Community Pharmacy Enhanced Service



Community Pharmacy Enhanced Service

Service Specification

for a cost-effective

“Specials” Review Service

Version 1

Effective from: December 2010

Review date: March 2011

Contents

| | |

|Introduction |3 |

|Nature and Scope of the Service |3 |

|Service Aims |3 |

|Access to the Service |3 |

|Terms of Service |3 |

|Commencement and Duration |3 |

|Service Description |4 |

|Service Funding |5 |

|Data Collection |5 |

|Payment Mechanism |5 |

|Record Keeping |6 |

|Service Activity |6 |

|Target Outcomes |6 |

|Performance Monitoring |6 |

|Termination of the Service |6 |

|Confidentiality and Data Protection |7 |

|Continuing Professional Development |7 |

|Significant Event Reporting |7 |

|Complaints |8 |

|Professional Indemnity Insurance |8 |

|Equity and Diversity |8 |

|Training and Health & Safety |8 |

|Freedom of Information |9 |

|Signatures |9 |

|Contacts and Enquiries |10 |

|Signatures / Agreement Form |11 |

|Appendices |12 |

1. Introduction

This service specification defines the terms and standards required by Central and Eastern Cheshire PCT for the delivery of a “Specials” Review Service

2. Nature and Scope of Service to be provided

Service Aims

|2.1 |To establish a “Specials” Review Service via. community pharmacies. For the purposes of this scheme the term “special”|

| |refers to any unlicensed medicine which is manufactured to meet a specific patient need or a high cost licensed |

| |liquid. |

|2.2 |To maintain a quality professional and safe service for patients. |

|2.3 |To ensure effective use of NHS resources. |

|3. Access to the Service |

|3.1 |Any patient / patient representative who presents a prescription for a “special” to a participating pharmacy. |

| | |

| |

|Terms of Service |

| |

|4. Commencement and Duration |

| |

|The community pharmacy will provide the service strictly in accordance with the specification outlined below. |

| |

|The service specification will be signed by the participating pharmacy and will be subject to full review in March 2011 and then|

|every year, should the service continue, unless there is a need to do so before this time. |

| |

|The service should be provided for the total hours the pharmacy is open and for the duration of the contract agreement period |

|between the contractor and the PCT. All pharmacists and dispensing staff are to be made aware of this service specification and |

|adhere to it with regard to “specials” reviews. This particularly includes locum and relief pharmacists who may be unfamiliar |

|with such a service. |

| |

|Local prescribers will be made aware of which pharmacies are participating in the scheme. |

| |

| |

| |

| |

| |

|6. Service Description |

|6.1 |Upon receipt of a prescription for an unlicensed “special”, the community pharmacist will contact the prescriber to |

| |inform them that the product is unlicensed (as recommended in MHRA Guidance Note 14). |

|6.2 |The pharmacist will assess the prescription and discuss with the GP the possibility of switching to an alternative |

| |licensed product. If the GP is agreeable then the pharmacist should request a replacement prescription for the new |

| |item. |

| | |

| |This process should be followed for both existing “specials” prescribing and newly initiated medicines. |

| | |

| |Appendix 1 contains a list of PCT recommended switches and alternatives to unlicensed “specials”. Please note that |

| |this list is not exhaustive and efforts should be made by the pharmacist to query all “specials” prescriptions and |

| |seek further information about licensed alternatives. This could include oral liquid medicines, nebulised products, |

| |bespoke topical formulations and ophthalmic preparations. |

|6.3 |Agree with the GP how the patient will be informed of the change. This should be based on the knowledge that both the |

| |pharmacist and the GP has of the patient, their condition, their perception of the patient’s acceptance of change etc.|

|6.4 |Dispense the new item as per the replacement prescription and, depending on the agreement in 6.3 above, either inform |

| |the patient of the change which has been sanctioned by the GP, or support the GPs conversation with the patient when |

| |they call to collect the medication. |

|6.5 |On the original prescription, strike through the unlicensed “special”, ensuring the text is still legible, and write |

| |“not dispensed” in the endorsement column. |

|6.6 |Photocopy the original and the replacement prescriptions, deleting any patient identification details and staple |

| |together. These will need to be submitted to the PCT to provide evidence for the PCT to authorise payment on the basis|

| |that a review was undertaken and a switch initiated. |

| | |

| |Ensure both prescriptions are stamped with the Pharmacy address and contact details. |

| | |

| |An invoice for payment (Appendix 2) should be raised on a monthly basis and sent directly to SBS who will process the |

| |payment once authorised by the Medicines Management Team. The address for these invoices is: |

| | |

| |Central and Eastern Cheshire PCT |

| |5NP Payables B365 |

| |Phoenix House |

| |Topcliffe Lane |

| |Wakefield |

| |WF3 1WE |

| | |

|6.7 |Submit the copy prescriptions to the PCT by the 5th day of every month for payment by the end of that month. |

| |Contractors should also include a copy of the invoice sent to SBS with their submission to the PCT. |

|6.8 |The PCT would consider patients who have had their medication changed in this way to be ideal candidates for a |

