Letter - Response from MSS to HSS re Review of Prescription for ADHD Medication - 4 September 2024

19-21 Broad Street | St Helier Jersey | JE2 4WE

Deputy Louise Doublet

Chair, Health and Social Security Scrutiny Panel

Sent by email  

3rd September 2024 Dear Deputy Doublet

Re: Health and Social Security Panel – Review of Prescription of Medication for ADHD (Attention Deficit Hyperactivity Disorder)

Thank you for your letter dated the 14th August, relating to the Panel's review of the prescription of medication for ADHD. I have responded to each of your queries in turn as follows:

1. What is the process around recommending the addition (or deletion) of a drug to the community prescription register?

The Prescribed List is a positive reimbursement list that determines those medicines and devices that can be dispensed in the community and reimbursed from the Health Insurance Fund (HIF). Recommendations for changes to the Prescribed List are made to the Minister for Social Security by the Pharmaceutical Benefit Advisory Committee (PBAC) that meets 4 times each year to consider applications from local health professionals. Such applications can be for products to be added or removed, where for example, they have been discontinued or are considered to be of low clinical value. The Committee may also recommend changes to the reimbursement status of the product, for example to reimburse for generic medicines only, ensuring value for money. In making its recommendations, the Committee is required to consider the safety, quality and effectiveness of the product as well as its suitability for prescribing in primary care. The Committee also considers the availability of products to patients in the Island and the robustness of supply.

2. Is there a particular reason as to why ADHD medication is exempt from this register?

Like all licensed medicines, those used in the treatment of ADHD can be considered for inclusion in the Prescribed List and applications have been considered by PBAC, most recently concluding that "they are supportive in principle but are not able to recommend inclusion on the Prescribed List while there are national shortages and before the ADHD pathways have been clarified".

Medicines for the treatment of ADHD should not be initiated in primary care or changed without support from hospital specialists. The ADHD pathway should ensure prescribers in primary care are integral to the overall care of their patients (not simply providing a signature on a repeat prescription). Therefore, ensuring that primary care prescribers have sufficient information and resources to undertake prescribing safely in the community is a key consideration. To this end, the Minister for Social Security's prescribing advisory service (InPAx) have worked closely with ADHD specialists from both adult and children's services to draft shared care protocols which would enable primary care prescribers to support an ADHD pathway. However, even if a final version of the protocol is confirmed, some GPs may not feel able to prescribe and have stated they will decline requests for shared care. GPs are responsible for the prescriptions they issue and the government cannot require GPs to prescribe a specific medicine or agree to participate in a shared care protocol.

Barriers at the moment can be summarised as:

• Supply

There are national supply shortages of some ADHD medicines. Access to shortage medicines is better managed through a central supply, rather than diluting scarce supply through 30 community pharmacies, which will inevitably create inefficiencies during a time of shortages.

• Patient Pathway

Clarity on the patient pathway is required. Once agreed, the Shared Care Protocol will transfer patients from a free service in the hospital into primary care where patients will incur charges. The cost for an adult consultation has been reduced significantly since 2022 by the introduction of a contracted medical benefit payment (£35) which is paid to Practices in addition to Statutory Medical Benefit (£20.28). However, consultation co-payment fees still range from £15 to £41 for an adult surgery appointment. Child consultations are funded by the HIF and free to patients but all practices charge adults and children for repeat prescriptions.

We could expect GPs to issue medicines over a short period of supply (possibly one month's supply) to mitigate the impact of medicine shortages. Therefore the patient could be required to pay for monthly repeats or consultations and this could have an impact on the patient's access to care and medicine.

The proposal to move repeat prescribing from secondary care into primary care has not been accompanied by a costed patient pathway which considers financial and behavioural impact.

• Process

Processes to communicate patient identifiable information securely between the hospital, general practice and community pharmacy do not exist.. These communications channels are particularly important for Shared Care Protocols and even more so during shortages. For example, if a pharmacist cannot supply the prescribed medicine, they have to refer the patient back to the GP. In the case of ADHD medicine, the GP in turn needs to liaise with the consultant about alternative treatment options. A change in treatment would require initiation by the specialist. This process is time consuming for practitioners and will cause delays and frustration for patients. These issues are already commonly encountered in the UK, and there are concerns that that Jersey may replicate the problem, rather than identifying solutions which are appropriate to Jersey and support patient access.

3. What provision, if any, is given from the Health Insurance Fund (HIF) to fund medication for ADHD?

No medicines for the treatment of ADHD are currently funded from the HIF. Patients receiving treatment with one of these medicines will receive supplies free of charge from the hospital or at full cost in the community on private prescription.

4. The Panel has been made aware that most people on the ADHD waiting list have little choice but to see a private consultant. Whilst GP appointment costs have been reduced in the last few months and given the waiting list is up to 2 years for an ADHD assessment, are there any plans for payment subsidies to be given to those currently on the ADHD waiting list to assist with private appointments and/or ADHD medication? If not, has this been considered?

The Health Insurance Fund is established to support residents with the cost of medical services and since its creation in 1967 these services have focussed on reducing the costs incurred in primary care. Using the fund to offset private consultant fees would be a significant digression from its historic use. Offering a subsidy to individuals who have sufficient means to pay for private consultants will add to Jersey's health inequalities. In addition, it is unclear how this subsidy would genuinely alleviate pressures in the service as there is a finite resource, whether accessed privately or publicly.

There will be a range of other options which could be considered to improve services and access to medicine, some of which will create less expense for patients and cost to Jersey's public funds. For example, using non-medical prescribers working in adult/CAMHS to take on repeat prescribing as part of their role.

Attempts to improve the service and patient experience would benefit from a methodical review which considers service barriers and cost from the view of the patient, the taxpayer, primary care and secondary care providers, to identify solutions appropriate to the health care system in Jersey.

5. Can you confirm if discussions have taken place regarding changes as to how ADHD medication can be prescribed by GP's, and if so, could you provide an update?

The Minister for Social Security's Prescribing Services Advisor has led on the development of the draft shared care protocol and consulted with GPs and Pharmacists. The Advisor and the Minister's officers have met with secondary care clinicians and HCS officers on several occasions to progress the issue. This is an area which we are actively keeping under review.

The Pharmaceutical Benefit Advisory Committee has considered the application for medicines for the treatment of ADHD to be included in the Prescribed List. At its most recent meeting in June 2024, the Committee concluded that "they are supportive in principle but are not able to recommend inclusion on the Prescribed List while there are national shortages and before the ADHD pathways have been clarified".

I would also like to take this opportunity to confirm that following the Panel's suggestion at the Quarterly Public Hearing in May, we have invited Dr Ulrich Müller-Sedgwick to join the Disability and Inclusion Advisory Group. This ensures that the group will include expert representation relating to ADHD.

I hope the above information is helpful for the Panel's review and would be happy to discuss this in more detail if required.

Kind regards,

Deputy Lyndsay Feltham Minister for Social Security