Medicines - achieving value and sustainability in prescribing: guidance

Appendix 1: Potential unintended consequences from implementation of this guidance

Unintended consequence: Interactions with specialists in secondary care and consequent costs.

Response: This will need monitoring but is not inevitable. For some products, joint local guidance with secondary care providers may be appropriate.

Unintended consequence: Use of appointments in primary care, for example pain management reviews.

Response: There could initially be an increased use of appointments in primary care to improve appropriateness of prescribing, however this is not expected to be sustained.

Unintended consequence: Some substitute treatments may not be clinically identical, such as side-effect profile.

Response: Prescribers should make shared decisions with patients, and appropriate resources should be provided to facilitate this e.g. Patient information leaflets.

Unintended consequence: Substitute treatments could, in some cases, be prescribed with cost consequences.

Response: This is an opportunity to review medication, and if appropriate to deprescribe, although alternatives may need to be considered.

Unintended consequence: Individual prescribers’ decision making.

Response: Prescribers must recognise and work within the limits of the competence, as recommended by the General Medical Council (GMC) and other professional regulators/bodies. The proposed guidance does not remove the clinical discretion of the prescriber in deciding what is an accordance with their professional duties.

Unintended consequence: People currently on treatment stopping or altering their treatments without appropriate advice.

Response: Prescribers should endeavour to explain the rationale for any proposed changes in treatments and come to a shared decision prior to any changes.

Unintended consequence: Complaints about general practice and associated administration time.

Response: To support communication of the changes proposed in the guidance, educational aids will be made available.

Unintended consequence: Effect on medicines supply.

Response: By proposing guidance on individual items, there is potential for substitute items to see increased demand. NHS Scotland will work with Department of Health colleagues to ensure that pharmaceutical companies are aware of the proposed guidance and potential need for increased supply of alternative products. Proposed changes will also be communicated to community pharmacies.

Unintended consequence: In some instances substitute therapies may carry a higher risk of dependence and withdrawal.

Response: Effective National and local strategies are required to support the delivery of alternative treatment options, particularly in chronic pain management (e.g. lidocaine). This is important to support safe deprescribing and prevent the increased prescribing of medicines with the potential for harm, dependence or withdrawal.