollowing circumstances: A man who is suffering from any of the following:
- diabetes- multiple sclerosis- Parkinson's disease- poliomyelitis- prostate cancer- severe pelvic injury- single-gene neurological disease- spina bifida- spinal cord injury A man who is receiving treatment for renal failure by dialysis.
A man who has had the following surgery:
- prostatectomy- radical pelvic surgery- renal failure treated by transplant.
A man with impotence which is causing severe distress as diagnosed by specialist services
(prescribing for this indication should remain the responsibility of secondary care)34.
Additionally, men receiving a course of NHS drug treatment for erectile dysfunction condition on 14September 1998 will continue to be eligible to receive treatment from their GP35.
It should be noted that any patient who does not adhere to a category may have the drug prescribedprivately, and that this list only covers medical categories23.
The frequency of treatment will need to be considered on a case-by-case basis, but prescribers mayfind it helpful to bear in mind that the average frequency of sexual intercourse in the 40–60 years ofage range has been estimated as once a week36. Prescribers may also wish to bear in mind that sometreatments for impotence have been found to have a ‘street value’ for men who consider, rightly orwrongly, that these treatments will enhance their sexual performance. Excessive prescribing couldtherefore lead to unlicensed, unauthorised and possibly dangerous use of these treatments.
The Welsh Office has advised prescribers that one treatment a week is appropriate for most patientstreated for erectile dysfunction34,35,37. If the GP, in exercising clinical judgement, considers that morethan one treatment a week is appropriate, it should be prescribed on the NHS. The GP should not writea private prescription; if a greater supply is deemed necessary, this should be prescribed on the NHS.
Prescriptions must be endorsed ‘SLS’.
Prescribing Dilemmas: A Guide for Practitioners
12.0 Doctors prescribing for themselves or their
families
The GMC advise that it is good practice for doctors and their families to be registered with a GPoutside the family who takes responsibility for their health care3. This gives the doctor and their familymembers access to objective advice and avoids the conflicts of interest that can arise when doctorstreat themselves or those close to them. Ideally, doctors, family and staff from a practice should beregistered with, and treated by, another practice.
From time to time, cases occur where a doctor's loss of objectivity in treating a family member resultsin misconduct, or where self-medication (with controlled drugs, for example) leads to drug misuse.
It is difficult to form an absolute rule: it may be sensible for a doctor to treat minor ailments, or takeemergency action where necessary; however, they should avoid treating themselves or close familymembers wherever possible. This is a matter of common sense as well as good medical practice.
13.0 Visitors from overseas
Patients entitled to NHS treatment in primary care, including the provision of any necessary
prescriptions, are as follows:
A person intending to be resident in this country for six months or more (registration with a practice isnecessary).
Patients from within the European Economic Area in possession of an EHIC.
Patients who require immediate, essential treatment, which the treating doctor deems cannotreasonably be delayed until the patient returns home (EHIC not required).
Patients holding E112 for specific treatment of a particular condition (and prescriptions for thiscondition only).
Refugees (those whose applications to reside in this country have been approved) and asylum seekers(those who have submitted an application and are awaiting a decision).
This list contains the most common categories, but please check an individual’s situation beforeproviding or declining NHS care as special conditions may apply.
Patients who do not fall into these categories may be offered and charged for private care, includingthe provision of private prescriptions where necessary.
Where appropriate, patients should be encouraged to register, permanently or as temporary residents,with a general practice to receive NHS care.
Further information is available from the Overseas Visitors section of the Department of Healthwebsite38.
All Wales Medicines Strategy Group
14.0 Vaccines for occupational health purposes
Immunisation against infectious disease (The Green Book)39 gives clinical recommendations for the useof vaccines, but does not identify those which are recommended to be NHS funded (see Appendix 1).
Where no remuneration is available from the HB, either via the GMS contract or Local EnhancedService for individual vaccines, NHS prescribing is strongly discouraged.
A patient sent by an employer to request occupational health immunisations should be advised thatthis is not the responsibility of the practice. The employer (not the patient) will have to make privatearrangements with a practice or occupational health provider to administer the vaccine(s).
Hepatitis B vaccinations for occupations as listed in the BNF should normally be provided by theemployer via their own occupational health provider or via private agreement with a practice (seeAppendix 2).
This guidance is open to interpretation. It is recognised that the use of the hepatitis B vaccine foroccupational health or travel purposes, as part of service provided by NHS under the GMS, is underdebate. To date, there is no definitive advice on this (for useful information see the Hepatitis B pages ofthe NHS Choices website40) and the decision as to whether or not a NHS prescription for the hepatitisB vaccine is appropriate should be made on an individual patient basis and may depend on the viewsof the medical practitioner involved. Students of health care (e.g. medical, nursing and dentalstudents) should be vaccinated by their educational organisation, as in practice the provision ofvaccination might include prior blood screening to assess immunity status, and guidance from anappropriate specialist on whether vaccination is necessary41,42.
Prescribers may wish to give special consideration for the following:
Individuals involved in needle exchange services.
Where an employer refuses to provide this intervention and the patient remains at risk.
Where the patient is an employee of a primary care organisation for which there is no occupationalhealth service.
For further advice contact your local occupational or public health teams.
Prescribing Dilemmas: A Guide for Practitioners
NHS Management Executive Letter EL (91) 127. Responsibility for prescribing between hospitalsand GPs. Nov 1991.
Welsh Health Circular (91) 94. Responsibility for prescribing between hospitals and GPs.
Nov 1991.
General Medical Council. Good practice in prescribing medicines. Sep 2008. Available at:
http://www.gmcuk.org/static/documents/content/Good_Practice_in_Prescribing_Medicines_
0911.pdf. Accessed Oct 2010.