| |Medicines Use Review or Prescription Intervention (where appropriate) to ensure that they understand how to use the |

| |alternative product. Pharmacists should consider taking this opportunity. |

| | |

|7. |Service Funding |

|7.1 |Community pharmacies providing a “Specials” Review Service will be reimbursed as follows: |

| | |

| |A fee of £28 will be paid for every item which is queried and subsequently switched to a licensed product of lower |

| |cost. |

| | |

| |The level of this fee is in line with the national payment structure for Medicines Use Reviews, Appliance Use Reviews |

| |and Prescription Intervention. It also reflects the level of input and time which may be required by the community |

| |pharmacist to initiate a change in prescribing. |

| | |

| |In the event of any dispute between the dispensing contractor and PCT regarding a claim for payment, the Medicines |

| |Management Team will seek to resolve the matter and make the final decision as to whether a payment is made. |

| |

|8. Data Collection |

|8.1 |The community pharmacist will provide copies of the original FP10 prescription (with the item crossed out and marked |

| |not dispensed) and the replacement FP10 prescription indicating the change of therapy (patient details excluded). |

| |

|9. Payment Mechanism |

|9.1 |Service payments will be made monthly for claims submitted by the 5th day of each month. |

| | |

| |Claims must be submitted promptly as charges unclaimed from previous months may be delayed. |

| | |

| |Claims must include: |

| |An invoice directly to SBS detailing the number of fees being claimed |

| |Copies of prescriptions and invoices as detailed in 6.6 & 6.7 to: |

| | |

| |Kathy Smith |

| |CECPCT Medicines Management Enhanced Service Co-ordinator |

| |Universal House |

| |ERF Way (off Pochin Way) |

| |Middlewich |

| |Cheshire |

| |CW10 0QJ |

| | |

| |At the end of the financial year (31st March 2011), claims must be submitted by 5th April for payment by the end of |

| |April. Any claims for the previous financial year which are not claimed within this timeframe may not be payable. |

| |

|10. Record Keeping |

|10.1 |A folder should be used to store all information relating to this scheme and photocopies of claims submitted to the |

| |PCT. |

|10.2 |The community pharmacist will maintain training records / SOPs relating to this service and will show evidence of this|

| |to the PCT if requested. |

| |

|11. Service Activity |

|11.1 |It is the responsibility of the participating pharmacy to have a process in place which ensures that all new staff, |

| |are aware of all enhanced services provided by the pharmacy and commissioned by the PCT and must maintain continuity |

| |of service during and after staff changes. |

|11.2 |If this commissioned service cannot be provided under the terms of this agreement, for whatever reason the pharmacy |

| |must contact the PCTs Contracts Officer. (see contacts and enquiries). |

| |

|12. Target Outcomes |

|12.1 |Not applicable for this service. |

| |

|13. Performance Monitoring |

|13.1 |The pharmacy must fully comply with the National Pharmacy Contract regulations for delivery of Essential Services |

| |before they can provide enhanced services. The PCT retains the right to audit any part of the service to ensure |

| |continued quality. |

|13.2 |The PCT reserves the right to ask for evidence from the Pharmacy that it is following the procedures outlined in this |

| |specification. |

|13.3 |The pharmacy will co-operate with any PCT led assessment of service user experience or audit of the service. |

|13.4 |Changes to the content of the service will not be introduced without prior agreement with the PCT. Changes will be |

| |authorized in writing. |

| |

|14. Termination of the Service |

|14.1 |Central and Eastern Cheshire PCT reserves the right to stop the service in one or all of its pharmacies with immediate|

| |effect if: |

| |a pharmacy/ pharmacist fails to comply with the service specification |

| | |

| |an individual pharmacist and/ or contractor acts outside the ethical governance framework for the profession, brings |

| |the profession into disrepute, or is subject to an NHS or professional disciplinary process. |

|14.2 |Either party may terminate this agreement by providing written notice of their intention to do so. A period of one |

| |month should be given as notice. |

|14.3 |Where the community pharmacy contractor gives notice to terminate the service the contractor must continue to provide |

| |a full service during the notice period. |

| |

|15. Confidentiality and Data Protection |

|15.1 |The pharmacy will provide a nonjudgmental patient centered confidential service. |

| | |

| |The pharmacist must not disclose to any person other than authorised by CECPCT, any information acquired by them in |

| |connection with the provision of the service which concerns. |

| |The CECPCT, its staff or procedures |

| |The identity of any service user |

| |The medical condition or any treatment received by any service user |

|15.2 |Pharmacists may need to share relevant information with other health care |

| |professionals and agencies, in line with locally determined confidentiality arrangements, including, where |

| |appropriate, the need for the permission of the patient to share the information. |

|15.3 |The pharmacy must protect personal data in accordance with provisions and principles of the Data Protection Act. |

|15.4 |The pharmacist must ensure that all their staff conform to the NHS Code of |

| |Practice on Confidentiality and data protection and ensure that all staff involved with the service are appropriately |

| |trained. |

| |

|16. Continuing Professional Development |

|16.1 |Where there are concerns regarding poor performance in the delivery of this service these will be addressed separately|

