Diverse Diagnostics

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Table of Contents

1. Introduction
2. Purpose of Policy
3. Policy Statement
4. Scope
5. Definitions
6. Procedure
7. Responsibilities
8. Enforcement / Compliance
9. Related information
10. Appendix

1. Introduction

Diverse Diagnostics provides an online service where we assess Attention Deficit Hyperactivity Disorder (ADHD) among adults and children. Moreover, we also assess other mental health conditions among children and adolescents, including Autism spectrum disorder (ASD) and other mental health disorders, such as Depression, Anxiety, Tics, Sleep Disorders, and Obsessive-Compulsive Disorder (OCD). Following assessments, diagnosis and management plan will be recommended. Patients who need medication as part of their treatment will be able to receive:

1. Adults: A private prescription from Diverse Diagnostics. Once dose has been stabilised, patients will be able to discuss Shared Care with their GPs.
2. Children and Adolescents: a prescription under Shared Care with their General Physician (GP), OR a private prescription, directly from Diverse Diagnostics.

Shared Care means that patients’ GP would provide an NHS prescription while patients maintain the follow-up with the child or adult psychiatrist at Diverse Diagnostics (depending on the patient’s age), who will recommend the dosage. Therefore, the psychiatrist at Diverse Diagnostics will monitor and recommend whilst the GP would provide the actual prescription based on the recommendations.

Note: Shared Care service/ arrangement cannot be guaranteed with Diverse Diagnostic as all GPs have different policies.

Private prescriptions can be provided directly from Diverse Diagnostics under a fee, and patients will be required to pay any pharmacy fees related to their medication. Patients will have the option to select their preferred pharmacy, to which all prescriptions will be dispatched via courier. The prescription cost and courier fee will be combined into a single combined fee which will be available at the clinic’s website or by calling the clinic directly.

Moreover, some medications will need a physical health parameters before the start of medicines to ensure patients' safety.

The prescription of medications will be decided, most of the time, according to the National Institute for Health and Care Excellence (NICE) Guidelines. Sometimes, on a case-by-case basis, some off label prescription may need to be considered, which will be discussed/explained with the patient, and it will be detailed in the patient’s medical record.

Diverse Diagnostics will also require access to the patient’s primary healthcare record from their general practitioner (GP) before prescribing medication. Diverse Diagnostics requires a comprehensive understanding of the patient’s medication history before prescribing a medication. This includes details about past illnesses, medications, surgeries, and any underlying health conditions. Diverse Diagnostics will request consent for access to patient care records. Obtaining this information from the patient's GP ensures that diagnostic procedures are tailored to the individual's specific health circumstances.

2. Purpose of Policy

Diverse Diagnostics is responsible for providing a proper and effective system to prescribe medicines safely and meet patients' clinical needs. It is important to highlight that Diverse Diagnostics will not handle medicines; we will prescribe medications privately or under Shared Care with the GP, depending on the patient’s age. The prescription of medications will comply with national guidance: The National Institute for Health and Care Excellence (NICE), the British National Formulary (BNF), the British National Formulary for Children (BNFC), and the Scottish Medicines Consortium and Scottish Intercollegiate Guidelines Network.

3. Policy Statement

The management of medications is a multidisciplinary activity involving medical doctors, pharmacists, nurses, and patients. When prescribing, Diverse Diagnostics’ primary duty is to ensure that medicines will be prescribed in line with the guidelines within this policy and in an evidence-based, safe, and effective manner. As we provide remote consultations at Diverse Diagnostics, we follow the ten high-level key principles:

1. Our priority is our patients' safety, and we raise concerns if the service or system they are working in does not have adequate patient safeguards, including appropriate identity and verification checks.
2. Understand how to identify vulnerable patients and take the appropriate steps to protect them.
3. At Diverse Diagnostics, we will always provide our professional registration details and will establish a dialogue and make sure the patient understands how the remote consultation is going to be delivered and explain the entire assessment process.
4. Explain that:
   • We can only prescribe if it is safe to do so and only in cases where it is needed.
   • It is not safe if we do not have sufficient information about the patient's health or if remote care is unsuitable to meet their needs.
   • It is unsafe if relevant information is not shared with other healthcare providers involved in their care such as GP. All prescribing or changes to medication will be communicated via letters to the GP and other appropriate professionals. Both cases will follow this: prescriptions under Shared Care or privately with Diverse Diagnostics.
5. Informed consent and follow relevant mental capacity law and codes of practice. (See Child and Adult: Patient Consent to Medicine Use and Patient Consent to Unlicensed Medicine Use)
6. Undertake an adequate clinical assessment and access medical records or verify important information by examination or testing. (See Procedure section below)
7. Give patients information about all the options available to them, including refusing treatment. Always explain it in a manner that patients will understand.
8. Make appropriate arrangements for aftercare by sharing all relevant information with their GPs to support ongoing monitoring and treatment.
9. Keep notes with a full explanation and justify the decisions made.
10. Keep up-to-date with relevant training, support and guidance for providing healthcare in a remote context.

