Home Methadone Instalment Dispensing
Where patients are collecting daily instalments against an FP10MDA prescription, contractors should complete one line on the FP10MDA Form and will receive one set of fees (dispensing fee, CD fee, container allowance and contribution towards the Practice Payment, Establishment Payment/Protected Professional Allowance and Transitional Payment).
Where an FP10 MDA prescription, which is being collected less frequently than daily, for example where the patient cannot visit the pharmacy daily or when the pharmacy is closed, if the prescription specifies ‘dispense in daily dose containers in advance,’ (or equivalent wording), and the contractor has dispensed this in daily dose bottles, contractors can complete one line on Form FP10MDA for each daily dose container dispensed and will receive one set of fees per daily dose container dispensed. In this scenario, if the prescription does not clearly indicate that the product should be dispensed in daily dose containers, only one set of fees should be claimed and will be reimbursed.
Where the prescriber has indicated supervised consumption or observed self-administration, a set of fees may be claimed for both the supervised instalment and for any instalments taken away in advance. If the prescriber has also indicated that the take-home supply should be dispensed in daily dose containers, contractors can complete one line on Form FP10MDA for each daily dose container dispensed and will receive one set of fees per daily dose container dispensed.
The NHS Prescription Services guidance on dispensing FP10MDA prescriptions can be downloaded in full by clicking on the link below:
NHS Prescription Services Instalment Dispensing Guidance (PDF File)
The Welsh Assembly Government has confirmed that this guidance applies in Wales.
For support on this issue, please contact the PSNC Information Team: 0844 381 4180.
Home Office Approved Wording on Collection of Doses
Where the prescription for a Controlled Drug contains a direction that specified instalments should be dispensed at specified intervals, supplies must not be made otherwise than in accordance with the directions unless the following text is on the prescription:
Supervised Consumption
“Supervised consumption of daily dose on specified days; the remainder of supply to take home. If an instalment prescription covers more than one day and is not collected on the specified day, the total amount prescribed less the amount prescribed for the day(s) missed may be supplied.”
Unsupervised Consumption
"Instalment prescriptions covering more than one day should be collected on the specified day; if this collection is missed the remainder of the instalment (i.e. the instalment less the amount prescribed for the day(s) missed) may be supplied".
or;
"If an instalment prescription covers more than one day and is not collected on the specified day, the total amount prescribed less the amount prescribed for the missed days may be supplied.”
The Home Office approved wording to be used if the prescriber would like to ensure that the patient is not supplied with their dose if they have missed collecting their dose for three days is:
“Instalment prescriptions covering more than one day should be collected on the specified day. If this collection is missed, the remainder of the instalment (i.e. the total amount less the instalments for the days missed) may continue to be supplied in the specified instalments at the stated intervals, provided no more than three days are missed.”
More information: Medicines Ethics and Practice, 34th Edition 2010. Royal Pharamaceutical Society of Great Britain.
Likewise, the following wording can be used to support the collection of Methadone when the pharmacy will be closed on the due date specified on the prescription:
“Instalments due on days when the pharmacy is closed should be dispensed on the day immediately prior to closure.”
The Royal Pharmaceutical Society advises (see Medicines, Ethics and Practice - Supply of Controlled Drugs to misusers): 'An instalment prescription that contains wording different from that approved by the Home Office would not provide the dispensing pharmacist the security conferred by a prescription containing Home Office approved wording'.
Frequently Asked Questions
Instalment Dispensing on NHS Prescriptions
What products can be prescribed by instalments on Form FP10MDA?
In England, only Schedule 2 Controlled Drugs plus Buprenorphine, Buprenorphine/Naloxone (Suboxone) and Diazepam can be prescribed in instalments on Form FP10MDA.
In Wales, it is possible to prescribe Schedule 2, 3, 4 and 5 Controlled Drugs in instalments on Form WP10MDA.
Can Suboxone be prescribed on an FP10MDA Prescription?
Suboxone contains buprenorphine and naloxone. The intention of the naloxone component is to deter intravenous misuse.
The NHS Prescription Services have confirmed that contractors will be reimbursed for dispensing Suboxone in instalments against Form FP10MDA.
Is the quantity that can be prescribed on Form FP10MDA limited?
Form FP10MDA can only be used for the purpose of ordering a supply by instalments, the period of treatment is not to exceed 14 days, and the prescriber must specify the number of instalments to be dispensed and the interval between each instalment(Reference: NHS (General Medical Service Contracts) Regulations 2004; Part 3 Regulation 39 (4))
Can a prescriber request that a product is dispensed in instalments using Form FP10?
No, the only form that can be used to request instalments in England is Form FP10 MDA.
Prescription Wording
If the prescriber would like the product to be dispensed in daily dose containers where the patient is collecting their medicine less frequently than daily, is there specific wording that should be on the prescription?
In the scenario where an FP10 MDA prescription is being collected less frequently than daily, if the prescription specifies ‘dispense in daily dose containers in advance,’ (or equivalent wording), and the contractor has dispensed this in daily dose bottles, contractors can complete one line on Form FP10MDA for each daily dose container dispensed and will receive one set of fees per daily dose container dispensed .
It is acceptable for the prescriber to use phrases other than ‘dispense in daily dose containers in advance,’ as long as it clear from the wording that they are requesting that the product is dispensed in daily dose containers.