| |as a clinical governance matter. |

| |

|17. Significant Event Reporting |

|17.1 |The pharmacy must have an adverse incident and near miss reporting system in place which includes maintaining a log of|

| |patient safety incidents. |

| | |

| |The pharmacy should be able to demonstrate that it has learnt from an event. |

|17.2 |ALL (Patient or staff) safety incidents directly linked to this service must be reported to the PCT in writing. |

| | |

| |Information should be promptly sent to the CECPCT Medicines Management Enhanced Service Co-ordinator. |

| | |

| | |

| | |

| |

|18. Complaints |

|18.1 |The pharmacy must have a complaints procedure that complies with national standards. Complaints directly linked to |

| |this service must be reported to the PCT who reserve the right of directly investigating any complaints about the |

| |service. |

|18.2 |Feedback both positive and negative should be forwarded to the PCT Enhanced Service Co-ordinator so that action can be|

| |taken to amend the service as necessary. |

| |

|19. Professional Indemnity Insurance |

|19.1 |It is the responsibility of the contractor / pharmacist to maintain insurance in respect of public liability and |

| |personal indemnity against any claims whatsoever which may arise out of the terms, conditions and obligations of this |

| |Agreement. |

| |

|20. Equity and Diversity |

|20.1 |The pharmacist/pharmacy staff must comply with requirements of the Race Relations Act of 1976 and the Race Relations |

| |(Amendment) Act 2000, and will not treat one group of people less favourably than others because of their colour, |

| |race, culture, religion, gender, nationality, age, marital status, sexual orientation, disability or ethnic origin. |

| | |

| |It is the responsibility of the pharmacist to audit the needs of the population they serve and amend the service along|

| |with support from the PCT. E.g. leaflets in other languages. |

| |

|21. Training and Health and Safety |

|21.1 |The community pharmacy shall comply with the requirements of the Health and Safety at Work Act 1974, the management of|

| |health and safety at work regulations 1999 and any other acts, regulation, orders or rules of law pertaining to health|

| |and safety. |

|21.2 |There are NO additional specific health and safety training issues that the PCT is aware of, over and above what is |

| |normally required in a community pharmacy in their normal course of business. |

| | |

|21.3 |The community pharmacy must have a standard operating procedure available to all staff which specifically details the |

| |overall delivery of this “Specials” Review Service. The procedure should be reviewed regularly, amended if necessary |

| |and the review documented. |

|21.4 |All staff must be made aware of and follow the service delivery standard operating procedures. |

|21.5 |A staff training log which deals specifically with this service must be maintained and shown to the PCT on request. |

| |The training log must be updated regularly to reflect any reviews of standard operating procedures. |

| |

|22. Freedom of Information |

|22.1 |Both parties recognize that this service specification and/or associated recorded information may be subject to FOI |

| |requests.   Each party shall comply with any such FOI requests received, in accordance with the Freedom of Information|

| |Act 2000 legal obligations. The PCT will advise if required. |

| |

|22. Signatures |

|22.1 |Pharmacies providing the service must have their names on an enhanced service provider list held at the PCT. |

CONTACTS AND ENQUIRIES

CECPCT Medicines Management Enhanced Service Co-ordinator

Kathy Smith

Universal House

ERF Way (off Pochin Way)

Middlewich

Cheshire

CW10 0QJ

Tel: 01606 544 668

E-mail: kathy.smith@cecpct.nhs.uk

CECPCT Prescribing Support Pharmacist

Andrew Swift

Universal House

ERF Way (off Pochin Way)

Middlewich

Cheshire

CW10 0QJ

Tel: 01606 544 482

Email: andrew.swift@cecpct.nhs.uk

CECPCT Medicines Management Project Facilitator

Marilyn Knass

Universal House

ERF Way (off Pochin Way)

Middlewich

Cheshire

CW10 0QJ

Tel: 01606 544 409

Email: marilyn.knass@cecpct.nhs.uk

SIGNATURES

Agreement to provide a “Specials” Review Service

under the terms outlined in this service specification from the pharmacy specified below

|Pharmacy | |

|Full Address | |

| | |

| | |

|Signed | |

| | |

| | |

|Print | |

|Position / Authority | |

A copy of this agreement to be held in the participating pharmacy

A copy of this page to be returned to:

Kathy Smith

CECPCT Medicines Management Enhanced Service Co-ordinator

Universal House

ERF Way (off Pochin Way)

