Advice for health and justice healthcare teams on medicines and pharmacy services continuity
- General key points
- Pharmacy dispensing services
- In-possession medication and medicines administration or supply
- Continuity of care on release and transfer
- Key links for COVID-19 information
- Appendix 1: Pre-release initiation of injectable buprenorphine (Buvidal) for prisoners in Wales – management of prisoners being released or transferred across the Wales/England border
Publications approval reference: 001559 / C0596
11 June 2020, Version 2
Updates are highlighted in yellow.
This guidance describes the changes that may be needed to provide continuity of medicines during an outbreak. Providers should already have plans for pandemic and seasonal flu outbreaks or major incidents that can be used and adapted for COVID-19 outbreaks.
The supply of medicines is a clinical priority to minimise the risks of harm from omitted and delayed medicines. Health and justice (HJ) patients have additional risks if continuity of medicines is interrupted.
General key points
- HJ healthcare and pharmacy teams should follow guidance published for primary care, community pharmacy and medicines supply and continuity guidance published by the NHS, Public Health England (PHE), NICE, General Pharmaceutical Council (GPhC), Royal Pharmaceutical Society (RPS) and Department of Health and Social Care (DHSC), including CAS alerts.
- Legislative changes to medicines regulations can be used by HJ as has been demonstrated by the use of the information in Serious Shortage Protocols (SSPs).
- Clear leadership of the pharmacy and medicines planning is needed. The pharmacy and medicines continuity plan should be overseen by the provider’s chief pharmacist (or chief HJ pharmacist) with on-site pharmacist or pharmacy technician operational leadership.
- Plans are likely to include changes that are triggered at different points to maintain medicines access. This will provide a phased approach as operational changes or infection rates in the HJ setting rise.
- Providers should take account of critical medicines lists when developing plans.
- Custodial, drug strategy, healthcare and pharmacy teams should work in partnership to develop and agree the phases and triggers within the medicines continuity plan.
- Prescriptions issued from HJ sites are NHS prescriptions under a subcontract with an NHS commissioned service. They are therefore not private prescriptions and the customised prescription meets all the legal requirements.
- Unless specific legislation changes are communicated, all legal requirements of the Human Medicines Regulations and Misuse of Drugs Regulations will need to be followed.
- The DHSC is working closely with industry, the NHS and others in the supply chain to ensure patients can access the medicines they need and precautions are in place to prevent future shortages.
- Pharmacies should not be stock piling. Providers are advised to reinforce the message with patients who raise concerns about medicines supply.
- Questions or queries about HJ medicines continuity should be sent to: email@example.com
- In the event of a COVID-19 outbreak or local incidents occurring that are affecting medicines continuity or pharmacy services, this should be escalated to regional and local EPRR routes.
- In the event of an outbreak, a pharmacy lead for the site will advise the head of healthcare or attend the outbreak control team (OCT) to advise on and raise issues about medicines supply and continuity. These issues can be escalated to the regional EPRR teams and HJ central teams if needed.
- HJ providers and their pharmacy teams need to check national COVID-19 updates daily for new published information. Specific communication to HJ providers of information about HJ medicines and pharmacy services will come to you via:
- HJ chief pharmacists and HJ commissioning teams
- EPRR regional teams and outbreak control teams.
Pharmacy dispensing services
- HJ providers should continue to use named patient medication for most medicines, including controlled drugs (except methadone and buprenorphine). This allows prompt conversion to in-possession (IP) for these supplies and for supplies on transfer and release.
- Contacting and collaborating with your contracted external pharmacy service providers or those providing services for your out-of-hours/urgent medicines supplies is essential so that they can share their contingency plans with you. For example, they can advise you about an alternative pharmacy that could receive and dispense the HJ prescriptions if they have to close or reduce their workload due to staff shortages.
- Dispensing pharmacies will need to know in advance if you plan to move to seven-day or daily IP for current non-IP medicines. This is because they will need to package the medicines differently which may affect their workflows.
- Plans need to include continuity of on-site pharmacy services and how dispensed medicines will be accessed from alternative pharmacies in the event the dispensing pharmacy in the prison closes.
- If an alternative dispensing pharmacy (on or off site) has to be used for routine prescriptions, the Health and Justice Information System (HJIS) customised prescription form should be used with agreements made about funding these services (ie dispensing and delivery fees). The use of FP10 forms for routine supplies should remain a last resort as access to the quantity of forms needed may not be possible within the required timeframe. Please note that to print FP10SS/FP10MDA prescriptions, the printer must be able to take 70gsm paper. More information is available here.
