Telephone Line Standard
Operating Procedure (SOP) –
Mind Professionals and Provide
Wellbeing
Version: V1
Ratified by: Quality Reference Group
Date ratified: 28/04/2026
Job Title of author: Director, Strategic Partnerships
Reviewed by Committee or Expert Group Medicines Governance and Safety Group
Related procedural documents
Review date: 28/04/2029
It is the responsibility of users to ensure that you are using the most up to date document template – ie obtained via the intranet.
In developing/reviewing this procedure Provide Community has had regard to the principles of the NHS Constitution.
Version Control Sheet
Version Date Author Status Comment
V1 April 2026 Director, Strategic Partnerships New
1. Purpose
To define the operational process for managing prescribing queries from community pharmacists relating to ADHD medication within the MSE ICB pathway, including:
• In-hours management
• Out-of-hours (OOH) escalation
• Governance and documentation requirements
• Compliance with commissioner specification
This SOP ensures safe, timely, and compliant responses to pharmacy queries, particularly those relating to medication shortages or urgent prescription amendments.
2. Scope
This SOP applies to:
• Provide Wellbeing ADHD Services
• Mind Professional ADHD Services
• Operational Teams (BSOs / CSOs)
• Prescribing Clinicians
• On-Call Managers / Directors
• Medicines Management and Clinical Governance Teams
It covers all prescribing queries received via the designated Community Pharmacy Telephone Line.
3. Background / Commissioner Specification Requirement
The service is contractually required to:
• Provide a direct dial telephone number for community pharmacy prescription queries
• Ensure availability Monday–Friday 08:00–18:30 (excluding Bank/Public Holidays)
• Ensure calls are answered within 3 minutes
• Respond to requests for prescription amendments due to medicines shortages promptly
• Issue a new prescription within 4 working hours where changes are required
The requirement was introduced during national ADHD medication shortages, which are now largely resolved. Commissioners anticipate low call volumes
4. Service Operating Model
Telephone Line Availability
The Community Pharmacy Telephone Line will operate:
• Core operational hours: 08:30–17:00 Monday–Friday
• Extended contractual coverage: 08:00–08:30 and 17:00–18:30
• Excluding Public/Bank Holidays
5. In – Hours Process (08.30-17.00)
Initial Call Handling
• Calls are answered by BSOs and CSOs within operational teams
• Target: Answer within 3 minutes
Nature of Queries
Typical queries may include:
• Clarification of prescription details
• Dose/formulation confirmation
• Supply shortages
• Requests for amended prescriptions
Medication Availability
• Prescribing clinicians will have access to the National Medication Availability Tool
• Clinicians must check availability prior to issuing prescriptions to reduce avoidable pharmacy queries
Prescription Amendments (Shortages)
Where a pharmacy requests a change due to stock shortages:
1. Query logged immediately
2. Escalated to prescribing clinician
3. Clinician reviews and confirms alternative
4. New prescription issued
5. Previous prescription cancelled on the electronic system
6. Must be completed within 4 working hours of enquiry
6. Out of Hours (OOH) Process
(08:00–08:30 and 17:00–18:30 Monday–Friday only)
Commissioners expect low call volumes.
Management Approach
OOH calls will be managed via Provide’s existing On-Call System
Responsibilities of Manager On Call
The Manager on Call will:
1. Respond to the call
2. Record full details using the designated Pharmacy Query Proforma (included in On-Call Pack)
3. Handover details to the ADHD service at the earliest opportunity on the next working day
7. Documentation Requirements
All pharmacy queries (in-hours and OOH) must be recorded including:
• Date and time of call
• Pharmacy name and contact details
• Patient identifier (minimum required for safety)
• Nature of query
• Action taken
• Escalation details (if applicable)
• Name of staff member handling the call
OOH calls must be documented using the approved On-Call Proforma and formally handed over.