Middlewich

Cheshire

CW10 0QJ

Tel: 01606 544668

E-mail: kathy.smith@cecpct.nhs.uk

APPENDIX 1 – List of Recommended Alternatives to Unlicensed “Specials”

|Drug & Form |Recommended Alternatives (Reference Sources: NEWT Guidelines, Handbook of Drug |

| |Administration via. Enteral Feeding Tubes & Product Manufacturers) |

|Acetazolamide Liquid 100mg/5ml |Standard tablets disperse within 5 minutes in 10ml of water |

|Acetylcysteine 5% P/Free Eye Drops |Suggest consider other preservative free lubricating eye-drops (see Hypromellose |

| |below) |

|Acetylcysteine 600mg Tablets |Often recommended by secondary care. No licensed form available - options include |

| |alternative mucolytic e.g. Carbocisteine (Mucodyne), requesting secondary care |

| |prescribe or available directly from IDIS Pharmaceuticals at £20/100. Would need to |

| |liaise with pharmacy to ensure this price is obtained. |

|Acetylcysteine 600mg Effervescent Tablets |As above (excluding IDIS pricing) |

|Alendronic Acid Liquid |No alternative as bisphosphonates only available in tablet form. For osteoporosis |

| |Strontium Ranelate granules are a therapeutic option. For all other indications - |

| |query as secondary care should prescribe and monitor. |

|Alfuzosin Liquid |The 2.5mg tablets can be crushed and mixed with water for administration. The |

| |modified-release 10mg tablets should not be crushed. |

|Allopurinol Liquid |100mg tablets will disperse within 1 minute in 10ml of water |

|Amiloride Liquid |Prescribe as branded product Amilamont - 5mg/5ml SF available at £39.73 per 150ml |

|Amisulpride Liquid |Prescribe branded product Solian Solution - 100mg/ml available at £33.76 per 60ml |

|Amitriptyline Liquid |Licensed Rosemont oral solutions available - 25mg/5ml £13.95 per 150ml, 50mg/5ml |

| |£14.79 per 150ml |

|Amlodipine Liquid |Tablets will dissolve in 10mls of water in 1-5 minutes but is light sensitive so |

| |should be taken immediately once dispersed. Istin brand may disperse better than some |

| |generics. |

|Atorvastatin Liquid |10mg, 20mg & 40mg tablets should all disperse in 10ml of water within 2-5 minutes |

|Azathioprine Liquid |Cytotoxic - inappropriate to crush - AMBER shared care drug but only in licensed |

| |tablet form. Recommend secondary care initiates and prescribes any unlicensed liquid |

| |preparations. |

|Bendroflumethiazide Liquid |Tablets will readily disperse in 10ml of water within 1-5 minutes |

|Betahistine Liquid |Tablets can be crushed and mixed with water for administration |

|Bisacodyl Rectal Solution |No licensed alternative available |

|Bisoprolol Liquid |Lower strength tablets will disperse in water in < 5 minutes. Higher strength tablets |

| |will need to be crushed and mixed with water or alternatively convert to Atenolol and |

| |use SF syrup. |

|Calcium Carbonate Liquid |Cacit effervescent tablets (1.25g = 500mg) |

|Calcium Gluconate Liquid |Calcium Gluconate 1g Effervescent tablets |

|Candesartan Liquid |Tablets will disperse in water within 5 minutes or can be crushed and mixed with |

| |water. |

|Captopril Liquid |Tablets will disperse in water in 1-5 minutes |

|Carbimazole Liquid |Tablets can be crushed and dispersed in water |

|Chloral Hydrate Liquid |Cloral Betaine (Welldorm) Elixir 143.3mg/5ml. Will require equivalence calculation to |

| |ensure correct dose volume. |

|Chlordiazepoxide Liquid |Capsule contents can be mixed with water. Crushing of tablets is not recommended. |

|Chlorothiazide Liquid |Consider using Bendroflumethiazide dispersed in water (as above) if appropriate for |

| |the indication. |

|Chlorpromazine Liquid |Licensed oral solutions available - 25mg/5ml £1.50 per 150ml, 100mg/5ml £3.76 per |

| |150ml |

|Ciclosporin Eye Drops & Eye Ointment |Specialist nature - recommend GPs request secondary care prescribes and monitors |

|Citalopram Liquid |Use the oral drops (note: 1 drop = 2mg. 8mg in drop form = 10mg in tablet form) or |

| |alternatively consider fluoxetine or paroxetine which are available as licensed |

| |liquids. |

|Clobazam Liquid |Tablets will disperse in water in < 5 minutes but may taste unpleasant |

|Clomipramine Liquid |The capsules can be opened and the contents mixed with water for administration. Do |

| |not crush M/R tablets. |

|Clonazepam Liquid |The tablets will disperse within 1 minute if placed in at least 30mls of water |

|Clonidine Liquid |The 100mcg tablets disperse within 2 minutes when placed in 10ml of water |

|Co-Careldopa Liquid |Standard Sinemet tablets will disperse in water for administration orally or via. |

| |Enteral Feeding Tubes. Lower strengths disperse within 1 minute and higher strengths |

| |in 1-5 minutes. The dose should be given immediately. Alternatively, convert to |

| |Co-Beneldopa (Madopar) dispersible tablets and adjust according to response. |

|Co-Dydramol Liquid |Options include Paracetamol liquid & either Dihydrocodeine 10mg/5ml Solution or |

| |Codeine 25mg/5ml syrup. Alternatively consider dispersible / effervescent Co-Codamol |

| |Tablets. |

|Colecalciferol Capsules & Tablets |No licensed alternative. Ideally GPs should request secondary care prescribes and |

