CCGs should encourage the use of a traffic light system to manage clinical risk. In my opinion these systems have been adulterated and abused over the years and some clarity of purpose has been lost.
The system should be engaged after a medicine has been approved for use, so there is no need for additional colours to reflect failure at a formulary. The system is purely to manage clinical risk and therefore affordability or cost is not an issue.
There are two important factors also to consider:
- Who ever signs the prescription is ultimately responsible, although may be able to share some of the blame. A prescriber must always work within their knowledge and competence.
- Separating medicine prescribing between primary and secondary care can hold significant risks. It is not unusual for a GP to not see specialist medicines on their medicines screen and to be unaware of specialist medicines managed by the hospital. This is particularly important for medicines which have drug interactions or contra-indications.
The system is based on three simple questions:
1) is the condition rare, difficult to diagnose and requires the expertise of a specialist to decide on treatment?
2) is the treatment difficult to initiate and titration and requires the expertise of a specialist to initiate?
3) is the treatment difficult to maintain, requiring tests, regular review for adverse effects and variation in dose that requires a specialist.
If the answer to all three questions is yes- then the medicine attracts a red traffic light and should be for specialist use only.
If the answers to all three questions are no – then the medicine attracts a green traffic light and can be available to all prescribers.
When only the third question is no – the medicine attracts an amber traffic light and shared care is required.
Sometimes the amber medicines are split into two, depending on the GP’s familiarity with the medicine. Perhaps amber 1 where there is a written shared care agreement in place and amber 2 where there is no written shared care agreement.
The practice medicines optimisation pharmacist should ensure that all medicines prescribed under a shared care agreement are appropriately monitored and the tests recommended by either the product license and/or the specialist are carried out. They should also document on the clinical system the initiator and the contact details should specialist advice be required.