Why Certain Services Aren’t Offered

This decision has been made after careful consideration and a review of our benzodiazepine prescribing related to fear of flying.

People often come to us requesting that we prescribe diazepam for fear of flying or to assist with sleep during flights.

Diazepam in the UK is a Class C/Schedule IV controlled drug.

We have outlined below the issues surrounding its use with regards to flying and why our practice no longer prescribes such medications for this purpose.

• The use of any sort of benzodiazepines causes longer reaction times & slowed thinking, which during a flight will put the passenger at significant risk of not being able to act in a manner which could save their life, or that of a loved one or co-passenger, in the event of a safety critical incident. Incapacitation from benzodiazepines is a risk to the lives of all on board the aircraft in the event of an emergency requiring evacuation.
• The use of such sedative drugs can make you fall asleep, however when you do sleep it is an unnatural non-REM sleep. This means you won’t move around as much as during natural sleep. This can cause you to be at an increased risk of developing a blood clot (Deep Vein Thrombosis – DVT) in the leg or even the lungs. Blood clots are very dangerous and can even prove fatal. This risk is even greater if your flight is greater than 4 hours.
• Whilst most people find benzodiazepines like diazepam sedating, a small number have paradoxical agitation and aggression. They can also cause disinhibition and lead you to behave in a way that you would not normally. This could impact on your safety as well as that of other passengers.
• Benzodiazepine use added to alcohol consumption causes an increase in the risk posed by the points above.
• According to the prescribing guidelines doctors follow (British National Formulary) diazepam is contraindicated (not allowed) in treating phobic states. It also states that “the use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate.” Your doctor would be taking a significant legal risk by prescribing against these guidelines.
• NICE guidelines suggest that medication should not be used for mild and self-limiting mental health disorders. In more significant anxiety related states, benzodiazepines, sedating antihistamines or antipsychotics should not be prescribed
• Diazepam stays in your system for quite a while. If your job requires you to submit to random drug testing you may fail this having taken diazepam
• Benzodiazepines have been linked to the onset of dementia.

Given the above we will no longer be providing Diazepam for flight anxiety and instead suggest the below aviation industry recommended flight anxiety courses which are easily accessible for those who wish to fly & conquer their fear of flying:

Easy Jet - www.fearlessflyer.easyjet.com
British Airways - www.flyingwithconfidence.com

Flight anxiety does not come under the remit of General Medical Services as defined in the GP contract and so we are not obliged to prescribe for this.

Patients who still wish to take benzodiazepines for flight anxiety are advised to consult with a private GP or travel clinic.
It is important to declare all medical conditions and medications you take to your travel insurer. If not, there is a risk of nullifying any insurance policy you may have

Sometimes patients ask us to prescribe Vaginal Micronised Progesterone (Cyclogest pessaries), in particular if they have had a miscarriage previously. Unfortunately, Cyclogest is a ‘Red Traffic Light Drug’ under the BNSSG prescribing guidelines . This means it can only be started by a specialist, usually in the recurrent miscarriage clinic of the Obstetrics and Gynaecology department, in line with NICE NG126 for women with symptoms of vaginal bleeding, with an intrauterine pregnancy confirmed by ultrasound scan who have a history of miscarriage.

MVMG prescribers are unable to prescribe Red Traffic light medications.

The NHS doesn’t fund surgery for mole removal, as described in the Benign Skin Lesion policy from Bristol, North Somerset and South Gloucestershire Integrated Care Board, who set the referral criteria. As a result, we are not able to refer patients for removal of simple benign skin lesions.

Sometimes we don’t know what a skin lesion is, in which case we will refer a patient via the 2 weeks wait dermatology referral. This currently involves a patient being booked in for a high definition, medical photograph prior to referral and then the photos and patient are reviewed by a dermatologist.

Similar policies also dictate when we are able to referral patients for other surgery such as varicose vein surgery, hernia repairs and circumcisions. The entire list of referral and funding policies can be found here.

MVMG prescribers have to prescribe according to local guidelines and the local NHS formulary. We sometimes prescribe testosterone within the guidelines from the NHS, which can be found here .