| |monitors. Alternatively, Specials Lab (Tel. 01661 831811) supply Colecalciferol |

| |20,000iu capsules branded as 'Dekristol' at a cost of £22.98 per 50. |

|Colecalciferol Liquid |No licensed alternative. Ideally GPs should request secondary care prescribes and |

| |monitors. Alternatively, IDIS supply Colecalciferol 1,500iu/ml at a cost of £4.20 per |

| |20ml. |

|Cyclizine Liquid |Tablets are scored and can be broken in half to aid swallowing but will not readily |

| |disperse in water. Also available in injection form. Consider other drugs before |

| |prescribing the unlicensed liquid. |

|Dantrolene Sodium Liquid |The capsules can be opened and the contents mixed with water or acidic fruit juice |

| |e.g. orange juice before administration. |

|Dexamethasone P/Free Eye Drops |Prescribe as Minims Dexamethasone P/Free 0.1% Eye Drops |

|Diclofenac Liquid |Use Voltarol 50mg Dispersible Tablets |

|Diltiazem 2% Cream |For GP prescribing - suggest Rectogesic (GTN) 0.4% ointment first line. If recommended|

| |by secondary care - GP should request they prescribe or alternatively prescribe as |

| |brand - Anoheal 2% Cream. |

|Dipyridamole Liquid |Dipyridamole 200mg M/R Capsules (Persantin Retard) can be opened and the contents |

| |mixed with a small quantity of liquid or of food (e.g. a spoonful of yoghurt). The |

| |granules should not be chewed. The liquid forms are not licensed post-stroke / TIA. |

|Donepezil |Tablets will disperse in water within 5 minutes or can be crushed and mixed with |

| |water. Alternatively seek Secondary Care advice regarding suitability of Galantamine, |

| |which is available as a licensed liquid, or Rivastigmine which is available as both a |

| |licensed liquid and transdermal patch. |

|Dosulepin Liquid |Tablets should not be crushed or capsules opened as powder has local anaesthetic |

| |action. Suggest review choice of drug as dosulepin no longer recommended due to |

| |complications in overdose. Consider SSRIs - some of which are available as licensed |

| |liquids or oro-dispersible formulations. |

|Doxazosin Liquid |Tablets can only be dispersed in de-ionised water as chloride ions in tap water cause |

| |the drug to precipitate out. Consider other antihypertensives where appropriate. |

|Doxepin Liquid |The capsules can be opened and the contents dispersed in water for administration but |

| |may taste bitter. |

|Enalapril Liquid |Tablets will disperse in 10ml of water within 5 minutes if agitated. Alternatively |

| |consider another ACE-Inhibitor (see Lisinopril & Ramipril) |

|Ergocalciferol Capsules, Tablets or Liquid |No licensed alternative. Recommend GPs request secondary care prescribes and monitors.|

| |Alternatively please contact Andrew Swift (01606 544482) to discuss. |

|Esomeprazole Liquid |Recommended alternatives include Esomeprazole 20mg sachets, Omeprazole Dispersible |

| |tablets or Lansoprazole Oro-dispersible tablets. Nexium tablets are licensed for use |

| |when dispersed in water for both swallowing difficulties and PEG tubes but the |

| |pellets/ granules released should not be chewed. |

|Felodipine Liquid |Tablets should not be crushed as they are modified-release. Suggest switch to |

| |Amlodipine and follow instructions to disperse as above. |

|Ferrous Sulphate Liquid |Prescribe licensed Ferrous Fumarate 140mg/5ml (Fersamal) Liquid. Iron content: 45mg / |

| |5ml compared with 65mg from a 200mg Ferrous Sulphate Tablet |

|Flecainide Liquid |Tablets can only be dispersed in deionised water and crushed tablets have anaesthetic |

| |effect. No licensed product, therefore recommend secondary care prescribes and |

| |monitors or alternatively use the liquid special. |

|Fludrocortisone Liquid |100mcg tablets (Florinef) will disperse in 10ml of water within 1-2 minutes |

|Flunarizine HCl Capsules |Rare calcium channel blocker. Consider other drugs from this therapeutic group. |

|Fluphenazine Liquid |The tablets can be crushed and dispersed in water |

|Folic Acid Liquid |Use Folicare 400mcg/5ml SF Solution or Folic Acid 2.5mg/5ml SF Syrup for higher doses |

|Gabapentin Liquid |Neurontin 250mg/5ml Liquid withdrawn from UK market - is unlicensed import from |

| |Ireland. The capsules can be opened and the contents added to water, sprinkled on food|

| |or given in fruit juice to mask the taste. The dose should be administered immediately|

| |as the drug rapidly hydrolyses. |

|Gliclazide Liquid |The tablets can be crushed and mixed with water or orange juice |

| |Use Rectogesic 0.4% ointment (licensed) |

|Glyceryl Trinitrate Creams & Ointments | |

|Glycopyrronium Tablets, Liquid & Topical Solution |Secondary care to prescribe. Alternatives for excessive salivation include Hyoscine |