Endorsements
How should Form FP10MDA be endorsed?
For each set of fees being claimed (i.e. dispensing fee, additional fee, container allowance and contribution towards the volume related allowances) contractors should ensure that they have completed one complete line on the right hand side of Form FP10MDA including the date, item dispensed, quantity supplied and the pharmacists initials.
Before submitting the form to the NHS Prescription Services, the endorsement column on the left hand side of the prescription form should also be endorsed with details of the pack size and brand/manufacturers name of the dispensed product where required. Guidance on endorsing can be found in the PSNC Dispensing Resources Guide (accessible from the PSNC online publications database)
The prescriber has ordered more than fourteen instalments (for a treatment period not exceeding 14 days). There is not enough space on Form FP10MDA to make all of the required endorsements. What should I do?
If a prescriber has ordered more than fourteen instalments, then the lines on the right hand side of the prescription form can be split to allow all of the instalments to be endorsed.
My patients receive doses of methadone twice daily, morning and afternoon. If the prescriber specifies on Form FP10MDA that each dose should be supplied in individual dose bottles in advance, will I be reimbursed for dispensing two bottles each day?
Yes, as long as the prescriber has clearly indicated on the prescription that the Methadone should be supplied in individual dose bottles in advance, contractors should complete one line on Form FP10MDA for each bottle dispensed and accordingly will receive one set of fees for each bottle dispensed.
If a prescriber has ordered more than fourteen instalments, then the lines on the right hand side of the prescription form can be split to allow all of the instalments to be endorsed.
In the bottom left hand side of the FP10MDA Form, there is a box to allow pharmacists to record the total number of items on the Form. Is it mandatory to complete this box
No, it is not mandatory to complete this box with the total items dispensed but it does serve as a useful check for prescription pricing staff so it is helpful if this box can be completed.
Patient Safety
Why might a prescriber request that Methadone is dispensed in daily dose bottles?
The NHS National Treatment Agency for Substance Misuse has raised concerns that dispensing methadone in bulk bottles can pose a serious patient safety risk as there is currently no appropriate existing measure available free from NHS community pharmacies for patients to measure their daily dose accurately (Part IV of the Drug Tariff sets out the arrangements for containers including 5ml spoons and oral syringes).
If patients are not able to accurately measure their dose (the methadone target maintenance dose is between 60ml and 120ml), there is a risk of underdosing or overdosing which may result in both harm to the patient and prevent a planned withdrawal. There is also evidence of patient’s using measures such as baby’s bottles to measure doses, as little as 5ml can kill a baby if a residual amount is left in the bottle.
A solution to this problem is for prescribers to request on Form FP10MDA that the product is dispensed in individual daily dose containers. For pharmacy contractors to be reimbursed for dispensing in individual bottles, the prescribers request must be clear from the wording on the prescription (full details in the NHSBSA Guidance).
Individual Bottles
The doctor has requested on Form FP10MDA that the patient's methadone is supplied in advance in individual daily dose bottles. I don't have sufficient bottles in stock, do I have to follow the prescriber's instructions?
The RPSGB have advised that pharmacists should comply with prescribers' directions and supply in individual daily dose bottles where this has been requested. It would not be a legal requirement under the Misuse of Drugs Regulations 2001, as amended, for the pharmacist to supply in individual daily dose bottles, therefore if for some reason daily dose bottles could not be supplied, it would not be unlawful to make a supply in a larger multidose bottle. However, it is a professional requirement of the Code of Ethics for pharmacists to act at all times, in the best interests of the patient and seek to provide the best possible health care. The pharmacist should contact the prescriber prior to making a supply contrary to that prescribers specific directions and should ensure they are clear as to the prescribers intentions. The pharmacist should then use their professional judgement on how to make the supply and should be able to justify his or her decision.
Pharmacists are also reminded that they have a professional responsibility to ensure that patients are provided with sufficient information and advice to enable the safe and effective use of their medicine. Therefore, where a bottle of medicine contains more than one dose, the pharmacist should ensure that the patient is able to correctly measure out their required doses themselves.
Contractors should claim payment only for what has been supplied, in accordance with the NHSBSA guidance on endorsing FP10MDA prescriptions.
Changes to the Processing Arrangements in 2006
The Department of Health approved a PSNC claim for £850,000 to help compensate pharmacy contractors who may have lost out through a change in the way that FP10MDA instalment dispensing prescriptions were processed at the NHS Prescription Services in late 2006 (July - October 2006). This was paid out to contractors through a 14p increase in the Schedule 2 Controlled Drug Fee for four months from December 2007 to March 2008. The fee returned to it's current level of £1.28 in April 2008.
Resources
Click on the link below to download a template letter that can be used to inform prescribers of the revised guidance: 
Template Letter to Prescribers (MS Word Format)
PSNC has written to suppliers of prescribing software to inform them of the changes and to ask them to support the generation of this wording on prescriptions.
Related Guidance
PSNC Guidance on Controlled Drugs
DOWNLOADS: Some documents are available in PDF format, you will require Adobe Acrobat Reader 5.0 or later for viewing which can be downloaded from the Adobe Website
DOWNLOADS: Some documents are available in ‘Microsoft Word’ format. If you do not have Microsoft Word, you can read these forms by downloading the free 'Word Viewer'. This program can be downloaded at the Microsoft website