Often private clinics, which specialise in menopause, will initiate a prescription for testosterone, in the hope that the GP will continue to prescribe despite being outside of our guidelines. Unfortunately, we are unable to prescribe this ongoing prescription.

MVMG prescribers will take on shared care prescribing for ADHD medication in the following circumstances:

Person diagnosed by an NHS clinic who has been started on medication for ADHD within NHS formulary and guidelines, who are stabilised and have requested shared care with the appropriate paperwork and remains under specialist for ongoing monitoring.

Person diagnosed by an NHS right to choose provider who has been started on medication for ADHD with NHS formulary and guidelines, who are stabilised and have requested shared care with the appropriate paperwork and remains under specialist for ongoing monitoring.

Person who joins MVMG, already on ADHD medication under a shared care protocol. 

However, we will not start ADHD medication at the request of with NHS or private specialist clinics. Mendip Vale prescribers will not take over prescribing of ADHD medication unless the shared care protocol is followed and completed by the specialist clinic, including starting the medication, stabilising the dose, and confirming ongoing follow up and monitoring.

It is important that patients remain on the caseload of a specialist clinic as there are frequent supply issues with medication, and MVMG prescribers will not be able to start or advise on alternative provisions in the case of a supply issue.

We commonly get asked why there isn’t a Prostate Cancer screening programme. This is because the UK National Screening Committee doesn’t currently recommend screening for prostate cancer, due to the PSA test by itself not being reliable enough to pick up cancerous changes. However, men between 50 and 75 can book direct for a PSA test under the Prostate Cancer Risk Management Programme. We will require you to read a patient information website to help you understand the test better. If the PSA is positive, then we will ask you for a urine sample to exclude infection. If the PSA is positive and the urine shows no infection, then we will refer you on the 2 week wait urology pathway for an MRI of your prostate.

MVMG prescribers are required to prescribe within NHS guidelines and formulary. Currently we are only allowed to prescribe Semaglutide and Tirzapetide for people with diabetes. Unfortunately, we are not able to prescribe it for weight loss in people without diabetes, not even for people with pre-diabetes.

Weight loss drugs can be accessed via the NHS Tier 3 weight management service. However, this can only be accessed when the referral criteria have been met. Information about the weight management referrals service can be found here.

If you have been diagnosed with prediabetes, then you are eligible to enrol for the National Diabetes Prevention Programme, which you can self-refer to using this link. You will need the following information, which is available via the NHS app:

• HbA1c result
• Date of HbA1c test
• NHS number
• Name of GP surgery

For more information regarding weight loss injections for MVMG patients go to out website page - Weight Loss Injections

Some of our patients now opt to seek private consultations, outside of the NHS, and we recognise that often by going privately a number of people will be saving the NHS an appointment on the waiting list. As a result, we often get requests to prescribe medication or perform tests or referrals, from the private specialist. MVMG’s  general approach to private healthcare is that we would prescribe something that we would consider prescribing ourselves, e.g. a common treatment for blood pressure or acne. However, we reserve the right to decline requests for investigations or treatment if we don’t feel they are appropriate under the NHS GP contract.

Examples of declined consultant requests might include:

• Unlicensed medications, or medications at unlicensed doses
• Medications that aren’t part of the NHS formulary
• Medications that require initiation by a specialist such as amber or ref traffic light drugs.
• Medications with significant side effects or risks that we feel haven’t been adequately addressed, eg drug dependence in benzodiazepines.
• Medications or investigations with no clear plan for monitoring or review.
• Medications that require starting urgently, which should be started by the specialists at the time.
• Referrals which aren’t available via the NHS due to funding criteria.
• Referrals which private consultants are able to undertake themselves.

A number of drugs we prescribe, usually for pain, are controlled drugs. Controlled drugs have very strict regulations around them, and consequently we take the safe and regulated prescribing of these drugs very seriously. Controlled drugs often have a high value when sold illegally and also are usually addictive or can form dependence.

Consequently, our policy at MVMG is to put all controlled drugs into the ‘acute’ category of the prescribing section, rather than repeat. We recognise that this is inconvenient for some patients but having this system in place ensure we retain tight control over these powerful and potentially dangerous drugs.