| |Patches |

|Haloperidol Liquid |Use Haloperidol SF oral solution 2mg/ml (10mg/5ml) |

|Hydrochlorothiazide Liquid |Consider using Bendroflumethiazide dispersed in water (as above) if appropriate for |

| |the indication. |

|Hydrocortisone Liquid |The 10mg and 20mg tablets will disperse in water within 1 minute |

|Hydroxycarbamide Liquid |Cytotoxic - inappropriate to crush - would be on secondary care recommendation |

| |therefore suggest GP requests they prescribe and monitor |

|Hydroxychloroquine Liquid |The tablets can be crushed and dispersed in water |

|Hyoscine Butylbromide |Tablets cannot be easily crushed as sugar-coated. Consider other antispasmodics before|

| |prescribing the unlicensed liquid. |

|Hyoscine Hydrobromide |Use Joy-rides or Kwells Kids OTC tablets (150mcg) which are both chewable or consider |

| |Scopoderm TTS patches |

|Hypromellose 0.25% Eye Drops |Use standard Hypromellose 0.3% drops |

|Hypromellose 0.3% P/Free Eye Drops |Prescribe as Artelac 0.32% P/Free Unit Dose Drops |

|Indometacin Liquid |No licensed alternative available. Consider other NSAIDs e.g. Diclofenac in |

| |dispersible form before prescribing the unlicensed liquid. |

|Irbesartan Liquid |Tablets will disperse in 10ml of water within 2-5 minutes. Alternatively the tablets |

| |can be crushed and added to water. |

|Isosorbide Mononitrate Liquid |No licensed alternative. Consider GTN patches |

|Isosorbide Dinitrate Liquid |No licensed alternative. Consider GTN patches |

|Ketamine Liquid |Specialist product - do not prescribe in primary care. Secondary care should prescribe|

| |and monitor. |

|Levodopa Liquid |If indication is Parkinson's disease - use Co-Beneldopa (Madopar) 125 dispersible |

| |tablets |

|Levomepromazine 6mg Tablets |The 25mg tablets can be broken into quarters |

|Levothyroxine Liquid |Prescribe as Evotrox Oral Solution (licensed) or alternatively crush the tablets and |

| |administer in water |

|Lisinopril Liquid |The tablets will disperse in 10ml of water within 1-5 minutes |

|Loperamide Liquid |Use Imodium 1mg/5ml SF Syrup |

|Lorazepam Liquid |Tablets can be crushed and mixed with water or administered sublingually |

|Losartan Liquid |Tablets can be crushed and mixed with water for administration. |

|Magnesium Glycerophosphate Tablets, Capsules & Liquid |No licensed alternative available but there are two ACBS vitamin supplement products -|

| |Magnaphate 97.2mg (4mmol) Chewable Tablets & Magnaphate 121.5mg (5mmol / 5ml) Liquid. |

|Magnesium Oxide Capsules |No licensed alternative available but there are two ACBS vitamin supplement products -|

| |Magnaphate 97.2mg (4mmol) Chewable Tablets & Magnaphate 121.5mg (5mmol / 5ml) Liquid. |

| |Magnesium Oxide 100mg = 2.5mmol. |

|Magnesium Sulphate Capsules |No licensed alternative available but there are two ACBS vitamin supplement products -|

| |Magnaphate 97.2mg (4mmol) Chewable Tablets & Magnaphate 121.5mg (5mmol / 5ml) Liquid. |

|Mebeverine Liquid |Licensed product available but high cost (£137 per 300ml). Consider other drugs before|

| |prescribing this liquid. |

|Megestrol Acetate Liquid |The 160mg tablets disperse in water within 1-5 minutes. |

|Melatonin Tablets, Capsules & Liquid |Prescribe Melatonin 2mg M/R (Circadin) Tablets. Other forms are not licensed and |

| |should not be prescribed in primary care. Recommend that GPs only agree to shared care|

| |with the licensed product - all others should be prescribed and monitored by secondary|

| |care, including for ADHD. |

|Menadiol Sodium Liquid |The 10mg tablets can be crushed and mixed with water or food |

|Mepacrine HCl 100mg Tablets |No licensed alternative available. Rarely used. |

|Metformin Liquid |Prescribe Metformin 500mg / 1g Powder Sachets (Glucophage) taken in 150ml of water. If|

| |liquid required due to fluid restrictions or any other reason - prescribe as Metsol |

| |500mg/5ml SF Oral Solution. |

|Methotrexate Liquid |Cytotoxic - inappropriate to crush - AMBER shared care drug therefore recommend |

| |secondary care initiates and prescribes any liquid preparations |

|Methylcellulose Liquid |The 500mg tablets can be crushed and mixed with water |

|Methyldopa Liquid |The tablets can be crushed and mixed with water |

|Metoprolol Tartrate Liquid |No licensed alternative available. Consider changing to Atenolol which is available in|

| |syrup form or prescribe the unlicensed liquid. |

|Midazolam 10mg/ml Buccal Liquid |No licensed alternative available. AMBER shared-care drug - prescribe as Epistatus |

| |10mg/ml Buccal Liquid to ensure continuity for the patient and ideally no more than 1 |