4. Scope

This policy details the process for prescribing medicines depending on patients' diagnoses. Diverse Diagnostics will not dispense or store any medicines.

5. Definitions

6. Procedure

Diverse Diagnostics will always check patients' identities before the first assessment. We will identify patterns of behaviour that may indicate severe concerns so that appropriate steps can be taken and protect patients. Consent will be asked before the first assessment, and treatment will be explained in detail after the full assessment is completed and the diagnosis is made. As we are currently providing a remote service for ADHD, ASD, Depression, Anxiety, Sleep Disorders, Tics, and OCD, we recognise our limitations at the time of prescribing. Some medicines will require some physical health parameters before prescribing, specifically those for ADHD. Therefore, our procedure of prescription will depend on the medication required:

1. If a patient with ADHD is needing medical treatment, they can receive their prescription via two different pathways, depending on their age:
   • Patients can consult with their GP for a Shared Care agreement at the start of medication. In some cases, Shared Care will only be discussed once a dose has been stabilised. Once GP agrees to Shared Care, patient and GP will receive a report. The psychiatrist at Diverse Diagnostics will monitor the patient and recommend medication dosage, whilst the GP would provide the actual prescription based on the recommendations.** Shared Care Agreement cannot be guaranteed by the Diverse Diagnostics. This would be at the discretion of individual GPs.
   • Private prescription from Diverse Diagnostics. Patients will be charged for the private prescription and they will pay for the pharmacy costs as well. The psychiatrist at Diverse Diagnostics will monitor the patient and prescribe the medication, but it is important to highlight that the patient’s GP will still receive medication initiation letters and medication review letters with all private prescriptions.ADHD medications will need a physical examination before taking them, including blood pressure, height, weight, and heart rate. All these measurements will be taken and plotted on appropriate growth/percentile charts and recorded in the clinical notes at Diverse Diagnostics. Physical observations can be completed by their NHS GP or by private GP practice. If the patient and their family (in young individual cases) feel comfortable and are able to take their own physical observations at home with the appropriate equipment, this can be discussed with the consultant.

     Patients will be referred to a Cardiologist or NHS CAMHS/Paediatrist (depending on patient’s age), if he/she has any of the following:

     1. history of congenital heart disease or previous cardiac surgery
     2. history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease
     3. shortness of breath on exertion compared with peers
     4. fainting on exertion or in response to fright or noise
     5. palpitations that are rapid, regular and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation)
     6. chest pain suggesting cardiac origin
     7. signs of heart failure
     8. a murmur heard on cardiac examination
     9. blood pressure that is classified as hypertensive for adults

     According to the NICE Guidelines, a young individual must be referred to a paediatric hypertension specialist before starting medication for ADHD if blood pressure is consistently above the 95th centile for age and height for children and young people.

     When prescribing or changing ADHD dose or medication, physical observations will always have to be completed beforehand. Diverse Diagnostics will undertake the maintenance medication review appointment in both cases: patients under Shared Care or receiving private prescriptions. Moreover, information from all reviews, including changes to medication, will be sent to the GP.

2. If a patient with ASD is required to follow a medical treatment they can receive their prescription via two different pathways:
   • Patients can consult with their GP for a Shared Care agreement at the start of medication. In some cases, Shared Care will only be discussed once a dose has been stabilised. Once GP agrees to Shared Care, patient and GP will receive a report. The psychiatrist at Diverse Diagnostics will monitor the patient and recommend medication dosage, whilst the GP would provide the actual prescription based on the recommendations.** Shared Care Agreement cannot be guaranteed by the Diverse Diagnostics. This would be at the discretion of individual GPs.
   • Private prescription from Diverse Diagnostics. Patients will be charged for the private prescription, and they will pay for the pharmacy costs as well. The psychiatrist at Diverse Diagnostics will monitor the patient and prescribe the medication, but it is important to highlight that the patient’s GP will still receive medication initiation letters and medication review letters with all private prescriptions.*ePrescription is also available at the clinic via ITH Health.

