The current commissioning of Covid Medicine Delivery Units (CMDUs) ends on the 27th of June. We feel it is important that GP practices understand what is happening as soon as possible given we are only now four weeks from CMDUs being stood down. We are clear that we do not believe it is appropriate for every GP to be required to start prescribing these medications. This is due to the complexity of the current cohort of eligible patients and the nature of the medications themselves.
There are 4 medications currently utilised in the CMDUs. The national Institute for Health and care excellence Multiple Technology appraisal recommends Paxlovid first line and or sotrovimab (for non hospitalised patients). The other 2 medications are currently not recommended. Therefore, NHSE has published a Rapid policy Statement for interim commissioning policy, this advises:
- First line: nirmatrelvir plus ritonavir (Paxlovid) (As per published NICE-MTA)
- Second Line: Sotrovimab (As per published NICE MTA)
- Third line : Remdesivir (where supply available)
- Forth line: Molnupiravir
GPCE and the wider BMA has attended the national steering group for CMDUs with NHSE, BMA members currently involved in running CMDUs explained in these meetings that the assessment of these patients was time consuming due to the large number of interactions and contra-indications, and often required input from specialist colleagues before prescribing. The first line drug (Paxlovid) is very difficult to prescribe, as it has interactions with many common and specialist medications that many in this patient group will be taking. Current numbers of eligible patients suggest prescribing levels are around 5/100,000 patients per week. This does not enable clinicians prescribing at practice level to develop the required knowledge or skill to safely prescribe this treatment.
The General Medical Council’s Good Medical Practice guidance is clear that ‘in providing clinical care, you must prescribe medicines only when you have adequate knowledge of the patient’s health and are satisfied that the medicine serves the patients needs’, and ‘that the treatment you provide is compatible with any other treatments the patient is receiving’. This treatment therefore does not allow for most GPs to prescribe under this guidance. It is our understanding from NHSE that the plan was for this to be a ‘referred to’ service. This may of course be a GP or specialist but with sufficient time, knowledge, and links to safely prescribe. We therefore recommend that GPs do not agree to prescribe this unless as part of an appropriate commissioned service. This may include where these medications have been through local medicines governance processes and local guidance to support prescribing with appropriate specialist input as required.
It is important that antiviral distribution services in all areas operate seven days a week and ensure a minimum of 95% of all eligible patients begin anti-viral treatment within at least 48 hours of testing positive for Covid-19. Ensuring this is being delivered will require some level of monitoring. We believe patients must be able to get access to this potentially lifesaving treatment in a timely manner.
Locally Lincolnshire ICB have assured us that a service will be put in place for this service although we await the detail.