All patients who have repeat medication will have their prescription reviewed annually either in person or virtually depending on the type and number of medications being prescribed. The following policy explains why medication may be removed from your repeat prescription.

Repeat Prescription reviews

Medication is often initiated by doctors and consultants at hospital. The following policy outlines how the practice manages these requests.

Hospital requested medications

What is it?

If you are registered with a GP in England and they refer you to a consultant or specialist doctor, you have the legal right to choose your provider.

• Right to Choose (RTC) is not currently available in Scotland, Wales or Northern Ireland. If you move out of England during your treatment, you will no longer be eligible for RTC. 
• The organisation you choose must be a ‘qualified provider’. 

In the current climate it is understandable that some patients are exercising their ‘right to choose’ and requesting referral to independent providers who hold an NHS contract with ICB’s.  Some providers are advertising NHS assessment and shorter waiting times.

Patients choosing such services should be mindful that some services will only diagnose and will not prescribe or provide the secondary care part of a shared care arrangement. This should be taken into account by the patient when making their decision of whether it is appropriate to refer to those providers only making a diagnosis in terms of what the patient is hoping for as an outcome.

Patients should check before they decide to exercise their Right to choose, that their GP will enter into a shared care agreement with the provider.

GP providers may be hesitant to enter into shared care agreements with private providers for several reasons:

1. Capacity Issues: Many NHS GP surgeries face capacity challenges, making it difficult to take on additional responsibilities associated with shared care arrangements.
2. Safety Concerns: Without a formal shared care agreement, there may be concerns about the safety and continuity of care, as well as the ability to ensure that all necessary clinical information is shared and acted upon appropriately.
3. Lack of Support: GPs may feel that there is insufficient support when expert help is needed, particularly if the private provider does not have established protocols for collaboration.
4. Governance and Quality Assurance: Shared care arrangements require clear governance and quality assurance processes. Without these, there may be concerns about accountability and the standard of care provided.
5. Health Inequalities: Engaging in shared care with private providers could potentially promote health inequalities, as not all patients may have access to or be able to afford private care.
6. NHS Constitution Principles: The NHS constitution emphasises keeping NHS and private care as separate as possible to ensure that NHS resources are used appropriately and that patients are not charged for NHS services.
7. Complexity of Care Coordination: Coordinating care between NHS and private providers can be complex, potentially leading to gaps in care or communication issues.

For these reasons, GPs typically prefer to work within established shared care frameworks when collaborating with private providers. This ensures that patient care is managed effectively and ethically.

Nettleham Medical Practice does not enter shared care agreements with third party providers that are not NHS services.

On occasions, patients are asked to have some blood tests as part of investigations being undertaken by a consultant at hospital. The following policy explains the process for hospital requested bloods at the practice. Hospital requested bloods

The full practice policy can be found at the following link – Shared Care medication

Policy: Primary Care Management of Antidepressants for Patients Under 18

Purpose: This policy outlines why primary care does not initiate antidepressant treatment for patients under 18 years of age, ensuring evidence-based, safe, and effective care in compliance with national guidelines.

Policy Statement

In primary care, antidepressants are not initiated for individuals under 18 years old. Management of depression or other mental health conditions in this age group requires specialized input due to the complexities of diagnosis, treatment, and monitoring. Initiation of antidepressants should occur under the guidance of a specialist in child and adolescent mental health.

Rationale

Specialist Expertise: Depression and other mental health conditions in children and adolescents are multifaceted and may present with overlapping symptoms with other conditions, including developmental disorders. Specialist assessment ensures accurate diagnosis and treatment tailored to the developmental and psychosocial context of the patient.

National Guidelines: The National Institute for Health and Care Excellence (NICE) recommends that antidepressants should only be prescribed for under-18s following assessment by a Child and Adolescent Mental Health Services (CAMHS) clinician and as part of a broader treatment plan, including psychological interventions. NICE also specifies fluoxetine as the first-line antidepressant for under-18s, initiated only after psychological therapy has been attempted unless symptoms are severe.