     Diverse Diagnostics will undertake the maintenance medication review appointment in both cases: patients under Shared Care or receiving private prescriptions. Diverse Diagnostics will report every change in patient mental state and changes to medications to the GP.

3. If a patient with Depression, Anxiety, Tics, Sleep Disorders and OCD is required to follow a medical treatment they can receive their prescription via two different pathways:
   • Patients can consult with their GP for a Shared Care agreement at the start of medication. In some cases, Shared Care will only be discussed once a dose has been stabilised. Once GP agrees to Shared Care, patient and GP will receive a report. The psychiatrist at Diverse Diagnostics will monitor the patient and recommend medication dosage, whilst the GP would provide the actual prescription based on the recommendations.
     ** Shared Care Agreement cannot be guaranteed by the Diverse Diagnostics. This would be at the discretion of individual GPs.
   • Private prescription from Diverse Diagnostics. Patients will be charged for the private prescription, and they will pay for the pharmacy costs as well. The psychiatrist at Diverse Diagnostics will monitor the patient and prescribe the medication, but it is important to highlight that the patient’s GP will still receive medication initiation letters and medication review letters with all private prescriptions..*ePrescription is also available at the clinic via ITH Health.

     Diverse Diagnostics will undertake the maintenance medication review appointment in both cases: patients under Shared Care or receiving private prescriptions. Diverse Diagnostics will report every change in patient mental state and changes to medications to the GP.

Before we prescribe any medication, we will ensure that we can provide an adequate assessment, establish a dialogue, and obtain the patient's consent. (See Child and Adult: Consent to Medicine Use) Establishing a dialogue with patients is key to helping them consider information about their options; in that way, they can decide whether or not to receive the treatment. This dialogue also allows our health professionals and our patients to ask questions and get more information. Medicine information leaflets will be given to all patients. Moreover, an adequate medical history will be made before any prescription is given, including:

• any previous adverse reactions to medicines
• current and/or recent use of other medications, including non- prescription and herbal medicines, illegal drugs and medicines purchased online or face to face
• other medical conditions

Parents must be warned to keep all medicines out of the reach and sight of children.

Prescription Dispensing

Patients will be asked to provide consent to release medication prescription regarding preferred pharmacy. Diverse Diagnostics will then send prescription via Royal Mail First Class. Patients will be given a tracking code. Diverse Diagnostics will notify patients if their prescription has arrived. It is the patient’s responsibility to check for medication availability at their preferred pharmacy before providing us the information. If medication is unavailable, it is the patient’s responsibility to seek out another pharmacy where medication is available.

7. Responsibilities

It is the responsibility of Dr Jagdish Basra to ensure that all staff has access to this policy.

We will follow any advice of external adviser, once a year, and update policies to provide best practices.

8. Enforcement / Compliance

If there is any detail from our policy that needs to be changed or improved, Diverse Diagnostics is committed to doing it immediately. An independent external adviser will audit our policy and our current practice on an annual basis. Diverse Diagnostics is also committed to keeping up to date with new treatment guidelines.

9. Related information

This policy was written according to the NICE Guidelines, the guidance for good practice in prescribing and managing medicines and devices (General Medical Council), and the legal responsibilities defined in the Medicines Act (1968).

10. Appendix

Good practice in prescribing and managing medicines and devices (2021)
https://www.gmc-uk.org/-/media/documents/prescribing-guidance-updated-english-20210405_pdf-85260533.pdf

Making decisions using NICE guidelines
https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/making-decisions-using-nice-guidelines#prescribing-medicines

Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes
https://www.nice.org.uk/guidance/ng5

Medicines Act 1968
https://www.legislation.gov.uk/ukpga/1968/67/contents

Misuse of Drugs Act 1971
https://www.legislation.gov.uk/ukpga/1971/38/contents

The high-level principles for good practice in remote consultations and prescribing
Can be downloaded at "Key documents":
https://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/independent_healthcare/register_a_new_service.aspx

The Maudsley Prescribing Guidelines in Psychiatry
https://www.wiley.com/en-gb/The+Maudsley+Prescribing+Guidelines+in+Psychiatry%2C+14th+Edition-p-9781119772231