| |x 5ml per prescription. There is suggestion from some consultants that patients who |

| |have been fit free for > 2 yrs do not need a stock of this product at home. |

|Midodrine HCl 2.5mg Tablets |No licensed alternative available. Recommend GPs request cardiologists prescribe and |

| |monitor in secondary care. |

|Naftidrofuryl Liquid |The capsules can be opened and the contents mixed with water for administration via. |

| |Enteral Feeding Tubes. For patients with swallowing problems use the unlicensed liquid|

| |or consider alternative drugs as there is a risk of oesophageal stricture if the |

| |powder is used orally. |

|Naltrexone HCl Capsules & Liquid |There are 50mg tablets available (licensed). Would be on recommendation of specialist,|

| |therefore recommend that GP requests secondary care prescribes and monitors. |

|Naproxen Liquid |The 'standard' non-e/c tablets can be crushed and mixed with water. Alternatively use |

| |another NSAID such as Ibuprofen in liquid form, Diclofenac dispersible tablets or |

| |Piroxicam melt tablets. |

|Nefazodone HCl 200mg Tablets |No licensed alternative available. Consider other antidepressant options. |

|Nefopam Liquid |No licensed alternative available. Consider other analgesics. |

|Nifedipine Liquid |Consider alternative calcium-channel blocker such as Amlodipine which can be dispersed|

| |in water |

|Nitrofurantoin Liquid |A licensed 25mg/5ml liquid is available at £65 per 300ml. Alternatively the 50mg & |

| |100mg capsules can be opened and the contents mixed with water (note: not the M/R |

| |capsules). |

|Olanzapine Liquid |Available in oro-dispersible form as 5mg, 10mg and 20mg strengths |

|Olmesartan Liquid |Use alternative ARB such as losartan or candesartan which can be crushed and mixed |

| |with a small volume of water. |

|Omeprazole Liquid |Use Omeprazole Dispersible Tablets (Losec MUPS) or change to Lansoprazole |

| |Oro-dispersible Tablets (Zoton FasTabs). Losec MUPS can be used in patients with PEG |

| |tubes and also for children. |

|Oxybutynin Liquid |Use licensed Ditropan 2.5mg/5ml Elixir |

|Paracetamol 500mg/5ml Liquid |Use licensed 250mg/5ml SF suspension |

|(Christies Formula) | |

|Perindopril Liquid |The tablets can be crushed and mixed with water |

|Phenobarbital Liquid |The tablets can be crushed and mixed with water. An elixir is available but contains a|

| |high proportion (38%) alcohol so is unsuitable in some circumstances e.g. children. In|

| |such instances the unlicensed liquid is preferable. |

|Phenytoin Liquid |Use licensed Epanutin 30mg/5ml Suspension - requires care if changing over from an |

| |unlicensed liquid due to narrow therapeutic index. |

|Pilocarpine P/Free Eye Drops |Use Minims Pilocarpine Nitrate 2% P/Free Single Dose Units |

|Pravastatin Liquid |The tablets can be crushed and mixed with water. Alternatively consider Simvastatin or|

| |Atorvastatin |

|Prazosin |The 500mcg and 1mg tablets will disperse in water within a few minutes. |

|Prednisolone P/Free Eye Drops |Use Minims Prednisolone 0.5% P/Free Single Dose Units |

|Pregabalin Liquid |The capsules can be opened and the contents mixed with water |

|Primidone Liquid |The tablets will rapidly disperse in 10mls of water |

|Probenecid 500mg Tablets |Used to prevent nephrotoxicity associated with Cidofovir which is a 'RED' drug. As |

| |such we would reasonably expect secondary care to prescribe this. |

|Promazine Liquid |Use the licensed liquids - 25mg/5ml or 50mg/5ml |

|Propranolol Liquid |Use the licensed liquids - 5mg/5ml, 10mg/5ml or 50mg/5ml |

|Pyrazinamide 500mg Tablets |The tablets will disperse in water within 1-5 minutes |

|Quetiapine Liquid |The tablets can be crushed and mixed with water or added to soft food e.g. yoghurt |

|Quinine Sulphate Liquid |No licensed alternative available and tablets are sugar coated so cannot be crushed. |

| |Assess ongoing need for drug in light of recent Drug Safety Bulletins. |

|Quinine Bisulphate Liquid |No licensed alternative available and tablets are sugar coated so cannot be crushed. |

| |Assess ongoing need for drug in light of recent Drug Safety Bulletins. |

|Ramipril Liquid |The capsules can be opened and the contents placed directly into the mouth, onto food |

| |such as bread or mixed with water. The tablets can be crushed and mixed with water. |

|Salicylic Acid Creams, Ointments and Mixtures |Use Salicylic Acid 2% Ointment (licensed). Consider asking dermatologists to prescribe|

| |more complex formulations as they have access to Preston Pharmaceuticals NHS |

| |Manufacturing Unit. |

|Sertraline Liquid |The tablets will disperse in water within 1-5 minutes. Alternatively, several SSRIs |

| |are available in liquid form e.g. Fluoxetine 20mg/5ml or Paroxetine 10mg/5ml. |