Safety Considerations: The under-18 population has an increased risk of adverse effects from antidepressants, including heightened suicidal ideation, agitation, and behavioural changes. Specialist care ensures close monitoring for these risks, particularly during the initiation and adjustment phases of treatment.

Psychological Therapies as First-Line Treatment: Evidence supports psychological therapies, such as cognitive-behavioural therapy (CBT), as the most effective and safest initial treatment for mild to moderate depression in young people. Antidepressants are generally reserved for moderate to severe cases or when psychological therapies alone have not been effective.

Continuity and Coordination of Care: Initiating antidepressants in primary care without specialist involvement may disrupt the coordinated care provided by CAMHS, which includes ongoing monitoring and access to multidisciplinary expertise. Collaboration with CAMHS ensures the patient and family receive holistic support.

Procedure

Referral to Specialist Services: Any young person presenting with symptoms of depression or other mental health concerns should be referred to Healthy Minds or the Primary Care Network Child and Adolescent Mental Health Worker for comprehensive assessment and management. Urgent referral should be considered for severe cases, including those with suicidal ideation or significant functional impairment.

Primary Care Role: Provide initial support, including psychoeducation, signposting to self-help resources, and liaison with schools or other agencies as appropriate. Monitor symptoms while awaiting specialist input and escalate concerns if necessary. This will normally be provided by the PCN mental health worker.

Shared Care: If antidepressant treatment is initiated by a specialist, primary care may take on a shared care role, including prescribing and monitoring under specialist guidance. This is decided on a case by case basis.

Exemptions: In exceptional cases, where immediate specialist input is unavailable and the patient’s condition is severe or life-threatening, primary care clinicians may consider initiating treatment but only in consultation with CAMHS or a consultant psychiatrist.

The practice does not write letters stating patients are fit to fly or participate in other activities. We don’t offer this service because assessing a patient’s fitness for specific activities requires specialised expertise. Determining someone’s suitability for activities like flying or sports is outside the scope of a GP’s medical training and qualifications. It is also not an NHS service.

We can provide a printout of your medical summary or a letter detailing your medical history.

We can complete forms that only require factual medical details and don’t ask us to make any judgments about your suitability or fitness for the activity.

Private doctors in the relevant fields may be able to help with any documentation you require.

Practice Policy in relation to prescription of sedatives for patients attending hospital or dental appointments, for imaging investigations or other procedures.

Sometimes we are asked to prescribe ‘a low dose sedative’ for patients attending hospital or dental appointments, for imaging investigations or other procedures. These are the reasons we do not prescribe this medication:

1. Small doses of benzodiazepines such at 2mg diazepam are probably sub-therapeutic (too low a dose to be effective) for most adults for any effective sedation.  Conversely sedatives can have the opposite response in patients, and even very small doses can cause increased agitation in some patients.
2. A patient may take a sedative ‘an hour’ before their assumed procedure, to then attend the hospital to find their procedure has been delayed, therefore the timing of the anxiolytic being no longer appropriate.
3. GPs are not regularly involved, skilled, trained or appraised in sedation skills.
4. All hospital consultants and dentists, both those requesting imaging and those providing it, have access to the same prescribing abilities as GPs for these medications. If a patient needs a certain medication to enable an investigation to go ahead, they are just as well positioned to provide a prescription, either through the hospital pharmacy or a hospital FP10. Dentists have similar prescriptions, although you may need to get a private prescription if your dentist is not an NHS dentist.
5. Sedated patients should be regularly monitored, and this is not likely to be arranged if a GP issues the prescriptions
6. The Royal College of Radiologists‘ own guidelines on sedation for imaging makes no mention of GP involvement or provision of low dose anxiolytics and stresses the importance of experienced well trained staff involved and the monitoring of sedated patients.
7. During the course of any investigation or procedure, other medications or contrast may be needed. The clinician in charge of the procedure knows which medications are likely to be needed and any interactions or risks associated with them in combination with sedatives.