8. Handover Process
For OOH calls:
• Email handover (secure NHS mail) to service inbox
• Mark as “Pharmacy Query – OOH”
• Include summary and actions required
• Service to acknowledge receipt of handover same/next working day
9. Risk Assessment (Medicines Management and Clinical Governance)
Risk Context
This process relates to the management of prescribing queries from community pharmacies regarding ADHD medications.
Commissioners have indicated that:
• Call volumes are expected to be low
• The requirement was introduced during national ADHD medication shortages
• Medication supply has now largely stabilised
Therefore, the inherent operational risk is considered low, with anticipated minimal service disruption.
However, due to the involvement of:
• Controlled drugs
• Potential prescribing amendments
• Out-of-hours decision-making
Governance oversight is required to ensure:
• Timely response
• Safe prescribing practice
• Clear documentation
• Auditability
Identified Risks and Mitigation
Risk
Delay in responding to pharmacy query
Delay in issuing amended prescription (shortagerelated)
Poor documentation / audit gap
Controlled drug governance concern
Low Low–Moderate
Low Moderate
Low Low
Low Moderate
Overall residual risk: Low Medicines Management Controls
Direct telephone line; 3-minute answer standard; OOH cover via on-call system
4 working hour requirement; escalation to prescribing clinician; access to national medication availability tool
Standardised proforma; secure NHS email handover; governance monitoring during trial
Prescribing changes only made by authorised clinicians; documentation retained; subject to medicines management oversight
To provide assurance to Medicines Management:
I. Prescribing Authority
a. Only authorised ADHD prescribers may amend prescriptions.
b. Managers on Call will not provide clinical prescribing decisions
II. Medication Availability Checking
a. Clinicians have access to the National Medication Availability Tool to minimise avoidable shortages-related queries.
III. Controlled Drug Governance
a. All ADHD medications prescribed under this pathway remain subject to:
i. Controlled drug regulations (where applicable)
ii. Local prescribing policies
iii. Audit and monitoring processes
IV. Documentation & Audit
a. All calls logged.
b. OOH contacts recorded using formal proforma.
c. Incidents reported
d. Complaints relating to shortages of medicines
Low
Low
Low
Low
e. Data available for review by Medicines Governance and Safety Group if required.
V. Time-Limited Trial with Review
a. 3-month review of:
i. Call volumes
▪ Nature of queries
▪ Any prescribing incidents
▪ Operational burden
This ensures the governance response remains proportionate to actual risk.
10.Roles and Responsibilities
Role Responsibility
BSOs / CSOs First-line call handling (in-hours)
Prescribing Clinician Clinical review and prescription amendments
Manager On Call OOH call handling and escalation Service Manager Oversight and monitoring
Clinical Governance Compliance and risk oversight
11.Review
This SOP will be:
• Reviewed at end of 3-month trial
• Updated following commissioner feedback
• Reviewed 3-yearly thereafter or earlier if required e.g., increase in incidents/complaints
12. Governance Position Statement
While commissioner requirements mandate extended telephone access, available intelligence suggests:
• Low anticipated demand
• Resolution of previous national shortages
• Minimal expected clinical escalation
The service has therefore implemented a proportionate governance model, ensuring:
• Contractual compliance
• Medicines management oversight
• Safe escalation pathways
• Minimal unnecessary operational burden
This approach balances:
• Patient safety
• Medicines governance
• Practical service delivery
• Appropriate use of on-call resource
13. Monitoring and Assurance Framework
During the 3-month trial period: The following will be reviewed:
• Number of calls (in-hours vs OOH)
• Response time compliance
• Number of prescription amendments
• Any reported incidents (Datix)
• Any complaints or pharmacy feedback
If call volume remains negligible, the service may seek commissioner agreement to:
• Amend extended cover arrangements
• Reconfirm proportionality of requirement
Findings will be reported to:
• Clinical Governance
• Medicines Management (if requested)
• Service Leadership Team
