When traffic lights go wrong. A little story of a private conversation

Last week up in Birmingham speaking to a group of very eminent sleep specialists – brains like planets. Pleased that things were going well.

 Outside the meeting one asked me to explain shared care and the traffic light system. Easy, I thought, home ground! And I suspected that they might be asking with reference to Oxybate which came up earlier.

Well it depends on how you answer three questions:

·         Is the condition difficult to diagnose or complex to manage with co-morbidities etc

·         Is the treatment uncommon, tricky to initiate, requires titration, stabilisation and/or require background tests that are difficult to interpret

·         Is the treatment tricky to maintain, requiring regular review and/or specialist tests.

It is all about clinical risk, bearing in mind that the clinician signing the prescription is responsible and whether the specialist or the generalist is the most appropriate clinician to safely  manage that situation.

In a flow – so stupidly carried on. You can use Oxybate as an example

·         So a condition like cataplexy in narcolepsy is a condition that needs a specialist to diagnose – that is your job.

·         Oxybate for example is a medicine that requires titration by someone who is familiar with the disease and treatment – that is also your job.

·         But once titrated and stabilised there is an argument that things become easier and as long as the specialist can be at hand, a GP might be happy to take over the prescribing – so I personally I would see that either a specialist or a generalist should continue treatment.

 There might be an argument here for Oxybate to be considered red and for specialist diagnosis, initiation and maintenance, I said, but I would suggest that this could be an amber drug with a shared care agreement in place.

Oh My God – there are times you realise you should just shut up!

In my opinion, where ever possible, prescribing responsibility should be held in one place. I don’t like it when one group of medicines are prescribed by the GP and another set is prescribed by a specialist. The risk is high that one clinician will not have the full picture. So I am an advocate of shared care whenever possible. 

There – breath – and feel comfortable that a reasonable explanation had been delivered.

And then he said – yes I understand all of that, but I was interested why Circadin had been given a red category. Afterall, he said, insomnia is a common and simple condition to diagnose, a single dose before bedtime treatment is not difficult to initiate and you only give it for 13 weeks. Also it is much safer than the other hypnotics that you could use, particularly in the over 55s where this drug is licensed.

I have had a few referrals for patients with a diagnosis of insomnia for assessment and initiation of Circadin. They are quite straightforward, but the PPCT pays a £260 first appointment, I treat and review in four weeks for a further £69 and then bring them back to offer up to 13 weeks for another £69. I worked out the economics of all this – nearly £400 in referral costs to manage a course of treatment that is simple and costs £45.

Well – he does have a point – and the correct answer…. Stop applying inappropriate traffic lights. 

On a serious point, traffic lights are a mechanism to reduce clinical risk. This is important and a central role for formulary and associated committees. And where was the GP, insulted that someone suggested that they were unable to diagnose primary insomnia in the over 55s, make a clinical choice between Circadin and other hypnotics, initiate treatment, review treatment and stop at a maximum of 13 weeks.Probably sitting in the back not getting involved. Well on April 1st it will be your money that is being wasted.


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