Use of Benzodiazepines (and related medications) for flying

For the following reasons we will no longer be providing Diazepam or similar drugs for flight anxiety and instead suggest the links to aviation industry recommended flight anxiety courses at the end of the page. Flight anxiety does not come under the remit of General Medical Services as defined in the GP contract and so we are not obliged to prescribe for this. Patients who still wish to take benzodiazepines for flight anxiety are advised to consult with a private GP or travel clinic.

Initial use of benzodiazepines, including the well-known Diazepam also known as ‘Valium’, was enthusiastic and they were hailed as a wonder drug. However, it became increasingly clear that, as well as having short term effects on memory, co-ordination, concentration and reaction times, they were also addictive if used for a long time, with withdrawal leading to fits, hallucinations, agitation and confusion, and further had long-term effects on cognition and balance. Unfortunately, benzodiazepines have also become a widely used drug of abuse since they first came on the market. Because of these reasons the use of benzodiazepines has been a lot more controlled around the world since the 1980-90s, especially in the UK. Diazepam in the UK is a Class C/Schedule IV controlled drug. The following short guide outlines the issues surrounding its use with regards to flying and why the surgery no longer prescribes such medications for this purpose.

People often come to us requesting the doctor or nurse to prescribe diazepam for fear of flying or assist with sleep during flights. Diazepam is a sedative, which means it makes you sleepy and more relaxed. There are a number of very good reasons why prescribing this drug is not recommended. · According to the prescribing guidelines doctors follow (British National Formulary) diazepam is contraindicated (not allowed) in treating phobic states. It also states that “the use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate.” Your doctor would be taking a significant legal risk by prescribing against these guidelines. They are only licensed short term for a crisis in generalised anxiety. If this is the case, you should be getting proper care and support for your mental health and not going on a flight. · NICE guidelines suggest that medication should not be used for mild and self-limiting mental health disorders. In more significant anxiety related states, benzodiazepines, sedating antihistamines or antipsychotics should not be prescribed. Benzodiazepines are only advised for the short-term use for a crisis in generalised anxiety disorder in which case they are not fit to fly. Fear of flying in isolation is not a generalised anxiety disorder.

· Although plane emergencies are a rare occurrence there are concerns about reduced awareness and reaction times for patients taking Diazepam which could pose a significant risk of not being able to react in a manner which could save their life in the event of an emergency on board necessitating evacuation.

· The use of such sedative drugs can make you fall asleep, however when you do sleep it is an unnatural non-REM sleep. This means you won’t move around as much as during natural sleep. This can cause you to be at an increased risk of developing a blood clot (Deep Vein Thrombosis – DVT) in the leg or even the lungs. Blood clots are very dangerous and can even prove fatal. This risk is even greater if your flight is greater than 4 hours, the amount of time which has been shown to increase the risk of developing DVT whether in an aeroplane or elsewhere.

· Whilst most people find Diazepam sedating, a small number have paradoxical agitation and aggression. They can also cause disinhibition and lead you to behave in a way that you would

not normally which can pose a risk on the plane. This could impact on your safety as well as that of other passengers and could also get you into trouble with the law. A similar effect can be seen with alcohol, which has led to people being removed from flights.

· A study published in 1997 from the Stanford University School of Medicine showed that there is evidence use of Benzodiazepines stops the normal adjustment response that would gradually lessen anxiety over time and therefore perpetuates and may increase anxiety in the long term, especially if used repeatedly. · Diazepam and similar controlled drugs are illegal in a number of countries. They may be confiscated or you may find yourself in trouble with the police. The passenger may also need to use a different strategy for the homeward bound journey and/or other legs of the journey.

· Diazepam stays in your system for quite a while. If your job requires you to submit to random drug testing, you may fail this having taken diazepam.

· It is important to declare all medical conditions and medications you take to your travel insurer. If not, there is a risk of nullifying any insurance policy you may have.

Please see below links for more information:

https://www.fearlessflyer.easyjet.com/

https://www.flyingwithoutfear.com/

https://www.britishairways.com/content/information/travel-assistance/flying-with-confidence