- FP10 and FP10MDA prescriptions with a prison address in the practice address with an HMP prefix are exempt from the prescription charge due to 2010 legislative changes. More information is available here.
- Pharmacy services both within the prison and in the community may become restricted due to staff shortages. This may mean that the supply of prescribed medicines becomes intermittent. National and regional EPRR guidance and communication will provide information about how to manage this issue.
- Prescribers should follow national clinical guidance COVID-19 case management and for any changes to usual clinical treatment for other conditions (eg substance misuse treatment).
- There is no need for prescribers to increase prescribed quantities so the usual quantities of 28 days for HJ prescriptions should continue.
- There is no need to order repeat prescriptions early unless changes to the routes for accessing dispensed medicines requires them. Any change should be formally triggered as part of the HJ plans and the dispensing pharmacy should be informed in advance so dispensing workflow and medicines supply can be managed.
- Consideration should be given to producing batch repeat prescriptions for up to four months (a limit within the current HJIS functionality) that can be dispensed each month in instalments by the dispensing pharmacy for patients on stable doses of medicines. An HJIS quick reference guide about how this functionality can be used is available and will be shared separately. Further information is available from your HJIS NELCSU lead. Collaborative working with the prison’s pharmacy team and the dispensing pharmacy team is essential to operationally achieve this. Information from repeat dispensing processes used in the community is available here.
- FP10 and FP10MDA prescription forms should be in place at all sites and can be used for urgent supplies and unplanned releases. All sites have NHSBSA practice and spurious codes so accounts can be set up to order FP10 forms. Orders for forms are usually delivered within six days. Information about accessing FP10 forms is available on the NHBSA website.
- If you are unsure which type of FP10 form to order, there is information about the different types here.
- Information about shortages of specific medicines will be communicated via business as usual routes. Prescribers should follow the actions described in these communications.
- Providers will need to plan for a reduced prescribing workforce and remote prescribing could be used. These should follow national professional guidance and legislation.
- Prescribing should follow usual formularies and national clinical guidance. PHE is publishing guidance for managing substance misuse treatment during COVID-19, including advice for people with COVID-19. HJ prescribers should use this as a basis for adjusting treatment where access to non-IP supply becomes compromised (see section In-possession medicines below).
- Injectable buprenorphine (Buvidal) is not recommended at this time due to operational, clinical and continuity of care challenges. If non-IP becomes severely affected to the point where supply of non-IP methadone is no longer feasible, then switching to oral buprenorphine can be considered to enable IP. In Wales, new arrangements will result in some prisoners being prescribed injectable buprenorphine as part of release planning. Information about this and how releases and transfers into prisons will be managed has been agreed with colleagues from prison healthcare in Wales (see Appendix 1).
- Regulation 225 and 226 in the Human Medicines Regulations 2012 allows the legal supply of a prescription-only medicine in an emergency and during a pandemic disease under specific criteria. This excludes Schedule 2 and 3 controlled drugs (CDs), but does include a supply of Schedule 4 and 5 CDs. This regulation can be used if a repeat prescription is needed and there are no prescribers available.
- Where there are changes to legislation about accessing prescription-only medicines without a prescription, information will be shared about the application of this in HJ settings.
In-possession medication and medicines administration or supply
- Symptomatic relief, antibiotics and other medicines needed to treat patients should be provided IP, unless in exceptional circumstances where the person is incapable of self-medicating.
- Patients are likely to require support and advice from healthcare and pharmacy teams about self-care and using paracetamol appropriately. Supplies should be via protocol to avoid the need for prescriptions. Supplies may need to be restricted to those with active COVID-19 symptoms and supplied free of charge via healthcare.
- Royal Pharmaceutical Society advice is available about pharmacies packing down paracetamol for over the counter supply. This applies to community pharmacies and on-site HJ pharmacies only.
- Medicines queues and supervision will need to implement social distancing in line with national guidance. Note that HMPPS guidance states that prisoners do not need to be unlocked individually for healthcare and medication activities unless they require social shielding (people who are at very high risk of severe illness from coronavirus (COVID-19) because of an underlying health condition). Small groups may be unlocked so that an efficient system is maintained. The precise number unlocked at any time must be judged locally and should be such that this activity is supervised so as to maintain social distancing.