Welsh Assembly Government. Non-medical prescribing in Wales. A guide for implementation.
2010. Available at: http://www.wales.nhs.uk/sites3/Documents/371/Non%20medical%20
prescribing%20in%20Wales%20-%20A%20guide%20for%20implementat.pdf. Accessed Oct 2010.
Improving the availability of medicines for patients in Wales: top-up payments. Implementation
Group report. Feb 2011. Available at: http://www.wales.nhs.uk/sites3/docopen.cfm?orgid=
498&id=169991. Accessed Aug 2011.
General Practitioners Committee. Information and guidance on prescribing in General Practice.
Sep 2004. Available at: http://www.lmc.org.uk/downloadfile.aspx?path=/uploads/files/guidance
/prescribing0904.pdf. Accessed Dec 2010.
NHS electronic drug tariff. Part XVIIIA: drugs, medicines and other substances not to be ordered
under a general medical services drug tariff. Nov 2010. Available at: http://www.ppa.org.uk/
edt/November_2010/mindex.htm.
NHS electronic drug tariff. Part XVIIIB: drugs, medicines and other substances that may be
ordered only in certain circumstances. Nov 2010. Available at: http://www.ppa.org.uk/edt/
November_2010/mindex.htm.
NHS Wales. General medical services contracts (Wales) regulations. Feb 2004. Available at:
http://www.opsi.gov.uk/legislation/wales/wsi2004/20040478e.htm. Accessed Dec 2010.
10 Excessive or inappropriate prescribing: guidance for health professionals on prescribing NHS medicines (GMS Contract Annex 8). Mar 2006. Available at: http://www.wales.nhs.uk/sites3/
Documents/480/Annex8_Excessive_or_Inappropriate_Prescribing.pdf. Accessed Oct 2010.
11 Midlands Therapeutic Review and Advisory Committee. Liability issues for GPs. Mar 2010.
Available at: http://www.keele.ac.uk/depts/mm/MTRAC/Guidance/unlicpsc.htm. Accessed Oct 2010.
12 Joint Committee on Vaccination and Immunisation. Statement on human papillomavirus vaccines to protect against cervical cancer. Jul 2008. Available at: http://www.dh.gov.uk/
prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_094739.pdf.
Accessed Dec 2010.
13 GlaxoSmithKline UK. Summary of Product Characteristics. Cervarix. Oct 2010. Available at: http://www.medicines.org.uk/EMC/medicine/20204/SPC/Cervarix/. Accessed Dec 2010.
14 Sanofi Pasteur MSD Limited. Summary of Product Characteristics. Gardasil. Sep 2010. Available at: http://www.medicines.org.uk/EMC/medicine/19016/SPC/GARDASIL/. Accessed Dec 2010.
15 Welsh Assembly Government Chief Medical Officer. Human papillomavirus vaccination 16 Public Health Wales. Dec 2010. Available at: http://www.publichealthwales.wales.nhs.uk/.
17 National Travel Health Network and Centre. Health information for overseas travel. Jun 2010.
18 NHS Choices. Healthcare abroad. Apr 2010. Available at: http://www.nhs.uk/nhsengland/
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20 Roche Products Limited. Summary of Product Characteristics. Lariam. Sep 2009. Available at: http://www.medicines.org.uk/EMC/medicine/1701/SPC/Lariam/. Accessed Dec 2010.
All Wales Medicines Strategy Group
21 GlaxoSmithKline UK. Summary of Product Characteristics. Malarone. Sep 2009. Available at: http://www.medicines.org.uk/EMC/medicine/756/SPC/Malarone/. Accessed Dec 2010.
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23 British Medical Association, Royal Pharmaceutical Society of Great Britain. British National 24 NHS clinical knowledge summaries. Opioid dependence - management. How do I advise someone who is travelling abroad? Feb 2008. Available at: http://www.cks.nhs.uk/
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Prescribing Dilemmas: A Guide for Practitioners
APPENDIX 1: VACCINES AND THE GMS CONTRACT
Private NHS
Comments
The vaccine is not indicated for mosttravellers, but may be appropriate forthose who are unable to takeadequate precautions in highlyendemic or epidemic settings. Thiswould include aid workers assisting indisaster relief or refugee camps, andmore adventurous backpackers whodo not have access to medical care17.
Refer to the Green Book39 forguidance.
Private prescription for travellers,unless they are in an at risk category as documented in the GreenBook39. Check local policy.
Unlicensed for use in the UK.
Vaccine available on a named- patient basis from Sanofi Pasteurand MASTA.
Combination vaccines are nowrecommended23.
of exposure to the virus throughtravel or employment.
Only available at designatedcentres. A listing of approved yellowfever vaccination centres in Wales may be found at:www.nathnac.org/yellowfevercentres.
aspx?comingfrom=professional. Pre-exposure immunisation isrecommended for some travellers.
For occupational risk and bat from the HPA Virus ReferenceDepartment. For more details ofthis, and post-exposure informationsee the Green Book39.
Electronic multi-vaccine claims
GP practices who submit monthly claims for administering multiple-dose vaccines are now able to do so
electronically via the Prescribing Services intranet site. WP10 forms should not be submitted to Prescription
Pricing Services in GP accounts for vaccines allowed via the WP34 claim form route.
*GPs may prescribe privately and charge their registered patients for vaccine only if use is in association with travel All Wales Medicines Strategy Group
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Prescribing Dilemmas: A Guide for Practitioners
All Wales Medicines Strategy Group

Source: http://www.awmsg.com/awmsgonline/docs/awmsg/medman/Prescribing%20Dilemmas%20-%20A%20Guide%20for%20Prescribers.pdf