|Sildenafil Liquid |Not for primary care prescribing - secondary care specialists should prescribe and |

| |monitor this drug in pulmonary hypertension. If using for erectile dysfunction - the |

| |tablets can be crushed and mixed with water or broken in half. |

|Simvastatin Liquid |A licensed SF liquid is now available via. Rosemont (20mg/5ml = £100 per 150ml, |

| |40mg/5ml = £150 per 150ml). Suggest specify 'ROSEMONT PHARMACEUTICALS' in the dosage |

| |directions. Alternatively, Atorvastatin 10-40mg tablets will readily disperse in |

| |water. |

|Sodium Bicarbonate Liquid |The capsules can be opened and the contents mixed with water |

|Sodium Chloride Capsules & Liquid |Use licensed Sodium Chloride 600mg M/R (Slow-Sodium) Tablets |

|Sodium Chloride 5% (incl. P/Free) Eye Drops & Eye Ointment |No licensed alternative available - assess ongoing need and prescribe in multiples of |

| |10ml bearing in mind the P/Free drops can expire 7 days after opening. |

|Sodium Chloride Nebuliser Solution |Prescribe as either MucoClear 6% Solution (4ml units) or Nebusal 7% Solution (4ml |

| |units) to ensure the lowest cost product is dispensed (£27 per 60). Any other forms |

| |are unlicensed. |

|Sod Cromoglicate 2% P/Free Eye Drops |Prescribe as Catacrom 2% P/Free Unit Dose Drops |

|Spironolactone Liquid |The tablets can be crushed and mixed with water |

|Sulfasalazine Liquid |Use licensed 250mg/5ml suspension |

|Tamoxifen Liquid |Crushing the tablets poses a risk if the powder makes contact with skin or is inhaled.|

| |No licensed alternative available - if required then use the unlicensed liquid |

|Tamsulosin Liquid |Where there is no other option available, the modified-release capsules can be opened |

| |and the granules mixed with water for administration. The granules should not be |

| |crushed or chewed therefore the patient must have sufficient understanding to take |

| |this correctly. Alternatively see Alfuzosin or Prazosin. |

|Terbinafine Liquid |The tablets can be crushed and mixed with water |

|Tetrabenazine Liquid |The tablets can be crushed and mixed with water |

|Thiamine Liquid |The tablets can be crushed and mixed with water |

|Tocopherol Acetate 100mg Chewable Tablets |Use licensed Alpha-Tocopheryl Acetate (Vitamin E) 500mg/5ml suspension |

|Tolterodine Liquid |The 1mg and 2mg tablets will disperse in water within 1-2 minutes |

|Tranexamic Acid Liquid |The tablets can be crushed and mixed with water. Cyclokapron brand will disperse in |

| |water within 2-5 minutes (safer option than crushing). |

|Tretinoin Cream (Various Strengths) |Use licensed Retin-A 0.025% or 0.01% Gel |

|Trihexyphenidyl Liquid |Use licensed Trihexyphenidyl 5mg/5ml Syrup |

|Venlafaxine Liquid |The standard-release tablets can be crushed and mixed with water. Alternatively the |

| |M/R capsules can be opened and the contents mixed with soft food e.g. yoghurt but must|

| |be swallowed whole and not chewed. |

|Verapamil Liquid |Use licensed Zolvera 40mg/5ml oral solution |

|Warfarin Liquid |No licensed alternative available. |

|Zinc & Ichthammol Cream |No licensed alternative available. Consider using other proprietary creams. |

|Zinc & Salicylic Acid Paste |Prescribe as Lassar's Paste (£3.35 per 500g) |

|Zopiclone Liquid |No licensed alternative available. Recommend change to Zolpidem tablets which can be |

| |crushed and added to water or consider other hypnotics such as Temazepam which is |

| |available as a licensed 10mg/5ml liquid. |

APPENDIX 2 – Claim form to be sent to SBS by the 5th of each month

[pic]

Date: 24/11/2010

Reference Number: Pharmacy contractor to use own preferred reference code here

Central and Eastern Cheshire PCT

5NP Payables B365

Phoenix House

Topcliffe Lane

Wakefield

WF3 1WE

|RAISED BY: |Andrew Swift |

|REFERENCE: |5NPASWIFT |

|FOR PERIOD: |MONTH & YEAR |

|DESCRIPTION |NUMBER |UNIT PRICE |LINE TOTAL |

| |  |  |  |

|‘Specials’ Reviews |0 |£28.00 |£0 |

| | | | |

|(that have been conducted and resulted in a change to a licensed | | | |

|product of lower cost) | | | |

| | | | |

| |Total | £ 0 |

COMPLETED BY:

PHARMACIST NAME (BLOCK CAPITALS): ______________________________

PHARMACIST SIGNATURE: ______________________________

-----------------------

PHARMACY PPD CODE

PHARMACY NAME

FULL ADDRESS

POSTCODE

CONTACT TELEPHONE NUMBER

PHARMACY ‘SPECIALS’ REVIEW SERVICE

................
................

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