- For people isolated in their cells, cell-to-cell supply for both non-IP and IP medicines (including medicines such as paracetamol for symptomatic relief) needs to form part of outbreak plans. This will be in line with usual arrangements for supply at a cell and include the recording of the supply on HJIS in line with national standards to retain an accurate clinical record of care. National PHE infection control such as PPE arrangements need to be applied.
- If healthcare staff capacity reaches a reduced and locally agreed point, healthcare providers and the governor will need to agree when and how:
- medication usually supplied non-IP can be supplied IP to maintain continuity of medicines and prevent harm from omitted doses
- continuation of non-IP supply of opioid substitution therapy (OST) is advised as a priority to maintain safety. The increased use of injectable buprenorphine (Buvidal) is not recommended. Enabling the IP of other Schedule 2, 3 and 4 CDs can be considered based on a revised risk assessment. This would usually be for seven-days IP.
- If methadone has to be supplied at the prison cell due to patient isolation, HJ sites can primary dispense the dose from stock supplies using an HCP and a witness:
- to ensure safe administration, doses should be prepared for one person at a time. HJIS can be checked for prescription and dose validity prior to preparing the dose
- prepare the dose from Methasoft or hand poured in the treatment room into a container that can be sealed
- a label can be printed or hand written with the patient’s name, medicines and volume and date on it – using the adapted dispensing procedure approach
- the HCP preparing or witnessing (if this is also an HCP) should ideally be the person administering, so that the process is completed by the same individuals to avoid miscommunication errors
- the witness will check the details as they would for usual procedures and check the label on the container, and act as the counter signatory in HJIS with details added as notes if another person (eg an officer) witnessed the actual dose administration at the cell
- the labelled container taken to the cell by an HCP and supplied to the patient with patient ID procedures followed and a witness (this could be the officer opening the cell) for patient ID purposes only and to confirm observing the dose being swallowed.
- the container the patient used to take the dose disposed of in line with COVID-19 infection control guidance
- HJIS records and CD books are updated after the dose is taken and as soon as is practically possible, but within 24 hours
- RPS Medicines Ethics and Practice (MEP) guidance should be followed in disposing of any residue in bottles or containers used to administer the dose.
- Unregistered staff can be deployed to distribute IP medication, but non-IP medication must continue to be provided by a registered HCP.
- When staff shortages (healthcare and custody) prevent a witness being available to witness the supply of CDs, a single registered HCP can supply it to maintain medicines continuity. Stock and records reconciliation can be used to provide assurance for these supplies during this period.
- People who are not capable of self-medicating IP and who have been identified as needing support by the healthcare team, can have support in self-administration from prison officers or social care workers (eg to prompt them about taking their medicines). This process would align with support provided by community domiciliary care workers and police custody staff. This has been confirmed with HMPPS and union leads.
Continuity of care on release and transfer
- HJ providers should continue to follow guidance and supply at least seven days (and a maximum of 28 days) supply of medicines when people are released or transferred – including CDs. This means an HJ provider can choose to supply more on release as community pharmacy services and community GP access may be limited at this time.
- HJ providers will need to be able to respond quickly to any plans shared by HMPPS or the HO about changes in national policy about releases from HJ. Medicines or FP10/FP10MDA prescriptions need to be provided to ensure continuity of medicines as GP practices and community pharmacies will be unfamiliar with providing emergency supplies of medicines for released prisoners or other detainees.
- Collaboration with community substance misuse services (which will have local COVID-19 plans for their services) and COVID-19 guidance published by PHE should be used to ensure that:
- release planning for people who will need continued OST will be able to access community services. This includes ongoing prescribing and supervised consumption services by community pharmacies
- usual HJ release plans can be adjusted in the light of the impact on COVID-19 on local services. This includes the provision of up to 14 days of OST on an HJ-issued FP10MDA
- take home naloxone is supplied on release from the HJ site where usual pathways use community services to supply it and these services are no longer able to supply it.
Key links for COVID-19 information
As a reminder, key information resources are as follows:
- Intranet page for COVID-19: https://nhsengland.sharepoint.com/sites/thehub/SitePages/COVID-19–Guidance-for-colleagues.aspx?source=/sites/thehub&promotedState=1
- NHS England and NHS Improvement COVID-19 web pages: https://www.england.nhs.uk/coronavirus/
- Government advice on COVID-19: https://www.gov.uk/coronavirus, complete list of all guidance: https://www.gov.uk/government/collections/coronavirus-covid-19-list-of-guidance and latest documents: https://www.gov.uk/government/latest?topical_events%5B%5D=coronavirus-covid-19-uk-government-response
- NICE COVID-19 web page: https://www.nice.org.uk/covid-19
- PSNC website for community pharmacy information: https://psnc.org.uk/the-healthcare-landscape/covid19/
- RPS COVID-19 information: https://www.rpharms.com/coronavirus/
- GPhC COVID-19 information: https://www.pharmacyregulation.org/contact-us/coronavirus-latest-updates
- PrescQipp https://www.prescqipp.info/news/covid-19-virus-and-medicines/ – membership registration required and is available for HJ healthcare and pharmacy staff.
Appendix 1: Pre-release initiation of injectable buprenorphine (Buvidal) for prisoners in Wales – management of prisoners being released or transferred across the Wales/England border
In May 2020, the Welsh government announced that funding would be provided to enable the initiation of injectable buprenorphine (Buvidal) within community substance misuse services in Wales. This excluded the routine use of Buvidal in prisoners except as part of pre-release planning.
There are six prisons in Wales: HMP Berwyn, Cardiff, Swansea, Parc, Prescoed and Usk. Further details about these prisons can be found here.
There will be implications for release planning for prisoners being released into England and for prisoners being released from England into Wales. This short briefing aims to support safer transfer of care and was developed by a stakeholder group from PHE Alcohol, Drugs Tobacco and Justice, drug treatment providers, NHS England and NHS Improvement Health and Justice leads, and clinical leads from prisons in Wales. This information could also be used to inform any transfers from Scotland (where Buvidal is being used in prisons in the short term as part of COVID-19 services) and for any community transfers across the England and Wales border.
How will clinicians use Buvidal for released prisoners in HMPs in Wales?
Individual prisons in Wales will agree if and how to introduce Buvidal into their release planning pathways and use local protocols. As part of pre-release planning, prisoners in Wales will be considered for Buvidal in collaboration with the patient and community services. Initiation will usually occur eight weeks before release to enable a stable monthly injection regime being in place before release.
How will releases into England be managed and from HMPs in England into Wales?
As access to injectable buprenorphine is not widespread in community services in England, prisoners being released from HMPs in Wales into England will be managed using the following principles:
- prisoners due to be released into England will not routinely be initiated on Buvidal
- however, if a community provider in England is using Buvidal in its care pathways, initiation of Buvidal for a prisoner being released into England from an HMP in Wales could occur if agreed, on an individual case basis, that it will be continued on release.
Prisoners being released from HMPs in England into Wales will be managed using the following principles:
- prisoners receiving OST in a prison in England will be released on oral therapy using current guidance. This is usually up to 14 days on a FP10MDA. Buvidal could be initiated, if appropriate, by community services in Wales
- for women prisoners, all of whom are residing in prisons in England: those released into Wales will be released on oral therapy and reviewed in the community as above.
How about prison transfers?
There is a chance that a prisoner in Wales may be transferred once they have been initiated on Buvidal but before they are released. This could be to a prison in Wales or England. In both instances, the decision about how to manage this will need to be on an individual case basis taking into account:
- local protocols on managing prisoners admitted on OST including Buvidal
- the expected release date and place of release.
For any transfer, clear information about Buvidal dose, date of last dose and when the next dose is due will be needed to support safe dose continuity. Note that receiving prisons may not have stock of Buvidal injection.
- Summary of Product Characteristics (SPC) – Buvidal: https://www.medicines.org.uk/emc/search?q=Buvidal
- PHE COVID-19 guidance for commissioners and providers of services for people who use drugs or alcohol: www.gov.uk/government/publications/covid-19-guidance-for-commissioners-and-providers-of-services-for-people-who-use-drugs-or-alcohol
- RCGP secure environments COVID-19 resources: https://elearning.rcgp.org.uk/mod/page/view.php?id=10539
- SMMGP Buvidal guidance: https://www.smmgp-fdap.org.uk/clinical-guidelines-for-use-of-depot-buprenorphine-buvidal-in-the-treatment-of-opioid-dependence
- NICE evidence summary opioid dependence: buprenorphine prolonged-release injection (Buvidal) (ES19- 2019): https://www.nice.org.uk/advice/es19/chapter/Key-messages